Variations in Managing Acute Spinal Cord Injury in the North American Clinical Trials Network and Partner Institutes

Abstract

Study Design

Survey based study.

Objectives

To evaluate current patterns for managing SCI among spine surgeons in North America.

Methods

A survey of the North American Clinical Trials Network (NACTN) and other institutions collected institutional demographics and specific practices on acute SCI management. Variables included trauma level designation, annual case volumes (patient number, spine fracture and surgery performed), steroid usage, emergent cervical traction, magnetic resonance imaging (MRI) access, surgical decompression timing, intraoperative ultrasound and neuromonitoring use, mean arterial pressure (MAP) and spinal cord perfusion pressure (SCPP) targets, lumbar drain use, and the influence of American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade on decision-making.

Results

Thirty surgeons from 23 institutions responded (93.3% Level 1 trauma centers). Most centers (93.3%) had immediate MRI access; about 70% of physicians did not use steroids. Emergent cervical traction was used by 60%. An aim of surgical decompression within 24 h was reported by 90%, with 20% operating immediately upon arrival. MAP goals were used by 93.3%, most targeting 85-90 mmHg for ≥5 days. Lumbar drains for SCPP optimization were used in 30%, typically targeting intrathecal pressure (ITP) < 15 mmHg and SCPP >60 mmHg. Management varied by AIS grade in 43.4%.

Conclusion

Despite agreement in the general scope of acute SCI care, significant implementation heterogeneity exists across North American spine centers. Variability was pronounced in steroid use, timing of decompression (90% within 24 h), cervical traction, and lumbar drain utilization. These findings call for evidence-based protocols to guide acute SCI management and reduce inter-institutional practice variation.

Keywords

spinal cord injury SCI SCI management SCI management variations North American clinical trials Network NACTN

Introduction

Spinal cord injury (SCI) is a challenging clinical condition associated with significant morbidity and mortality. Broadly, SCI involves damage to the spinal cord, which may result in temporary or permanent neurological damage related to the level and extent of the injury.^1–7 SCI most commonly arises from trauma and vertebral fracture, causing mechanical and vascular injury with ensuing pathophysiological and biochemical cascade leading to damage to spine tissue.^8,9

SCI is graded based on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), including American Spinal Injury Association (ASIA) Impairment Scale (AIS), ranging from AIS E (normal) to AIS A (complete, with no motor, sensory, or sacral sparing) with additional separate motor and sensory scores.¹⁰ The level and extent of the injury to the spinal cord and other concomitant injuries influence the neurological presentation.¹⁰

Over the last 40 years, SCI management has made significant strides, including efforts to mitigate secondary injuries to the cord through acute neuroprotection, encompassing both medical and surgical interventions..^11,12,13,14

Several guidelines and recommendations exist regarding the management of acute SCI.^15–17 Literature from other places has shown inconsistency regarding acute SCI care.^18,19 However, actual practice patterns amongst North American SCI centers and of newly developed management modalities have not been explored. Thus, this study assessed the patterns of SCI management in multiple institutions, utilizing a survey targeting spine surgeons from these institutions.

Methods

To understand practice patterns amongst a broad geographic range of SCI centers, we conducted a survey through email amongst members of the North American Clinical Trials Network (NACTN).²⁰ In addition, a survey was sent to physicians within institutes known to have high volumes of acute SCI cases (Table 1). This was complemented with snow ball sampling method. Since there was no patient related data accessed or patients involved, there was no need for IRB approval. NACTN is a syndicate of university-affiliated clinical centers (8 centers currently) equipped with expertise and resources in SCI management with a goal to advance quality of life for people with SCI through clinical trials of promising therapies.²⁰ The survey (Supplement material 1) questions were developed with the aim of addressing some of the ongoing questions and new frontiers in modern management of SCI. For pilot testing, the survey was initially sent to a small group of experts active within the NACTN group, in order to refine the questions to best understand current trends in SCI management, as well as optimize the survey for conciseness and directness. Snowball sampling was used, to reach the largest group possible who treat SCI that allows to characterize national trends in treatment. The main aim was to include as many participants from NACTN centers as possible since these centers appear to be hubs of acute SCI management. However, additional participants from other centers with known capacity and burden in treating SCI were included to get a larger scope. While this approach could introduce heterogeneity, describing this heterogeneity is the target of our study. For this same reason, we did not remove the few duplicate responses (from different physicians) within the institutes but were included to assess the scope of management variation among physicians.

Table 1.

Institutes That Participated in the Survey and the Number of Professionals That Responded From the Specific Institute

Institute, City and State/Province	Respondents
Banner University Medical Center, Tucson, Arizona	1
Duke University Hospital, Durham, North Carolina*	2
Froedtert Hospital, Milwaukee, Wisconsin	1
Harbor University of California Los Angeles Medical Center, Los Angeles, California	1
Harborview Medical Center, Seattle, Washington	1
HonorHealth Osborn, Scottsdale, Arizona	1
Jackson Memorial Hospital, Miami, Florida*	3
Johns Hopkins University, Baltimore, Maryland	1
Maine Medical Center, Portland, Maine*	1
Massachusetts General Hospital, Boston, Massachusetts	1
Mount Sinai Hospital, New York, New York	1
Thomas Jefferson University, Philadelphia, Pennsylvania*	1
University of Cincinnati, Cincinnati, Ohio	1
University of Florida Health, Gainesville, Florida	1
University of Maryland Medical Center, Baltimore, Maryland*	3
University of Toronto, Toronto, Ontario*	1
University of Utah Medical Center, Salt Lake City, Utah	1
University of Wisconsin, Madison, Wisconsin*	1
UPMC Presbyterian Hospital, Pittsburgh, Pennsylvania	2
Vancouver General Hospital, Vancouver, British Columbia	2
Walter Reed Military Medical Center, Bethesda, Maryland*	1
West Virginia University, Morgantown, West Virginia	1
Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California	1
Grand Total	30

* = NACTN Center; UPMC, university of pittsburgh medical center

The final version of the survey queried demographic information, as well as institutional practices related to the management of SCI. Specific items included American College of Surgeons (ACS) Level of trauma for the institute, yearly average spine fractures treated, yearly spine surgeries performed, yearly acute SCI patients treated, utilization of the Second National Acute Spinal Cord Injury Study (NASCIS II) for acute complete and incomplete SCI management, application of emergent cervical traction, access to magnetic resonance imaging (MRI) in emergency room, application of mean arterial pressure (MAP) goals and duration of application, time to operative decompression, utilization of intra operative ultrasound and neuromonitoring, the use of lumbar drains in acute SCI for managing intrathecal pressure (ITP) and spinal cord perfusion pressure (SCPP), target ITP, target SCPP and question if AIS plays a role in management strategy chosen (Table 2). In addition, survey respondents were invited to give additional feedback.

Table 2.

