Initial surgical management of spinal injuries in patients with multiple and/or severe injuries- the 2022 update of the German clinical practice guideline.

purposeOur aim was to update evidence-based and consensus-based recommendations for the initial surgical management of spinal (cord) injuries in patients with multiple and/or severe injuries based on current evidence. This guideline topic is part of the 2022 update of the German Guideline on the Treatment of Patients with Multiple and/or Severe Injuries.

methodsMEDLINE and Embase were systematically searched to May 2021. Further literature reports were obtained from clinical experts. Randomised controlled trials, prospective cohort studies, and comparative registry studies were included if they compared interventions and the timing of interventions for the initial surgical management of spinal (cord) injuries in patients with polytrauma and/or severe injuries. We considered patient-relevant clinical outcomes such as mortality, complication rates, and lengths of stay. Risk of bias was assessed using NICE 2012 checklists. The evidence was synthesised narratively, and expert consensus was used to develop recommendations and determine their strength.

resultsSeven new studies were identified. All studies compared different moments for the initial surgical management of spinal injuries. Three recommendations were modified, and three additional recommendations were developed. All achieved strong consensus.

conclusionThe following key recommendations are made. (1) Patients with spinal injuries or deformities with confirmed or assumed neurological deficits which can be treated operatively should undergo surgery as soon as possible (ideally on day 1) if their other medical conditions permit. (2) If suggested by fracture morphology with spinal canal compression or translational injury and if spinal neurological damage cannot be ruled out, assume the presence of spinal neurological damage until it can be ruled out. (3) In the absence of neurological signs and/or symptoms, unstable spinal injuries should be treated by early surgical stabilization based on the patient's overall condition. (4) Depending on the injury, an anterior and/or posterior approach or, in exceptional cases, a halo fixation device can be used to stabilize the cervical spine. (5) Posterior internal fixation should be used as the primary surgical technique for stabilizing injuries to the thoracic and lumbar spine.