# French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury

A. Roquilly, B. Vigué, M. Boutonnet, Pierre Bouzat, K. Buffenoir, E. Cesareo, A. Chauvin, C. Court, F. Cook, A.C. de Crouy, et al.

► To cite this version:

A. Roquilly, B. Vigué, M. Boutonnet, Pierre Bouzat, K. Buffenoir, et al. French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury. Anaesthesia Critical Care & Pain Medicine, 2020, 39 (2), pp.279-289. 10.1016/j.accpm.2020.02.003. hal-04821273

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for surgical management? (8) What are the best arrangements for orotracheal intubation in the hospital environment? (9) What are the specific conditions for weaning these patients from mechanical ventilation for? (10) What are the procedures for analgesic treatment of these patients? (11) What are the specific arrangements for installing and mobilising these patients? (12) What is the place of early intermittent bladder sampling in these patients? Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE<sup>10</sup> Methodology.

*Results:* The experts' work synthesis and the application of the GRADE method resulted in 19 recommendations. Among the recommendations formalised, 2 have a high level of evidence (GRADE 1+/-) and 12 have a low level of evidence (GRADE 2+/-). For 5 recommendations, the GRADE method could not be applied, resulting in expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations.

*Conclusions:* There was significant agreement among experts on strong recommendations to improve practices for the management of patients with spinal cord injury.

© 2020 The Author(s). Published by Elsevier Masson SAS on behalf of Société française d'anesthésie et de réanimation (Sfar). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

**Experts coordinators**

Bernard Vigué and Antoine Roquilly (SFAR)

**Organisers**

Hervé Quintard and Lionel Velly (SFAR)

**Reviewer panels**

SFAR Guidelines committee: Lionel Velly (President), Marc Garnier (Secretary), Julien Amour, Alice Blet, Gérald Chanques, Hélène Charbonneau, Vincent Compere, Philippe Cuvillon, Etienne Gayat, Catherine Huraux, Hervé Quintard, Emmanuel Weiss

**Introduction**

Spinal cord injury (SCI) is a common pathology with one million new cases worldwide every year, and 27 million patients living with the sequelae of SCI. In France, approximately 2000 patients are affected by SCI every year. SCIs are a burden for healthcare systems and economies through lost productivity and high healthcare costs.

Care for SCI patients requires cooperation between several care-providers (emergency teams, anaesthesiologists and intensivists, surgeons and rehabilitation specialists). Each stage of caring for SCI patients is critical to enhance neurological recovery. Recent progress in knowledge of this pathophysiology, in the prevention of complications and also in techniques has changed the way SCI patients are managed. We therefore decided to update the 2004 recommendations for SCI patients. The guideline committees of the French Society of Anaesthesia and Intensive Care (Société française d'anesthésie et de réanimation [SFAR]) appointed an organising committee which selected twenty-seven French-speaking experts following approval by their respective boards: SOFCOT (Société française de chirurgie orthopédique et traumatologique), SFMU (Société française de médecine d'urgence), SOFMER (Société française de médecine physique et de réadaptation), SFCR (Société française de chirurgie rachidienne) and ANARLF (Association des Neuro-anesthésistes réanimateurs de langue française). Two independent bibliographic experts analysed the literature from the past 16 years in the field using pre-defined keywords.

**Methodology**

As a first step, the organising committee, together with the expert coordinators, defined the issues to be addressed and selected the experts in charge of each of them. Questions were

formulated in PICO (Patient Intervention, Comparison, Outcome) format. Extensive bibliographic research dating back to 2004 was made via the PubMed and Cochrane databases. To be eligible for inclusion in the analysis, the publications had to be published in English or French according to the 2004 French guidelines and considered by the group of experts as being important. The group schedule is provided in Table 1.

**GRADE methodology**

The GRADE method was used to formulate these guidelines. Following a quantitative literature analysis, this method was used to separately determine the quality of available evidence, i.e. estimation of the confidence level required to analyse the effect of the quantitative intervention, and the level of recommendation. The quality of evidence was rated as follows:

* high-quality evidence: further research is very unlikely to change the confidence level in the estimate of the effect;

* moderate-quality evidence: further research is likely to have an impact on confidence in the estimate of the effect and may change the estimate of the effect itself;

* low-quality evidence: further research is very likely to have an impact on confidence in the estimate of the effect and is likely to change the estimate of the effect itself;

* very low-quality evidence: any estimate of the effect is very unlikely.