Hospital Type/Capacity and Burden of Acute Spinal Cord Injury Where Survey Respondents Practice. MRI- Magnetic Resonance Imaging

Survey question	Hospital capacity	Number (%)
Number of fractures treated annually
	0-100	6 (20)
	101-400	17 (56.7)
	401-700	3 (10)
	701-1000	2 (6.6)
	1000+	2 (6.6)
Spine surgeries performed annually
	0-100	1 (3.3)
	101-400	4 (13.3)
	401-700	1 (3.3)
	701-1000	4 (13.3)
	1000+	23 (66.7)
Level of trauma center
	Level 1	28 (93.3)
	Level 2	2 (6.7)
Number of acute spinal cord injuries treated annually
	0-25	7 (23.3)
	26-50	11 (36.7)
	51-100	5 (16.7)
	100+	7 (23.3)
Do you have an MRI scanner in the emergency room or one with immediate access?
	Yes	28 (93.3)
	No	2 (6.7)

After distributing the survey amongst members of the NACTN group, the results were tabulated via Microsoft Excel, and descriptive statistics were performed. A sub-group analysis of variation s in management between NACTN and non-NACTN centers was performed using GraphPad Prism (GraphPad Prism version 10.6.1 (892) for Windows, GraphPad Software, Boston, Massachusetts USA, https://www.graphpad.com/) and P-value <0.05 was set to establish statistical significance.

Results

Institution Demographics

The survey was sent to individuals within the 8 NACTN institutions and select institutes with a high volume of acute SCI care. A total of 30 individuals from 23 institutions responded. The response rate was 100% from NACTN centers. Data regarding participating institutions can be found in Tables 1 and 2 The geographic location of the institutes is displayed in a map (Figure 1). Survey questions are displayed in Table 3. Of note, most (93.3%) respondents were from Level 1 trauma centers. The majority (76.7%) of respondents confirmed their institutions treated up to 400 spine fractures annually (Table 2). The annual spine surgery volume was >1000 cases according to 66.7%, while 13.3% had 700 to 1000 cases and another 13.3% replied they had 100 and 400 cases per year. A majority (93.3%) of respondents reported either immediate access to MRI or access via the emergency department.

Figure 1.

Geographical location of institutes displayed by state/province and city. Developed using RStudio 2025.05.1 + 513 “Mariposa Orchid” release (2025-06-01) for windows. Posit software, PBC. https://posit.co/products/open-source/rstudio/

Table 3.

Pattern of Steroid Use Among Respondents in Treating Acute Spinal Cord Injury

Survey Questions	Responses	Number (%)
Do you use NASCIS-2’s protocol for acute complete spinal cord injury patients?
	Yes	5 (16.7)
	No	21 (70)
	Selectively	4 (13.3)
Do you use NASCIS-2’s protocol for acute incomplete spinal cord injury patients?
	Yes	4 (13.3)
	No	22 (73.3)
	Selectively	4 (13.3)

NASCIS-2, second national acute spinal cord injury study

Steroid Usage

Most surveyed institutes do not use the NASCIS II²¹ recommendation of steroids for acute SCI management. The results showed that 70% of respondents do not use steroids (methylprednisolone) for complete SCI, and 73% did not use steroids for incomplete SCI. However, 16.7% and 13.3% of institutions still reported using the NASCIS II protocol in patients with complete and incomplete SCI, respectively. It was also noted that patient factors played a role in doctors’ decision to use steroids, making the total percentage of respondents using steroids 30% for complete and 26.6% for incomplete SCI (Table 3).

Emergent Cervical Traction and Time to Decompression

Attempted cervical spinal cord decompression by closed reduction of anteriorly displaced vertebra, (ie, cervical traction), was reported by 90% of the respondents (Table 4). Emergent use of cervical traction was reported by 90% of respondents, but 30% stated they “rarely” use it. Significant heterogeneity existed amongst the respondents regarding the timing of surgical decompression, with the majority (90%) aiming for early (<24 h) decompression, while 10% would consider the grade of injury to decide the timing of decompression. Among the early decompression group, 20% reported decompressing the spine immediately up on arrival, 30% in <12 h (ultra early) and 40% within 24 h (early). Ultrasound to confirm adequate decompression is used by 70% of respondents (56.7% regularly and 13.3% sometimes). Intraoperative neuromonitoring is utilized by 86.7%, with 46.7% using it regularly and 40% reporting intermittent usage (Table 5).

Table 4.

Pattern of Spine Decompression in Managing Acute Spinal Cord Injury Among Survey Respondents

Survey Questions	Responses	Number (%)
Do you perform emergent cervical traction?
	Yes	18 (60)
	No	3 (10)
	Rarely	9 (30)
Do you perform emergent surgical decompression and what is your time frame?
	Immediate on arrival	6 (20)
	Less than 12 h	9 (30)
	Less than 24 h	12 (40)
	Depends on the grade of injury	3 (10)

Table 5.

Pattern of Intraoperative Ultrasound and Neuro-Monitoring in Managing Acute SCI Among Survey Participants

Survey Questions	Responses	Number (%)
Do you use ultrasound intra-operatively?
	Yes	17 (56.7)
	No	9 (30)
	Sometimes	4 (13.3)
Do you use neuro-monitoring intraoperatively?
	Yes	14 (46.7)
	No	4 (13.3)
	Sometimes	12 (40)

Mean Arterial Pressure (MAP) goals

For the support of spinal blood flow, the majority (93.3%) of respondents reported using MAP goals, with 72.4% targeting a MAP of 85-90 mmHg (Table 6). Of those that have a MAP target >90 mmHg (13.8%), half aim for a MAP between 90-95 mmHg, and the other half aim for >95 mmHg. The majority (75.9%) reported applying an MAP goal duration for ≥5 days, with 48.3% maintaining an MAP goal duration of 5 days, and 27.6% maintaining >5 days. The other respondents reported 1 and 3 days as the duration for MAP goal maintenance, and a few (3.4%) reported MAP goals dependent on patient presentation and examination to determine the overall duration.

Table 6.

Pattern of Mean Arterial Pressure (MAP) Management in Acute Spinal Cord Injury Among Survey Respondents

Survey Questions	Responses	Number (%)
Do you use MAP goals for spinal cord injury patients?
	Yes	28 (93.3)
	No	1 (3.3)
	Sometimes	1 (3.3)
What are your MAP goals for spinal cord injury patients?
	>80	1 (3.4)
	85-90	21 (72.4)
	90-95	2 (6.9)
	>95	2 (6.9)
	Patient dependent	3 (10.3)
How long do you use MAP goals for acute spinal cord injury patients?
	Post injury day 1	1 (3.4)
	Post injury day 3	5 (17.2)
	Post injury day 5	14 (48.3)
	Post injury day >5	8 (27.6)
	Variable based on patient presentation and exam	1 (3.4)

Lumbar Drains for Spinal Cord Perfusion Management

About one-third (30%) reported using lumbar drains to manage SCPP in SCI, while the remaining majority (70%) did not report usage (Table 7). Among those that use lumbar drains, 55.6% drain CSF to keep intrathecal pressure (ITP) < 15 mmHg, while 22.2% target ITP <10 mmHg. The other 22.2% use drains for ITP monitoring only. Of those that use lumbar drains, the majority (88.9%) aim for SCPP of >60 mmHg and the remaining for >55 mmHg.

