Guidelines for the management of acute cervical spine and spinal cord injuries neurosurgery supplement march 2013

FOREWORD
TOPIC FOREWORD

O
Daniel K. Resnick, MD n behalf of the AANS/CNS Joint Guide- reserve? Is the evidence for benefit really strong
lines Committee, I am pleased to intro- enough to warrant the risk in an individual
University of Wisconsin School of Med-
icine and Public Health, Department of
duce the updated Guidelines for the patient? What about routine imaging for vertebral
Neurosurgery, Madison, Wisconsin Management of Acute Cervical Spine and Spinal artery injuries—how many asymptomatic patients
Cord Injury. This work describes the “state of the need to be exposed to radiation and potentially
Correspondence: literature” with regard to the treatment of patients anticoagulated for radiographic findings that may
Daniel K. Resnick, MD,
University of Wisconsin School of
with cervical spine and spinal cord injuries and is or may not have clinical importance? These
Medicine and Public Health, a useful guide to help clinicians make important decisions cannot be made by a writing panel,
Department of Neurosurgery, decisions in the care of these patients. As with all no matter how expert—they require “boots on the
600 Highland Avenue, evidence-based guidelines, recommendations made ground” judgment, often made with incomplete
Madison, WI 53792.
E-mail: resnick@neurosurg.wisc.edu
cannot exceed the strength of the literature, and information. Guidelines provide the best evi-
where there is a lack of evidence or disagreement in dence, but only the evidence that exists.
the literature, strong recommendations cannot be Additionally, application of guidelines needs to
Copyright ª 2013 by the made. These recommendations represent a foun- be mitigated by patient desires when such desires
Congress of Neurological Surgeons dation for one leg of the “three-legged stool” of can be assessed. A decision regarding collar vs halo
evidence-based practice. Having a well-described vs surgical immobilization of odontoid fractures
and vetted summary of the available medical may be substantially guided by patient-related
evidence helps to structure decisions also depen- factors and preferences—the same radiographic
dent upon clinical judgment and patient desires. fracture may be treated differently depending on
In some cases, the guidelines can provide firm patient age, community, and preference.
and easily applicable guidance—the (non)use of This update of the Guidelines for the Management
steroids is an example of such a recommendation of Acute Cervical Spine and Spinal Cord Injury is an
in this volume. The authors present a compelling impressive accomplishment. The evolution of skill
case from high-quality clinical studies demon- in evidence-based review in neurosurgery is evident
strating a greater propensity for such medication throughout the document, as every process has
to harm rather than benefit patients with spinal been improved over the last decade. The authors
cord injuries. In most cases, however, the use of have not only updated the guidelines based on new
guidelines requires further reflection. Application literature, but they have improved the applicability
of clinical judgment to the use of guidelines begins of the guidelines to clinical practice through better
with the determination of whether a guideline question formulation, illustrated graphically the
applies to your patient. For example, fracture evolution of evidence to allow readers to appreciate
patterns at the craniocervical junction may be what has been learned over the past decade, and
complex, may be influenced by congenital abnor- incorporated a more sophisticated discussion of the
malities, and may not fit into the neat boxes literature to explain areas of continued uncertainty.
selected by the authors for classification. Similarly, The reader is encouraged to critically read the
application of clinical practice guidelines needs to supporting evidence for the recommendations in
be balanced against the cost of the application—is order to appreciate the context of the recommen-
aggressive blood pressure augmentation appropri- dations as well as the limitations. The authors are
ate for an elderly patient with limited cardiac congratulated on an outstanding piece of work.

NEUROSURGERY VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT | 1

Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.

