BACKGROUND AND OBJECTIVE
Spinal cord injury (SCI) can produce a sudden and sometimes devastating impact on the quality of life due to severe motor, sensory and autonomic dysfunction; however, while a common pathological process underlies most traumatic SCIs, each case is unique [1]. That is why all phases are considered critical and relevant in the management of SCI and it is important to standardize procedures as much as possible. While the clinical evaluation and classification of SCI are actually well established and universally accepted with the: American Spinal Injury Association (ASIA) Impairment Scale, clinical management, indication for medical treatment and/or surgical intervention are less defined and subject to continuous evolution. It is necessary and crucial to establish a common language and guidelines [2].
Considering scientific knowledge is being generated more rapidly than we can assimilate it, we must continuously review gold-standards for diagnosis, best treatment options according to the severity of illness, as well as have feedback to understand whether these methods actually serve the purpose they were created for. The aim of this paper is to provide an update on the best assessment and treatment options for “early management of spinal cord injury,” in order to produce acceptable worldwide recommendations to standardize clinical practice as much as possible.
METHODS
An international committee of spinal surgeons (members of the World Federation of Neurosurgical Society [WFNS] Spine Committee) performed 2 Consensus Conferences on the Management of Traumatic Spinal Cord Injury. Part I was conducted in Moscow in June 2019 with 13 experienced spinal surgeons of the WFNS Spine Committee present. The aim of the meeting was to assess the statements through a preliminary review of the literature and the present levels of evidence to create one to 6 statements for the voting session. Part II was held in Peshawar in November 2019. The statements and the literature review were presented to 10 members of the WFNS Spine Committee.
Delphi method was used to administer the questionnaire to have a high degree of validity. To establish a consensus, the levels of agreement or disagreement on each item were voted independently in a blind way using a Likert-type scale from 1 to 5 (1=strongly disagree, 2=disagree, 3=somewhat agree, 4=agree, 5=strongly agree). Results were expressed as a percentage of respondents who scored each item as 1 or 2 (disagreement) or as 3, 4, or 5 (agreement). Consensus was achieved when the sum for disagreement or agreement was ≥ 66%. Each consensus point was clearly defined with evidence strength, recommendation grade, and consensus level provided [3-5].
The literature review included papers from the last 10 years and was conducted using the Cochrane Database of Systematic Reviews and MEDLINE/PubMed. From the identified articles, a secondary search of the listed citations was performed to ensure that all relevant publications had been included. All the reviewers then double-checked abstracts for duplicates and nonrelated papers (according to the topic, early evaluation, or human studies) to be excluded. They then proceeded to the fulltext reading of papers to meet inclusion criteria: level I through IV evidence, low to moderate bias, and low or high-quality patient-oriented evidence.
RESULTS
The panel was divided into 3 main topics: (1) clinical assessment and classification of SCI; (2) emergency care and early management; (3) cardiopulmonary management. A total of 10 statements were drafted and voted in the first session in Moscow in June 2019. One statement about emergency care was excluded from the final voting session in Peshawar.
1. Clinical Assessment and Classification of SCI
Research: publication date from 2009 up to 2019; English language; main word search in all-fields: “acute spinal cord injury” and “spinal cord injury”; and a combination of the following: all-fields: “clinical assessment,” “classification,” “guidelines”; with or without the following on title: “score,” “index,” “neurological status,” “ASIA score,” “Frankel score.” We obtained 1,201 papers after all search rounds. We excluded 1,020 papers (16 duplicates and 1,004 nonrelated) after abstract review by an independent double-check. Following a full-text review of the remaining 181 papers, we selected 32 papers that met the inclusion criteria to draw conclusions (Fig. 1). Classifications of SCI are intended to standardize clinical evaluation but can also lead to oversimplification precluding the ability to find an effect of an experimental therapeutic [6].
Five papers evaluated the use of biomarkers to assess neurological injury and prognosis. Only 1 nonrandomized clinical trial (nRCT) level III evidence offered no serious bias and level 1 type-A high-quality patient-oriented evidence; the remaining 7 papers were one nRCT, 3 prospective cohorts, and 1 retrospective cohort, with moderate bias and level 2 type B recommendation. The biomarkers have been extensively studied, and many biological compounds have been highlighted as potentially useful compounds to assess neurological injury at admission and help predict prognosis; nevertheless, the profile is white extensive, and no uniform criteria (or dataset) have been defined [6]. Based on these papers, we can conclude that the use of biomarkers on blood and cerebrospinal fluid (CSF) to predict neurological injury and severity remains on translational research since a specific array of biomarkers needs to be designed and tested before widespread clinical use [7-11].