The level of recommendation was binary (either positive or negative), and strong or weak:

* strong recommendation: we recommend, or we do not recommend (Grade 1+ or 1-);

* weak recommendation: we probably recommend, or we probably not recommend (Grade 2+ or 2-).

The strength of the recommendations was determined according to key factors and validated by the experts after a vote, using the Delphi and Grade Grid method which encompasses the following criteria:

<table><caption>**Table 1**
Guideline timeline.</caption><tr><td>Kick-off meeting</td><td>July 3rd, 2018</td></tr><tr><td>Vote: first round</td><td>October 20th, 2018</td></tr><tr><td>Post-vote deliberation meeting</td><td>November 27th, 2018</td></tr><tr><td>Vote: second round</td><td>January 20th, 2019</td></tr><tr><td>Guideline finalisation meeting</td><td>April 10th, 2019</td></tr><tr><td>Endorsement of the recommendations by the SFAR</td><td>May 24th, 2019</td></tr></table>
* the estimate of the effect;

* the global level of evidence: the higher the level of evidence, the stronger the recommendation;

* the balance between desirable and undesirable effects: the more favourable the balance, the stronger the recommendation;

* values and preferences: in the event of uncertainty or large variability, the level of evidence of the recommendation is probably weak, and values and preferences must be more clearly obtained from the affected persons (patient, physician and decision-maker);

* cost: the greater the costs or the use of resources, the weaker the recommendation.

To constitute a recommendation, at least 50% of the voting participants must have the same opinion with fewer than 20% of participants voting for the opposite proposal. For strong agreement, at least 70% of the voting participants must agree.

## Results

### Areas of guidelines

The three main goals of these recommendations were: first, the optimisation of the initial management of patients with suspected SCI, from clinical suspicion to hospital admission; second, standardisation of early in-hospital management including anaesthesia, radiology and surgery considerations and, lastly, promotion during the first week of the prevention of respiratory and haemodynamic failures, treatment of spasticity and pain, and also early rehabilitation.

### Recommendations

After summarising the work of the experts and applying the GRADE method, 19 recommendations were formalised. All of the recommendations were submitted to the expert group for rating with the GRADE® method. After two rounds of rating and various amendments, a strong agreement was reached for 100% of the recommendations. Among the recommendations, 2 are strong (Grade 1+/-), 12 are weak (Grade 2+/-) and, for 5 recommendations, the GRADE® method could not be applied and therefore required an expert opinion.

These recommendations replace the 2004 recommendations in the same field of application published by the SFAR. The SFAR encourages all anaesthesiologists-intensivists to comply with these recommendations to ensure a high quality of care for SCI patients. However, in applying these recommendations, each practitioner must exercise his judgment, considering his expertise and the specificities of his institution, to determine the best-suited intervention method to the condition of the patient he is responsible for.

### Question 1: In the severely traumatised patient, does early immobilisation of the spine improve the functional prognosis?

**R1.1**-It is probably recommended to immobilise the spine of any traumatised patient suspected of spinal cord injury early to limit the onset or aggravation of neurological deficit to the initial phase.

(GRADE 2+) STRONG AGREEMENT

### Rationale

Of the 97,341 patients in the 10-year records on road traffic accidents in the Rhône department, spinal cord injuries concerned 21,623 (22%) patients in 1997 and 1667 (1.8%) spinal cord injuries in 2006 [1]. One of the objectives of initial management is to avoid

making the injuries worse, in particular, the appearance of a spinal cord injury secondary to inappropriate spinal manipulation. A retrospective study on 59 patients with spinal cord injuries estimated that 46% of them had suffered lesion aggravation secondary to mobilisation, which could probably have been avoided in 90% of cases [2]. However, so far no high-level evidence-based studies have been conducted on the risk benefit ratio of complete or localised immobilisation of a suspected case of spine trauma. The requirements of care in the field involve extraction, being transported on stretcher and by vehicle, all of which are often sources of potential movement of the spinal segments. For these reasons, immobilisation techniques are quickly deployed in pre-hospital settings.

**Cervical spine immobilisation:** Studies testing the impact of devices to immobilise the cervical spine are numerous, fragmented, and mainly on corpses or healthy volunteers. Moreover, they are very heterogeneous, with unconvincing results [3,4] and sometimes harmful consequences (increase in intracranial pressure, difficulty of intubation). The indication and implementation of a device for holding and immobilising the cervical spine must therefore be integrated into a management algorithm (Fig. 1). This strategy, as reported in the Norwegian referential, is based on the Nexus study [5-7]. When the indication is established, it is proposed to immobilise the cervical spine by holding the head with the addition of lateral blocks or, failing this, a rigid cervical collar [8].