COMMENTARY
TOPIC COMMENTARY

T
Copyright ª 2013 by the hese revised guidelines are an outstanding designated specialty care centers (ie, “we can
Congress of Neurological Surgeons achievement, and neurosurgeons should be do it better so you should send all your cases
proud of these authors who have taken the to us”).
time and effort to create this work. Overall, the Finally, the summary Table in the introduc-
methodology is sound and the results are solid. I tion is incomplete. It lists many of the recom-
congratulate the authors for not being tempted to mendations listed in this volume but does not list
comment on popular but yet inadequately stud- all of them. A complete and comprehensive
ied topics such as hypothermic treatment of acute tabulation of all the recommendations would be
spinal cord injury just because this topic appears very helpful.
in the newspapers. Jeffrey W. Cozzens
Some of the recommendations in this volume Springfield, Illinois
are repeated in different chapters. For example,
the first two recommendations in the paper on In this newest edition of the Guidelines for the
the management of acute traumatic central cord Management of Acute Cervical Spine and Spinal
syndrome (ATCCS) are also found in the paper Cord Injury, the author group has updated the
dealing with cardio-pulmonary management of 2002 guidelines in a number of ways, incor-
spinal cord injury. porating the newest available studies as well as
The paper on transportation of patients with scrutinizing existing studies. The review process
acute traumatic cervical spine injuries raises some for this edition has included additional review
interesting policy questions for providers. In this by the AANS/CNS Joint Guidelines Commit-
paper, the second recommendation is that, tee, and this has prompted several refinements
whenever possible, patients with acute cervical of the recommendations that have resulted in
spine or spinal cord injuries be transported to a work that is very tightly tied to the available
specialized acute spinal cord injury treatment evidence in the literature. Features such as
centers. But what makes an institution a “specialized a summary of changes between the two sets of
acute spinal cord injury treatment center”? Are guidelines, and evidence tables that are easy to
these centers designated by a governmental agency/ cross-reference with text and recommendations
regulatory body, or are they self-designated? If the make this edition more accessible than ever
answer is that an acute spinal cord injury center is before.
any institution that can provide acute critical care As a community neurosurgeon, it can some-
and surgical care, then isn’t it the care itself that is times be difficult to glean practical rules from
important and not the designation of the many of the EBM practice guidelines currently
institution? available; I believe this set will be an aid not only to
What about care of the acute spinal cord injury academicians and those with backgrounds in
patient that is provided within all the recommen- epidemiology and evidence-based medicine, but
dations for critical care and surgical care published also to the vast majority of neurosurgeons who are
in these guidelines but provided in an institution extremely skilled in patient care and who look to
that does not choose to call itself an “acute spinal these types of published practice guidelines for
cord injury treatment center”? Is the care changes in current thinking about what is—and is
inadequate because of the lack of designation or not—supported in the neurosurgical literature.
recognition? This is not a trivial issue from The more accessible and transparent these guide-
a medical-legal standpoint. lines efforts are, the more readily they will be
There is a concern shared by a number of embraced both by our colleagues in neurosurgery
healthcare providers that a recommendation and well as in other disciplines, including
like the second recommendation in this par- emergency medicine and trauma surgery; the
ticular paper is the result of a conflict of interest use of the same sets of guidelines by multiple
from large medical centers that are often self- specialties will surely foster better communication

2 | VOLUME 72 | NUMBER 3 | MARCH 2013 SUPPLEMENT www.neurosurgery-online.com


COMMENTARY

and collaboration in the care of many patients. The author group investigated topics. Although this table is handy and informative,
should be congratulated on another excellent effort. the reader should not use this as a substitute for reading the
individual chapters in detail, as the material provided allows for
J. Adair Prall
a better understanding of the genesis of the recommendations.
Littleton, Colorado
All of the topics are thoroughly investigated and presented, yet I
In recent years, there has been a growing national interest in must make special mention of the chapter entitled “Pharmaco-
enhancing the quality of patient care. One of the commonly used logical Therapy for Acute Spinal Cord Injury.” The use of
methods is standardization, which has been associated with steroids in acute SCI is a very controversial subject, with
increased quality of care in various health care settings. In the practitioners falling on either side of the treatment line. To
setting of spinal trauma, rigid standardization is frequently many, the literature has previously lacked clarity on this subject.
impractical and difficult, as there are often subtle differences One of the few criticisms of the 2002 guidelines is that the role of
between patient characteristics, injury patterns, and other clinical methylprednisolone was not clearly defined: “Treatment with
considerations that may result in two similarly presenting methylprednisolone for either 24 or 48 hours is recommended as
patients receiving different, yet appropriate treatment. Another an option in the treatment of patients with acute spinal cord
method to enhance quality is to provide practitioners with injuries...” The present day usage of methylprednisolone is fueled
factual, evidenced-based information that may validate estab- by both a desire to do everything humanly possible for these
lished consensus opinion, or, in some cases, may even shift tragically injured patients, as well as medicolegal concerns, which
treatment paradigms. The 2012 Guidelines for the Management can be quite significant in some communities. The 2012
of Acute Cervical Spine and Spinal Cord Injury is likely to guidelines clearly state that methylprednisolone is not recom-
improve the quality of patient care through both mechanisms. mended in the management of acute SCI, and that there is no
Students of the 2002 Guidelines for the Management of Acute Class I or II evidence to support its use. In stark contrast, there is
Cervical Spine and Spinal Cord Injury will be very pleased with the Class I–III evidence that this treatment is associated with harmful
current offering. The present rendition provides a balanced, side effects. This powerful and well-written chapter will provide
evidenced-based assessment of the available literature regarding an immediate and beneficial impact on patient care.
a broad swath of management strategies ranging from underap- The authors should be congratulated for their excellent work.
preciated topics such as the transportation of acute SCI patients, This was an arduous and challenging task that was completed in an
to more provocative subjects such as the use of steroids in acute elegant and outstanding fashion.
spinal injury. The authors provide an easy to use table that Langston Holly
contrasts the 2002 and 2012 recommendations for each of the Los Angeles, California



