Anaesth Crit Care Pain Med 39 (2020) 279–289

Guidelines

French recommendations for the management of patients with spinal

cord injury or at risk of spinal cord injury§
A. Roquilly a,1,*, B. Vigué b,1, M. Boutonnet c, P. Bouzat d, K. Buffenoir e, E. Cesareo f,
A. Chauvin g, C. Court h, F. Cook i, A.C. de Crouy j, P. Denys k, J. Duranteau b, S. Fuentes l,
T. Gauss m, T. Geeraerts n, C. Laplace b, V. Martinez o, J.F. Payen p, B. Perrouin-Verbe q,
A. Rodrigues b, K. Tazarourte r, B. Prunet s, P. Tropiano t, V. Vermeersch u, L. Velly v,
H. Quintard w
a
Anaesthesiology and Intensive Care Unit, Hôtel-Dieu, Nantes University Hospital, Nantes, France
b
Anaesthesiology and Intensive Care Unit, Bicêtre University Hospital, AP–HP, Le Kremlin-Bicêtre, France
c
Hôpital d’instruction des armées Percy, Clamart, France
d
Grenoble Alps Trauma Centre, Department of Anaesthesia and Critical Care, Grenoble University Hospital, Grenoble, France
e
Neurosurgery department, Nantes University Hospital, Nantes, France
f
Edouard-Herriot University Hospital, Lyon, France
g
Anaesthesiology and Intensive Care Unit, Lariboisière Hospital, AP–HP, Paris, France
h
Orthopaedic Surgery Department, Spine and Bone Tumor Unit, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
i
Unité de réanimation chirurgicale polyvalente et de polytraumatologie, Albert-Chenevier–Henri-Mondor University Hospital, Créteil, France
j
Unité SRPR/Réanimation chirurgicale, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
k
Orthopaedic department, Spine and Bone Tumor Unit. Bicêtre University Hospital, Le Kremlin Bicêtre, France
l
Aix-Marseille University, AP–HM, Department of Neurosurgery, University Hospital Timone, Marseille, France
m
Post-Intensive Care Rehabilitation Unit, Bicêtre University Hospital, Le Kremlin Bicêtre, France
n
Anaesthesiology and Critical Care Department, Toulouse University Hospital, University of Toulouse 3-Paul Sabatier, Toulouse, France
o
Neuro Urology Unit, Department of Physical Medicine and Rehabilitation. Raymond Poincaré University Hospital, Garches, France
p
Department of Anaesthesia and Critical Care, Grenoble Alps University Hospital, 38000 Grenoble, France
q
Department of Neurological Physical Medicine and Rehabilitation, Nantes University Hospital, Nantes, France
r
Emergency department, Edouard-Herriot University Hospital, 69003 Lyon, France
s
Department of Anaesthesia and Critical Care, Val-de-Grâce Hospital, Paris, France
t
Aix-Marseille University, AP–HM, Orthopaedic and traumatic surgery, University Hospital Timone, Marseille, France
u
Anaesthesiology and Intensive Care Unit, Brest University Hospital, Brest, France
v
Aix Marseille University, AP–HM, Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France
w
Intensive Care Unit, Nice University Hospital, Pasteur 2 Hospital, Nice, France

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To update the French guidelines on the management of trauma patients with spinal cord
Available online 27 March 2020 injury or suspected spinal cord injury.
Design: A consensus committee of 27 experts was formed. A formal conflict-of-interest (COI) policy was
Keywords: developed at the outset of the process and enforced throughout. The entire guidelines process was
Spine trauma conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors
Spinal cord injury were advised to follow the rules of the Grading of Recommendations Assessment, Development and
Tetraplegia
Evaluation (GRADE1) system to guide assessment of quality of evidence. The potential drawbacks of
Paraplegia
making strong recommendations in the presence of low-quality evidence were emphasised.
Methods: The committee studied twelve questions: (1) What are the indications and arrangements for
spinal immobilisation? (2) What are the arrangements for pre-hospital orotracheal intubation? (3) What
are the objectives of haemodynamic resuscitation during the lesion assessment, and during the first few
days in hospital? (4) What is the best way to manage these patients to improve their long-term
prognosis? (5) What is the place of corticosteroid therapy in the initial phase? (6) What are the
indications for magnetic resonance imaging in the lesion assessment phase? (7) What is the optimal time

§
Guidelines reviewed and endorsed by the French Society of Anaesthesia and Intensive Care Medecine (Société française d’anesthésie réanimation [SFAR] 29/06/2019).
* Corresponding author at: Réanimation medico-chirurgicale, hôpital Hôtel-Dieu, Nantes University Hospital, 1, place Ricordeau, 44035 Nantes, France.
E-mail address: antoine.roquilly@chu-nantes.fr (A. Roquilly).
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.accpm.2020.02.003
2352-5568/ C 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/).

