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

Author:

CreveCoeur Travis S.1,Alexiades Nikita G.2,Bonfield Christopher M.3,Brockmeyer Douglas L.4,Browd Samuel R.5,Chu Jason6,Figaji Anthony A.7,Groves Mari L.8,Hankinson Todd C.9,Harter David H.10,Hwang Steven W.11,Jea Andrew12,Kernie Steven G.13,Leonard Jeffrey R.14,Martin Jonathan E.15,Oetgen Matthew E.16,Powers Alexander K.17,Rozzelle Curtis J.18,Skaggs David L.19,Strahle Jennifer M.20,Wellons John C.3,Vitale Michael G.21,Anderson Richard C. E.10

Affiliation:

1. Departments of Neurological Surgery and

2. Department of Neurological Surgery, University of Arizona–Phoenix, Arizona;

3. Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee;

4. Department of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;

5. Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Seattle, Washington;

6. Department of Neurosurgery, Children’s Hospital of Los Angeles, California;

7. Department of Neurosurgery, University of Cape Town, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa;

8. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;

9. Department of Pediatric Neurosurgery, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado;

10. Department of Neurosurgery, New York University, New York, New York;

11. Shriners Hospital for Children, Philadelphia, Pennsylvania;

12. Department of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma;

13. Department of Pediatrics, Columbia University, New York, New York;

14. Department of Neurosurgery, Nationwide Children’s Hospital, Columbus, Ohio;

15. Department of Pediatric Neurosurgery, Connecticut Children’s Hospital, Hartford, Connecticut;

16. Department of Orthopedic Surgery, Children’s National Hospital, Washington, DC;

17. Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina;

18. Department of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama;

19. Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California; and

20. Department of Neurosurgery, Washington University in St. Louis, Missouri

21. Orthopedic Surgery, Columbia University Medical Center, New York, New York;

Abstract

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.

Publisher

Journal of Neurosurgery Publishing Group (JNSPG)

Subject

General Medicine

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