GUIDELINES COMMITTEE
TOPIC Guidelines Committee



INTRODUCTION
TOPIC INTRODUCTION

Introduction to the Guidelines for the Management
of Acute Cervical Spine and Spinal Cord Injuries

M
edical evidence-based guidelines, when patients with acute cervical spine and/or spinal
Mark N. Hadley, MD*
properly produced, represent a contem- cord injuries. The medical evidence summa-
Beverly C. Walters, MD, MSc, porary scientific summary of accepted rized within each guideline has been painstak-
FRCSC‡ management, imaging, assessment, classification, ingly analyzed and ranked according to rigorous
*Co-Lead Author, Guidelines Author
and treatment strategies on a focused series of evidence-based medicine criteria, and have been
Group; Charles A. & Patsy W. Collat medical and surgical issues.1-3 They are an linked to 112 evidence-based recommendations
Professor of Neurosurgery and Program evidence-based hierarchal ranking of the scien- for these topics.1-3
Director, University of Alabama Neurosur-
tific literature produced to date. They record and There are many important differences in this
gical Residency Training Program, Division
of Neurological Surgery, University of rank the collective experiences of scientists and iteration of these Guidelines compared to those
Alabama at Birmingham, Birmingham, clinicians and are a comprehensive reference we published 10 years ago. Regrettably, how-
Alabama; ‡Co-Lead Author, Guidelines source on a given topic or group of topics. ever, for some of the topics considered and
Author Group; Professor of Neurologi-
cal Surgery and Director of Clinical Research, Medical evidence-based guidelines are not included in this medical evidence-based com-
University of Alabama at Birmingham, meant to be restrictive or to limit a clinician’s pendium, little new evidence beyond Class III
Birmingham, Alabama; Professor of Neuro- practice. They chronicle multiple successful medical evidence has been offered in the last 10
sciences, Virginia Commonwealth Univer-
sity - Inova Campus and Director of Clinical
treatment options (for example) and stratify years by investigators and surgeons who treat
Research, Department of Neurosciences, the more successful and the less successful patients with these disorders. Our specialties and
Inova Health System, Falls Church, Virgin- strategies based on scientific merit. They are our patients desperately need comparative Class
ia; Affiliate Professor of Molecular Neuro- I and Class II medical evidence derived from
sciences, George Mason University, Fairfax,
not absolute, “must be followed” rules. This
Virginia process may identify the most valid and reliable properly designed analytical clinical studies to
imaging strategy for a given injury, for example, further our understanding on the best ways to
but because of regional or institutional resources, assess, diagnose, image and treat patients with
Copyright ª 2013 by the or patient co-morbidity, that particular imaging these acute traumatic injuries.
Congress of Neurological Surgeons
strategy may not be possible for a patient with Good progress has been made in several
that injury. Alternative acceptable imaging clinical research areas since the original Guide-
options may be more practical or applicable in lines publication in 2002. One hundred twelve
this hypothetical circumstance. evidence-based recommendations are offered
Guidelines documents are not tools to be used in this contemporary review, compared to
by external agencies to measure or control the only 76 recommendations in 2002. There are
care provided by clinicians. They are not 19 Level I recommendations in the current
medical-legal instruments or a “set of certain- Guidelines; each supported by Class I medical
ties” that must be followed in the assessment or evidence.
treatment of the individual pathology in the • Assessment of Functional Outcomes (1)
individual patients we treat. While a powerful • Assessment of Pain After Spinal Cord
and comprehensive resource tool, guidelines Injuries (1)
and the recommendations contained therein do • Radiographic Assessment (7)
not necessarily represent “the answer” for the • Pharmacology (2)
medical and surgical dilemmas we face with our • Diagnosis of AOD (1)
many patients. • Cervical Subaxial Injury Classification
This second iteration of Guidelines for the Schemes (2)
Management of Acute Cervical Spine and Spinal • Pediatric Spinal Injuries (1)
Cord Injuries represents 15 months of diligent • Vertebral Artery Injuries (1)
volunteer effort by the Joint Section on Disorders • Venous Thromboembolism (3)
of the Spine and Peripheral Nerves author There are an additional 16 Level II recom-
group to provide an up-to-date review of the mendations based on Class II medical evidence
medical literature on 22 topics germane to the and 77 Level III recommendations based on Class
care, assessment, imaging and treatment of III medical evidence.



