A Canadian national survey of the medical management of acute traumatic spinal cord injury

Introduction

Acute spinal cord injury (SCI) is a devastating condition that affects approximately 250,000 to 500,000 patients worldwide each year (1). The severity of these injuries can range from mild impairment to complete loss of motor and sensory function below the level of injury (1-4). The pathophysiology of SCI involves a two-step process, with the initial primary mechanical insult followed by a cascade of secondary pathobiological consequences, including cord edema, ischemia/reperfusion, and progressive neuronal degeneration (3).

Understanding the mechanisms of injury and their devastating consequences has driven advancements in preventive measures and research aimed at minimizing the effects of secondary injury (3,5-7). The primary injury to the spinal cord can be attributed to various mechanisms, such as contusion, distraction, laceration, or acute compression, with the severity dependent on the magnitude of force applied and the underlying condition of the cord and nerve roots (3,8). While the primary injury is established prior to hospital presentation and cannot be altered, the secondary injury that follows is a key target for both neuroprotective and regenerative interventions (2,8).

In the acute setting, polytrauma patients with SCI often experience neurogenic shock from relative hypovolemia or cardiogenic causes, which can further exacerbate injury to the spinal cord (9,10). With limited options for enhancing neurologic recovery outside of urgent surgical intervention, hemodynamic management has become a critical focus in the care of these patients (9). The rationale is that optimizing vascular perfusion and oxygen delivery to the injured spinal cord may help minimize secondary ischemic damage and improve neurologic outcomes (9,11-14).

Published guidelines recommend that acute SCI patients should be monitored in an intensive care unit (ICU) setting, where their cardiopulmonary status can be closely evaluated and managed (9,15). Initial resuscitation with crystalloid, blood products, and vasopressors is vital, and the current 2013 American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) clinical practice guidelines recommend maintaining the mean arterial pressure (MAP) between 85 and 90 mmHg for the first 5 to 7 days after injury (9,15).

The monitoring of spinal cord perfusion pressure (SCPP) has gained increased attention in recent years, driven by the publication of additional studies since 2011 that have examined the relationship between MAP, SCPP, and neurological outcomes (11,12). This heightened focus reflects a growing recognition of the importance of hemodynamics in managing spinal cord injuries which are postulated to reduce the risk of secondary injury (11,12,15,16).

Anemia is also a common occurrence in this patient population, and it is hypothesized that a significant drop in hemoglobin (Hb) level could further increase the risk of secondary injury due to inadequate cord perfusion, similar to the established risk of hypotension (8,17,18). However, this topic has not been well studied in the literature, and specific transfusion targets for SCI patients do not yet exist (17,18).

The aim of this study is to explore the perspectives of the Canadian healthcare community on various management strategies for acute SCI, including preferences related to MAP targets, SCPP targets, and Hb transfusion thresholds which tend to be monitored and controlled in the ICU settings. By identifying areas of consensus or discordance among practitioners, this research can help facilitate the development of more standardized, evidence-based guidelines for the acute management of SCI, with the ultimate goal of improving patient outcomes. We present this article in accordance with the SURGE reporting checklist (available at https://jss.amegroups.com/article/view/10.21037/jss-24-64/rc).

Methods

Survey development

A comprehensive multi-stage approach was utilized to develop our survey on management options for patients with acute SCI. The first step involved a detailed review of the available literature on management strategies for patients with acute SCI. This allowed the research team to gain a thorough understanding of the existing knowledge and guidelines in this field. Based on the insights gathered from the literature review, a survey template was developed in alignment with previously published best practices for academic survey design (19,20). The draft survey template was then reviewed by a three-person focus group, which included two academic neurosurgeons (one with spine fellowship training) and one neurosurgery resident. This focus group provided valuable feedback to increase the clarity, readability, and generalizability of the survey, while also helping to minimize potential biases. The survey was then circulated amongst members of the Collaborative Research Program in Neurosurgery and Intensive Care (CRANI) for further validation.