**Immobilisation of the lumbar and thoracic spine:** Concerning thoracolumbar spinal immobilisation, it is still recommended in the event of suspicion of vertebral lesions (risk of staged vertebral lesions). A hard surface is therefore the gold standard for the extraction phase, but may lead to complications (particularly cutaneous), which impacts survival during prolonged use [9-12]. During transport, the vacuum mattress is recommended for the patient's comfort, providing a spinal support identical to that of a hard surface [12].

### Question 2: In patients with cervical spinal cord injury or suspected cervical spinal cord injury, what management of tracheal intubation in prehospital settings can reduce complications associated with intubation while limiting the mobilisation of the cervical spine?

**R2.1**-Experts suggest, in patients with or at risk of cervical spinal cord injury, manual in-line stabilisation, combined with removal of the anterior part of the cervical collar during tracheal intubation procedures to limit mobilisation of the cervical spine and promote glottic exposure.

**EXPERT OPINION**

**R2.2**-In patients with or at risk of cervical spinal cord injury, for pre-hospital tracheal intubation, a procedure integrating rapid induction with direct laryngoscopy, use of a gum elastic bougie and retention of the cervical spine in the axis without Sellick manoeuvre is probably recommended to increase the success rate at the first attempt.

(GRADE 2+) STRONG AGREEMENT

### Rationale for R2.1

The benefit or the risk of neurological aggravation of manual inline stabilisation (MILS) of the cervical spine during ventilation or intubation manoeuvres is based on a comparison of historical series, in which manual stabilisation was either applied or not. Even if the level of evidence appears low, the results show a major reduction in complications with MILS [13,14]. For these reasons, MILS is still
<figure><img src="image_2.png" /><figcaption>**Fig. 1.** Algorithm for spinal immobilisation of patients with cervical spinal cord injury or at risk of cervical spinal cord injury (Expert Opinion).</figcaption></figure>

recommended during mask ventilation and orotracheal intubation. MILS is also responsible for an increase in the rate of difficult intubations due to lower quality exposure in direct laryngoscopy [15]. However, opening the cervical collar at the time of intubation facilitates mouth opening and improves glottic exposure. The effect of mask ventilation and direct laryngoscopy on cervical spine mobility has been studied since the late 1970s, but the models used are imperfect (corpses or patients without intubated spinal cord injury for scheduled surgery) [16]. The level of evidence from these studies does not support a significant risk of neurological aggravation related to intubation. Only a few published clinical cases draw attention to the possibility of this risk [17].

**Rationale for R2.2**

Several alternative techniques of indirect laryngoscopy or videolaryngoscopy have been studied compared to direct laryngoscopy with Macintosh blade. In the prehospital setting, the use of videolaryngoscopy cannot be recommended as a first-line treatment based on data from the only published randomised prospective study [18]. Experience with the use of videolaryngos-

copes by the operator must be taken into account [19]. The use of a gum-elastic bougie is interesting in this context and seems to facilitate the success of the gesture [20].

**Question 3.1: In patients with spinal cord injury, what is the minimum level of blood pressure that should be maintained before the injury assessment to reduce mortality?**

R3.1–In patients at risk of spinal cord injury, it is probably recommended to maintain a systolic blood pressure level > 110 mmHg, before the injury assessment performed, to reduce mortality.

(GRADE 2+) STRONG AGREEMENT

**Rationale**

Mortality of severe trauma patients, whether traumatic brain injury or not, is inversely correlated with systolic blood pressure
(SBP) at hospital admission. An analysis of data from 87,0634 National Trauma databank patients found a 4.8% increase in severe trauma mortality with each 10 mmHg decrease in SBP at admission from 110 mmHg SBP in severe trauma patients without severe head injury and from 115 mmHg SBP when severe head injury was not excluded from the analysis [21].

**Question 3.2: In patients with spinal cord injury, what is the minimum level of arterial pressure required during the first week post-trauma to improve the neurological prognosis?**

**R3.2**–In patients with suspicion of spinal cord injury, the experts suggest maintaining mean arterial pressure level up to 70 mmHg during the first week to limit the risk of worsening of the neurological deficit.

**EXPERT OPINION**

**Rationale**

There are no randomised controlled trials comparing the neurological prognosis of patients with spinal cord injury to a specific blood pressure objective. Hypotension at hospital admission, defined as systolic blood pressure (SBP) < 110 mmHg, is an independent factor of patient mortality after spinal cord injury [22]. One small retrospective study (n = 17) describes a reverse correlation between the time spent with a MAP < 65 mmHg or < 70 mmHg and neurological improvement. This correlation is no longer found for MAPs below 75, 80 or 85 mmHg [23].