HADLEY AND WALTERS

TABLE. Comparison of Cervical Spine and Spinal Cord Injury Guidelines Recommendations Between 2 Iterations Where Differences in
Recommendations Have Occurred. All Other Recommendations Remain as Previously Stated
Previous Current
Level of Level of
Topic Recommendation Recommendation 2002 Recommendation Recommendation 2012
Immobilization Option • All trauma patients with a cervical Level II • Spinal immobilization of all trauma
spinal column injury or with patients with a cervical spine or spinal
a mechanism of injury having the cord injury or with a mechanism of
potential to cause cervical spine injury having the potential to cause
injury should be immobilized at the cervical spinal injury is recommended.
scene and during transport by
using 1 of several available
methods.
• Triage of patients with potential spinal
injury at the scene by trained and
experienced EMS personnel to
determine the need for immobilization
during transport is recommended.
• A combination of a rigid cervical • Immobilization of trauma patients who
collar and supportive blocks on are awake, alert, and are not
a backboard with straps is effective intoxicated, who are without neck pain
in limiting motion of the cervical or tenderness, who do not have an
spine and is recommended. abnormal motor or sensory
examination and who do not have any
significant associated injury that might
detract from their general evaluation is
not recommended.
None Not addressed Level III • Spinal immobilization in patients with
penetrating trauma is not
recommended due to increased
mortality from delayed resuscitation.
Transportation None Not addressed Level III • Whenever possible, the transport of
patients with acute cervical spine or
spinal cord injuries to specialized acute
spinal cord injury treatment centers is
recommended.
Clinical Assessment: Option • The ASIA international standards Level II • New Class II medical evidence.
Neurological status are recommended as the preferred
neurological examination tool.
Clinical Assessment: Guideline • The Functional Independence Level I • The Spinal Cord Independence
Functional status Measure is recommended as the Measure (SCIM III) is recommended as
functional outcome assessment the preferred Functional Outcome
tool for clinicians involved in the Assessment tool for clinicians involved
assessment and care of patients in the assessment, care, and follow-up
with acute spinal cord injuries. of patients with spinal cord injuries.
Option • The modified Barthel index is N.A. (Not included N.A. (Not included in
recommended as a functional in current current iteration)
outcome assessment tool for iteration)
clinicians involved in the
assessment and care of patients
with acute spinal cord injuries.
Clinical Assessment: None Not addressed Level I • The International Spinal Cord Injury
Pain Basic Pain Data Set (ISCIBPDS) is
recommended as the preferred means
to assess pain including pain severity,
physical functioning and emotional
functioning among SCI patients.

(Continues)



INTRODUCTION

TABLE. Continued
Previous Current
Level of Level of
Radiographic Standard • Radiographic assessment of the Level I • In the awake, asymptomatic patient
Assessment: cervical spine is not recommended who is without neck pain or
Asymptomatic in trauma patients who are awake, tenderness, who has a normal
Patient alert, and not intoxicated, who are neurological examination, is without
without neck pain or tenderness, an injury detracting from an accurate
and who do not have significant evaluation, and who is able to
associated injuries that detract complete a functional range of motion
from their general evaluation. examination; radiographic evaluation
of the cervical spine is not
recommended.
• Discontinuance of cervical
immobilization for these patients is
recommended without cervical spinal
imaging.
Option • It is recommended that cervical Level III • In the awake patient with neck pain or
spine immobilization in awake tenderness and normal high-quality CT
patients with neck pain or imaging or normal 3-view cervical
tenderness and normal cervical spine series (with supplemental CT if
spine x-rays (including indicated), the following
supplemental CT as necessary) be recommendations should be
discontinued after wither a) normal considered:
and adequate dynamic flexion/
extension radiographs, or b)
a normal magnetic resonance
imaging study is obtained within
48 hours of injury.
1) Continue cervical immobilization until
asymptomatic,
2) Discontinue cervical immobilization
following normal and adequate dynamic
flexion/extension radiographs,
following a normal MRI obtained within
48 hours of injury (limited and
conflicting Class II and Class III medical
evidence), or,
• Cervical spine immobilization in 4) Discontinue cervical immobilization at
obtunded patients with normal the discretion of the treating physician.
cervical spine x-rays (including
supplemental CT as necessary) may
be discontinued a after dynamic
flexion/extension studies
performed under fluoroscopic
guidance, or b) after a normal
magnetic resonance imaging study
is obtained within 48 hours of
injury, or c at the discretion of the
treating physician.