Table 7.

Use of Lumbar Drain and Spinal Cord Perfusion Pressure Pattern in Managing Acute SCI Among Survey Participants

Survey Questions	Responses	Number (%)
Do you use lumbar drains for spinal cord perfusion in acute spinal cord injury?
	Yes	9 (30)
	No	21 (70)
How do you use lumbar drains for spinal cord perfusion in acute spinal cord injury?
	Transduce/drain with goal ITP <15 mmHg	5 (55.6)
	Transduce/drain with goal ITP <10 mmHg	2 (22.2)
	Observe ITP only	2 (22.2)
Do you use lumbar drains for spinal cord and treat spinal cord perfusion pressure (SCPP)? What is goal?
	>55 mmHg	1 (11.1)
	>60 mmHg	8 (88.9)

Difference in Management Based on AIS

A difference in how respondents manage patients depending on the presenting AIS was confirmed in 43.4% (Table 8). The main difference was the operative time frame (23.3%). Other differences were MAP goals (13.3%), Steroid use (3.3%), and target SCPP (3.3%). The details were not explored.

Table 8.

Pattern of Acute Spinal Cord Injury Management Difference Based on American Spinal Injury Association [ASIA] Impairment Scale (AIS) Among Survey Participants

Survey Questions	Responses	Number (%)
Does your management of spinal cord injury patients vary depending on the severity of injury (ie AIS C vs AIS D)?
	Yes	13 (43.4)
	No	17 (56.6)
How does it differ?
	Different operative timeline	7 (23.3)
	Different MAP goals	4 (13.3)
	Different steroid use	1 (3.3)
	Different SCPP goals	1 (3.3)

Difference in all Variables Based on NACTN Affiliation

There was no statistically significant variation in managing acute SCI between NACTN and non-NACTN centers except in usage of lumbar drains for monitoring SCPP. According to the finding 92.3% of participants from NACTN centers do not use SCPP for managing acute SCI while 47.1% of participants from other centers reported using it (Table 9).

Table 9.

Comparison of Differences Between NACTN Affiliated and Other Institutes in Managing Acute Spinal Cord Injury

Survey question	Sub-groups	NACTN centers (%, 95% CI)	Other centers (%, 95% CI)	P-value
Number of fractures treated annually
	0-100	2 (15.4, 2.7-42.2)	4 (23.5, 9.6-47.3)	.0638
	101-400	5 (38.5, 17.7-64.5)	12 (70.6, 46.9 - 86.7)
	401-700	3 (23.1, 8.2-50.3)	0 (0, 0-18.4)
	701-1000	2 (15.4, 2.7-42.2)	0 (0, 0-18.4)
	1000+	1 (7.7, 0.4-33.3)	1 (5.9, 0.3-27)
Spine surgeries performed annually
	0-100	1 (7.7, 0.4-33.3)	0 (0, 0-18.4)	.2041
	101-400	2 (15.4, 2.7-42.2)	2 (11.8, 2.1-34.3)
	401-700	1 (7.7, 0.4 - 33.3)	0 (0, 0 - 18.4)
	701-1000	0 (0, 0-22.8)	4 (23.5, 9.6-47.3)
	1000+	9 (69.2, 42.4-87.3)	11 (64.7, 41.3-82.7)
Level of Trauma Center
	Level 1	12 (92.3, 66.7-99.6)	16 (94.1, 73-99.7)	>.9999
	Level 2	1 (7.7, 0.4-33.3)	1 (5.9, 0.3-27)
Number of acute spinal cord injuries treated annually
	0-25	3 (23.1, 8.2-50.3)	4 (23.5, 9.6-47.3)	.2574
	26-50	3 (23.1, 8.2-50.3)	8 (47.1, 26.2-69)
	51-100	4 (30.8, 12.7-57.6)	1 (5.9, 0.3-27)
	100+	3 (23.1, 8.2-50.3)	4 (23.5, 9.6-47.3)
Do you use NASCIS-2’s protocol for acute complete spinal cord injury patients?
	Yes	3 (23.1, 8.2-50.3)	2 (11.8, 2.1-34.3)	.7349
	No	8 (61.5, 35.5-82.3)	13 (76.5, 52.7-90.4)
	Selectively	2 (15.4, 2.7 - 42.2)	2 (11.8, 2.1 - 34.3)
Do you use NASCIS-2’s protocol for acute incomplete spinal cord injury patients?
	Yes	2 (15.4, 2.7-42.2)	2 (11.8, 2.1-34.3)	>.9999
	No	9 (69.2, 42.4-87.3)	13 (76.5, 52.7-90.4)
	Selectively	2 (15.4, 2.7-42.2)	2 (11.8, 2.1-34.3)
Do you perform emergent cervical traction?
	Yes	7 (53.8, 29.1-76.8)	11 (64.7, 41.3-82.7)	.7596
	No	2 (15.4, 2.7-42.2)	1 (5.9, 0.3-27)
	Rarely	4 (30.8, 12.7-57.6)	5 (29.4, 13.3-53.1)
Do you have an MRI scanner in the emergency room or one with immediate access?
	Yes	11 (84.6, 57.8-97.3)	17 (100, 81.6-100)	.1793
	No	2 (15.4, 2.7-42.2)	0 (0, 0-18.4)
Do you perform emergent surgical decompression and what is your time frame?
	Immediate on arrival	2 (15.4, 2.7-42.2)	4 (23.5, 9.6-47.3)	.95
	Less than 12 hours	4 (30.8, 12.7-57.6)	5 (29.4, 13.3-53.1)
	Less than 24 hours	6 (46.2, 23.2-70.9)	6 (35.3, 17.3-58.7)
	Depends on the grade of injury	1 (7.7, 0.4-33.3)	2 (11.8, 2.1-34.3)
Do you use MAP goals for spinal cord injury patients?
	Yes	13 (100, 77.2-100)	15 (88.2, 65.7-97.9)	>.9999
	No	0 (0, 0-22.8)	1 (5.9, 0.3-27)
	Sometimes	0 (0, 0-22.8)	1 (5.9, 0.3-27)
What are your MAP goals for spinal cord injury patients?
	>80	0 (0, 0-22.8)	1 (6.3, 0.3-28.3)	>.9999
	85-90	10 (76.9, 49.7-91.8)	11 (68.8, 44.4-85.8)
	91-95	1 (7.7, 0.4-33.3)	1 (6.3, 0.3-28.3)
	>95	1 (7.7, 0.4 - 33.3)	1 (6.3, 0.3 - 28.3)
	Patient dependent	1 (7.7, 0.4-33.3)	2 (12.5, 2.2-36)
How long do you use MAP goals for acute spinal cord injury patients?
	Post injury day 1	1 (7.7, 0.4-33.3)	0 (0, 0-19.4)	.0745
	Post injury day 3	0 (0, 0 - 22.8)	5 (31.3, 14.2 - 55.6)
	Post injury day 5	6 (46.2, 23.2-70.9)	8 (50, 28-72)
	Post injury day >5	5 (38.5, 17.7-64.5)	3 (18.8, 6.6-43)
	Variable based on patient presentation and exam	1 (7.7, 0.4-33.3)	0 (0, 0-19.4)
Do you use ultrasound intra-operatively?
	Yes	9 (69.2, 42.4 - 87.3)	8 (47.1, 26.2 - 69)	.3378
	No	2 (15.4, 2.7-42.2)	7 (41.2, 21.6-64)
	Sometimes	2 (15.4, 2.7-42.2)	2 (11.8, 2.1-34.3)
Do you use neuro-monitoring intraoperatively?
	Yes	4 (30.8, 12.7-57.6)	10 (58.8, 36-78.4)	.1192
	No	1 (7.7, 0.4-33.3)	3 (17.6, 6.2-41)
	Sometimes	8 (61.5, 35.5-82.3)	4 (23.5, 9.6-47.3)
Do you use lumbar drains for spinal cord perfusion in acute spinal cord injury?
	Yes	1 (7.7, 33.3-0.4)	8 (47.1, 69-26.2)	.0417
	No	12 (92.3, 99.6-66.7)	9 (52.9, 73.8-31)
Does your management of spinal cord injury patients vary depending on the severity of injury (ie, AIS C vs AIS D)?
	Yes	8 (61.5, 35.5-82.3)	0.4621 (0, 0-0)	.4621
	No	5 (38.5, 17.7-64.5)	(0, 0-0)