The final survey developed by the authors consisted of a 14-item questionnaire, which included a 5-question demographic section (see Table 1) and 11-question practice preference section, divided into topics such as practitioner experience in managing acute SCI, as well as preferences related to MAP, SCPP, and Hb thresholds in the acute management of SCI (see Table 2). Table 3 contains questions regarding evidence equipoise and future directions.

The survey was administered using the REDCAP platform (REDCAP; Vanderbilt University) (https://neurosurgery.mcmaster.ca/redcap).

To reach healthcare professionals actively engaged in the management of acute SCI patients, the survey link was disseminated through various channels targeting individuals in neurosurgery, orthopedics, trauma surgery, emergency medicine, and critical care medicine. Emails were sent to all neurosurgery, orthopedics, and critical care residency programs in Canada, and to community spine surgeons across the country. In addition, the survey was circulated via the Canadian Neurosurgical Society (CNSF) website. A cover letter introducing the study was created by the research team and sent by the project’s Principal Investigator (S.S.). This letter outlined the study objective, explained passive consent via survey completion, emphasized the confidential and anonymized nature of the questionnaire, and provided an estimated time for survey completion. No incentives were offered for completing the survey. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Hamilton Integrated Research Ethics Board (HiREB) under the reference number 2022-14421-GRA, dated March 2023. Informed consent was obtained from all individual participants.

The survey questionnaire was divided into three main parts, each focusing on specific aspects of acute SCI management (see Table 2). Part I, “MAP”, in this section, respondents were asked whether they routinely set a MAP target for patients with neurologic impairment due to acute SCI. If they answered “Yes” or “In select cases”, they were then asked to provide their MAP floor target (in mmHg) and the duration (in days) for which they would maintain this target. Part II, “SCPP”, respondents were asked whether they routinely set an SCPP target for patients with neurologic impairment due to acute SCI. If they answered “Yes” or “In select cases”, they were asked to provide their SCPP floor target (in mmHg) and the duration (in days) for which they would maintain this target. Part III, “Hemoglobin threshold”, respondents were asked about their Hb transfusion thresholds for patients with SCI. They were then asked at what minimum initial injury threshold they would maintain the above transfusion threshold. Additionally, respondents were asked about their Hb transfusion thresholds for patients with a spinal column injury but no neurological deficit, as well as whether they would ever transfuse a patient with a SCI based on clinical status alone, regardless of the Hb level. Finally, the survey concluded by asking respondents whether they believe the current equipoise in transfusion targets for SCI warrants a randomized controlled trial (RCT) to further investigate this topic.

Respondents

The survey targeted participants who are involved in the acute management of patients with SCI. The respondent pool included specialists in neurosurgery, orthopedic, intensive care, trauma surgery, and emergency medicine. In terms of professional roles, the survey included responses from staff physicians/surgeons, fellows, senior residents (post graduate year 3+), and junior residents (post graduate year 1–2), drawn from both university/academic practices as well as community-based practices. This diverse sample of healthcare providers, all with significant experience in the management of acute spinal cord injuries, ensured the survey captured a comprehensive range of perspectives and practices from the key stakeholders in this field.

Statistical analysis

The collected data were anonymized, and statistical analyses were performed using SPSS software version 29 (IBM Corp., Armonk, NY, USA). Categorical data were summarized and reported in Tables 1-3. Chi Square test was employed, and statistical significance was set at P<0.05. Free text responses provided by the participants were analyzed using qualitative methods and categorical data were reported as counts and percentages to provide a clear representation of the distribution of responses across different categories or groups.

Consensus

The aim of the survey was to identify areas of consensus or discordance between practitioners in their management strategies for patients with acute SCI, specifically regarding Hb level targets, MAP and SCPP.