Since the initial review on assessment tools for acute SCI was presented by Hadley et al. [12] in 2002, the ASIA Impairment Scale (AIS, short form for ASIA International Standards for Neurological Classification of Spinal Cord Injury [ISNCSCI]) has been designated as the recommended evaluation tool to evaluate and classify initial neurological impairment on admission and provide information on improvement at follow-up. The AIS comprises 5 grades of neurological injury: grade A, complete neurological injury (no motor or sensory function at S4, S5 segment); grade B, no motor function but preserved sensory function below the neurological injury with preservation including S3 and S4; grade C, incomplete neurological injury (with the preserved motor function below the neurological level with muscle strength below 3; grade D, Incomplete neurological injury (with the preserved motor function below the neurological level with muscle strength above 3; grade E, normal motor or sensory function; Its primary role is to classify neurological injury based on a practical manner on admission (Fig. 2) [13]. Three papers evaluated the use of this scale to assess neurological function at admission. Two of those papers have level I evidence, both systematic reviews following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement offer level 1 high-quality patient-oriented evidence, while the last paper of level III evidence with moderate bias provides level 2 low-quality evidence. We found no papers evaluating other scales. Based on these studies, we found that the AIS, described by the ASIA, is recommended as the preferred clinical evaluation tool to assess and classify neurological impairment at admission in patients with acute SCI. We also found that the Spinal Cord Independence Measure (SCIM III) may be preferred to assess the functional abilities and impairment in the follow-up of patients with chronic SCI. Finally, we found that the International Spinal Cord Injury Basic Pain Data Set (ISCIBPDS) may be the preferred scale to evaluate pain on early assessment to the follow-up on chronically injured patients [14-16]. The ASIA ISNCSCI provides the fundamental for the former classification; it details the neurological pattern of injury in a chart divided in motor and sensory evaluations. The motor score combines the upper extremity motor score and the lower extremity motor score assigning up to 25 points by extremity to a total of 100; The sensory score combines light touch score and pinprick scores to yield a total score out of 2,224 points by grading sensitivity as follows: 0=absent, 1=altered, and 2=normal. Eleven papers evaluated the use of ASIA ISNCSCI to assess the severity of neurological impairment on admission. One paper of level I evidence, unfortunately provides level 2 low-quality patient-oriented evidence, as not adhering to the PRISMA statement. Ten papers of level III evidence with moderate bias provide level 3 low-quality patient-oriented evidence. Based on these results, we found that there is insufficient new evidence to change (not in favor, nor against) the previous consensus statement on the use of ISNCSCI as the assessment tool to classify the severity of neurological impairment on admission for acute SCI [1,17-26].
The SCIM assess the ability to perform basic daily life activities using a 19-item disability chart, scoring up to 100 points by evaluation: self-care, respiration and sphincter management and mobility, currently it has been demonstrated that its role remains in the long-term assessment of neurological function changes in every day performance (Fig. 3) [27,28]. Furthermore, pain is a significant problem for many individuals with SCI, the ISCIBPDS was developed in 2008 by Widerström -Noga et al. [29,30], as a necessity to understand the nature of pain and to assess the efficacy of treatment with a valid reliable and standardize tool in an individual with SCI. It serves to assess pain, including pain severity, physical functioning, and emotional functioning, among SCI patients as it comprises a pain-intensity rating, a pain classification, and questions related to the temporal pattern of pain for each specific pain problem (Fig. 4) [29]. Thirteen papers evaluated the use of magnetic resonance imaging (MRI) to assess SCI at admission. Two level I evidence systematic reviews present level 1 high-quality patient-oriented evidence recommendations. Eight papers of level III evidence (7 prospective, 2 retrospectives) with moderate bias provide level II low-quality patient-oriented evidence. Finally, the last 2 papers are case series with level IV evidence, presenting moderate bias and providing level II low-quality patient-oriented evidence. Based on these results, we concluded that conventional MRI protocol with BASIC (Brain and Spinal Injury Center score) criteria evaluation on T2 axial sequence is the recommended imaging study in the setting of acute SCI to be done whenever possible before surgery to help in decision making. Injury level at C3 (or otherwise above C5), a maximum canal compromise greater or equal to 50%, a lesion length greater or equal to 20 mm, the presence of cord oedema and osteophyte formation at the level of injury significantly predicts the need for early tracheostomy. We also concluded that diffusion tensor imaging has better sensitivity than conventional MRI, especially with fractional anisotropy protocol, but up-to-date, a more straightforward protocol to implement remains to be created in order to facilitate its widespread clinical use [15,31-43]. Literature review is summarized in Tables 1–3.