280 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289

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 GRADE1 Methodology.
Results: The experts’ work synthesis and the application of the GRADE method resulted in 19 recommenda-
tions. 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.
C 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 formulated in PICO (Patient Intervention, Comparison, Outcome)

Bernard Vigué and Antoine Roquilly (SFAR)
Organisers
Hervé Quintard and Lionel Velly (SFAR)
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.

Reviewer panels GRADE methodology

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
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:

Spinal cord injury (SCI) is a common pathology with one million  high-quality evidence: further research is very unlikely to
new cases worldwide every year, and 27 million patients living change the confidence level in the estimate of the effect;
with the sequelae of SCI. In France, approximately 2000 patients  moderate-quality evidence: further research is likely to have an
are affected by SCI every year. SCIs are a burden for healthcare impact on confidence in the estimate of the effect and may
systems and economies through lost productivity and high change the estimate of the effect itself;
healthcare costs.  low-quality evidence: further research is very likely to have an
Care for SCI patients requires cooperation between several care- impact on confidence in the estimate of the effect and is likely to
providers (emergency teams, anaesthesiologists and intensivists, change the estimate of the effect itself;
surgeons and rehabilitation specialists). Each stage of caring for SCI  very low-quality evidence: any estimate of the effect is very
patients is critical to enhance neurological recovery. Recent unlikely.
progress in knowledge of this pathophysiology, in the prevention
of complications and also in techniques has changed the way SCI The level of recommendation was binary (either positive or
patients are managed. We therefore decided to update the negative), and strong or weak:
2004 recommendations for SCI patients. The guideline committees
of the French Society of Anaesthesia and Intensive Care (Société  strong recommendation: we recommend, or we do not
française d’anesthésie et de réanimation [SFAR]) appointed an recommend (Grade 1+ or 1 );
organising committee which selected twenty-seven French-speak-  weak recommendation: we probably recommend, or we
ing experts following approval by their respective boards: SOFCOT probably not recommend (Grade 2+ or 2 ).
(Société française de chirurgie orthopédique et traumatologique),
SFMU (Société française de médecine d’urgence), SOFMER (Société The strength of the recommendations was determined accord-
française de médecine physique et de réadaptation), SFCR (Société ing to key factors and validated by the experts after a vote, using
française de chirurgie rachidienne) and ANARLF (Association des the Delphi and Grade Grid method which encompasses the
Neuro-anesthésistes-réanimateurs de langue française). Two inde- following criteria:
pendent bibliographic experts analysed the literature from the past
Table 1
16 years in the field using pre-defined keywords. Guideline timeline.
Kick-off meeting July 3rd, 2018
Methodology Vote: first round October 20th, 2018
Post-vote deliberation meeting November 27th, 2018
As a first step, the organising committee, together with the Vote: second round January 20th, 2019
expert coordinators, defined the issues to be addressed and Guideline finalisation meeting April 10th, 2019
Endorsement of the recommendations by the SFAR May 24th, 2019
selected the experts in charge of each of them. Questions were
 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289
 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 agree-
ment, 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, standardi-
sation 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 GRADE1 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 recommenda-
tions, the GRADE1 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 inter-
vention 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
281
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
282 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289
Fig. 1. Algorithm for spinal immobilisation of patients with cervical spinal cord injury or at risk of cervical spinal cord injury (Expert Opinion).
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 laryn-
goscopy 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
 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289
(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 admis-
sion, 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
283
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 recom-
mended 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 improve-
ment 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
284 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289
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 compres-
sion 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 lumbosa-
cral 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 neuro-
logical 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 videolaryn-
goscopy 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
 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289
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 immobilisa-
tion [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 tech-
nique 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-
Fig. 2. Procedure for tracheal intubation in patients with cervical spinal cord injury or at risk of cervical spinal cord injury (Expert Opinion).
285
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 sponta-
neous breathing or raising procedures;
 active physiotherapy and a mechanically-assisted in-
sufflation/exsufflation device to remove bronchial se-
cretions;
 aerosol therapy combining beta-2 mimetics and anti-
cholinergics.
(GRADE 2+) STRONG AGREEMENT
R9.2–The experts suggest performing a tracheostomy to ac-
celerate 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
286 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289
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/exsuf-
flator 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 physiothera-
py with bronchial drainage and mechanically assisted coughing
(Cough-Assist type device) can sometimes lead to successful
respiratory withdrawal without tracheostomy [67]. In tetra-
plegic 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, particu-
larly 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 mono-
therapy 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, gabapenti-
noids 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 recommen-
ded 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 stretch-
ing techniques in the treatment and prevention of vicious attitudes
is likely but has not been entirely demonstrated [94]. Stretching
 A. Roquilly et al. / Anaesth Crit Care Pain Med 39 (2020) 279–289
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 exoskele-
ton), 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 develop-
ment 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 (musculotendi-
nous 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
287
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 indwell-
ing 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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