AIS, american spinal injury association (ASIA) impairment scale (AIS); CI, confidence interval; MAP, mean arterial pressure; MRI, magnetic resonance imaging; NASCIS-2, second national acute spinal cord injury study; NACTN, north american clinical trials network.

Discussion

The management of SCI in the acute phase is an area of medicine that is under constant investigation. Due to poor outcomes in terms of neurological and functional recovery, as well as the heavy psychological and economic burden,^22,23,24,25 validated and appropriate investigational treatments should be implemented to mitigate injury effects and reduce eventual disability. The varied findings from the survey regarding the management of SCI indicate that, despite expert-based guidelines and recommendations, treating medical professionals treating SCI often vary in their treatment decisions and approaches across different institutions. Research in the past few decades has focused on preventing further damage to neural elements using neuroprotective interventions, including reducing inflammation to reduce secondary damage, maintaining spinal cord blood perfusion, and early surgical intervention to decompress the spinal cord.¹⁷ Acute inflammation reduction was proposed to the mechanism of action of high dose steroids (mainly methylprednisolone),¹⁵ while improving perfusion has been addressed using interventions like early diagnosis of residual spinal cord compression with imaging,²⁶ keeping MAP in a a defined range using fluids and vasopressors,¹⁶ decompressing the spine in a timely fashion (either by closed or open methods in cervical spine dislocation/subluxation, or surgically, in all regions of the spine),²⁷ maintaining local cord perfusion by decreasing ITP using cerebrospinal fluid drainage,²⁸ and ensuring the cord is adequately decompressed and has favorable pressure surrounding it using ultrasound and neuromonitoring.²⁹ These interventions inform the principles of acute SCI management. However, the results of this study highlight differences in how these principles are implemented among institutions and physicians.

The era of steroid use, more specifically methylprednisolone, for treatment in the acute phase of SCI has come to its near demise. This survey study indicates the current dwindling use of steroids amongst practitioners at major acute SCI centers.^30,31 The use of steroids was established in the 1990s after a series of NASCIS studies showed improved motor and sensory recovery in the treatment group.^21,32,33 However, adverse events and minimal clinical benefits led to advice against its use by professional societies and persistent questioning of the study results.^30,34,35 Later, the AO spine suggested there was still a place for steroids considering the small benefit and no actual different pooled risk of harmful effects in the treatment group.¹⁵ Recent studies, systematic reviews, and meta-analyses, however, specifically recommend not administering methylprednisolone following SCI because of no significant short- and long-term benefits.^36,37,38 Despite this, nine (30%) and eight (26.6%) doctors reported its use in complete and incomplete SCI, respectively, with about half of them in each group mentioning patient selective approach in their decision. Unfortunately, our survey did not further investigate the rationale behind this use of steroids or what patient factors are considered to indicate the use of steroids in acute SCI. From what we can understand based on recent similar survey-based studies, steroids are used either because doctors believe it has clinical benefits, to adhere to the standard of care in their institute, or because of medicolegal implications.^31,39 Interestingly, the use of steroids in acute SCI is a continuing topic of extensive research with regard to enhancing their delivery to the SCI site while limiting their systemic effects through the use of nanoparticles.^40,41,42,43

The 2013 Congress of Neurological Surgeons guidelines provide a level III recommendation for the use of cervical traction in fracture and dislocation injuries.⁴⁴ The timing in our study refers to the acute phase care (24-48 h) but there is a potential for treating physician-based timing and diagnosis discretion after preliminary imaging confirmation is achieved. Unfortunately, the depth of knowledge and decision algorithm of treating physicians on when and for what diagnosis of SCI cervical traction is used is not within the scope of this study. Cervical traction (closed reduction in general), however, is a controversial technique that aims to provide closed decompression of the cervical spine after injury.^45,46 The main areas of controversy, as Liu and colleagues⁴⁵ stated in their review, are the differing weights applied for traction by different authors, anesthesia during manipulation of the neck, the need for pre-procedural MRI with its implications on management decision, and risks and general success of the procedure, ranging from 30%–100%. In addition, surgical stabilization is required after closed reduction, and patients will still undergo surgical procedures.⁴⁵ Further, some studies reported that cervical traction may cause neurological worsening.⁴⁷ Dvorak and authors⁴⁸ suggested possible worse outcomes at long-term follow-up for patients with isolated unilateral facet fractures, subluxations, and dislocations that were treated non-operatively compared to surgical treatment. A systematic review by Kepler and colleagues⁴⁹ found that closed reduction was successful in 56.4% of cases when using a halo vest and 63.8% using Gardner-Wells tongs. Use of open reduction had the highest success rate (94.9%), with the odds of success 12.8 times higher compared to closed reduction. Therefore, the finding that 90% of institutes are utilizing cervical traction is peculiar and should be clarified further with larger cohort studies.

Surprisingly, there are no definitive high-quality guidelines recommending the use of MRI in SCI. Fehlings and colleagues “suggested” MRI be performed in patients with SCI after the initial trauma as well as before and after surgical intervention based on limited evidence (weak recommendation).⁵⁰ A recent systematic review and meta-analysis²⁶ identified the importance of MRI in SCI management to detect soft tissue injury (including the anterior longitudinal ligament, intervertebral disk injury/herniation) intramedullary hemorrhage/contusion/edema without radiographic abnormality, epidural hematoma, to determine if surgery is needed, and influence surgical planning (including timing, approach, levels to decompress, the need for instrumentation, and a need to reoperate. The study also identified a pooled result of 0% adverse events when performing MRI, although timing of MRI and outcomes of patients not undergoing MRI are not yet understood. Obtaining an MRI can prove difficult, as it is an expensive and time-consuming process. In sum, MRI is a powerful tool in SCI management, and 93.3% of respondents reported that they have immediate access to MRI, or that they have an MRI in the emergency department.

