Abstract
Translational research on the importance of secondary injury mechanisms has promoted development of management strategies for patients with acute spinal cord injuries (SCIs). These findings have been adopted in guidelines such as the 2013 AANS/CNS and the 2017 AOSpine guidelines on SCI management. However, despite these guidelines, uncertainty remains regarding optimal hemodynamic management, timing of surgical decompression and the use of steroids.
The goal of this study was to examine knowledge, adoption and barriers to guideline implementation around these three key areas of SCI management. We sought to examine the current international practices of spine care professionals regarding the acute administration of steroids, hemodynamic management, and timing of surgical decompression in acute SCI.
A survey was distributed to all members of AOSpine International on October 1st, 2021. The questionnaire was structured into (1) demographic data and preferred practices surrounding (2) steroid use, (3) hemodynamic management and (4) timing of surgical decompression. Data were analyzed in Stata version 16.1.
A total of 593 members completed the survey including orthopaedic surgeons (54,3%, n=319), neurosurgeons (35.6%; n=209), and traumatologists (8.4%; n=49). Most [61.2% (n=352)] respondents were from low and middle-income countries (LICs and MICs) with 38.8% (n=223) from high income countries (HICs). There was a bimodal distribution with regard to the administration of steroids with 53.6% using this neuroprotective option (n=256) and 46.4% (n=222) not. Respondents from LICs and MICs were more likely to administer steroids than HICs (178 vs 78, p <.001). Interestingly, when steroids were given, AIS A patients were less likely to receive steroids (72.6%; n=185), than AIS B (82.8%; n=211) and AIS C patients (76.5%; n=195). A total of 331 respondents (81.5%) answered that patients would receive mean arterial pressure (MAP) targeted treatment in the intensive care unit or an analogous setting. Whereas 24.2% (n=51) of orthopedic surgeons would not use MAP targeted treatment at their institutions; this was the case in only 12.8% (n=20) for neurosurgeons, (p <.05). In LICs and MICs, SCI patients were less likely to be provided with MAP-targeted treatment (76.9%, n=193) as compared to HICs, (89%, n=138; p < .05). The majority of respondents (87.8%) reported that patients with SCIs would benefit from early decompression. Despite overwhelming evidence and surgeons' responses that would offer early surgery, 231 (62.4%) stated they encounter logistical barriers in their institutions. This was particularly evident in LICs and MICs, where 129 respondents (57.9%) indicated that early intervention would be rather unlikely to accomplish (p < .001).
This survey highlights challenges in the implementation of standardized practice regarding the use of steroids, hemodynamic management and practical use of early surgical intervention, despite clear evidence for surgeon preference to implement a “Time is Spine” approach. This work highlights the importance of continuing to refine SCI guidelines. Moreover, future research efforts will need to address barriers of guideline implementation, such as logistic hurdles in the implementation of early decompressive surgery.
This abstract does not discuss or include any applicable devices or drugs.