Based on the presented literature and personal experience the committee voted as follow:
Statement 1: AIS described by the ASIA must be used as the preferred clinical evaluation tool for acute neurological assessment in patients with SCI. This statement reached a strong positive consensus (all voted grade 5 of Linkert scale [LS]).
Statement 2: The SCIM, may be preferred as the best scale to assess the functional abilities and impairment in the follow-up of patients with chronic SCI. This statement reached a strong positive consensus (86% voted grade 5 of LS, 13% voted grade 4 of LS).
Statement 3: The ISCIBPDS may be the preferred scale to evaluate the pain of a chronically injured patient. This statement reached a strong positive consensus (86% voted grade 5 of LS, 13% voted grade 4 of LS).
2. Emergency Care and Early Management
Literature search on PubMed and MEDLINE from 2009 to 2019 was undertaken using keywords: "spinal cord injury/ies” OR “spinal cord trauma/s” OR “spinal cord transection/s” OR “spinal cord laceration/s” OR “spinal cord contusion” OR “SCI” AND “surgery/ies” OR “operation/s OR “procedure/s” OR “decompression/s” AND “eight hours” OR “timing” OR “early” OR “ultra” OR “urgent”. A total of 208 results were obtained. After a first screening for English language and abstract, a total of 112 papers were fully read and 7 papers were considered significant for evaluation. After that we differentiated papers comparing early (<24 hours) versus late surgery (>24 hours). Furthermore, we differentiated very early (<8 hours) versus early (>8 hours < 24 hours) surgery. Of those articles, we focused on the ones centered on surgical treatment instead of medical therapy (Fig. 1). After the literature review, we obtained the following results. In National Acute Spinal Cord Injury Study Bracken et al identified the optimal therapeutic window for SCI treatment as up to 8 hours in 1990, however, it was a study on pharmacological therapy [44,45]. Lee et al. [46], based on the fact that minimizing secondary injury is the only therapeutic option to influence neurological outcome, conducted a study comparing early surgical decompression (within 24 hours) and very early surgical decompression (within 8 hours). They found a better neurological outcome if the patient is operated on in the first 8 hours than from 8 to 24 hours from injury. They failed to demonstrate better secondary outcome related to time of surgery. Furthermore, in line with literature, a better improvement has been seen in patients with incomplete SCI. Grassner et al. [47] also examined the early decompression within 8 hours and clinical outcome at 1 year using AIS and SCMI. In detail, they found significant differences in AIS grade after 1 year and between neurological and motor levels that were both caudal in case of early decompression. However, it is necessary to specify that no significant differences were seen between the first assessment after surgery and at 1-year follow-up. Liu et al. [48], using the same surgical timing, demonstrated shorter hospital stays and fewer perioperative complications associated with early surgery. On the contrary, Pointillart et al. [49] did not identify significant differences in neurological outcome related to time of surgery, but their primary focus was on the pharmacological therapy and not surgery. Ter Wengel et al. studied surgical decompression within 24 hours specifically in complete cervical SCI. In clinical practice, patients with complete SCI are often treated less urgently than those with incomplete SCI, but this does not have a scientific basis. With the purpose of analyzing outcomes in this specific population of patients, they performed a metanalysis providing a class II level of evidence. They concluded that early surgical decompression in patients with complete SCI consented a better outcome of 2 ASIA grades, in contrast to patients with incomplete SCI which did not benefit significantly as much from early decompression. This result is in contrast with most common clinical practice and many other studies have demonstrated the opposite conclusion. Further studies with specific subgroups of patients are needed to settle the role of early decompression both for complete and incomplete SCI [50-52]. The same group performed a metanalysis using as surgical timing within 24 hours and they failed to demonstrate a better outcome related to time of surgery. However, they only included patients with thoracic and thoracolumbar injury and this represents a bias of this study due to the lower incidence of trauma at this level with respect to cervical SCI and the fact that at lumbar level the injury affects less quality of life for those patients [53]. Furthermore, the majority of the cited studies analyzed the reason for the delay in surgical decompression and 2 main problems were identified. The first one is the time necessary for transportation in center (preferably a level I neurotrauma center) able to manage and surgically treat the patients. The second one is the necessity to stabilize the patients before surgery in the case of politraumatic patients. Literature review is summarized in Table 4.