(Continues)



HADLEY AND WALTERS

TABLE. Continued
Previous Current
Level of Level of

Radiographic Standard • A 3-view cervical spine series Level I • In the awake, symptomatic patient,
Assessment: (anteroposterior, lateral, and high-quality computed tomographic
Symptomatic odontoid views) is recommended (CT) imaging of the cervical spine is
Patient for radiographic evaluation of the recommended.
cervical spine in patients who are
symptomatic after traumatic injury.
This should be supplemented with
computed tomography (CT) to
further define areas that are
suspicious or not well visualized on
the plain cervical x-rays.
• If high-quality CT imaging is available,
routine 3-view cervical spine
radiographs are not recommended.
• If high-quality CT imaging is not
available, a 3 view cervical spine series
(AP, lateral, and odontoid views) is
recommended. This should be
supplemented with CT (when it
becomes available) if necessary to
further define areas that are suspicious
or not well visualized on the plain
cervical x-rays.
Option • It is recommended that cervical Level III • In the awake patient with neck pain or
spine immobilization in awake tenderness and normal high-quality CT
patients with neck pain or imaging or normal 3-view cervical
tenderness and normal cervical spine series (with supplemental CT if
spine x-rays (including indicated), the following
supplemental CT as necessary) be recommendations should be
discontinued after either a) normal considered:
and adequate dynamic flexion/
extension radiographs, or b)
a normal magnetic resonance
imaging study is obtained within
48 hours of injury.
1) Continue cervical immobilization until
asymptomatic,
following normal and adequate dynamic
flexion/extension radiographs,
following a normal MRI obtained within
48 hours of injury (limited and
conflicting Class II and Class III medical
evidence), or,
4) Discontinue cervical immobilization at
the discretion of the treating physician.

(Continues)



INTRODUCTION

TABLE. Continued
Previous Current
Level of Level of

Radiographic Option • Cervical spine immobilization in Level I • In the obtunded or un-evaluable
evaluation in obtunded patients with normal patient, high-quality CT imaging is
obtunded (or cervical spine x-rays (including recommended as the initial imaging
unevaluable) supplemental CT as necessary) may modality of choice. If CT imaging is
patients be discontinued a) after dynamic available, routine 3-view cervical spine
flexion/extension studies radiographs are not recommended.
performed under fluoroscopic
guidance, or b) after a normal
magnetic resonance imaging study
is obtained within 48 hours of
injury, or c) at the discretion of the
treating physician.
• If high-quality CT imaging is not
available, a 3 view cervical spine series
(AP, lateral, and odontoid views) is
recommended. This should be
supplemented with CT (when it
becomes available) if necessary to
further define areas that are suspicious
or not well visualized on the plain
cervical x-rays.
Closed Reduction Option • Early closed reduction is Level III No changes in recommendations
recommended.
Cardiopulmonary Option • Management of patients with acute Level III No changes in recommendations
Management SCI in a monitored setting is
recommended.
• Maintain mean arterial BP 85 to 90
mm Hg after SCI is recommended.
Pharmacology Option • Treatment with Level I • Administration of methylprednisolone
Management: methylprednisolone for either 24 (MP) for the treatment of acute SCI is
Corticosteroids or 48 hours is recommended as an not recommended. Clinicians
option in the treatment of patients considering MP therapy should bear in
with acute spinal cord injuries that mind that the drug is not FDA
should be undertaken only with approved for this application. There is
the knowledge that the evidence no Class I or Class II medical evidence
suggesting harmful side effects is supporting the clinical benefit of MP in
more consistent than any the treatment of acute SCI. Scattered
suggestion of clinical benefit. reports of Class III evidence claim
inconsistent effects likely related to
random chance or selection bias.
However, Class I, II, and III evidence
exists that high-dose steroids are
associated with harmful side effects
including death.
Pharmacology Option • Treatment of patients with acute Level I • Administration of GM-1 ganglioside
Management: GM-1 spinal cord injuries with GM-1 (Sygen) for the treatment of acute SCI
Ganglioside ganglioside is recommended as an is not recommended.
option without demonstrated
clinical benefit.
Occipital Condylar Guidelines (CT) • CT recommended to diagnose OCF. Level II (CT) No changes in recommendation
Fractures:
Diagnostic
Option (MRI) • MRI recommended to assess Level III (MRI)
ligaments.

