Abstract
Dear Editor,
The recent article by Gebeyehu et al, “Variations in Managing Acute Spinal Cord Injury in the North American Clinical Trials Network and Partner Institutes”, provides a critical snapshot of the significant heterogeneity in SCI care across high-resource settings. 1 The study highlights notable disparities in steroid use, surgical timing, cervical traction, and advanced monitoring, despite general consensus on core management principles.
While this work underscores the need for standardized protocols in well-resourced environments, two other recent studies offer complementary perspectives that can enrich this discourse, particularly regarding resource-adapted and context-sensitive guidelines.
The BOOTStrap-SCI initiative (Marchesini et al, 2025) addresses a different but equally pressing challenge: the applicability of SCI guidelines in low- and middle-income countries (LMICs).2,3 Through a Delphi consensus process, the authors developed stratified protocols for prehospital, emergency, ICU, and surgical care, tailored to varying levels of resource availability; from settings with no imaging to those with advanced CT/MRI capabilities. This approach does not propose new interventions but reorganizes existing evidence-based practices into feasible and tiered pathways, ensuring that care can be optimized even when resources are limited.
Key lessons from BOOTStrap-SCI relevant to the North American context include: 1. Flexibility in Imaging and Surgical Timing: In resource-limited settings, decompression may proceed based on X-ray findings alone if advanced imaging is unavailable within 24 hours. This pragmatic approach acknowledges that timely intervention should not be delayed by ideal but inaccessible diagnostics.
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2. Stratified Hemodynamic and ICU Management: Protocols are adapted based on available monitoring, from basic clinical assessments to advanced spinal cord perfusion pressure (SCPP) monitoring, ensuring that core principles of perfusion support are maintained across contexts.2,3 3. Emphasis on Training and Feasibility: The BOOTStrap protocols are designed to be implemented by providers with varying training levels, promoting practical adherence over theoretical perfection.
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These insights resonate with the heterogeneity described by Gebeyehu et al, suggesting that variability is not merely a problem of inconsistency but also of contextual appropriateness. 1 Even in high-resource settings, not all centres have equal access to advanced monitoring (eg, lumbar drains for SCPP), and local protocols may reasonably differ based on available expertise and tools.
We therefore propose that future efforts toward standardization in SCI care should: • Incorporate Resource-Stratified Recommendations: Guidelines should explicitly outline acceptable alternatives when ideal resources are unavailable, as demonstrated by BOOTStrap-SCI.2,3 • Promote Context-Sensitive Protocols: Standardization should not mean rigidity. Protocols must allow for adaptation based on institutional capabilities, patient presentation, and regional logistics. • Encourage Cross-Context Learning: High-resource centres can learn from LMIC innovations in triage, transfer, and basic care optimization, while LMICs can benefit from advanced research on neuroprotection and regeneration.
The findings from Gebeyehu et al, combined with the resource-adapted frameworks of BOOTStrap-SCI, highlight a unified theme: optimal SCI care requires both evidence-based principles and pragmatic adaptability. We commend Global Spine Journal for publishing work that spans this spectrum and encourage continued dialogue on how to develop guidelines that are both scientifically rigorous and globally applicable.
