CreveCoeur Travis S, Alexiades Nikita G, Bonfield Christopher M, Brockmeyer Douglas L, Browd Samuel R, Chu Jason, Figaji Anthony A, Groves Mari L, Hankinson Todd C, Harter David H, Hwang Steven W, Jea Andrew, Kernie Steven G, Leonard Jeffrey R, Martin Jonathan E, Oetgen Matthew E, Powers Alexander K, Rozzelle Curtis J, Skaggs David L, Strahle Jennifer M, Wellons John C, Vitale Michael G, Anderson Richard C E
Departments of1Neurological Surgery and.
2Department of Neurological Surgery, University of Arizona-Phoenix, Arizona.
J Neurosurg Spine. 2023 Mar 17:1-14. doi: 10.3171/2023.1.SPINE221188.
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.
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.
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.
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.
这项改良德尔菲研究的重点是调查并就中重度急性脊髓损伤（SCI）儿童在首次住院期间的医疗管理达成共识。开展这项研究的动力源自2013年发布的美国神经外科医师协会/美国神经外科医师学会（AANS/CNS）小儿脊髓损伤指南，该指南指出，文献中未就小儿脊髓损伤患者的医疗管理达成共识。
邀请了一个由19名医生组成的国际多学科团队参与，其中包括儿科神经外科医生、骨科医生和重症监护医生。由于小儿脊髓损伤总体发病率较低、潜在病理生理机制可能相似，且探索不同病因的脊髓损伤是否应区别管理的文献稀缺，作者选择纳入创伤性和医源性病因（如脊柱畸形手术、脊柱牵引、硬脊膜内脊柱手术等）导致的完全性和不完全性损伤。首先对当前的治疗方法进行了调查，并根据调查结果，分发了一份关于潜在共识声明的后续调查问卷。共识的定义为≥80%的参与者在4级李克特量表（强烈同意、同意、不同意、强烈不同意）上达成一致。最后举行了一次线上会议以形成最终的共识声明。
在最后一轮德尔菲调查之后，经过对先前声明的修改和整合，35项声明达成了共识。声明分为以下八个部分：住院护理单元、脊柱固定、药物治疗、心肺管理、静脉血栓栓塞预防、泌尿生殖系统管理、胃肠道/营养管理以及压疮预防。所有参与者均表示，他们愿意或 somewhat愿意根据共识指南改变自己的治疗方法。
医源性（如脊柱畸形、牵引等）和创伤性脊髓损伤的总体管理策略相似。仅建议在硬脊膜内手术后使用类固醇，急性创伤性或医源性硬脊膜外手术后不建议使用。已达成共识，脊髓损伤后血压目标首选平均动脉压范围，6岁及以上儿童的目标为80至90毫米汞柱。建议对急性神经监测变化后类固醇的使用进行进一步的多中心研究。