(Continues)



HADLEY AND WALTERS

TABLE. Continued
Previous Current
Level of Level of
Occipital Condylar Option • Treatment with external cervical Level III • External cervical immobilization is
Fractures: Treatment immobilization is recommended. recommended for all types of occipital
condyle fractures.
• More rigid external immobilization in
a halo vest device should be
considered for bilateral OCF.
• Halo vest immobilization or
occipitocervical stabilization and
fusion are recommended for injuries
with associated AO ligamentous injury
or evidence of instability.
AOD: Diagnostic None Not addressed Level I • CT imaging to determine the CCI in
pediatric patients with potential AOD
is recommended.
Option • If there is clinical suspicion of Level III • If there is clinical or radiographic
atlanto-occipital dislocation, and suspicion of AOD, and plain
plain x-rays are non-diagnostic, radiographs are non-diagnostic, CT of
computed tomography or the craniocervical junction is
magnetic resonance imaging is recommended. The Condyle-C1
recommended, particularly for the interval (CC1) determined on CT has
diagnosis of non-Type II the highest diagnostic sensitivity and
dislocations. specificity for AOD among all
radiodiagnostic indicators.
AOD: Treatment Option • Traction may be used in the Level III • Traction is not recommended in the
management of patients with management of patients with AOD,
atlanto-occipital dislocation, but it and is associated with a 10% risk of
is associated with a 10% risk of neurological deterioration.
neurological deterioration.
Atlas Fractures Option • Treatment based on specific Level III No changes in recommendations
fracture type and integrity of
transverse ligament.
Odontoid Fracture Guideline • Treatment of Type II odontoid Level II No change in recommendations
fractures based on 50 years of age.
Axis Fractures: None Not addressed Level III If surgical stabilization is elected, either
Odontoid anterior or posterior techniques are
recommended.
Axis Fractures: Option • External immobilization is Level III No changes in recommendations
Hangman’s recommended.
• Surgery is recommended for
angulation, instability.
Axis Fractures: Option • External immobilization is Level III • External immobilization for the
Miscellaneous Body recommended for treatment of treatment of isolated fractures of the
isolated fractures of the axis body. axis body is recommended.
Consideration of surgical stabilization
and fusion in unusual situations of
severe ligamentous disruption and/or
inability to achieve or maintain fracture
alignment with external
immobilization is recommended.
• In the presence of comminuted
fracture of the axis body, evaluation for
vertebral artery injury is
recommended.

(Continues)



INTRODUCTION

TABLE. Continued
Previous Current
Level of Level of

Atlas/Axis Option • Treatment based on characteristics Level III No changes in recommendations
Combination of axis fracture.
Fractures
Os Odontoideum: Option • Plain radiographs with flex/ext 6 Level III No changes in recommendations
Diagnostic CT or MRI is recommended.
Os Odontoideum: Option • Occipital-cervical fusion with or Level III • Occipital-cervical internal fixation and
Management without C1 laminectomy may be fusion with or without C1 laminectomy
considered in patients with os is recommended in patients with os
odontoideum who have irreducible odontoideum who have irreducible
dorsal cervicomedullary dorsal cervicomedullary compression
compression and/or evidence of and/or evidence of associated
associated occipital-atlantal occipital-atlantal instability.
instability. Transoral
decompression may be considered
in patients with os odontoideum
who have irreducible ventral
cervicomedullary compression.
• Ventral decompression should be
considered in patients with os
odontoideum who have irreducible
ventral cervicomedullary compression.
Classification of None Not addressed Level I SLIC and CSISS
Subaxial Injuries
Level III Harris and Allen
Subaxial Cervical None Not addressed Level III • The routine use of CT and MR imaging
Spinal Injuries of trauma victims with ankylosing
spondylitis is recommended, even after
minor trauma.
• For patients with ankylosing
spondylitis who require surgical
stabilization, posterior long segment
instrumentation and fusion, or
a combined dorsal and anterior
procedure is recommended. Anterior
stand-alone instrumentation and
fusion procedures are associated with
a failure rate of up to 50% in these
patients.
Central Cord Option • Aggressive multimodality Level III No changes in recommendations
Syndrome management of patients with
ATCCS is recommended.
Pediatric Injuries: None Not addressed Level I • CT imaging to determine the condyle-
Diagnostic C1 interval for pediatric patients with
potential AOD is recommended.
Guideline • In children who have experienced Level II • Cervical spine imaging is not
trauma and are alert, conversant, recommended in children who are
have no neurological deficit, no greater than 3 years of age and who
midline cervical tenderness, and no have experienced trauma and who:
painful distracting injury, and are
not intoxicated, cervical spine x-
rays are not necessary to exclude
cervical spine injury and are not
recommended.