Surgical decompression is critically important in the management of acute SCI. The findings in our study showed heterogeneity in this regard, 90% agreeing to the <24 h cut off point, assuming surgery upon immediate arrival correlates to patient presentation immediately after trauma. Moderate-to high-quality evidence and ‘strong’ recommendation exists that early (<24 h) decompression is associated with improved neurological recovery⁵¹; however, the role of ultra-early (<12 h) surgery remains a topic of ongoing investigation. A study by Badhiwala and colleagues²⁷ pooling individual patient data from four high-quality, prospective, multicenter acute SCI datasets [NACTN SCI Registry, the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS), the Sygen Trial, and NASCIS III] showed early surgery was associated with improvement in total motor score, light touch score, pin prick score and AIS grade change after 1 year of SCI. The study also showed prolonged time to surgical decompression to be associated with a steep decline in the change in recovered total motor score after the first 24-36 h after SCI. The same study revealed that change in total motor score recovery plateaued 36 h post-SCI despite subsequent surgical decompression. Ultra-early decompression has more recently displayed a greater benefit, with a meta-analysis showing that patients with cervical SCI show significant neurological improvement with ultra-early decompression.⁵² The meta-analysis also revealed that patients with AIS A injury benefited significantly, showing a 3.86-fold recovery increase in surgical decompression effect in the first 12 h following SCI. However, the effect of ultra-early decompression was not prominent for patients with AIS B, C or D.⁵² In our study, surgery immediately upon arrival could potentially imply ultra-early, early, or late surgeries since patients could have been transported to the hospital in a range of times after SCI. This is especially important since recent studies have shown that up to 40% of SCI patients are transferred to a level I trauma center after being admitted to a lower-level hospital, often leading to delayed care. These studies suggested a need to increase level I trauma centers or focus care on established spinal cord excellence centers to most effectively provide early surgical decompression and expert critical care.^53,54

Compromised blood flow leading to cell death is important in the pathophysiology of SCI and has been an area of investigation with significant breakthrough understandings since the late 1980s.^16,55,56,57 To mitigate ischemia after SCI, blood pressure augmentation using fluid resuscitation and vasopressors has been investigated thoroughly. However, there is considerable disagreement regarding what MAP target and duration provide the best outcome, as interventions aimed at increasing blood pressure may lead to cardiopulmonary complications. According to our study results and other literature, an area of majority agreement is a post-SCI MAP target of >85 mmHg for a duration of at least 5 days, which is associated with neurological recovery.^58,59 This commonly implemented MAP goal is based on small studies that showed a neurological outcome benefit of maintaining MAP >85 mmHg^60,61,62 and there was a weak recommendation towards “target MAP” of 85-90 mmHg by the AO in 2023.⁵¹ Recently, Torres-Espin and colleagues⁶³ studied intraoperative MAP records from two centers in California, utilizing machine learning and identified that a MAP of 90 mmHg with a range of 76-117 mmHg resulted in an AIS improvement. Furthermore, Agarwal and authors⁶⁴ identified that the amount of time the intraoperative MAP was in an extreme low or high range predicted lack of AIS grade improvement. The same authors^64,65 also demonstrated that the ideal intra-op MAP range is 76-104 mmHg and the ideal intra-op average MAP is between 80-96 mmHg. Notably, all patients with an average MAP exceeding 96.3 mmHg showed no improvement (same or worse) in AIS at discharge. They also showed that the maximum cumulative time that intra-op MAP can be out of the recommended range should not exceed 93 min. Building on this finding, a guideline development group from the AO Spine recently suggested that the lower limit of MAP maintenance should be 75-80 mmHg, and the upper limit, 90-95 mmHg, to optimize spinal cord perfusion in acute traumatic SCI.¹⁶ The suggested duration was 3-7 days and is based on weak evidence.¹⁶ Therefore, this area of MAP is a topic of further research, and variability in management can be due to patient presentation and complications arising during treatment.

Very few institutes responded to the question regarding the details on usage of SCPP agreeably because only 30% (9/30) use SCPP. The importance of maintaining an elevated MAP is directly linked to reduced SCPP to minimize the risk of ischemic events during the disruption of autoregulated blood flow that follows SCI.^58,59 A scoping review by Gee and colleagues²⁹ summarized findings of studies regarding the significance of SCPP in SCI. From those studies, it was evident that maintaining SCPP was associated with better drug (methylprednisolone) delivery to the injury site⁶⁶ and neurological recovery.^67–70 A multi-center observational study⁶⁹ found that adherence to SCPP targets of 60-65mmHg, and not only MAP targets, was the best indicator of improved neurologic recovery. The study also mentions that failing to maintain the SCPP target ranges, especially on the lower side, was detrimental to neurological recovery.⁶⁹ Theoretically, the utility of lumbar drainage is in the reduction of intrathecal pressure to increase SCPP, allowing for more spinal cord perfusion,^71,72 which in turn reduces ischemia risk in the cord injury region. The use of lumbar drainage following SCI may have become more commonplace due to increasing evidence citing minimal risk of surgical complications in addition to lessening hypoperfusion events and supporting SCPP goals.^28,71,73 However, crucial open questions remain about its utilization, including a lack of a clear relationship between CSF drainage and pressure within the intrathecal space²⁹ and its feasibility for routine use in smaller centers,²⁹ which can possibly explain the low usage among the respondents. However, the high percentage of non-users within NACTN centers and relatively larger use in non-NACTN centers is a topic of interest that should be interpreted carefully considering the small number of participants to allow performing inferential statistics.

Overall, our study demonstrates significant heterogeneity in approaches to SCI management. Despite substantial advances, recovery after SCI is still often very limited. Given that neuroprotection is the best opportunity for improved recovery after SCI continued advances in our knowledge about pathophysiology and its mitigation are essential.⁷⁴ Optimized blood flow has a significant role in recovery,⁷⁵ with more research on SCBF needed in the context of other standardized practices. To better understand outcomes, multiple pieces of evidence are needed. This calls for further research into all treatment aspects of acute traumatic SCI. With more of such evidence, management of acute SCI should be standardized and improved based on newly emerging findings regarding surgical, hemodynamic and neuroprotective therapies. In recent years research on neuro-regeneration and neuromodulation are advancing.^13,19,76 With such knowledge, physicians can better understand, plan, and implement optimized care after SCI.

