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建立共识的医疗管理children with moderate and severe acute spinal cord injury: a modified Delphi study

Travis S. CreveCoeur Departments ofNeurological Surgery and

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Nikita G. Alexiades Department of Neurological Surgery, University of Arizona–Phoenix, Arizona;

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Christopher M. Bonfield Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee;

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Douglas L. Brockmeyer Department of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

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Samuel R. Browd Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Seattle, Washington;

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Jason Chu Department of Neurosurgery, Children’s Hospital of Los Angeles, California;

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Anthony A. Figaji Department of Neurosurgery, University of Cape Town, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa;

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Mari L. Groves Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;

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Todd C. Hankinson Department of Pediatric Neurosurgery, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado;

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David H. Harter Department of Neurosurgery, New York University, New York, New York;

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Steven W. Hwang Shriners Hospital for Children, Philadelphia, Pennsylvania;

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Andrew Jea Department of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma;

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Steven G. Kernie Department of Pediatrics, Columbia University, New York, New York;

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Jeffrey R. Leonard Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio;

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Jonathan E. Martin Department of Pediatric Neurosurgery, Connecticut Children’s Hospital, Hartford, Connecticut;

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Matthew E. Oetgen Department of Orthopedic Surgery, Children’s National Hospital, Washington, DC;

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Alexander K. Powers Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina;

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Curtis J. Rozzelle Department of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama;

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David L. Skaggs Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California; and

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Jennifer M. Strahle Department of Neurosurgery, Washington University in St. Louis, Missouri

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John C. Wellons III Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee;

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Michael G. Vitale Orthopedic Surgery, Columbia University Medical Center, New York, New York;

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Richard C. E. Anderson Department of Neurosurgery, New York University, New York, New York;

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Publication Date:
17 Mar 2023
Page Range:
744–757
Volume/Issue:
Volume 38: Issue 6
DOI link:
https://doi.org/10.3171/2023.1.SPINE221188
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OBJECTIVE

The focus of this modified Delphi study was to investigate and build consensus regarding the medical management of children with moderate and severe acute spinal cord injury (SCI) during their initial inpatient hospitalization. This impetus for the study was based on the AANS/CNS guidelines for pediatric SCI published in 2013, which indicated that there was no consensus provided in the literature describing the medical management of pediatric patients with SCIs.

开云体育世界杯赔率

An international, multidisciplinary group of 19 physicians, including pediatric neurosurgeons, orthopedic surgeons, and intensivists, were asked to participate. The authors chose to include both complete and incomplete injuries with traumatic as well as iatrogenic etiologies (e.g., spinal deformity surgery, spinal traction, intradural spinal surgery, etc.) due to the overall low incidence of pediatric SCI, potentially similar pathophysiology, and scarce literature exploring whether different etiologies of SCI should be managed differently. An initial survey of current practices was administered, and based on the responses, a follow-up survey of potential consensus statements was distributed. Consensus was defined as ≥ 80% of participants reaching agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A final meeting was held virtually to generate final consensus statements.

RESULTS

Delphi的最后一轮后,35语句再保险ached consensus after modification and consolidation of previous statements. Statements were categorized into the following eight sections: inpatient care unit, spinal immobilization, pharmacological management, cardiopulmonary management, venous thromboembolism prophylaxis, genitourinary management, gastrointestinal/nutritional management, and pressure ulcer prophylaxis. All participants stated that they would be willing or somewhat willing to change their practices based on consensus guidelines.

CONCLUSIONS

General management strategies were similar for both iatrogenic (e.g., spinal deformity, traction, etc.) and traumatic SCIs. Steroids were recommended only for injury after intradural surgery, not after acute traumatic or iatrogenic extradural surgery. Consensus was reached that mean arterial pressure ranges are preferred for blood pressure targets following SCI, with goals between 80 and 90 mm Hg for children at least 6 years of age. Further multicenter study of steroid use following acute neuromonitoring changes was recommended.

ABBREVIATIONS

BP = blood pressure ; CPP = cerebral perfusion pressure ; DVT = deep venous thrombosis ; GM-1 = GM-1 ganglioside ; ICP = intracranial pressure ; IONM = intraoperative neuromonitoring ; MAP = mean arterial pressure ; MP = methylprednisolone ; SBP = systolic BP ; SCI = spinal cord injury ; TBI = traumatic brain injury ; TLSO = thoracic-lumbar-sacral orthosis ; VTE = venous thromboembolism .
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Cover Journal of Neurosurgery: Spine

Volume 38: Issue 6 (Jun 2023)

inJournal of Neurosurgery: Spine

临近椎板切除术和fusio的辩论n for grade 1 lumbar spondylolisthesis, the authors leveraged simulation to show how differences between the fusion groups of landmark randomized control trials (RCTs) led to seemingly divergent conclusions, and they offer insights into the design of future RCTs. Lami = laminectomy alone; SLIP = Spinal Laminectomy versus Instrumented Pedicle Screw. See the article in this issue by Meade et al. (pp 696–704). Reprinted with permission, Cleveland Clinic Foundation ©2023. All rights reserved.

Volume 38: Issue 6

Contributor Notes

CorrespondenceTravis S. CreveCoeur: Columbia University Medical Center, New York, NY.tc2682@cumc.columbia.edu.

INCLUDE WHEN CITINGPublished online March 17, 2023; DOI: 10.3171/2023.1.SPINE221188.

T.S.C. and N.G.A. contributed equally to this work.

DisclosuresDr. Hwang reported personal fees from Auctus, DePuy Synthes Spine, NuVasive, and ZimVie outside the submitted work. Dr. Skaggs reported grants from NuVasive; being a co–principal investigator on a research grant paid to the Pediatric Spine Foundation; consulting for and receiving royalties from Globus Medical; consulting for Top Doctors; consulting for, owning stocks in, and being a co-editor in chief forOrthobullets; receiving stock options from Green Sun Medical and Zipline Medical Inc.; receiving stocks options and royalties from Wolters Kluwer Health outside the submitted work; having a patent with royalties paid for Medtronic and Zimmer Biomet; and being on the editorial boards ofSpine Deformity, Orthopedics Today, andJournal of Children’s Orthopedics.
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