(Continues)



HADLEY AND WALTERS

TABLE. Continued
Previous Current
Level of Level of
• In children who have experienced
trauma and who are either not
alert, non-conversant, or have
neurological deficit, midline
cervical tenderness, or painful
distracting injury, or are
intoxicated, it is recommended that
anteroposterior and lateral cervical
spine x-rays be obtained.
1) are alert,
2) have no neurological deficit,
3) have no midline cervical tenderness,
4) have no painful distracting injury,
5) do not have unexplained hypotension,
6) and are not intoxicated.
• Cervical spine imaging is not
recommended in children who are less
than 3 years of age who have
experienced trauma and who:
1) have a GCS.13,
2) have no neurological deficit,
3) have no midline cervical tenderness,
4) have no painful distracting injury,
5) are not intoxicated,
6) do not have unexplained hypotension,
7) and do not have motor vehicle collision
(MVC),
8) a fall from a height greater than 10 feet,
9) or non-accidental trauma (NAT) as
a known or suspected mechanism of
injury.
• Cervical spine radiographs or high
resolution computed tomography (CT)
is recommended for children who have
experienced trauma and who do not
meet either set of criteria above.
• Three-position CT with C1-C2 motion
analysis to confirm and classify the
diagnosis is recommended for children
suspected of having atlanto-axial
rotatory fixation (AARF).
Options • In children younger than age 9 Level III • AP and lateral cervical spine
years who have experienced radiography or high-resolution CT is
trauma, and who are non- recommended to assess the cervical
conversant or haven an altered spine in children less than 9 years of
mental status, a neurological age.
deficit, neck pain, or painful
distracting injury, are intoxicated,
or have unexplained hypotension,
it is recommended that
anteroposterior and lateral cervical
spine x-rays be obtained.

(Continues)



INTRODUCTION

TABLE. Continued
Previous Current
Level of Level of
• In children age 9 years or older who • AP, lateral, and open-mouth cervical
have experienced trauma, and who spine radiography or high-resolution
are non-conversant or have an CT is recommended to assess the
altered mental status, cervical spine in children 9 years of age
a neurological deficit, neck pain, or and older.
painful distracting injury, are
intoxicated, or have unexplained
hypotension, it is recommended
that anteroposterior, lateral, and
open-mouth cervical spine x-rays
be obtained.
• Computed tomographic scanning • High resolution CT scan with attention
with attention to the suspected to the suspected level of neurological
level of neurological injury to injury is recommended to exclude
exclude occult fractures or to occult fractures or to evaluate regions
evaluate regions not seen not adequately visualized on plain
adequately on plain x-rays is radiographs.
recommended.
• Flexion/extension cervical x-rays or • Flexion and extension cervical
fluoroscopy may be considered to radiographs or fluoroscopy are
exclude gross ligamentous recommended to exclude gross
instability when there remains ligamentous instability when there
a suspicion of cervical spine remains a suspicion of cervical spinal
instability after static x-rays are instability following static radiographs
obtained. or CT scan.
Magnetic resonance imaging of the • Magnetic resonance imaging (MRI) of
cervical spine may be considered to the cervical spine is recommended to
exclude cord or nerve root exclude spinal cord or nerve root
compression, evaluate ligamentous compression, evaluate ligamentous
integrity, or provide information integrity, or provide information
regarding neurological prognosis. regarding neurological prognosis.
Pediatric Injuries: None Not addressed Level III • Reduction with manipulation or halter
Treatment traction is recommended for patients
with acute AARF (less than 4 weeks
duration) that does not reduce
spontaneously. Reduction with halter
or tong/halo traction is recommended
for patients with chronic AARF (greater
than 4 weeks duration).
• Internal fixation and fusion are
recommended in patients with
recurrent and/or irreducible AARF.
• Operative therapy is recommended for
cervical spine injuries that fail non-
operative management.
SCIWORA: Diagnosis Option • Plain spinal x-rays of the region of Level III • Magnetic resonance imaging (MRI) of
injury and computed tomographic the region of suspected neurological
scanning with attention to the injury is recommended in a patient
suspected level of neurological with SCIWORA.
injury to exclude occult fractures
are recommended.