Limitations

The main limitations of this study are the level of evidence and the small number of survey respondents. In situations where performing a randomized controlled trial is met with various knowledge, technical, and ethical challenges, the professional world is left to depend on expert opinions. Although various trials are investigating the different areas of management explored in this study, the observed differences indicate a need for research aimed at standardization in SCI management. The small sample size limits the generalizability of our findings to widespread norms. It is also possible that different spine surgeons use different approaches in managing SCI within the same institute, further limiting conclusions about how a specific institute addresses acute SCI. The results indicate there remains considerable practice heterogeneity and that further consensus is needed. In addition, there is potential for self-report bias. There can also be regional variability, and over representation of academic centers since the respondents are from academic institutes only. However, SCI is managed in Level I/II trauma centers in the North American setting making inclusion of non-academic centers which do not manage such trauma difficult.

Conclusion

The general concept of SCI management in North American centers in the acute phase include timely steroid or neuroprotectant administration, maintaining MAP and SCPP, promptly decompressing the spinal cord, and stabilizing the vertebral column. The resources required to achieve and verify these management goals involve early diagnosis with MRI, administration of fluids and vasopressors, and the use of intraoperative neuromonitoring and ultrasound. Although many experts agree on the fundamental principles of the management strategy, there are notable differences among institutions and practitioners in how these strategies are executed. This variation underscores the need for more evidence that can lead to developing a standardized treatment protocol, which is a goal of NACTN and other institutions.

Footnotes

Acknowledgment

Our team would like to thank Laura DeLoretta at Thomas Jefferson University Library for thoroughly editing this manuscript. A special thanks to Pamela Walter for facilitating the process of editing.

ORCID iDs

Teleale Fikru Gebeyehu

Ashmal Sami Kabani

Stavros Matsoukas

Michael G. Fehlings

Author Contributions

Teleale F. Gebeyehu — Conceptualization, Writing- Original Draft Preparation, Writing- Review & Editing, Data Curation, Methodology, Visualization, Supervision, Project Administration. Zachary Sokol — Conceptualization, Methodology, Formal Analysis, Data Curation, Writing- Original Draft Preparation, Project Administration. James D. Guest – Conceptualization, Writing — Review & Editing. Joseph D. Harrington — Writing- Original Draft Preparation. Ashmal Sami Kabani — Writing- Original Draft Preparation. Evan Fitchett— Writing- Review & Editing. Alejandro Lopez— Writing- Review & Editing, Supervision. Stavros Matsoukas— Supervision. Daniel Franco— Supervision. Jack Jallo—Supervision. Alexander R. Vaccaro — Writing- Review & Editing. Shekar N. Kurpad — Writing- Review & Editing. Muhammad Abd-El-Barr — Writing- Review & Editing. Charles H. Tator — Writing- Review & Editing. Michael G. Fehlings — Writing- Review & Editing. James S. Harrop — Conceptualization, Writing- Review & Editing, Project Administration, Supervision.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Alexander R Vaccaro - Receives royalty payments from Alphatec (Atec), Atlas Spine, Curiteva, Elseviere, Globus, Jaypee, Medtronics, Spinal Elements, SpineWave, Stryker Spine, Taylor Francis/Hodder and Stoughton, Thieme, and Wheel House Medical. Stock/stock option ownership interests are held in Accellus, Advanced Spinal Intellectual Properties, Atlas Spine, AVKN Patient Driven Care, Avaz Surgical, Cytonics, Deep Health, Dimension Orthotics, LLC, Electrocore, Flagship Surgical, FlowPharma, Globus, Harvard Medtech, Innovative Surgical Design, Jushi, Orthobullets, Parvizi Surgical Innovation, Progressive Spinal Technologies, Rothman Institute and Related Properties, See All AI, Sentryx, Stout Medical, and ViewFi Health. Consulting/Independent Contractor for Accellus, Curiteva, Ferring Pharmaceutical, Globus, Medcura, Spinal Elements, Stryker Spine, and Wheel House Medical. Service on a Scientific Advisory Board/Board of Directors/ Service on Committees for Accellus, the National Spine Health Foundation (NSHF), and Sentryx. Member in good standing/independent contractor for AO Spine and Expert Testimony. The other authors delare no conflicting interests that can influence the contents of this study.

Data Availability Statement

Data collected is displayed in a tabular format within the manuscript.*

IRB Approval

Not needed. Survey conducted among NACTN group and other physicians through internal email.

References

Adams

Hicks

. Spasticity after spinal cord injury. Spinal Cord. 2005;43(10):577-586.

Cruz-Almeida

Felix

Martinez-Arizala

Widerström-Noga

. Pain symptom profiles in persons with spinal cord injury. Pain Med. 2009;10(7):1246-1259. doi:10.1111/j.1526-4637.2009.00713.x

Hagen

. Acute complications of spinal cord injuries. World J Orthoped. 2015;6(1):17-23. doi:10.5312/wjo.v6.i1.17

Jensen

Kuehn

Amtmann

Cardenas

. Symptom burden in persons with spinal cord injury. Arch Phys Med Rehabil. 2007;88(5):638-645.

Karlsson

A-K

. Overview: autonomic dysfunction in spinal cord injury: clinical presentation of symptoms and signs. Prog Brain Res. 2006;152:1-8.

Prott

Rutkowski

, et al. Gastrointestinal symptoms in spinal cord injury: relationships with level of injury and psychologic factors. Dis Colon Rectum. 2005;48(8):1562-1568.

Ahuja

Wilson

Nori

, et al. Traumatic spinal cord injury. Nat Rev Dis Primers. 2017;3:17018. doi:10.1038/nrdp.2017.18

Guest

Datta

Jimsheleishvili

Gater

JDR

. Pathophysiology, classification and comorbidities after traumatic spinal cord injury. J Personalized Med. 2022;12(7):1126.

Hachem

Fehlings

. Pathophysiology of spinal cord injury. Neurosurgery Clinics. 2021;32(3):305-313.

10.

Rupp

Biering-Sørensen

Burns

, et al. International standards for neurological classification of spinal cord injury: revised 2019. Top Spinal Cord Inj Rehabil. Spring. 2021;27(2):1-22. doi:10.46292/sci2702-1

11.

Flack

Sharma

Xie

. Delving into the recent advancements of spinal cord injury treatment: a review of recent progress. Neural Regen Res. 2022;17(2):283-291.

12.

Srikandarajah

Alvi

Fehlings

. Current insights into the management of spinal cord injury. J Orthop. 2023;41:8-13. doi:10.1016/j.jor.2023.05.007

13.

Fehlings

Moghaddamjou

Harrop

, et al. Safety and efficacy of Riluzole in acute spinal cord injury study (RISCIS): a multi-center, randomized, placebo-controlled, double-blinded trial. J Neurotrauma. 2023;40(17-18):1878-1888. doi:10.1089/neu.2023.0163

14.

Dididze

Green

Dietrich

Vanni

Wang

Levi

. Systemic hypothermia in acute cervical spinal cord injury: a case-controlled study. Spinal Cord. 2013;51(5):395-400. doi:10.1038/sc.2012.161

15.

Fehlings

Wilson

Tetreault

, et al. A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the use of methylprednisolone sodium succinate. Glob Spine J. 2017;7(3 Suppl):203s-211s. doi:10.1177/2192568217703085

16.