Results

Seventy-one healthcare provider completed the survey with 100% completion rate. The majority of participants were from the fields of intensive care (31.0%), followed by neurosurgery (25.4%), orthopedics (12.7%), neurosurgery with >50% spine practice (12.7%), Orthopedics with >50% spine practice (12.7%), then Emergency medicine and Trauma Surgery with (2.8%) each (Table 1). The participants were from Ontario (38.6%), Alberta (24.3%), Quebec (20%), Nova Scotia (4.3%), Saskatchewan (4.3%), and British Columbia (1.9%). The majority of participants were staff physicians (49.3%), with the remaining being senior residents (29.6%), fellows (15.5%), and junior residents (5.6%). Two fellows (2.9%) selected “other” for their province of practice, suggesting they may be from an international background and may have inadvertently missed selecting the appropriate answer. Most participants (88.6%) practiced in an academic setting, with the remaining 11.4% in a community setting. For attending physicians, the years of practice were distributed as follows: 1–5 years (9.9%), 6–10 years (9.9%), and >10 years (29.5%). The study reports that the average number of patients with acute traumatic SCI cared for by each participating institute is 86.2. The median number of patients is 50, and the standard deviation is 99.7. This finding aligns with the recent national estimate of 1,199 admitted cases of SCI in 2019 (21). Furthermore, each participant reported caring for an average of 22.5 patients with acute SCI. The median number of patients is 13.50, and the standard deviation is 30.4.

MAP management

Most participants (75.7%) routinely set a MAP target for patients with acute traumatic SCI, while 20.0% did so in select cases (Table 2). The reported MAP floor target ranged between 60–90 mmHg with a mean of 81.21 mmHg and SD of 5.7 mmHg. The reported duration for maintaining the MAP floor target ranged from two to ten days with a mean of 5.88 days and 7 days median. For those participants who answered that they would set a MAP target in select cases, their responses indicated a range of factors that would influence their decision-making. These included the location of the SCI, with a focus on cervical injuries. The severity of the injury, as measured by the American Spinal Injury Association (ASIA) impairment scale, was also a consideration, with clinicians more likely to provide the treatment for ASIA impairment scale C injuries or worse. Patient comorbidities, their overall clinical response and the mechanism of injury were other important factors. Lastly, surgeon request as reported by some intensive care practitioners.

SCPP management

Only 7.1% of participants routinely set a SCPP target for patients with acute traumatic SCI (Table 2). The reported SCPP floor target ranged from 70–85 mmHg with a mean of 81 mmHg and 6.52 SD. The duration for maintaining the SCPP floor target ranged between 3 to 7 days with a mean of 5.4 days and 5 days median. No participant answered that they would set an SCPP target in select cases.

Hb transfusion thresholds

For patients with SCI and neurological deficit, the most common Hb transfusion threshold was <7 g/dL (50.7%), followed by <8 g/dL (30.4%), <9 g/dL (5.8%) and <10 g/dL (11.6%) (Table 2). The majority of participants (62.3%) would maintain the above transfusion threshold for all patients, regardless of initial injury severity. For patients with spinal column injury and no neurological deficit, the most common Hb transfusion threshold was <7 g/dL (69.6%). Only 15.9% of participants would consider transfusing a patient with a SCI based on clinical status, regardless of the Hb level. Their clinical indication is dependent on patient hemodynamic instability and if there is any signs of active bleeding or anemia.

Equipoise and future directions

Approximately 66.7% of participants believed the current equipoise in transfusion targets for SCI warrants a RCT (Table 3). Of those who believed an RCT is warranted, 79.5% indicated they would be willing to enroll patients.

Statistical analysis of responses and subgroups

We analyzed survey responses across different medical specialties responsible for care of acute SCI patients (Table S1). The chi-square test analysis revealed several statistically significant associations. Respondents were more likely to be staff physicians and surgeons compared to senior residents, junior residents, and fellows. This strengthens and validates the survey results, as staff members typically have more knowledge, experience, and awareness of the current literature regarding SCI patient management (P<0.001). Similarly, staff respondents were likely to have more years of practice, further validating this point (P<0.001).