The American Association of Neurological Surgeons/Congress of Neurological Surgeons recommends that all acute phases of arterial hypotension (SBP < 90 mmHg) be banned until day 5–7 [2]. These experts also propose to target supra-physiological objectives of mean blood pressure (MAP > 85 mmHg) within the first 5 to 7 days. This last recommendation is essentially based on two prospective interventional studies, none of which had a control group [24,25]. Therefore, there is an insufficient level of evidence to recommend a MAP level of over 70 mmHg. An analysis of continuous blood pressure collection in 74 patients with spinal cord injury showed that it is difficult to achieve a target MAP as the MAP is below the determined objective 25% of the time [23]. For this reason, it is recommended to continuously monitor MAP with an arterial catheter. The correlation between MAP level and neurological improvement during hospitalisation appeared for MAP values > 70–75 mmHg and only existed for 2–3 days after admission. More recently, a study evaluated the neurological prognosis at 6 months in 92 patients with traumatic spinal cord injury according to their level of spinal cord perfusion pressure [26]. A spinal perfusion pressure > 50 mmHg was correlated with better neurological status at 6 months. Analysis of the different relative risks by combining the MAP variations led to the determination of an optimal MAP level > 70 mmHg.

**Question 4: In patients with traumatic spinal cord injury or suspected traumatic spinal cord injury, does transfer to a specialised care unit prevent complications, improve prognosis and decrease long-term mortality?**

**R4.1**–It is probably recommended to transfer patients with traumatic spinal cord injury (including those patients with transient neurological recovery) to a specialised care unit to decrease morbidity and long-term mortality.

**(GRADE 2+) STRONG AGREEMENT**

**Rationale**

Within the first hours after trauma, the direct admission of trauma patients to Level 1 trauma centres reduces their morbidity and mortality [27]. Level 1 trauma centres have constant access to a fully fitted technical platform for the diagnosis and treatment of spinal cord injury and any other associated traumatic lesions. In the context of spinal cord injury, this direct admission is associated with earlier surgical procedures, a reduction in length of stay at the intensive care unit [28] and an improvement in neurological outcomes [29].

After discharge from intensive care units, the overall level of evidence to recommend the best patient orientation is low and relies on observational studies [30,31]. Direct transfer from a Level 1 trauma centre to a specialised spinal rehabilitation unit has been associated with a reduction in the incidence of pressure ulcers and venous thromboses [32,33]. The impact on neurological recovery and independence scores of transferring the patient to a specialised spinal rehabilitation unit is probably positive but has yet to be demonstrated [32,33].

**Question 5: After spinal cord injury, does early administration of steroids improve post-traumatic neurological outcomes?**

**R5.1**–After post-traumatic spinal cord injury, it is not recommended to administrate steroids early on to improve the neurological prognosis.

**(GRADE 1–) STRONG AGREEMENT**

**Rationale**

Three randomised controlled trials have investigated the role of methylprednisolone in patients with traumatic spinal cord injury. The NACSIS 1 trial [34] compared two doses of steroids (1 g vs 100 mg bolus within the first 10 days). The authors did not find any difference in terms of neurologic improvement and there was no control group. It should be noted that a higher rate of infectious complications was found in the low-dose group. The NACSIS II trial [35] randomised patients in three groups: high dose, naloxone and placebo within the first 12 hours post-trauma. A modest improvement of motor scores was observed at 6 months in the sub-group of patients treated with steroids within the first 8 hours, without any standardised long-term assessment. More infections were also reported in the steroid group (7% in the steroid group vs. 3% in the placebo group) with no statistical significance. The NACSIS 3 trial [36] compared a 24 h-administration vs. a 48 h-administration of steroids. Patients in the 48 h group did not have better motor improvement but had a higher rate of infectious complications. There was no control group. Finally, a recent propensity score analysis of a large Canadian cohort did not find any beneficial effect of steroids on one-year motor function [37]. The authors found more infectious pulmonary and urinary complications in patients treated with steroids.

**Question 6: In patients with spinal cord injury, does early Magnetic Resonance Imaging (MRI) in addition to a spine CT scan modify the surgical procedure?**

**R6.1**–Experts suggest that spinal MRI should be performed as soon as possible to reach a final diagnosis in the event of post-traumatic neurological deficit, which is unexplained by an injury observed with a CT scan.