Kwon

Tetreault

Martin

, et al. A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on hemodynamic management. Glob Spine J. 2024;14(3_suppl):187S-211S.

17.

Wang

Park

Zhang

, et al. Management of acute traumatic spinal cord injury: a review of the literature. Frontiers in Surgery. 2021;8:698736.

18.

Hejrati

Moghaddamjou

Pedro

, et al. Current practice of acute spinal cord injury management: a global survey of members from the AO spine. Glob Spine J. 2024;14(2):546-560. doi:10.1177/21925682221116888

19.

Sharwood

Dhaliwal

Ball

, et al. Emergency and acute care management of traumatic spinal cord injury: a survey of current practice among senior clinicians across Australia. BMC Emerg Med. 2018;18(1):57. doi:10.1186/s12873-018-0207-0

20.

Toups

Ugiliweneza

Howley

, et al. North American clinical trials network for spinal cord injury registry: methodology and analysis. J Neurotrauma. 2023;40(17-18):1817-1822. doi:10.1089/neu.2022.0403

21.

Bracken

Shepard

Collins

, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the second national acute spinal cord injury study. N Engl J Med. 1990;322(20):1405-1411. doi:10.1056/nejm199005173222001

22.

Malekzadeh

Golpayegani

Ghodsi

, et al. Direct cost of illness for spinal cord injury: a systematic review. Glob Spine J. 2021;12(6):1267-1281. doi:10.1177/21925682211031190

23.

Merritt

Taylor

Yelton

Ray

. Economic impact of traumatic spinal cord injuries in the United States. Neuroimmunol Neuroinflamm 2019;6:9. doi:10.20517/2347-8659.2019.15

24.

Budd

Gater

JDR

Channell

. Psychosocial consequences of spinal cord injury: a narrative review. J Personalized Med. 2022;12(7):1178.

25.

Conti

Clari

Nolan

, et al. The relationship between psychological and physical secondary conditions and family caregiver burden in spinal cord injury: a correlational study. Top Spinal Cord Inj Rehabil. 2019;25(4):271-280. doi:10.1310/sci2504-271

26.

Ghaffari-Rafi

Peterson

Leon-Rojas

, et al. The role of magnetic resonance imaging to inform clinical decision-making in acute spinal cord injury: a systematic review and meta-analysis. J Clin Med. 2021;10(21):4948. doi:10.3390/jcm10214948

27.

Badhiwala

Wilson

Witiw

, et al. The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data. Lancet Neurol. 2021;20(2):117-126. doi:10.1016/s1474-4422(20)30406-3

28.

Menacho

Floyd

. Current practices and goals for mean arterial pressure and spinal cord perfusion pressure in acute traumatic spinal cord injury: defining the gaps in knowledge. J Spinal Cord Med. 2021;44(3):350-356. doi:10.1080/10790268.2019.1660840

29.

Gee

Kwon

. Significance of spinal cord perfusion pressure following spinal cord injury: a systematic scoping review. J Clin Orthop Trauma. 2022;34:102024. doi:10.1016/j.jcot.2022.102024

30.

Hurlbert

Hamilton

. Methylprednisolone for acute spinal cord injury: 5-year practice reversal. Article. Can J Neurol Sci. 2008;35(1):41-45. doi:10.1017/S031716710000754X

31.

Miękisiak

Łątka

Jarmużek

Załuski

Urbański

Janusz

. Steroids in acute spinal cord injury: all but gone within 5 years. World Neurosurg. 2019;122:e467-e471. doi:10.1016/j.wneu.2018.09.239

32.

Bracken

Collins

Freeman

, et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA. 1984;251(1):45-52.

33.

Bracken

Shepard

Holford

, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury: results of the third national acute spinal cord injury randomized controlled trial. JAMA. 1997;277(20):1597-1604.

34.

Hurlbert

. Methylprednisolone for acute spinal cord injury: an inappropriate standard of care. J Neurosurg Spine. 2000;93(1):1-7.

35.

Hurlbert

Hadley

Walters

, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013;72(Suppl 2):93-105. doi:10.1227/NEU.0b013e31827765c6

36.

Liu

Yang

, et al. High-dose methylprednisolone for acute traumatic spinal cord injury: a meta-analysis. Neurology. 2019;93(9):e841-e850. doi:10.1212/wnl.0000000000007998

37.

Sultan

Lamba

Liew

, et al. The safety and efficacy of steroid treatment for acute spinal cord injury: a systematic review and meta-analysis. Heliyon. 2020;6(2):e03414. doi:10.1016/j.heliyon.2020.e03414

38.

Sunshine

Dagal

Burns

, et al. Methylprednisolone therapy in acute traumatic spinal cord injury: analysis of a regional spinal cord model systems database. Anesth Analg. 2017;124(4):1200-1205. doi:10.1213/ane.0000000000001906

39.

Lee

Jeong

. Review: steroid use in patients with acute spinal cord injury and guideline update. Korean J Nutr. 2022;18(1):22-30. doi:10.13004/kjnt.2022.18.e21

40.

Cerqueira

Oliveira

Silva

, et al. Microglia response and in vivo therapeutic potential of methylprednisolone-loaded dendrimer nanoparticles in spinal cord injury. Small. 2013;9(5):738-749. doi:10.1002/smll.201201888

41.

Chvatal

Kim

Bratt-Leal

Lee

Bellamkonda

. Spatial distribution and acute anti-inflammatory effects of methylprednisolone after sustained local delivery to the contused spinal cord. Biomaterials. 2008;29(12):1967-1975. doi:10.1016/j.biomaterials.2008.01.002

42.

Lin

, et al. NEP(1-40)-modified human serum albumin nanoparticles enhance the therapeutic effect of methylprednisolone against spinal cord injury. J Nanobiotechnol. 2019;17(1):12. doi:10.1186/s12951-019-0449-3

43.

Jiang

Cui

, et al. Synthesis of methylprednisolone loaded ibuprofen modified dextran based nanoparticles and their application for drug delivery in acute spinal cord injury. Oncotarget. 2017;8(59):99666-99680. doi:10.18632/oncotarget.20649

44.

Walters

Hadley

Hurlbert

, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013;60(CN_suppl_1):82-91. doi:10.1227/01.neu.0000430319.32247.7f

45.

Liu

Zhang

. Reduction of lower cervical facet dislocation: a review of all techniques. Neurospine. 2023;20(1):181-204. doi:10.14245/ns.2244852.426

46.

Zileli

Osorio-Fonseca

Konovalov

, et al. Early management of cervical spine trauma: WFNS spine committee recommendations. Neurospine. 2020;17(4):710-722. doi:10.14245/ns.2040282.141

47.

Wang

Daniels

Palumbo

Eberson

. Cervical traction for the treatment of spinal injury and deformity. JBJS Rev 2014;2(5):e4. doi:10.2106/JBJS.RVW.M.00108

48.

Dvorak

Fisher

Aarabi

, et al. Clinical outcomes of 90 isolated unilateral facet fractures, subluxations, and dislocations treated surgically and nonoperatively. Spine. 2007;32(26):3007-3013. doi:10.1097/BRS.0b013e31815cd439

49.

