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Building consensus for the medical management of children with moderate and severe acute spinal cord injury: a
Travis S CreveCoeur1, Nikita G Alexiades2, Christopher M Bonfield3
1Departments of1Neurological Surgery and.
Insights
This study established consensus on managing pediatric spinal cord injuries (SCI), recommending similar strategies for traumatic and iatrogenic cases. Steroids are advised only after intradural surgery, with specific blood pressure targets for children.
Area of Science:
- Pediatric neurosurgery
- Orthopedic surgery
- Critical care medicine
Background:
- Lack of consensus on medical management for pediatric spinal cord injury (SCI).
- Existing guidelines (AANS/CNS 2013) highlight this gap.
- Need for standardized inpatient care protocols for pediatric SCI.
Purpose of the Study:
- To achieve expert consensus on the medical management of moderate to severe acute pediatric SCI during initial hospitalization.
- To address the absence of established guidelines for pediatric SCI management.
- To inform clinical practice through a modified Delphi study.
Main Methods:
- Modified Delphi study involving 19 international pediatric specialists (neurosurgeons, orthopedic surgeons, intensivists).
- Inclusion of traumatic and iatrogenic etiologies (e.g., spinal deformity surgery, traction) due to low incidence and similar pathophysiology.
- Surveys and virtual meetings to establish consensus (≥80% agreement on Likert scale).
Main Results:
- 35 consensus statements developed across eight categories: inpatient care, immobilization, pharmacology, cardiopulmonary, VTE prophylaxis, genitourinary, gastrointestinal/nutrition, and pressure ulcer prophylaxis.
- General management strategies found similar for iatrogenic and traumatic SCIs.
- Participants expressed willingness to adapt practices based on consensus guidelines.
Conclusions:
- Steroid use recommended only for post-intradural surgery SCI, not for acute traumatic or iatrogenic extradural SCI.
- Consensus on mean arterial pressure (MAP) targets: 80-90 mm Hg for children ≥6 years.
- Further multicenter research on steroid use post-acute neuromonitoring changes is recommended.
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.