Based on the presented literature and personal experience the committee voted as follows:
Statement 4: Early surgery (within 8 hours) should be performed in most cases of SCI. This statement reached a strong positive consensus (6 out of 7 voted grade 5 of LS and only 1 voted grade 4)
Statement 5: If feasible, SCI patients need to be treated in a specialized level 1 neurotrauma center. This statement also reached a strong positive consensus (6 out of 7 voted grade 5 of LS and only 1 voted grade 4).
3. Cardiopulmonary Management and Its Effect on Prognosis
Literature search from 2009 to 2019 was undertaken using keywords “cardiopulmonary management using spinal cord injuries” from Google Scholar resulting in 14,400 hits. 193 were left after refining the search terms and removing non-English articles. The same search was performed in PubMed using the above-mentioned key words resulting in 55 hits and after removing non-English articles the results were reduced to 29 articles. After reviewing, only 7 articles were selected from PubMed and 96 articles were selected from Google Scholar. We focused on 4 specific topics concerning human patients with acute SCI: management in an intensive care unit (ICU), cardiac instability, hypotension, and respiratory/pulmonary dysfunction. Additional citations were extracted from the reference lists of the remaining papers. Finally, members of the author group were asked to contribute articles known to them on the subject matter that was not found by other search means. Articles describing economics, epidemiology, anesthesia, monitoring techniques, penetrating cord injuries, nursing care, infectious or urologic complications, chronic complications, or remote SCIs were excluded. These efforts resulted in 11 articles, which form the foundation for this updated review. All studies provided class III medical evidence (Fig. 1).
The Swiss Paraplegic Center prospectively reported their medical management outcome, of 117 patients with spinal cord injuries, 40 years ago. They monitored those patients in ICU with central venous pressure monitoring, along with volume expansion and they were given steroids for 10 days. They showed an overall improvement in 62% in cervical level and, 70% in of T11–L1 level SCI. Patients admitted early had an early recovery. They reported that early transfer and “immediate treatment of the spinal injury” with attention to the maintenance of acceptable blood pressure (BP) improved the outcome of those patients [54]. Vale et al. published a prospective pilot study of patients with acute SCI, managed aggressively with attention to BP, oxygenation, and hemodynamic performance. They treated 77 patients with acute SCI, in the ICU, with BP augmentation to maintain mean arterial pressure (MAP) more than 85 mmHg for 7 days. 52% of incomplete cervical SCI patients required pressors to maintain MAP above 85 mmHg. There were no harmful effects from this therapy and exhibited improved neurological outcome. Despite these observations, in modern practice patients of acute traumatic SCI are not universally treated with BP augmentation postinjury [55-58]. Levi et al. [59] investigated 50 acute SCI patients with aggressive management protocol with invasive hemodynamic monitoring, volume, and pressor support to maintain a mean BP of more than 90 mmHg. At admission, 8 patients had severe hypotension (systolic BP [SBP] < 90 mmHg). 82% of the patients had volume-resistant hypotension requiring pressors within the first 7 days, which was 5½ times more common with complete motor injuries. Overall, the mean pulmonary vascular resistance was less than normal in 58%. Forty percent of these patients, including the complete injuries, had neurological improvement, 42% remained unchanged, and 9 patients died (18%). Levi et al. [59] suggested that hemodynamic monitoring in the ICU enables the early identification and prompt treatment of cardiac dysfunction and hemodynamic instability, leading to reduce morbidity and mortality. The results of Vale et al. and Levi et al. provide the rationale for the level III recommendation from the American Association of Neurologic Surgeons regarding cardiopulmonary resuscitation in SCI. These guidelines recommend the maintenance of MAP between 85 and 90 mmHg for the first 7 days following acute cervical SCI. Although limited by the paucity of current literature on the topic, this recommendation provides the foundation for the medical management of SCI in many institutions [47,48].
