Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury in the Setting of Spine Surgery: A Proposed Care Pathway

Nisaharan Srikandarajah; Nader Hejrati; Mohammed Ali Alvi; Ayesha Quddusi; Lindsay A Tetreault; Nathan Evaniew; Andrea C Skelly; Sam Douglas; Vafa Rahimi-Movaghar; Paul M Arnold; Steven Kirshblum; Brian K Kwon; Michael G Fehlings

doi:10.1177/21925682231217980

Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury in the Setting of Spine Surgery: A Proposed Care Pathway

Global Spine J. 2024 Mar;14(3_suppl):166S-173S. doi: 10.1177/21925682231217980.

Authors

Affiliations

¹ Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
² Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
³ Department of Neurology, NYU Langone Medical Center, New York, NY, USA.
⁴ McCaig Institute for Bone and Joint Health, Department of Surgery, Orthopaedic Surgery, Cumming School of Medicine, University of Calgary, AB, Canada.
⁵ Aggregate Analytics, Inc., Fircrest, WA, USA.
⁶ Praxis Spinal Cord Institute, Vancouver, BC, Canada.
⁷ Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
⁸ Department of Neurosurgery, University of Illinois Champaign-Urbana, Urbana, IL, USA.
⁹ Kessler Institute for Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA.
¹⁰ Department of Orthopaedics, University of British Columbia, Vancouver, BC, Canada.
¹¹ International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC, Canada.
¹² Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.

Abstract

Study design: This study is a mixed methods approach.

Objectives: Intraoperative spinal cord injury (ISCI) is a challenging complication in spine surgery. Intra-operative neuromonitoring (IONM) has been developed to detect changes in neural function. We report on the first multidisciplinary, international effort through AO Spine and the Praxis Spinal Cord Institute to develop a comprehensive guideline and care pathway for the prevention, diagnosis, and management of ISCI.

Methods: Three literature reviews were registered on PROSPERO (CRD 42022298841) and performed according to PRISMA guidelines: (1) Definitions, frequency, and risk factors for ISCI, (2) Meta-analysis of the accuracy of IONM for diagnosis of ISCI, (3) Reported management approaches for ISCI and related events. The results were presented in a consensus session to decide the definition of IONM and recommendation of its use in high-risk cases. Based on a literature review of management strategies for ISCI, an intra-operative checklist and overall care pathway was developed by the study team.

Results: An operational definition and high-risk patient categories for ISCI were established. The reported incidence of deficits was documented to be higher in intramedullary tumour spine surgery. Multimodality IONM has a high sensitivity and specificity. A guideline recommendation of IONM to be employed for high-risk spine cases was made. The different sections of the intraoperative checklist include surgery, anaesthetic and neurophysiology. The care pathway includes steps (1) initial clinical assessment, (2) pre-operative planning, (3) surgical/anaesthetic planning, (4) intra-operative management, and (5) post-operative management.

Conclusions: This is the first evidence based comprehensive guideline and care pathway for ISCI using the GRADE methodology. This will facilitate a reduction in the incidence of ISCI and improved outcomes from this complication. We welcome the wide implementation and validation of these guidelines and care pathways in prospective, multicentre studies.

Keywords: care pathway; intraoperative SCI; spinal cord injury; spine surgery.