Kepler

Vaccaro

Chen

, et al. Treatment of isolated cervical facet fractures: a systematic review. J Neurosurg Spine. 2016;24(2):347-354. doi:10.3171/2015.6.Spine141260

50.

Fehlings

Martin

Tetreault

, et al. A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction. Glob Spine J. 2017;7(3 Suppl):221s-230s. doi:10.1177/2192568217703089

51.

Fehlings

Moghaddamjou

Evaniew

, et al.

The 2023 AO spine-praxis guidelines in acute spinal cord injury: what have we learned? What are the critical knowledge gaps and barriers to implementation?

Glob Spine J. 2024;14(3_suppl):223s-230s. doi:10.1177/21925682231196825

52.

Yousefifard

Hashemi

Forouzanfar

Khatamian Oskooi

Madani Neishaboori

Jalili Khoshnoud

. Ultra-early spinal decompression surgery can improve neurological outcome of complete cervical spinal cord injury; a systematic review and meta-analysis. Arch Acad Emerg Med. 2022;10(1):e11. doi:10.22037/aaem.v10i1.1471

53.

Gebeyehu

Mendoza-Ayús

Perez-Chadid

Matsoukas

Vaccaro

Harrop

. Analyzing spinal cord injury patients: Directly admitted compared to individuals transferred into level I trauma centers. J Spinal Cord Med. Published online September 2, 2025. doi:10.1080/10790268.2025.2548068

54.

Kelly-Hedrick

Ugiliweneza

Toups

, et al. Interhospital transfer delays care for spinal cord injury patients: a report from the north American clinical trials network for spinal cord injury. J Neurotrauma. 2023;40(17-18):1928-1937. doi:10.1089/neu.2022.0408

55.

Fehlings

Tator

Linden

. The effect of nimodipine and dextran on axonal function and blood flow following experimental spinal cord injury. J Neurosurg. 1989;71(3):403-416. doi:10.3171/jns.1989.71.3.0403

56.

Guha

Tator

Rochon

. Spinal cord blood flow and systemic blood pressure after experimental spinal cord injury in rats. Stroke. 1989;20(3):372-377. doi:10.1161/01.str.20.3.372

57.

Tator

Fehlings

. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg. 1991;75(1):15-26. doi:10.3171/jns.1991.75.1.0015

58.

Dakson

Brandman

Thibault-Halman

Christie

. Optimization of the mean arterial pressure and timing of surgical decompression in traumatic spinal cord injury: a retrospective study. Spinal Cord. 2017;55(11):1033-1038. doi:10.1038/sc.2017.52

59.

Hawryluk

Whetstone

Saigal

, et al. Mean arterial blood pressure correlates with neurological recovery after human spinal cord injury: analysis of high frequency physiologic data. J Neurotrauma. 2015;32(24):1958-1967. doi:10.1089/neu.2014.3778

60.

Aarabi

Hadley

Dhall

, et al. Management of acute traumatic central cord syndrome (ATCCS). Neurosurgery. 2013;72(Suppl 2):195-204. doi:10.1227/NEU.0b013e318276f64b

61.

Levi

Wolf

Belzberg

. Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery. 1993;33(6):1007-1016.

62.

Vale

Burns

Jackson

Hadley

. Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg. 1997;87(2):239-246. doi:10.3171/jns.1997.87.2.0239

63.

Torres-Espín

Haefeli

Ehsanian

, et al. Topological network analysis of patient similarity for precision management of acute blood pressure in spinal cord injury. Elife. 2021;10:e68015. Published 2021 Nov;16. doi:10.7554/eLife.68015

64.

Agarwal

Aabedi

Torres-Espin

, et al. Decision tree-based machine learning analysis of intraoperative vasopressor use to optimize neurological improvement in acute spinal cord injury. Neurosurg Focus. 2022;52(4):E9. doi:10.3171/2022.1.Focus21743

65.

Chou

Torres-Espin

Kyritsis

, et al. Expert-augmented automated machine learning optimizes hemodynamic predictors of spinal cord injury outcome. PLoS One. 2022;17(4):e0265254. doi:10.1371/journal.pone.0265254

66.

Phang

Zoumprouli

Papadopoulos

Saadoun

. Microdialysis to optimize cord perfusion and drug delivery in spinal cord injury. Ann Neurol. 2016;80(4):522-531. doi:10.1002/ana.24750

67.

Chen

Smielewski

Czosnyka

Papadopoulos

Saadoun

. Continuous monitoring and visualization of optimum spinal cord perfusion pressure in patients with acute cord injury. J Neurotrauma. 2017;34(21):2941-2949. doi:10.1089/neu.2017.4982

68.

Saadoun

Chen

Papadopoulos

. Intraspinal pressure and spinal cord perfusion pressure predict neurological outcome after traumatic spinal cord injury. J Neurol Neurosurg Psychiatry. 2017;88(5):452-453. doi:10.1136/jnnp-2016-314600

69.

Squair

Bélanger

Tsang

, et al. Empirical targets for acute hemodynamic management of individuals with spinal cord injury. Neurology. 2019;93(12):e1205-e1211. doi:10.1212/wnl.0000000000008125

70.

Squair

Bélanger

Tsang

, et al. Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury. Neurology. 2017;89(16):1660-1667. doi:10.1212/wnl.0000000000004519

71.

Kwon

Curt

Belanger

, et al. Intrathecal pressure monitoring and cerebrospinal fluid drainage in acute spinal cord injury: a prospective randomized trial. J Neurosurg Spine. 2009;10(3):181-193. doi:10.3171/2008.10.Spine08217

72.

Phang

Werndle

Saadoun

, et al. Expansion duroplasty improves intraspinal pressure, spinal cord perfusion pressure, and vascular pressure reactivity index in patients with traumatic spinal cord injury: injured spinal cord pressure evaluation study. J Neurotrauma. 2015;32(12):865-874. doi:10.1089/neu.2014.3668

73.

Lavadi

Johnson

Chalif

, et al. Comparing reactive versus empiric cerebrospinal fluid drainage strategies for spinal perfusion pressure optimization in patients with acute traumatic spinal cord injuries. J Clin Neurosci. 2024;127:110757. doi:10.1016/j.jocn.2024.110757

74.

Fehlings

Pedro

Hejrati

. Management of acute spinal cord injury: where have we been? Where are we now? Where are we going? J Neurotrauma. 2022;39(23-24):1591-1602. doi:10.1089/neu.2022.0009

75.

Gallagher

Hogg

FRA

Zoumprouli

Papadopoulos

Saadoun

. Spinal cord blood flow in patients with acute spinal cord injuries. J Neurotrauma. 2019;36(6):919-929. doi:10.1089/neu.2018.5961

76.

Ahuja

Nori

Tetreault

, et al. Traumatic spinal cord injury-repair and regeneration. Neurosurgery. 2017;80(3s):S9-s22. doi:10.1093/neuros/nyw080