Regarding the acute cardiopulmonary management of patients with cervical spinal cord injuries, Ryken et al recommended management should be in an ICU or similar monitored setting. In order to detect cardiovascular dysfunction and respiratory insufficiency, they recommend the use of cardiac, hemodynamic, and respiratory monitoring devices. Early correction of hypotension in SCI (SBP < 90 mmHg) when possible is encouraged. The mean arterial BP should be maintained between 85–90 mmHg for the first 7 days following an acute SCI [60]. Hawryluk et al. [61] used q1 minute data to demonstrate that MAP goals > 85 mmHg were associated with improved neurologic outcomes. Elevated mean MAP during the first 2–3 days following injury was associated with improved neurologic outcome. The likely benefit of vasopressor administration for SCI management in this study is backed by the q1 minute MAP monitoring, which provides the strongest evidence. The same group analyzed the association between MAP and neurological improvement in patients stratified by their postresuscitation AIS score. They demonstrated a positive correlation between higher MAP values and neurological improvement in patients who are AIS A, and B/C on the postresuscitation exam, but not those who are AIS D. This suggests the possibility that AIS A patients may have greater benefit from MAP augmentation than AIS D patients and that it is important to avoid pessimism when considering MAP augmentation in patients with initially complete SCIs. Vasopressor administration is associated with greater risk of complications in AIS A patients and duration of therapy should be determined in view of these complications. Despite the absence of benefit from MAP augmentation in AIS D patients, they recommended that we should continue to encourage intensive MAP monitoring in these patients [62].
Regarding intrathecal pressure (ITP) and its role in SCI, greater emphasis has been placed on augmentation of mean arterial BP in acute SCI, while little data is available on the role of ITP during this period, when spinal cord perfusion pressure (mean arterial blood pressure-ITP) is of vital significance. ITP is inversely related to spinal cord perfusion, hence raised ITP postinjury may also lead to secondary injury via reduced perfusion of the spinal cord. Kwon et al. [63] conducted a prospective randomized trial on 22 patients and placed a lumbar intrathecal catheter for 72 hours in these patients. Acute SCI motor scores were documented at baseline and 6 months postinjury. Mean ITP on insertion was 13.8 mmHg, which increased to a mean peak of 21.7 mmHg intraoperatively. The restoration of CSF flow across the injury site after surgical decompression was characterized by changes observed in the ITP waveform. This waveform can be utilized during surgery to determine if the thecal sac has been adequately decompressed. The numbers were too small and at least the drainage of CSF did not show any side effects. 11 patients with AIS A, B, and C injuries were enrolled and studied by Altaf et al to see the differential spinal cord pressure. In comparison with dopamine, norepinephrine maintained a MAP with a lower ITP and correspondingly higher perfusion pressure [63-65]. Different papers discuss the role of vasopressors. Agents with inotropic, chronotropic, and vasoconstrictive properties should be used to maintain BP. Dopamine, norepinephrine, or epinephrine α1- and β1-agonist properties are acceptable options. Phenylephrine acts on α1- receptors as an agonist with minimal risk of reflex bradycardia (β1 effect). Dobutamine can cause vasodilation with the possible risk of reflex bradycardia and has a limited role in SCI [66,67]. Readdy et al. [68] showed that dopamine had a greater complication rate in SCI, although it was non-significant. The complication rate was 68% with dopamine while 45% for phenylephrine. Patients older than 55 years were associated with all kinds of vasopressor complications. 90% of older patients experienced complications in comparison to 52% of the younger patients. The Consortium for Spinal Cord Medicine suggested using vasopressors depending on the level of spinal cord involved. In high cervical and thoracic injuries, agents with both α- and badrenergic activity are recommended i.e., Dopamine, norepinephrine because of bradyarrhythmias due to unopposed vagal tone. In lower thoracic injuries, where hypotension can result in vasodilation, pure α -adrenergic agents such as phenylephrine are the drugs of choice [69]. Saadeh et al. [56], in their systemic review, demonstrated that cardiogenic complications are independently associated with both dopamine and phenylephrine. Dopamine resulted in more serious complications among elderly patients. They explained that vasopressor choice is governed by level of injury (e.g., above or below T-6), age (e.g., an elderly patient with autonomic dysfunction), and presence of comorbid conditions. In updated guidelines for the management of acute cervical spine and SCI patients, Resnick stressed the systemic cardiorespiratory status and the impact it has on outcomes. They narrated that both hypoxia (oxygen saturation< 90%) and hypotension (SBP < 90 mmHg) are relatively common after polytrauma, and even brief periods are associated with worse outcomes. This is recognizable and amenable to treatment [70,71]. Berney et al. [71] did a systemic review of 21 studies including definitive protocols for the respiratory management of acute cervical SCI. Mortality, incidence of respiratory complications, and the requirement for a tracheostomy were significantly reduced when caregivers used a respiratory protocol in the management of acute SCI patients. Specifically, the use of a clinical pathway reduced the duration of mechanical ventilation by 6 days and ICU length of stay by 6.8 days. There is level III evidence that keeping MAP above 85 for 7 days in patients with SCI improves neurological outcome. Early correction of hypotension in SCI (SBP < 90 mmHg) when possible is recommended. Patients with SCI suffer from cardiac issues including hypotension and bradycardia. Phenylephrine is recommended for ionotropic support when compared to dobutamine in patients over 55 years (avoids reflex bradycardia). In cervical or high thoracic lesions with both hypotension and bradycardia, a drug like norepinephrine with chronotropic, inotropic, and vasoconstrictor properties might be required. For low thoracic lesions, where hypotension is usually the result of peripheral vasodilation, a pure vasopressor drug such as phenylephrine may be appropriate. Table 5 summarizes main characteristics of the cited papers.
