Abstract
The treatment of acute spinal cord injury (SCI) is a multidisciplinary effort that spans from the time of injury through to an acute care center, and in some cases the remainder of the individual's life. Recovery from SCI depends on the care received at each point along this spectrum in time. In order to facilitate the practice of evidence-based medicine and best clinical practices, a multidisciplinary team of clinicians and researchers systematically reviewed the literature on SCI and set out to answer pertinent clinical questions and establish evidence-based recommendations. This article introduces the series of systematic reviews, summarizes the most notable findings, and gives an overview of the questions asked in each review and the evidence-based recommendations for care. Some of the most important recommendations are as follows: (1) Patients should be immobilized before transport to a hospital using a cervical collar, head immobilization, and a spinal board; (2) MRI is strongly recommended for the prognostication of acute SCI; (3) early surgical intervention (from 8–24 h) should be considered following acute traumatic SCI; (4) SCI patients are at significant risk of cardiovascular and respiratory problems and management should proactively anticipate these potential complications; and (5) outcomes can be improved by management in specialized centers with access to intensive care.
Introduction
T
Advances in the care of SCI patients at any point along the spectrum from pre-hospital stabilization to long-term rehabilitation offer a great opportunity to improve the quality and duration of a person's life. Identifying inconsistencies and integrating advances along this spectrum of care will certainly benefit the long-term outcome of persons suffering from SCI. This series of reviews not only integrates all aspects of this spectrum with regard to the published literature, but also incorporates the clinical expertise of health professionals. The recommendations reflect aspects of care that demonstrate evidence-based benefit to patients. The authors of the systematic reviews also point out opportunities for future research in areas where evidence is lacking. Consensus expert opinion is provided where the evidence is emerging.
Highly-cited works in acute SCI have largely focused on the fundamental science underlying this devastating condition, with a relative paucity of highly-cited works that directly address the application of these therapies to patients (Furlan and Fehlings, 2006). In 2007, experts gathered at the SCI-Translational Research Network in Toronto and developed a list of the most clinically-relevant issues in acute care for SCI that had not been recently reviewed (Furlan et al., 2010d). Members of the Rick Hansen Institute acute care and practice team, which is a multidisciplinary team consisting of researchers and clinicians across Canada, took this list and conducted a series of systematic reviews. The goal of this project was to develop a set of best practices and recommendations to help translate evidence into clinical practice.
The systematic reviews cover the spectrum of acute care, including pre-hospital care, the role of specialized centers of care, assessments of impairment and disability, the role of MRI, the timing of surgery, pediatric SCI, predictors of outcome, deep-vein thrombosis and nutrition management, special cardiopulmonary needs, and the role of therapies for acute SCI. Promising scientific research was also reviewed, as these pre-clinical and experimental treatments may become the next standard of care for SCI. From these reviews, the authors, in conjunction with an expert panel, established a set of recommendations (Table 1). Some of the most notable recommendations are as follows:
• Patients should be immobilized before transport to a hospital using a cervical collar, head immobilization, and a spinal board (Ahn et al., 2010).
• MRI is strongly recommended for the prognostication of acute SCI (Bozzo et al., 2010).
• Early surgical intervention (from 8–24 h) should be considered following acute traumatic SCI (Furlan et al., 2010a).
SCI patients are at significant risk of cardiovascular and respiratory problems. Outcomes can be improved by management in specialized centers with access to intensive care facilities with specific protocols established for the management of SCI (Casha and Christie, 2010).
The overarching goal of this project is to increase the quality of care for people with SCI, and to ensure the uniform implementation of best practices. With these results, doctors and other health care professionals will be better equipped to provide the best care for their patients.
Footnotes
Author Disclosure Statement
No conflicting financial interests exist.