A greater proportion of neurosurgeons and orthopedic surgeons, compared to other specialties, stated that they would set a MAP target for SCI patients (P<0.001). This point was further explained by some of the comments from other specialists indicating that they would follow the primary surgeons’ recommendations in regard to MAP augmentation. However, there was no statistical significance between specialties regarding the duration of MAP augmentation or the specific MAP target. Responses regarding SCPP did not reveal any statistical significance between different groups. This can be attributed to the paucity of evidence and the recent adoption of this practice in SCI management.

Hb thresholds and blood transfusion practices in SCI patients revealed an interesting trend toward maintaining a Hb level of approximately 7 g/L. This trend was particularly evident among intensive care specialists when transfusing SCI patients with neurological deficits (P<0.001). Similarly, maintaining the aforementioned transfusion threshold in all patients regardless of their ASIA impairment scale score, was statistically significant, especially among intensive care providers (P<0.001).

Discussion

The findings of this survey highlight the significant variability in the management strategies employed by Canadian healthcare providers caring for patients with acute traumatic SCI. The diverse respondent pool, which included specialists from neurosurgery, orthopedics, intensive care, trauma surgery, and emergency medicine, as well as providers from both academic and community settings, ensured a comprehensive representation of the key stakeholders involved in the acute management of these complex patients.

The survey was meticulously designed and implemented, utilizing a multi-stage approach that included a detailed literature review, focus group feedback, and validation by the CRANI. The use of the REDCap platform and distribution through various channels, such as residency programs and the Canadian Neurosurgical Society, further strengthened the reach and accessibility of the survey. The response rate and 100% completion rate among the 71 participants underscores the importance of this topic and the engagement of the targeted healthcare providers. This comprehensive survey provides a wide-ranging insight into the variabilities that exist in the medical management of SCI patients across Canada, which is further reinforced by the high response rate obtained from healthcare professionals nationwide.

Management of MAP targets in SCI

The observed heterogeneity in the management of MAP, SCPP, and Hb transfusion thresholds is concerning, as these interventions are critical in optimizing neurological outcomes for patients with acute traumatic SCI. This reflects the current available literature, as there is no level one evidence regarding the management of MAP targets, SCPP, and Hb transfusion thresholds in patients with acute SCI. The 2013 AANS/CNS guideline on the hemodynamic management of SCI made three key recommendations: the use of monitoring devices to detect cardiovascular and respiratory dysfunction, the correction of hypotension (systolic blood pressure <90 mmHg) as soon as possible, and the maintenance of MAP between 85–90 mmHg for the first 7 days (9,22,23). More recently, a 2024 multidisciplinary guideline development group published updated comprehensive systematic review and management recommendations, suggesting that MAP should be augmented to at least 75–80 mmHg as the lower limit, but not actively increased beyond 90–95 mmHg, to optimize spinal cord perfusion (15,22,23). However, the quality of evidence supporting these MAP targets was very low, leading to a weak recommendation. Similarly, the group suggested augmenting MAP for 3–7 days, but again the evidence was limited. The guideline development group felt there was insufficient evidence to make recommendations on the choice of vasopressor or the use of SCPP targets.

Management of SCPP targets in SCI

The finding that only 7.1% of participants routinely set a SCPP target, compared to 75.7% who set a MAP target, is particularly noteworthy. This discrepancy may suggest that the importance of SCPP in the management of acute SCI is underappreciated, or that there is a lack of familiarity with the practical application of this parameter. Furthermore, one of the most interesting areas of investigation since the 2013 AANS/CNS guidelines is the recognition that SCPP may be a more relevant metric than MAP for neurologic recovery after SCI (15). This work has been largely pioneered by Papadopoulos and colleagues, who developed a pressure sensor that is inserted at the injury site to detect swelling of the spinal cord against the dura and demonstrated that neurologic recovery may be more closely tied to the SCPP than to the MAP (24). Currently, an ongoing clinical trial that uses cerebrospinal fluid (CSF) drainage to improve SCPP (“CASPER”; Clinicaltrials.gov NCT03911492) is running and will enhance the literature available on this topic. Future research and educational initiatives should aim to address this gap and promote the widespread adoption of SCPP monitoring and management.