Based on the presented literature and personal experience the Committee voted as follows:
Statement 6: MAP above 85 for 7 days in patients with SCI improves neurological outcome. Correction of hypotension in SCI (SBP < 90 mmHg) is recommended as soon as possible. This statement reached a strong positive consensus (6 out of 7 voted grade 5 of LS and only 1 voted grade 4).
Statement 7: Patients with SCI suffer from cardiac issues including hypotension and bradycardia and it is worse in complete injuries. Hypotension and bradycardia must be aggressively managed. This statement reached a strong positive consensus (6 out of 7 voted grade 5 of LS and only 1 voted grade 4).
Statement 8: In Cervical or high thoracic lesions with both hypotension and bradycardia, a drug like norepinephrine and chronotropic and inotropic effects as well as vasoconstrictor properties may be used. This statement reached a strong positive consensus (5 out of 7 voted grade 5 of LS and 2 voted grade 4 of LS).
Statement 9: Level, completeness of the injury, age, previous diseases, and tachypnea at admission are associated with a higher likelihood of respiratory complication. These patients should be aggressively managed. This statement reached a strong positive consensus (all expressed a vote of grade 5 of LS).
DISCUSSION
Early phases of SCI are critical in the management of these patients, and in particular definition of the clinical assessment and classification represent the first essential step to help the therapeutic process decision making. Moreover, these tools can also be used to predict prognosis. The role of worldwide accepted recommendations may help in communication of clinical data, an aspect particularly relevant for those patients who must be referred to a trauma center from a secondary or tertiary hospital.
1. Clinical Assessment and Classification of SCI
A scarcity of papers exists on this topic explained by the widespread use of existing tools; further investigations are required to confirm the performance of those tests in the acute care setting [11]. Most of the research was focused on emerging technologies to better define neurological impairment and predict prognosis. Translational research has proved to provide increasing evidence but unsatisfactory solutions [14,72,73]. From those papers, biomarkers have been extensively studied, and many biological compounds have been highlighted as potentially useful compounds to assess neurological injury at admission and help predict prognosis; nevertheless, the profile is quite extensive, and no uniform criteria (or dataset) have been defined [6]. Since the initial review on assessment tools for acute SCI the AIS has been designated as the recommended evaluation tool to evaluate and classify initial neurological impairment on admission [36] and provide information on improvement at follow-up [12]. Both scores (AIS and ISNCSCI) have been largely studied and validated to assess and predict prognosis and correlate with the severity of SCI on imaging studies, besides it is recognized that additional quantitative assessments may be needed [5,19,29,74]. Currently, the ISCIBPDS is the preferred scale for evaluating pain from early assessment to the follow-up in chronically injured patients as it has the highest reliability and validity of any of the pain classification instruments [63,65].
Regarding radiological assessment of SCI, MRI defines the profile of neurological damage in the acute setting and helps make a better decision regarding treatment options; nevertheless, further research is needed to increase the precision of diagnosis and decrease the false-negative rates in cases such as SCIWORA, and protocols are to be standardized before widespread clinical use of the advantages can be done [12,24]. We consider that clinical assessment tools and classifications can be changed as there will be the advent of standardized biomarker data sets and more sophisticated MRI protocols. We agree with Krishna et al that in the new MRI era, protocols will be developed and will help define neurological injury better and accurately classify SCI severity in the early future [63]. We hope these advances in neurological assessment can help us change the patient's prognosis for good. In the meantime, we must remain on current tools and resume evidence on critical points to evaluate and care for acute SCI patients.