**EXPERT OPINION**
**R6.2**-When it is possible to perform an MRI exam without delaying surgical treatment or endangering the patient, it is probably recommended to realise a preoperative spinal MRI to improve and guide the surgical procedure.

(GRADE 2+) STRONG AGREEMENT

Rationale

No randomised studies have specifically assessed the effects of preoperative MRI on the recovery of patients with traumatic spinal cord injuries. In one prospective observational study, early MRI on the functional outcome of cervical lesions led to urgent surgery in 34 patients (54%) [38]. Patients in the "MRI-based protocol" group had better functional recovery on the modified Frankel scale and a shorter ICU stay than 25 control patients who had not had MRI due to contraindications. Among patients with an initial complete motor deficit, the ability to walk autonomously was recovered in 8 (12%) patients in the "MRI-based protocol" group, and in 0% patients of the "MRI-free" group. However, this study presented serious biases that might explain the differences observed in terms of neurological outcome (average improvement of 0.7 on the modified Frankel scale) or length of stay [38].

Despite the low level of evidence of the impact of MRI on patient recovery, the expert recommendation was also motivated by the indirect evidence of the capabilities of MRI to detect medullary compression, medullary contusion, ligament lesion, herniated disc and epidural haematoma. MRI can diagnose bone marrow compression and determine its aetiology with accuracy judged as "good to excellent" in the studies [39], and a higher sensitivity than CT for the diagnosis of epidural haematomas or disc herniation [40]. In several observational studies, MRI diagnosis of spinal cord compression was associated with an improved neurologic prognosis (OR = 2.83, 95% CI: 1.10–7.28) [41] with faster surgical decision (decompression) [42].

In a recent series of 1916 patients treated for a traumatic lesion of the cervical spine, the frequency of post-traumatic epidural haematoma was 9.1%. More than 13% of them had an interpreted scanner as normal and were only diagnosed on MRI. MRI studies in patients with cervical spinal cord injury find a high rate hernia or associated disc protrusion (36%) [39]. The presence of a large herniated disc is a parameter that is likely to change the surgical strategy by performing surgical decompression by anterior instead of, or in addition to posterior decompression.

Finally, the experts also considered the risks associated with performing the MRI procedure. This depends on many factors such as the existence or not of associated lesions or possible spinal shock responsible for haemodynamic instability, and also the risk of maintaining the patient in a supine position for about 30 minutes, in particular, risk of intracranial hypertension in patients with traumatic brain injury. The experts agree that, provided the patient's safety conditions are considered satisfactory, the expected benefits of MRI may be greater than these undesirable effects.

**Question 7: In patients with traumatic spinal cord injury or traumatic lumbosacral plexus injury or suspected spinal cord or traumatic lumbosacral plexus injury, what is the optimal surgical timing to enhance neurological recovery?**

**R7.1**-In patients with traumatic spinal cord injury or lumbosacral plexus injury, it is probably recommended to realise an emergency surgical decompression, no later than 24 hours after the neurological deficit, to improve the long-term neurological recovery.

(GRADE 2+) STRONG AGREEMENT

Rationale

Compared to delayed surgery (beyond 24 hours from trauma), early surgery has been associated with an improvement in neurological recovery as assessed by the number of patients with neurological deficit as well as an improvement in the mean ASIA score measured after discharge. This association has been reported, in prospective studies, for patients with cervical or thoracic injury (Relative Risk of recovery with early surgery (RR) = 8.9, 95% CI [1.12–70.64] P = 0.01, n = 84) [43] and for patients with complete or incomplete neurological deficit (AIS impairment scale A versus B-D n = 888) [44]. Although smaller prospective studies found no differences (n = 35 [45], n = 73 [46]), none of them found a better neurological recovery in patients operated later on (≥ 24 hours). Finally, the authors of a meta-analysis found a neurological benefit with early surgery for patients with complete neurological deficit (ASIA impairment scale A, n = 1111) [47]. Early surgery is also associated with a reduction of the risk of pulmonary complications (atelectasis, pneumopathy) [48,49].

Ultra-early surgery (< 8 hours after trauma) has been described in few retrospective studies and in one meta-analysis [50–52]. Many specialists believe that, in a very safe situation combining well-organised patient reception and patient stability, surgery within the first 8 hours post-trauma may reduce complications, especially respiratory complications, and increase the chances of neurological recovery [51,52]. French Level 1 trauma centres are frequently able to safely operate SCI patients within the first 8 hours, which reinforces the point about transferring these patients to specialised centres.

