Building consensus for the medical management of children with moderate and severe acute spinal cord injury: a modified Delphi study

Travis S. CreveCoeurDepartments of Neurological Surgery and

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Nikita G. AlexiadesDepartment of Neurological Surgery, University of Arizona–Phoenix, Arizona;

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Christopher M. BonfieldDepartment of Neurological Surgery, Vanderbilt University, Nashville, Tennessee;

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Douglas L. BrockmeyerDepartment of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

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Samuel R. BrowdDepartment of Neurosurgery, University of Washington/Seattle Children’s Hospital, Seattle, Washington;

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Jason ChuDepartment of Neurosurgery, Children’s Hospital of Los Angeles, California;

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Anthony A. FigajiDepartment of Neurosurgery, University of Cape Town, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa;

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Mari L. GrovesDepartment of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;

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Todd C. HankinsonDepartment of Pediatric Neurosurgery, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado;

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David H. HarterDepartment of Neurosurgery, New York University, New York, New York;

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Steven W. HwangShriners Hospital for Children, Philadelphia, Pennsylvania;

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Andrew JeaDepartment of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma;

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Steven G. KernieDepartment of Pediatrics, Columbia University, New York, New York;

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Jeffrey R. LeonardDepartment of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio;

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Jonathan E. MartinDepartment of Pediatric Neurosurgery, Connecticut Children’s Hospital, Hartford, Connecticut;

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Matthew E. OetgenDepartment of Orthopedic Surgery, Children’s National Hospital, Washington, DC;

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Alexander K. PowersDepartment of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina;

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Curtis J. RozzelleDepartment of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama;

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David L. SkaggsDepartment of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California; and

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Jennifer M. StrahleDepartment of Neurosurgery, Washington University in St. Louis, Missouri

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John C. Wellons IIIDepartment of Neurological Surgery, Vanderbilt University, Nashville, Tennessee;

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Michael G. VitaleOrthopedic Surgery, Columbia University Medical Center, New York, New York;

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Richard C. E. AndersonDepartment of Neurosurgery, New York University, New York, New York;

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Publication Date:
17 Mar 2023
Page Range:
1–14
Volume/Issue:
Publish Before Print
DOI link:
https://doi.org/10.3171/2023.1.SPINE221188
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OBJECTIVE

The focus of this modified Delphi study was to investigate and build consensus regarding the medical management of children with moderate and severe acute spinal cord injury (SCI) during their initial inpatient hospitalization. This impetus for the study was based on the AANS/CNS guidelines for pediatric SCI published in 2013, which indicated that there was no consensus provided in the literature describing the medical management of pediatric patients with SCIs.

METHODS

An international, multidisciplinary group of 19 physicians, including pediatric neurosurgeons, orthopedic surgeons, and intensivists, were asked to participate. The authors chose to include both complete and incomplete injuries with traumatic as well as iatrogenic etiologies (e.g., spinal deformity surgery, spinal traction, intradural spinal surgery, etc.) due to the overall low incidence of pediatric SCI, potentially similar pathophysiology, and scarce literature exploring whether different etiologies of SCI should be managed differently. An initial survey of current practices was administered, and based on the responses, a follow-up survey of potential consensus statements was distributed. Consensus was defined as ≥ 80% of participants reaching agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A final meeting was held virtually to generate final consensus statements.

RESULTS

Following the final Delphi round, 35 statements reached consensus after modification and consolidation of previous statements. Statements were categorized into the following eight sections: inpatient care unit, spinal immobilization, pharmacological management, cardiopulmonary management, venous thromboembolism prophylaxis, genitourinary management, gastrointestinal/nutritional management, and pressure ulcer prophylaxis. All participants stated that they would be willing or somewhat willing to change their practices based on consensus guidelines.

CONCLUSIONS

General management strategies were similar for both iatrogenic (e.g., spinal deformity, traction, etc.) and traumatic SCIs. Steroids were recommended only for injury after intradural surgery, not after acute traumatic or iatrogenic extradural surgery. Consensus was reached that mean arterial pressure ranges are preferred for blood pressure targets following SCI, with goals between 80 and 90 mm Hg for children at least 6 years of age. Further multicenter study of steroid use following acute neuromonitoring changes was recommended.

ABBREVIATIONS

BP = blood pressure; CPP = cerebral perfusion pressure; DVT = deep venous thrombosis; GM-1 = GM-1 ganglioside; ICP = intracranial pressure; IONM = intraoperative neuromonitoring; MAP = mean arterial pressure; MP = methylprednisolone; SBP = systolic BP; SCI = spinal cord injury; TBI = traumatic brain injury; TLSO = thoracic-lumbar-sacral orthosis; VTE = venous thromboembolism.
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Contributor Notes

Correspondence Travis S. CreveCoeur: Columbia University Medical Center, New York, NY. tc2682@cumc.columbia.edu.

INCLUDE WHEN CITING Published online March 17, 2023; DOI: 10.3171/2023.1.SPINE221188.

T.S.C. and N.G.A. contributed equally to this work.

Disclosures Dr. Hwang reported personal fees from Auctus, DePuy Synthes Spine, NuVasive, and ZimVie outside the submitted work. Dr. Skaggs reported grants from NuVasive; being a co–principal investigator on a research grant paid to the Pediatric Spine Foundation; consulting for and receiving royalties from Globus Medical; consulting for Top Doctors; consulting for, owning stocks in, and being a co-editor in chief for Orthobullets; receiving stock options from Green Sun Medical and Zipline Medical Inc.; receiving stocks options and royalties from Wolters Kluwer Health outside the submitted work; having a patent with royalties paid for Medtronic and Zimmer Biomet; and being on the editorial boards of Spine Deformity, Orthopedics Today, and Journal of Children’s Orthopedics.

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