2. Emergency Care and Early Management
From a pathophysiological point of view, the mechanism of damage in spinal cord injuries can be divided in primary, due to the trauma itself (spinal cord contusion or compression), and secondary, due to blood flow reduction/interruption, inflammation cascade, and edema. The treatment goal is to reverse neurological injury, avoiding secondary injury and stabilize spinal column if necessary. The timing of surgery, age, and initial neurological status affect clinical outcome as independent factors. Nowadays, the concept of early surgery is accepted worldwide but there is a lot of heterogeneity in defining time in term of hours for early surgical decompression. Since 2010, the majority of papers have identified a time limit of 24 hours. But recently a new limit of 8 hours takes importance with an interval considered between 6 and 12 hours. In particular, most studies found that early surgery < 8 hours has advantages on neurological recovery (in terms of AIS score), especially in patients with complete neurological compromise; in terms of postoperative complications and hospitalization the correlation has not been proven. However, we must consider defining the timing of surgery, since it may have importance from a legal issue as well. For this reason, the recommendation must be acceptable worldwide, in accordance with the different facilities of each country. At present, the ideal surgical time is within 8 hours from trauma, if that is not possible it is recommended to not exceed 24 hours. Furthermore, early surgical decompression is indicated not only for incomplete but also in the case of complete SCI.
3. Cardiopulmonary Management and Its Effect on Prognosis
It is well known that patients with SCI may present cardiovascular dysfunction and respiratory insufficiency, and during initial management, an ICU or similar monitored setting is advocated in order to detect these complications promptly [60]. Early correction of hypotension (SBP < 90 mmHg) when possible is encouraged and must be performed as soon as possible. The role of vasopressors has been discussed in many papers and globally we accept that agents with inotropic, chronotropic, and vasoconstrictive properties should be used to maintain BP. Dopamine, norepinephrine, or epinephrine α1-and β1-agonist properties are also acceptable options.
CONCLUSION
To guarantee the best neurological outcome in SCI the early management of patients remains crucial from different points of view. Our committee defined the most useful and feasible scales to assess neurological injury and predict severity and they are: the AIS, ISNCSCI, and ISCIBPDS. Cardiopulmonary management plays an essential role in those patients: correction of hypotension (SBP < 90 mmHg), and bradycardia is strongly recommended as soon as possible and drugs like norepinephrine and chronotropic and inotropic effects, as well as vasoconstrictor properties, may be used. Regarding surgical treatment, it is our opinion that it is important to proceed with surgical decompression as soon as possible. At present, the ideal surgical time is within 8 hours from trauma, while if that is not possible it is recommended not to exceed 24 hours. Furthermore, it emerged that early surgical decompression is indicated not only for incomplete but also in the case of complete SCI.
WFNS RECOMMENDATIONS FOR EARLY MANAGEMENT OF SCI
Recommendations for Clinical Assessment and Classification of SCI
• AIS described by the ASIA is recommended as the preferred clinical evaluation tool for acute neurological assessment in patients with SCI.
• The SCIM III, may be preferred to assess the functional abilities and impairment in the follow-up of patients with chronic SCI.
• The ISCIBPDS may be the preferred scale to evaluate the pain in chronically injured patients.
Recommendations for Emergency Care and Early Management of SCI
• Early surgery (within 8 hours) should be performed in most cases of SCI.
• Corticosteroids are not indicated in the majority of acute phase of SCI.
• If feasible, SCI patients need to be treated in a specialized level 1 neurotrauma center.
Recommendations for Cardiopulmonary Management of SCI
• The MAP above 85 for 7 days in patients with SCI improves neurological outcome. Correction of hypotension in SCI (SBP < 90 mmHg) when possible and as soon as possible is recommended.
• Patients with SCI suffer from cardiac issues including hypotension and bradycardia, and it is worse in complete injuries.
• In cervical or high thoracic lesions with both hypotension and bradycardia, a drug like norepinephrine with chronotropic and inotropic effects, as well as vasoconstrictor properties, may be required.
• Level, completeness of the injury, age, previous disease, and tachypnea at admission are associated with a higher likelihood of respiratory complication, hence these patients should be aggressively nursed.
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