**Question 8: In patients with cervical spinal cord injury or suspected cervical spinal cord injury, what management of tracheal intubation in the operating theatre can reduce complications associated with intubation while limiting the mobilisation of the cervical spine?**

**R8.1**-In an emergency condition, it is probably recommended to perform rapid-sequence induction and to use videolaryngoscopy in the first instance to facilitate tracheal intubation and to reduce the risk of intubation failure.

(GRADE 2+) STRONG AGREEMENT

**R8.2**-In non-emergency condition and in cooperative patient, it is probably recommended to realise a fiberoptic intubation with spontaneous ventilation in patients with a risk of difficult mask ventilation and/or indirect laryngoscopy difficulties (mouth opening < 2.5 cm), to reduce the risk of intubation failure.

(GRADE 2+) STRONG AGREEMENT

Rationale

In the context of potentially difficult intubation due to head and neck immobilisation, several alternative techniques for indirect laryngoscopy or videolaryngoscopy, as against direct laryngoscopy with a Macintosh blade, have been studied in the operating theatre. One meta-analysis selected 24 studies including 1866 patients [53]. The authors found a decrease in the risk of intubation failure in the first trial associated with the use of videolaryngoscopy systems compared with the Macintosh laryngoscope (RR 0.53, 95% CI 0.35–0.80). Among the different types of videolaryngoscopes, only the Airtraq has benefitted from studies to demonstrate a reduction in the risk of intubation failure (3.4% versus 28.6% with Macintosh laryngoscope, RR 0.14, 95% CI 0.06–0.33, NNT 5.0, 95% CI 3.9–8.1). Other systems (Airway Scope, C-Mac, Glidescope and
McGrath) are not significantly associated with a reduction in the rate of intubation failures. Moreover, with or without cervical trauma, the latest French SFAR recommendations for difficult intubation specify the first-line use of videolaryngoscopes in patients with effective mask ventilation and at least two difficult intubation criteria [54]. All the aforementioned studies used a conventional induction protocol with administration of a non-depolarising curare. Extrapolation to rapid sequence induction in an emergency context must therefore be cautious.

There is evidence of decreased cervical spine movements associated with the use of videolaryngoscopy compared with direct laryngoscopy in the absence of head and neck immobilisation [55,56]. However, intubation by videolaryngoscopy is not a guarantee of absence of mobilisation of cervical vertebral structures as shown by studies of biomechanics or analyses of spinal movements by radioscopy [57,58]. Fiberoptic intubation with spontaneous ventilation remains the best intubation technique to minimise mobilisation of the cervical spine [5,7]. However, it requires cooperation from the patient and it is not compatible with emergency intubation. Outside these contexts, its use is recommendable, especially in situations where videolaryngoscopy and/or mask ventilation are likely to fail. In all cases, the operator must use a technique for which he has sufficient control and experience (Fig. 2).

Remember: succinylcholine can be used as a rapid-acting curare for the emergency induction of anaesthesia in the early hours after spinal cord injury [59–63]. As in all situations of nerve deafferentation, the deadline for use is conventionally set at 48 hours after trauma [60,61]. Although intubation conditions with succinylcholine compared to rocuronium under emergency conditions have been described as better, the choice of a quick-

acting muscle-relaxant to facilitate intubation is entirely up to the anaesthesiologist in charge of the patient [64].

**Question 9: In patients with spinal cord injury, does a weaning protocol for mechanical ventilation specifically reduce mechanical ventilation times and length of stay in intensive care?**

**R9.1-**It is probably recommended to use a bundle to facilitate respiratory weaning in patients with traumatic cervical cord injury, combining:

* an abdominal contention belt during periods of spontaneous breathing or raising procedures;

* active physiotherapy and a mechanically-assisted insufflation/exsufflation device to remove bronchial secretions;

* aerosol therapy combining beta-2 mimetics and anticholinergics.

(GRADE 2+) STRONG AGREEMENT

**R9.2-**The experts suggest performing a tracheostomy to accelerate ventilatory weaning within the first 7 days in patients with upper level spinal cord injury (C2–C5), and only after one or more tracheal extubation failures in patients with lower cervical spinal cord injury (C6–C7).

