Abstract
Dear Editor,
We thank Dr Arvinte for his thoughtful letter and endorsement of our 2024 AO Spine/Praxis clinical practice guidelines for the management of acute spinal cord injury (SCI).1-4 In these guidelines, our international multidisciplinary team used the rigorous GRADE methodology to generate systematic reviews and guidelines to address (a) the role and timing of surgical intervention for acute SCI; (b) the optimal hemodynamic management of acute SCI; and (c) the prevention, diagnosis and management of intraoperative SCI. These guidelines articulated a strong recommendation for surgical intervention within 24 h of an acute SCI, when medically and logistically feasible. 2 It was recognized that the management of elderly or medically unstable patients, as well as patients with a mild AIS D central cord injury, requires clinical judgement and that early surgical intervention may not be possible or medically appropriate. The treatment of mild central cord injury is currently being examined in the InTWIN study through the AO Spine SCI Knowledge Forum. In terms of hemodynamic management of acute SCI, we endorsed several recommendations from the 2013 AANS/CNS guidelines 5 but provided a more pragmatic range for mean arterial blood pressure targets (75-95 mmHg) and duration of treatment in an advanced care unit (3-7 days—depending on physician judgment). 3 Due to lack of suitable evidence, our team was unable to develop recommendations related to spinal cord perfusion pressure monitoring. This knowledge gap is currently being addressed by prospective research studies at multiple centres.
Dr Arvinte provides unique perspectives given his background as a critical care physician in the community as well as the father of a son who sustained a C4 SCI. He advocates for stronger, more compelling wording of our recommendations given the devastating nature of SCI. He suggests that patients and families would accept any treatment that might alter the course of SCI, even if only marginally. This sentiment has been shared by many individuals living with SCI that have participated as key stakeholders in both the 2017 and 2024 guideline development process. Due to the rigor of GRADE methodology, the language used in the 2024 AO Spine/Praxis guidelines is perhaps more restrained than Dr Arvinte might wish but reflects the current body of evidence. We also recognize that guidelines are intended to compliment clinical judgement based on consideration of the individual patient as well as setting and have attempted to convey that in the publications surrounding the guideline.
Dr Arvinte also highlights that the language of the guideline may discourage implementation by the non-academic community and obstruct effective knowledge translation. Our team in the AO Spine SCI Knowledge Forum is currently engaged in knowledge dissemination efforts to increase physician awareness through international engagement, courses, webinars and other communication streams. However, we understand other factors may impede guideline adherence, including physicians’ attitudes towards the recommendations, guideline related factors and external factors, such as organizational constraints. We welcome any suggestions that the community may have to identify and address some of the barriers to effective dissemination and implementation, with the ultimate goal of improving outcomes for patients with SCI.
Finally, it is anticipated that new knowledge related to spinal cord perfusion management, the optimal methods to achieve surgical decompression (including the possible role of duroplasty), the role of ultra-early (<12 h after acute SCI) surgery and the management of central cord injury will result in revised guidelines in the next several years. Moreover, emerging research regarding neuromodulation, neuroprotective approaches (eg riluzole) and neuroregenerative strategies, including targeting inhibitory molecules such as NOGO, RGMA and PTEN and engineering neural stem cells, will change the landscape of clinical options to manage SCI. The upcoming years hold promise to further advance the treatment of acute SCI and updating of guidelines to incorporate new evidence will be important.
Footnotes
Acknowledgments
MGF is supported by the Robert Campeau Family Foundation/Dr C.H Tator Chair in Brain and Spinal Cord Research. BKK is the Canada Research Chair in Spinal Cord Injury and the Dvorak Chair in Spinal Trauma.
Author Contributions
MGF: Conceptualization; writing – original draft; writing–review and editing. NE: Conceptualization; writing – original draft; writing–review and editing. SNK: Conceptualization; writing – original draft; writing–review and editing. ACS: Conceptualization; writing – original draft; writing–review and editing. LAT: Conceptualization; writing – original draft; writing–review and editing. BKK: Conceptualization; writing – original draft; writing–review and editing.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors received no financial support for this work. The original clinical practice guidelines were funded by AO Spine and the Praxis Spinal Cord Institute.