(Continues)



HADLEY AND WALTERS

TABLE. Continued
Previous Current
Level of Level of
• Magnetic resonance imaging of the • Radiographic screening of the entire
region of suspected neurological spinal column is recommended.
injury may provide useful
diagnostic information
• Plain X-rays of the entire spinal • Assessment of spinal stability in
column may be considered. a SCIWORA patient is recommended,
using flexion-extension radiographs in
the acute setting and at late follow-up,
even in the presence of a MRI negative
for extra-neural injury.
SCIWORA: Treatment Option • External Immobilization is Level III • External immobilization of the spinal
recommended until spinal stability segment of injury is recommended for
is confirmed by flexion/extension up to 12 weeks.
x-rays.
External immobilization of the spinal • Early discontinuation of external
segment of injury for up to 12 weeks immobilization is recommended for
may be considered. patients who become asymptomatic
and in whom spinal stability is
confirmed with flexion and extension
radiographs.
• Avoidance of “high risk” activities • Avoidance of “high-risk” activities for
for up to 6 months after spinal cord up to 6 months following SCIWORA is
injury without radiographic recommended.
abnormality may be considered.
SCIWORA: Prognosis Option • Magnetic resonance imaging of the None Not addressed (see Diagnosis)
region of neurological injury may
provide useful prognostic
information about neurological
outcome after spinal cord injury
without radiographic abnormality.
Vertebral Artery Injury: Option • Conventional angiography or Level I • Computed tomographic angiography
Diagnostic magnetic resonance angiography (CTA) is recommended as a screening
is recommended for the diagnosis tool in selected patients after blunt
of vertebral artery injury after cervical trauma who meet the
nonpenetrating cervical trauma in modified Denver Screening Criteria for
patients who have complete suspected vertebral artery injury (VAI).
cervical spinal cord injuries,
fracture through the foramen
transversarium, facet dislocation,
and/or vertebral subluxation.
Level III • Conventional catheter angiography is
recommended for the diagnosis of VAI in
selected patients after blunt cervical
trauma, particularly if concurrent
endovascular therapy is a potential
consideration, and can be undertaken in
circumstances in which CTA is not
available.
• Magnetic resonance imaging is
recommended for the diagnosis of VAI
after blunt cervical trauma in patients
with a complete spinal cord injury or
vertebral subluxation injuries.

(Continues)



INTRODUCTION

TABLE. Continued
Previous Current
Level of Level of

Vertebral Artery Injury: Option • Anticoagulation with intravenous Level III • It is recommended that the choice of
Treatment heparin is recommended for therapy for patients with VAI,
patients with vertebral artery injury anticoagulation therapy vs antiplatelet
who have evidence of posterior therapy vs no treatment, be
circulation stroke. individualized based on the patient’s
vertebral artery injury, their associated
injuries and their risk of bleeding.
• Either observation or treatment • The role of endovascular therapy in VAI
with anticoagulation in patients has yet to be defined; therefore no
with vertebral artery injuries and recommendation regarding its use in
evidence of posterior circulation the treatment of VAI can be offered.
ischemia is recommended.
• Observation in patients with
vertebral artery injuries and no
evidence of posterior circulation
ischemia is recommended.
Venous None Not addressed Level II • Early administration of VTE prophylaxis
Thromboembolism: (within 72 hours) is recommended.
Prophylaxis
Option • Vena cava filters are recommended Level III • Vena cava filters are not recommended
for patients who do not respond to as a routine prophylactic measure, but
anticoagulation or who are not are recommended for select patients
candidates for anticoagulation who fail anticoagulation or who are not
therapy and/or mechanical devices. candidates for anticoagulation and/or
mechanical devices.
Nutritional Support Option • Nutritional support of patients with Level II • Indirect calorimetry as the best means
spinal cord injuries is to determine the caloric needs of
recommended. Energy expenditure spinal cord injury patients is
is best determined by indirect recommended.
calorimetry in these patients
because equation estimates of
energy expenditure and
subsequent caloric need tend to be
inaccurate.
Level III • Nutritional support of SCI patients is
recommended as soon as feasible. It
appears that early enteral nutrition
(initiated within 72 hours) is safe, but
has not been shown to affect
neurological outcome, the length of
stay or the incidence of complications
in patients with acute SCI.

The Table shows the differences in the recommendations changed, the recommendations previously made are compared to
between the 2 sets of guidelines. One key change is that in those being made currently. Where we have introduced new
nomenclature: “Standards” has been replaced by “Level I,” recommendations not included in the previous iteration of the
“Guidelines” has been replaced by “Level II,” and “Options” guidelines, a statement is found indicating what the recommen-
has been replaced by “Level III,” as described in detail in the dations are alongside “None” and “Not addressed,” which
Methodology section of these guidelines. Not every recommen- represents the lack of previous recommendations on a particular
dation is listed since some have not changed, and the statement aspect or topic. This summary table highlighting the changes in the
“No changes in recommendations” indicates that. When they have guidelines is not a substitute for reading and understanding this



Guidelines for the management of acute cervical spine and spinal cord injuries neurosurgery supplement march 2013

Guidelines for the management of acute cervical spine and spinal cord injuries neurosurgery supplement march 2013

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