EXPERT OPINION

<figure><img src="image_3.png" /><figcaption>**Fig. 2.** Procedure for tracheal intubation in patients with cervical spinal cord injury or at risk of cervical spinal cord injury (Expert Opinion).</figcaption></figure>
## Rationale

### Protocol for weaning from mechanical ventilation

A review of the literature including 21 studies has highlighted the effectiveness of a ventilatory management protocol to reduce respiratory complications and the use of tracheotomy [65]. In a before-after study, an early rehabilitation strategy with an early tracheostomy (< 7 days) in case of upper injury (> C5), bronchial drainage physiotherapy, assisted cough with insufflator/exsufflator in atelectasis and aerosol therapy based on beta-2 mimetics, has been associated with better neurological recovery at 1 year [66]. When extubation is possible, protocols combining early extubation followed by intensive respiratory physiotherapy with bronchial drainage and mechanically assisted coughing (Cough-Assist type device) can sometimes lead to successful respiratory withdrawal without tracheostomy [67]. In tetraplegic patients, lying down is often better tolerated than sitting due to the effects of gravity on abdominal contents and inspiratory capacity [68]. Wearing an abdominal contention belt may increase the tolerance of spontaneous ventilation, particularly when a sitting position has been chosen [69,70]. Previous studies on respiratory muscle training techniques mainly included patients during the chronic phase of spinal cord injury [71]. Therefore, we do not have a sufficient level of evidence to strongly recommend a specific protocol for weaning patients with spinal cord injury from mechanical ventilation to reduce mechanical ventilation times and their length of stay at the intensive care unit.

### Tracheostomy

The main risk factors associated with mechanical ventilation weaning failure are an upper level spinal cord injury (above C5) and a complete spinal cord injury (ASIA Impairment Scale A) [72,73]. It is often necessary to perform a tracheostomy when the patient's residual vital capacity (VC) is decreased [74]. Upper level spinal cord injuries often reduce VC by more than 50%. When prolonged airway support is recognised and the possibility of tracheostomy is considered, the literature generally recommends performing this after 7 days if surgery has been performed with an anterior cervical approach [75]. An earlier time point may be possible with a posterior surgical procedure. Early tracheostomy (< 7 days) may not only reduce ICU hospitalisation times but also the incidence of laryngeal complications due to prolonged intubation [76]. The notion of a greater comfort with tracheostomy should be taken into account.

## Question 10: What analgesic strategies can reduce neuropathic pain in patients with spinal cord injury?

**R10.1**-It is probably recommended to introduce multimodal analgesia, combining non-opioid analgesics, antihyperalgesic drugs (ketamine) and opioids during surgical management, to prevent the occurrence of prolonged pain in patients with spinal cord injury.

(GRADE 2+) STRONG AGREEMENT

**R10.2**-It is recommended to introduce an oral gabapentinoid treatment for more than 6 months to control neuropathic pain in patients with spinal cord injury in association with tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient.

(GRADE 1+) STRONG AGREEMENT

## Rationale

In patients with spinal cord injury, the prevalence of chronic pain is 65–85%, 40% of which is neuropathic. Severe pain is more commonly neuropathic at sub-lesional level.

Questionnaires DN4 (Neuropathic Pain in 4 Questions) and NPSI (Neuropathic Pain Symptom Inventory) can be used respectively to help diagnose and assess the intensity of neuropathic pain [77,78]. No further examinations are required to recognise neuropathic pain.

In the long-term management of neuropathic pain, gabapentinoids and antidepressants (tricyclic or norepinephrine and serotonin reuptake inhibitors) are recommended as first-line therapy [79–85]. A meta-analysis focusing on spinal cord injury patients with neuropathic pain reports significant analgesic efficacy with gabapentinoids (8 studies, 524 patients, SMD 2.8 [2.4–3.2]) and a moderate effect with antidepressants (4 studies, 188 patients, SMD = 0.34 [0.05–0.62]). These two therapeutic classes need several days to take effect and careful titration during their introduction. Because of their anticholinergic effects, tricyclic antidepressants are more difficult to deal with, especially with spinal cord injury, where it is important to preserve bladder autonomy. The usual practice is to start with low doses and gradually increase them according to efficacy and tolerance. If effective, the treatment should be continued for several months (> 6 months). Treatment with a dual therapy (associations of molecules of different classes) may be useful [79]. Regular evaluation of effectiveness and tolerance is required.

In clinical situations of severe pain, the need for rapid relief (transport, intensive care) or waiting for other treatment to take effect, it is recommended to use strong opioid treatments and/or ketamine [86–88]. The anti-hyperalgesic effect of ketamine and its efficacy in preventing the chronification of postoperative pain, whatever the surgical modality, appears to have been established [89,90].

Lidocaine, tested in three randomised trials, is not recommended for central neuropathic pain, as the results are inconsistent, and the reported effects are low and transient [91–93].

