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3. Neurosurgery During Pregnancy

Author

Szuflita, Nicholas S., Boulter, Jason H., Gilhooly, Jonathan E., Neal, Chris J., Nezhat, Ceana H., editor, Kavic, Michael S., editor, Lanzafame, Raymond J., editor, Lindsay, Michael K., editor, and Polk, Travis M., editor

Published
2019
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5. Demographics, Mechanism of Injury, and Outcomes for Acute Upper and Lower Cervical Spinal Cord Injuries: An Analysis of 470 Patients in the Prospective, Multi-Center, North American Clinical Trials Network Registry

Author

Futch, Brittany Grace, primary, Kouam, Romaric Waguia, additional, Ugiliweneza, Beatrice, additional, Harrop, James, additional, Kurpad, Shekar, additional, Foster, Norah, additional, Than, Khoi, additional, Crutcher, Clifford, additional, Goodwin, C. Rory, additional, Tator, Charles, additional, Shaffrey, Christopher I., additional, Aarabi, Bizhan, additional, Fehlings, Michael, additional, Neal, Chris J., additional, Guest, James, additional, and Abd-El-Barr, Muhammad M., additional

Published
2023
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8. Development of a Systems Medicine Approach to Spinal Cord Injury

Author

Guest, James D., primary, Kelly-Hedrick, Margot, additional, Williamson, Theresa, additional, Park, Christine, additional, Ali, Daniyal Mansoor, additional, Sivaganesan, Ahilan, additional, Neal, Chris J., additional, Tator, Charles H., additional, and Fehlings, Michael G., additional

Published
2023
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9. Variability in Early Surgery for Acute Cervical Spinal Cord Injury Patients: An Opportunity for Enhanced Care Delivery

Author

Neal, Chris J., primary, Ugiliweneza, Beatrice, additional, Toups, Elizabeth G., additional, Abd-El-Barr, Muhammad, additional, Jimsheleishvili, George, additional, Kurpad, Shekar N., additional, Aarabi, Bizhan, additional, Harrop, James Shields, additional, Shaffrey, Christopher, additional, Fehlings, Michael G, additional, Tator, Charles, additional, Grossman, Robert, additional, and Guest, James, additional

Published
2023
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10. An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery

Author

Fehlings, Michael G., Kwon, Brian K., Evaniew, Nathan, Tetreault, Lindsay A., Fehlings, Michael G., Tetreault, Lindsay A., Hachem, Laureen, Evaniew, Nathan, Ganau, Mario, McKenna, Stephen L., Neal, Chris J., Nagoshi, Narihito, Rahimi-Movaghar, Vafa, Aarabi, Bizhan, Hofstetter, Christoph P., Wengel, Valerie ter, Nakashima, Hiroaki, Martin, Allan R., Kirshblum, Steven, Rodrigues Pinto, Ricardo, Marco, Rex A. W., Wilson, Jefferson R., Kahn, David E., Newcombe, Virginia F. J., Zipser, Carl M., Douglas, Sam, Kurpad, Shekar N., Lu, Yi, Saigal, Rajiv, Samadani, Uzma, Arnold, Paul M., Hawryluk, Gregory W. J., Skelly, Andrea C., and Kwon, Brian K.

Abstract

Study Design Clinical practice guideline development.Objectives Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that “early” surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI).Methods A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the “evidence-to-recommendation” framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.Results The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence.Conclusions It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Published
2024
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11. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management

Author

Fehlings, Michael G., Kwon, Brian K., Evaniew, Nathan, Tetreault, Lindsay A., Kwon, Brian K., Tetreault, Lindsay A., Martin, Allan R., Arnold, Paul M., Marco, Rex A.W., Newcombe, Virginia F.J., Zipser, Carl M., McKenna, Stephen L., Korupolu, Radha, Neal, Chris J., Saigal, Rajiv, Glass, Nina E., Douglas, Sam, Ganau, Mario, Rahimi-Movaghar, Vafa, Harrop, James S., Aarabi, Bizhan, Wilson, Jefferson R., Evaniew, Nathan, Skelly, Andrea C., and Fehlings, Michael G.

Abstract

Study Design Clinical practice guideline development following the GRADE process.Objectives Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets.Methods A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences.Results The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the “lower limit,” but not actively augmented beyond an “upper limit” of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the “target MAP” was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG “suggested” that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence.Conclusion We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI.

Published
2024
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16. Interhospital Transfer Delays Care for Spinal Cord Injury Patients: A Report from the North American Clinical Trials Network for Spinal Cord Injury.

Author

Kelly-Hedrick, Margot, Ugiliweneza, Beatrice, Toups, Elizabeth G., Jimsheleishvili, George, Kurpad, Shekar N., Aarabi, Bizhan, Harrop, James S., Foster, Norah, Goodwin, Rory C., Shaffrey, Christopher I., Fehlings, Michael G., Tator, Charles H., Guest, James D., Neal, Chris J., Abd-El-Barr, Muhammad M., and Williamson, Theresa

Published
2023
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25. Patterns of International Standards for Neurological Classification of Spinal (ISNCSCI) Grade Change and Neurosurgical Management in Penetrating Spinal Cord Injuries, Interim Analysis

Author

Szuflita, Nicholas S, primary, Neal, Chris J, additional, Wilson, Jason D, additional, Shah, Hamid M, additional, Villahermosa, Alex, additional, Toups, Elizabeth G, additional, Ugiliweneza, Beatrice, additional, Burden, George, additional, Aarabi, Bizhan, additional, Harrop, James S, additional, Guest, James D, additional, and Grossman, Robert G, additional

Published
2020
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27. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management.

Author

Kwon, Brian K., Tetreault, Lindsay A., Martin, Allan R., Arnold, Paul M., Marco, Rex A.W., Newcombe, Virginia F.J., Zipser, Carl M., McKenna, Stephen L., Korupolu, Radha, Neal, Chris J., Saigal, Rajiv, Glass, Nina E., Douglas, Sam, Ganau, Mario, Rahimi-Movaghar, Vafa, Harrop, James S., Aarabi, Bizhan, Wilson, Jefferson R., Evaniew, Nathan, and Skelly, Andrea C.

Subjects
MEDICAL personnel, HEMODYNAMICS, SPINAL cord injuries, NERVE tissue, PATIENT preferences, SPINAL cord
Abstract

Study Design: Clinical practice guideline development following the GRADE process. Objectives: Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. Methods: A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. Results: The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the "lower limit," but not actively augmented beyond an "upper limit" of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the "target MAP" was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG "suggested" that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence. Conclusion: We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI. [ABSTRACT FROM AUTHOR]

Published
2024
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35. Catastrophic Non-Survivable Brain Injury Care–Role 2/3

Author

Neal, Chris J, primary, Bell, Randy S, additional, Carmichael, J Jonas, additional, DuBose, Joseph J, additional, Grabo, Daniel J, additional, Oh, John S, additional, Remick, Kyle N, additional, Bailey, Jeffrey A, additional, and Stockinger, Zsolt T, additional

Published
2018
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