Following the recent publication of clinical practice guidelines for spinal cord injury (SCI), leading authors Michael G Fehlings and Mohammed Ali Alvi (both Toronto, Canada) discuss why they represent “an important step toward standardising care and highlighting key knowledge gaps”.
The field of SCI has seen significant advances in medical, surgical and rehabilitative aspects of care. However, many management challenges remain. In the most recent issue of the Global Spine Journal (GSJ), our team has presented new guidelines for three key clinical issues pertaining to SCI: the role and timing of surgical intervention for acute SCI; haemodynamic management of SCI; and intraoperative SCI identification and management.1
For the role and timing of surgery, the clinical practice guidelines addressed two key issues, which were a) recommending surgical decompression within 24 hours of injury, and b) recommending “ultra-early” surgical decompression with more stringent cut-offs, such as 12 hours or eight hours.
The Guidelines Development Group (GDG) made a strong recommendation that surgical decompression be completed within 24 hours after injury when medically feasible. This was in contrast to the 2017 AO Spine guidelines, which made a weak recommendation suggesting early surgery could be offered as an option for adult SCI patients.2 The ability to generate a stronger recommendation than the AO Spine guidelines of 2017 was in part related to a 2021 meta-analysis that combined the results of four large datasets with over 1,500 patients to conclude that ASIA impairment scale (AIS) grade conversion and ASIA motor score improvement were higher in those who were decompressed within 24 hours.3
However, despite the robust recommendation, there remains a significant gap in understanding the impact of timing on outcomes—particularly concerning ultra-early surgery. While the 24-hour window is deemed practical, emerging evidence suggests potential biological benefits associated with earlier interventions. The question of the role and impact of ultra-early surgery for acute SCI is a key issue that will require research to define. An additional challenge relates to the management of geriatric patients with acute SCI—an important issue given the shifting demographics of neurotrauma in our society.
Regarding haemodynamic management of SCI, the GDG acknowledged limited evidence leading to weak recommendations to maintain mean arterial pressure (MAP) between 75–80mmHg (low end) and 90–95mmHg (upper end) for three to seven days post-injury. Specific vasopressor or inotrope recommendations were omitted due to insufficient evidence. Departing from prior guidelines, the GDG noted inconsistent support for maintaining MAP between 85–90mmHg for seven days and insufficient evidence for its neurological benefit. These new guidelines underscore uncertainties and emphasise the need for high-quality prospective studies to clarify the relationship between MAP targets and neurological outcomes. With advancements in electronic medical records, institutions can gather extensive physiologic data, enabling advanced analyses to elucidate this relationship further. Moving forward, the challenge lies in establishing causal relationships rather than mere associations between MAP augmentation and acute SCI care.
With regards to intraoperative SCI (ISCI), the current guidelines aimed to unify the definition of ISCI, delineate risk factors of ISCI, define the diagnostic accuracy of intraoperative neuromonitoring (IONM) techniques, and propose treatment algorithms for the management of potential ISCI. The GDG put forth the following definition for ISCI after reviewing evidence from the scoping review, and subsequently voting and discussing it in depth, in accordance with the Delphi process: “a new or worsening neurological deficit attributable to spinal cord dysfunction during spine surgery that is diagnosed intraoperatively via neurophysiologic monitoring, by an intraoperative wake-up test or immediately postoperatively based on clinical assessment.”
Regarding risk factors of SCI, the GDG delineated certain profiles that may increase the risk of ISCI including complex spine deformity, such as a rigid thoracic kyphoscoliosis with high deformity angular ratio (dAR); revision congenital spine deformity; spine conditions associated with significant cord compression and myelopathy; intramedullary spinal cord tumour; unstable spine fractures, and ossification of the posterior longitudinal ligament (OPLL) associated with severe cord compression and moderate to severe myelopathy. In terms of the role of IONM, the GDG determined, after performing an exhaustive review of the literature, that there was sufficient high-quality evidence to recommend considering the use of IONM for high-risk patients undergoing spine surgery. The current guidelines also proposed a five-step systematic approach to the management of ISCI. The steps include initial clinical assessment to identify patient risk, preoperative planning, intraoperative planning, intraoperative management including anaesthesiologic, neurophysiological/technical and surgical strategies, as well as postoperative management.
In brief, the updated AO Spine-Praxis guidelines for acute SCI management offer new recommendations on surgery timing, MAP targets, and ISCI prevention. These guidelines aim to improve safety and outcomes in complex spinal surgery and SCI cases. Recognising the need for ongoing updates, we encourage research to address knowledge gaps and advance SCI care.
We would like to acknowledge the leadership team, including Michael G Fehlings, Brian Kwon, Nathan Evaniew, Lindsey Tetreault, and Andrea Skelley. We would also like to acknowledge the efforts of the collaborative team as well as funding support from AO Spine and the Praxis Institute.
Key references:
- Kwon B K, Tetreault L A, Evaniew N et al. AO Spine/Praxis Clinical Practice Guidelines for the Management of Acute Spinal Cord Injury: An Introduction to a Focus Issue. Global Spine J. 2024; 14: 5S–9S.
- Fehlings M G et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery. Global Spine J. 2017; 7: 195S–202S.
- Badhiwala J H et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol. 2021; 20: 117–126.
Michael G Fehlings is a professor of neurosurgery and co-director of the University of Toronto Spine Program in Toronto, Canada. He combines an active clinical practice in complex spinal surgery at Toronto Western Hospital with a translationally oriented research programme focused on discovering novel treatments for the injured spinal cord. He has published over 1,150 peer-reviewed articles (h-index 124) chiefly in the area of central nervous system injury and complex spinal surgery. Fehlings has held prominent leadership roles, including past president of the International Neurotrauma Society, past president of the Cervical Spine Research Society, and leading several international clinical research trials.
Mohammed Ali Alvi is a physician-scientist currently working as a post-doc in Fehlings’ Lab for Neural Repair and Regeneration, and is a second-year PhD candidate at the Institute of Medical Sciences (IMS), University of Toronto, under Fehlings’ mentorship. Alvi’s research interests include judicious use of machine learning and artificial intelligence (AI) for outcomes research pertaining to traumatic and non-traumatic SCI. He is currently investigating the use of radiomics to facilitate precision medicine for patients with degenerative cervical myelopathy.
The authors declared no relevant disclosures.