Management of Hb levels in SCI

The wide range of Hb transfusion thresholds reported by participants, with the most common threshold being <7 g/dL, highlights the ongoing debate and uncertainty surrounding the optimal Hb targets in this patient population. The fact that a significant proportion (15.9%) of respondents would consider transfusing based on clinical status alone, regardless of the Hb level, further underscores the need for clear, evidence-based guidance to support clinical decision-making. The current recommendations by both World Society of Emergency Surgery (WSES) & the European Association of Neurosurgical Societies (EANS) is transfuse red blood cells for patients with SCI if Hb level drops below 7 g/dL especially if those patients are having severe hemorrhage or undergoing an emergency spine surgery (18). Furthermore, elderly patients or others with preexisting cardiovascular conditions may benefit from a higher Hb level threshold (18).

Nonetheless, the current published data highlight the lack of clinical evidence guiding transfusion strategies in SCI patients. The optimal Hb transfusion threshold remains undefined, but it might be higher than restrictive protocols suggest (17,18). Studies have shown that patients with Hb levels between 9.1 and 10 mg/dL were less likely to undergo brain tissue hypoxia and metabolic crises, while Hb concentrations of <8 mg/dL were associated with a higher mortality rate (17,25). Similarly, Biglari et al. suggested that an elevated concentration of Hb in peripheral blood is associated with higher odds of neurological remission after SCI, whereas an early decrease in Hb concentrations might support unfavorable tissue oxygenation and thus is associated with a higher probability of absence of recovery (17,25).

The high proportion of participants (66.7%) who believed the current equipoise in transfusion targets for SCI warrants a RCT, and the willingness of 79.5% of these respondents to enroll patients, is a promising finding. This enthusiasm for further research reflects the recognition among healthcare providers of the need to establish best practices and optimize the management of patients with acute traumatic SCI.

Limitations

The present study has several limitations including the possibility of recall bias, where participants may inaccurately recall or report their practices and experiences. Furthermore, the survey did not deeply explore the rationale behind the various management strategies employed by the participants, which could have provided valuable insights into the decision-making process and the factors influencing their choices. The response rate remained low despite a prolonged data collection period which may affect the generalizability of the findings to the practices across the country. In addition, another limitation is the uneven distribution of different specialties and levels of training between participants which may have introduced bias in our results, potentially limiting the generalizability of our findings across all specialties involved in SCI management.

Conclusions

This survey of healthcare providers caring for patients with acute traumatic SCI highlights the significant variability in the management of MAP, SCPP, and Hb transfusion thresholds across the nation. The results demonstrate a lack of consensus among participants, despite the critical importance of these interventions in optimizing neurological outcomes. Future studies should aim to establish best practices and provide clear guidance to healthcare providers and ultimately improving patient outcomes. The development of a multicenter RCT, with a large sample size and robust methodology, would be a significant step forward in optimizing the management of this complex topic.

Acknowledgments

The authors would like to thank all the participants including neurosurgeons, orthopedic surgeons, intensive care specialists, emergency doctors, trauma surgeons, residents, and fellows who participated in this study. Special thanks to all neurosurgery, orthopedics and intensive care program directors who facilitated the distribution of the survey to their corresponding department. In addition, special thanks to the Canadian Neurological Sciences Federation for distributing the survey in their platform. We also would like to thank the individuals who assisted in fine tuning the survey including Dr Taylor Duda and other members of the Collaborative Research Program in Neurosurgery and Intensive Care (CRANI).

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://jss.amegroups.com/article/view/10.21037/jss-24-64/rc

Data Sharing Statement: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-64/dss

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-24-64/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-24-64/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Hamilton Integrated Research Ethics Board (HiREB) (reference number: 2022-14421-GRA, dated March 2023) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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