Finally, the search and treatment for "pain triggers" (infections, occult injuries, pressure ulcers, constipation, fractures, osteomas...) helps to reduce the intensity of neuropathic pain.

## Question 11: What strategies for early positioning and mobilisation can reduce complications and/or improve the functional status of patients with spinal cord injury?

**R11.1**-To reduce neuro-orthopaedic complications and limb spasticity in patients with spinal cord injury, the experts suggest applying the following measures at least once a day right from the acute phase:

* rehabilitation and passive mobilisation of joints affected by the motor deficit;

* positioning the joints in the opposite direction from the predictable deformation;

* application of an orthosis;

* manual muscle reinforcement.

### EXPERT OPINION

#### Rationale

As soon as the patient arrives at the ICU, the major challenges are to maintain joint amplitudes, prevent and treat spasticity and strengthen the existing musculature. The effectiveness of stretching techniques in the treatment and prevention of vicious attitudes is likely but has not been entirely demonstrated [94]. Stretching
should be performed for at least 20 minutes per zone and completed by a simple posture orthosis (elbow extension, flexion-torsion of the metacarpophalangeal joint, opening of the thumb-index commissure) and, more importantly, by bed and chair positioning to correct and prevent predictable deformities. All this prepares the specific work of rehabilitation.

There have been no studies on the interest of functional electrical stimulation during the acute phase at the ICU, on activity-based therapy (repetition of activity by robotic exoskeleton), or walking in suspension, as these studies are always carried out during rehabilitation and/or the chronic phase. These techniques lead to a significant gain in strength perceived by the patient [95]. However, electrical stimulation orthoses have not shown any efficacy on the recovery of grip capacity [96–98].

## PICO: What mobilisation strategies can reduce skin complications in patients with spinal cord injury?

**R11.2-**Right from the acute phase, it is probably recommended to introduce the following measures to prevent the development of pressure ulcers in patients with spinal cord injury:

* early mobilisation as soon as the spine is stabilised;

* visual and tactile checks of all areas at risk at least once a day;

* repositioning every 2-4 hours with pressure zone checks;

* use of tools for discharge (cushions, foam, pillows) to avoid interosseous contact (knees);

* use of high-level prevention supports (air-loss mattress, dynamic mattress).

(GRADE 2+) STRONG AGREEMENT

### Rationale

Strategies for positioning and mobilising patients with spinal cord injuries in the acute phase are essentially aimed at preventing not only neuro-orthopaedic limb complications (musculotendinous contractions, joint stiffness or contractures) and their functional consequences, but also the occurrence of pressure ulcers. These strategies will be continued at the rehabilitation centre. The Ile-de-France Regional Health Agency recommends that all neurological rehabilitation centres have the equivalent of 2.5 full-time physiotherapists per 15 patients. We are in agreement with this calculation.

The prevalence of pressure ulcers can reach 26%, the main locations being the sacrum (39%), heels (13%), ischium (8%) and occiput (6%) [99]. Ulcer prevention strategies during the early phase, their levels of evidence and guidelines are clearly outlined in the Clinical Practice Guidelines for Professionals entitled "Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury" published by the Consortium for Spinal Cord Medicine (Paralysed Veterans of America). These recommendations are mostly based on case series studies [100–102].

## Question 12: Should intermittent bladder catheterisation be used to prevent urinary complications in SCI patients?

**R12.1-**It is probably recommended to use an intermittent urinary catheterisation as soon as the volume of daily diuresis is adequate, to reduce urological complications (urinary tract infection, urolithiasis) in patients with spinal cord injury.
(GRADE 2+) STRONG AGREEMENT

### Rationale

Intermittent urinary catheterisation is the reference method for urine drainage in SCI patients as it is associated with a long-term reduction in the risk of urinary tract infection and urolithiasis, and an increased probability of urination continence [103–108]. Self-intermittent urethral catheterisation is recommended by national and international neuro-urology societies [109–112]. The indwelling catheter should be removed as soon as possible, i.e. as soon as the patient is medically stable, to minimise urological risks [112]. A micturition calendar helps to adapt the frequency and schedule of intermittent urinary catheterisation.

### Disclosure of interest

The authors declare that they have no competing interest. Dr. Roquilly reports personal fees from MSD, grants and personal fees from BioMerieux outside the submitted work. Dr. Bouzat reports grants from LFB and personal fees from Octapharma outside the submitted work. Dr. Martinez reports personal fees from Pfizer, personal fees from Mylan, from Symposium for Grunenthal outside the submitted work.

### Funding

Funds were provided by the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation [SFAR]).

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