LITERATURE REVIEW J Neurosurg Spine 31:457–463, 2019 The case for the future role of evidence-based medicine in the management of cervical spine injuries, with or without fractures JNSPG 75th Anniversary Invited Review Article Mark N. Hadley, MD,1 and Beverly C. Walters, MD, MSc, FRCSC1,2 1Department of Neurosurgery, University of Alabama at Birmingham, Alabama; and 2Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence–based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in at- tempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape in- vestigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors’ view that the science of EBM is es- sential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many varia- tions and complexities of patients who sustain acute cervical spine fracture injuries. https://thejns.org/doi/abs/10.3171/2019.6.SPINE19652 KEYWORDS evidence-based medicine; neurosurgery guidelines; cervical spine injury; spinal cord injury HE authors have long been students, practitioners, and ultimately outcomes and outcome measurement after cer- promoters of evidence-based medicine (EBM)—or vical spinal trauma and cervical spinal fracture injuries, as we prefer to call it, “evidence-based methodol- if performed using well-designed medical evidence–based Togy”—in neurological surgery, one for 25 years (M.N.H.), comparative investigations with meaningful follow-up, and the other experienced and well-versed author (B.C.W.) has both merit and the remarkable potential to identify for almost 40 years. We believe that the standardized and optimal strategies for assessment, characterization, and systematic study of immobilization techniques, diagnostic clinical management.41 We have twice led multiple author modalities, medical and surgical treatment strategies, and groups with varied backgrounds, specialties, and experi- ABBREVIATIONS EBM = evidence-based medicine; NASCIS = National Acute Spinal Cord Injury Studies; SCI = spinal cord injury; SLIC = Subaxial Injury Classification; STASCIS = Surgical Timing in Acute Spinal Cord Injury Study. SUBMITTED June 2, 2019. ACCEPTED June 19, 2019. INCLUDE WHEN CITING DOI: 10.3171/2019.6.SPINE19652. ©AANS 2019, except where prohibited by US copyright law J Neurosurg Spine Volume 31 • October 2019 457 Unauthenticated | Downloaded 10/02/21 02:23 AM UTC Hadley and Walters ences to review the existing scientific literature, create associated with multiple injury variables, including mal- evidentiary tables, and write summary guidelines based alignment, interspace or facet compromise, neural or vas- on well-defined principles of EBM for the management of cular injury, and involvement of more than one cervical acute cervical spine and spinal cord injuries, which were vertebra, makes characterization of the fracture injury thoroughly reviewed and officially ratified by our national problematic because several aspects of the injury pattern neurosurgical organizations (the Washington Committee, and its influence on neural structures and the remainder the American Association of Neurological Surgeons, and of the cervical spine may influence treatment. For the few the Congress of Neurological Surgeons). They have now randomized clinical trials that have been carried out in twice been published, first in 2002, and most recently in patients with SCI, these details have never been addressed, 2013.12,14,42 These guideline summaries, particularly the much less accounted for within the randomization scheme 2013 updated version, represent the current “official” or statistical analysis process. stance of our specialty on these multiple and varied as- The more complicated cervical fracture injuries are, pects of cervical spine fractures and spinal cord injuries the more likely they are to require treatment for initial (SCIs). immobilization and ultimately for surgical realignment; Topics reviewed and discussed in 2013 include prehos- decompression of the spinal canal, cord, or root; and pital immobilization of potentially injured patients;39 their spinal stabilization and fusion. These types of cervical transport,38 clinical assessment,13 and radiographic assess- spine fractures and dislocation-malalignment injuries are ment;32 initial closed reduction of fracture-dislocation in- heterogeneous in both pattern and pathogenesis and are juries;11 acute cardiopulmonary management;33 pharmaco- difficult to discretely classify. Treatment strategies involv- logical therapy;18 cervical fracture classification schemes;1 ing surgery when required are many, involving anterior individual fracture injuries and subtypes—from occipital approaches, posterior approaches, or both, and include a condyle fracture injuries through fracture-dislocation in- spectrum of potential internal fixation and fusion options juries of the cervical vertebra through the cervical-thorac- and techniques that are variously used based on the frac- ic junction (for both adult and pediatric patients);10,26–31,36,37 ture pattern and such associated characteristics as adja- and related important topics of traumatic vertebral artery cent-level and neurological injury, spinal deformity, insti- injuries15 and venous thromboembolism.7 In all, 21 top- tutional resources, and individual surgeon preferences and ics were meticulously reviewed and 21 guidelines were experience. With so many injury pattern and treatment generated offering 103 evidence-based recommendations variables, rigorous comparative evidence-based studies including 18 level I (highest evidence) recommendations of specific yet different treatment strategies of these com- (Table 1), 17 level II recommendations, and 68 level III plex, multifactorial fracture injuries have not been accom- recommendations, using a clear, well-defined, science- plished to date, and truthfully, may never be. based methodology and a supportive bibliography of 2565 EBM has been applied to these types of injuries, not citations.12 This undertaking inspired official praise in the for a specific treatment or operation but to assess the need United States Congress by Congressman James Langevin, for surgical therapy rather than external immobilization himself a quadriplegic victim of SCI, along with fellow and follow-up. Several subaxial cervical spine injury clas- Congressmen and -women representing the home states sification schemes have been developed to provide algo- of each of the guidelines’ authors, that can be found in the rithms to help guide the management of these more com- United States Congressional Record.20 plex injuries and to predict their outcome with or without There is inherent difficulty in attempting to apply surgery. These schemes incorporate fracture injury mor- EBM to identify ideal treatment strategies for individual phology, compromise of related disc and ligaments (disco- cervical fracture injuries. First and foremost, there is al- ligamentous complex) using contemporary imaging, and most no medical evidence reported in our literature for the patient’s neurological status. The Harris classification16 the management of specific isolated cervical fracture and the Allen classification2 systems of subaxial cervical subtypes; simply stated, specific treatment strategies for spine injury have low reliability, demonstrated by low in- specific fracture injuries have not been routinely