Dear Professors Fehlings, Kwon, Tetreault, Evaniew, Skelly, Alvi & AO Spine/Praxis team, Thank you for your work, care, and leadership service.
I have read and entirely re-read, with raptured interest, your March 2024, volume 4, issue 3 Supplement of Global Spine Journal on the 2024 AO Spine & Praxis Spinal Cord Institute Guidelines for the Management of Acute Spinal Cord Injury https://journals.sagepub.com/toc/gsja/14/3_suppl.
A scientific & clinical tour-de-force, and a monumental oeuvre of multidisciplinary consensus-seeking collaboration project. I wish the clinical community at-large gave it the consideration it deserves, but…
The language (not the contents) of these Guidelines, as scientifically accurate and statistically honest as it is, risks discouraging the non-academic medical community at large, and failing the dissemination and implementation it deserves, by being not compelling enough to counterbalance the sorts of pressures many of us, in the US, face when we care for extremely complex pathology such as the acute spinal cord injury (SCI). Let me explain:
I have been a non-academic medical intensivist in the US for almost 30 years, in many community hospitals, during which I have collaborated side-by-side with many tens of fantastic non-academic spine (neuro/ortho) surgeons, of whom only a single-digit minority have applied the 2017 recommendation of early (<24-h) surgical decompression, or those of 2008 targeted blood pressure management after acute SCI. So much so that I, as a 3-times-board re-certified critical care US physician, had never encountered those 2008/2017 guidelines in my board materials, and thought those rare surgeons I had witnessed doing it were outliers fueled by personal anecdotal training habits.
Come 2021, when my own son had a traumatic SCI, cared acutely in another community trauma center, where those guidelines were, again, not followed by his fantastic trauma and spine surgeons, whom I otherwise owe my son’s life. And I, as his parent and advocate, and a medical intensivist, did not know to advocate for those guidelines.
My frantic drive to catch up with the latest in SCI care since 2021 culminated with my passing the 2024 US NeuroCritical Care Boards, where I encountered the 2008/2017 iteration of your hemodynamic/decompression guidelines (respectively) for the first time in my professional career. Why is that?
I assure you that my community, non-academic spine (neuro/ortho) surgeons have been up to date with their/your specialty literature. I am convinced that some the leaders of my own critical care societies were, too, aware of your Guidelines. Why did all this not penetrate in our standard of practice? Why do exceptional surgeons with impeccable skills and work ethics are reluctant to urgently take on less-than-24-h post-injury spinal decompression in complex, often hypoxemic, hemodynamically-unstable, poly-trauma patients, deferring instead until some preop stabilization? Why do only a minority of surgeons and intensivists pursue supra-physiologic MAPs in acute SCI, in the face of hemodynamic swings, and often-daunting multi-system dysfunction (TBI with hemorrhagic risks, myocardial contusion, TACO/TRALI, etc)? I humbly venture to guess:
The accurate-but overly-sophisticated statistical and probabilistic language of your Guidelines is not expressing strongly-enough realities that you (and all other clinicians) know too well from caring for complex, critically-ill patients:
1) that any commission or omission of therapeutic options carries complex, often unpredictable risks;
2) that acute SCI can be a lifelong, utterly-devastating injury whose mitigation might justify almost any short-term risks;
3) that our acute patients and their families do not know all this, but we do, and we owe them not only preaching what we know, but also doing what we preach.
I respect your Guidelines’ scientific and statistical integrity, and fully understand that SCI trials gather much smaller cohorts than Cardiology’s and Stroke Neurology’s large, standard-of-care-generating trials, but AO/Praxis’ SCI Guidelines’ language like “uncertain,” “unclear,” “weak,” “very low quality,” “caution,” “option,” “suggested,” “controversial,” “contentious,” “conflicting,” “lacking precision,” “failed,” “not justified,” “arbitrary” is detracting from the message: that SCI may impart such a devastating, incurable, lifelong plight, that, had patients and families really knew what they were facing, many might choose to risk anything to alter that course, with the proper informed consent.
Moreover, a stronger, more compelling wording of your Guidelines might lend our non-academic medical community some medico-legal, regulatory, and public-opinion protection in the face of relentless pressure to “limit postoperative mortality,” to “be cost-effective providers,” and to “practice safe, evidence-based medicine.” We can all learn from the rise and fall (and rise again?) of intravenous high-dose MethyPrednisolone’s (iv MP) fame in acute SCI. We, community clinicians, are aching to use anything that could alter the course of SCI, but indecisive language and conflicting recommendations have inflamed the iv MP debate, and left us in a precarious position in the face of medico-legal, regulatory, and public opinion scrutiny, from NASCIS’ 1990s new-standard enthusiasm, to its detraction and avoidance by 2010, to my healthy then-23 year-old son’s trauma surgeons declining its use in 2021, and back to its reconsideration and discussion in Cervical Spine Research Society’s January 2025 meeting.
Guidelines’ wording matters, and makes the difference between having “teeth” and “traction,” vs sowing doubt in our peers and public about our profession’s knowledge of tradeoffs, and intent to improve the odds of our patients. Maybe it’s time to learn from our politicians, lawyers, and clergy, and cloak our scientific integrity and statistical uncertainty in some legitimate swagger. Our patients and their families might better support our science translation, dissemination, and implementation efforts, and thank us for “proclaiming (best available) truth from the rooftops.”
Gratefully and Respectfully Yours,
Cristian (dad of an awesome 27 y/o son with C4-motor-complete quadriplegia)
Cristian Arvinte, MD
NASCIC-Certified, Spinal Cord Injury Research Advocate
ABIM Board-Certified, NeuroCritical Care & Critical Care, Pulmonary & Internal Medicine
Thornton & Denver, CO
carvinte@msn.com
ORCID iD
Cristian Arvinte https://orcid.org/0000-0002-0870-1536