In Reply: AO Spine & Praxis Spinal Cord Institute Clinical Practice Guidelines for the Management of Acute Spinal Cord Injury

To the Editor: The AO Spine/Praxis guidelines on acute spinal cord injury (SCI), which were published in a focus issue of the Global Spine Journal, address 3 key topics: (1) the timing of surgical decompression, (2) hemodynamic management, and (3) intraoperative SCI.1-3 The introductory article outlines the scope of the project and the rationale for selecting these 3 topics. Importantly, it was never intended that these guidelines comprehensively address all aspects of acute SCI care.4 The rationale for updating the 2017 AO Spine/Cervical Spine Research Society guideline on the role and timing of surgery for acute SCI was based on new data (17 papers vs 5 in the 2017 guidelines) that examined this topic.5 Similarly, the stimulus to re-examine the hemodynamic management of acute SCI was not based on any actual or implied criticism of the 2013 American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) guidelines,6 but rather, on the emergence of updated evidence and the growing interest in spinal cord perfusion pressure. Finally, we aimed to better define the diagnosis and management of intraoperative SCI as this area represents a recognized knowledge gap. The letter by Raksin et al7 voiced concerns that the AO Spine/Praxis clinical practice guidelines (CPGs) could supersede clinical judgment and potentially create medicolegal challenges. We have emphasized in the focus issue that CPGs should NOT replace clinical judgment, and that the management of acute SCI is complex and must consider individual patient factors. Furthermore, systemic and logistical obstacles to patient care (eg, complex interhospital transfers, elderly or medically frail patients, and patients with polytrauma) must be considered when applying these CPGs in practice. Raksin et al7 commented on the use of the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach for guideline development. We have used GRADE in the guideline development process because it is currently recognized as a rigorous, transparent methodology. Although GRADE is not the only process for producing CPGs, it is the most widely adopted tool for grading the quality of evidence and for developing recommendations.8-10 Raksin et al also raised several issues around the systematic reviews in our focus issue. The data analysis for the systematic reviews was overseen by independent nonclinical methodologists to ensure that accepted standards were followed. Furthermore, the PICO (Population, Intervention, Comparison, Outcome) questions in the AO Spine/Praxis guidelines were appropriately outlined, and the overall body of evidence was rigorously evaluated using standardized rating scales and the GRADE approach. Using the Evidence to Decision framework, multidisciplinary international guideline development groups, including individuals with lived experience, reviewed the results from the systematic reviews to generate recommendations and guidelines statements. All key issues were discussed, and each recommendation required at least 80% agreement to achieve consensus. Importantly, there was strong consensus around the recommendation that surgery for acute SCI be undertaken within 24 hours when “medically feasible.” The latter statement recognizes the position of the AANS/CNS Section on Disorders of the Peripheral Nerves and Spine that considerable medical judgment is required to effectively and safely manage patients with acute SCI. Raksin and colleagues commented on the hemodynamic management guideline.3 The aim of the systematic review for this guideline was to evaluate the role of mean arterial pressure (MAP) augmentation in the management of SCI and summarize evidence supporting a role for spinal cord perfusion management. Unfortunately, the evidence was insufficient to generate a recommendation for spinal cord perfusion management. In developing the recommendation on MAP targets, the guideline development group agreed that a MAP less than 75 mm Hg or greater than 95 mm Hg may be associated with worse neurological outcomes or an increase in adverse events. We agreed that setting a range of 75-80 mm Hg to 90-95 mm Hg might be more effective at preventing the drop of MAP below 75 mm Hg or the sudden increase of MAP above 95 mm Hg. This range would encourage a tighter control of MAP between 80 and 90 mm Hg with an understanding that inadvertent ‘transgressions’ beyond these limits are inevitable in the management of acute SCI. In this focus issue, we also aimed to provide guidance on the prevention, diagnosis, and management of intraoperative SCI, an issue that has been flagged by the international community.1,11 We developed a provisional framework to approach a patient at potentially high risk of intraoperative SCI. In such patients, we recommended that multimodal intraoperative neuromonitoring be used to identify a potential intraoperative SCI and that a care pathway be adopted to optimize the management of these patients. We recognize that further prospective controlled studies are required to validate the care pathways, and we hope that our focus issue will stimulate such efforts. We sought broad input and consultation in creating the current AO Spine/Praxis CPGs. We submitted drafts of our systematic reviews and CPGs to the Joint Guidelines Research Committee of the AANS and CNS in April 2023, almost a year before the eventual publication of the guidelines in March 2024. We appreciated receiving a detailed critique by the JGRC in January 2024, and we provided a detailed response and did include a number of edits to our manuscripts. We also consulted other organizations including the North American Spine Society, Paralyzed Veterans of America, the International Spinal Cord Society, the European Association of Neurosurgical Societies, and the World Federation of Neurosurgical Societies. In conclusion, we wish to engage the clinical community to address the optimal implementation of these CPGs and hope that they will lead to improved clinical outcomes for patients with acute SCI. Additional discussion can be found in Editorials recently published in the Journal of Neurosurgery: Spine.12,13 Funding This study did not receive any funding or financial support. The original AO Spine/Praxis Clinical Practice Guidelines for the Management of Acute Spinal Cord Injury were jointly organized and funded by the AO Foundation through the AO Spine Knowledge Forum Spinal Cord Injury (SCI) (www.aospine.org/kf-sci), a focused group of international SCI experts, and the Praxis Spinal Cord Institute (https://praxisinstitute.org/) through funding from Western Economic Diversification Canada.

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