Skip to main content
SpringerLink
Log in

Adopting and adapting clinical practice guidelines for timing of decompressive surgery in acute spinal cord injury from a developed world context to a developing region

  • Original Article
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Purpose

The proper application of high-quality clinical practice guidelines improves trauma patients’ care and outcomes. This study aimed to adopt and adapt guidelines on the timing of decompressive surgery in acute spinal cord injury (SCI) in Iranian clinical settings.

Methods

This study followed a systematic search and review of the literature to enter them into the selection process. The source guidelines’ clinical suggestions were converted into clinical scenarios for clinical questions on the timing of decompressive surgery. After summarizing the scenarios, we prepared an initial list of recommendations based on the status of the Iranian patients and the health system. The ultimate conclusion was reached with the help of a national interdisciplinary expert panel comprising 20 experts throughout the country.

Results

A total of 408 records were identified. After title and abstract screening, 401 records were excluded, and the full texts of the remaining seven records were reviewed. Based on our screening process, only one guideline included recommendations on the topic of interest. All of the recommendations were accepted by the expert panel with slight changes due to resource availability in Iran. The final two recommendations were the consideration of early surgery (≤24 h) as a treatment option in adult patients with traumatic central cord syndrome and in adult patients with acute SCI regardless of the level of injury.

Conclusion

Considering early surgery for adult patients with acute traumatic SCI regardless of the level of injury was the final recommendation for Iran. Although most of the recommendations are adoptable in developing countries, issues with infrastructure and availability of resources are the limitations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Alnaami I, Alsaleh S, Al-Amri MS, Al-Alamri A, Al-Zahrani F, Al-Amri MA et al (2021) Traumatic spinal cord injury in southern Saudi Arabia: patterns, time to surgery and outcomes. Journal of family medicine and primary care 10(4):1726–1730. https://doi.org/10.4103/jfmpc.jfmpc_1913_20

    Article  PubMed  PubMed Central  Google Scholar 

  2. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G et al (2010) AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ: Canadian Medical Association journal = journal de l'Association medicale canadienne 182(18):E839–E842. https://doi.org/10.1503/cmaj.090449

    Article  PubMed  Google Scholar 

  3. Chen L, Yang H, Yang T, Xu Y, Bao Z, Tang T (2009) Effectiveness of surgical treatment for traumatic central cord syndrome. J Neurosurg Spine 10(1):3–8. https://doi.org/10.3171/2008.9.SPI0822

    Article  PubMed  Google Scholar 

  4. Derakhshanrad N, Yekaninejad MS, Vosoughi F, Sadeghi Fazel F, Saberi H (2016) Epidemiological study of traumatic spinal cord injuries: experience from a specialized spine center in Iran. Spinal Cord 54(10):901–907. https://doi.org/10.1038/sc.2016.10

    Article  CAS  PubMed  Google Scholar 

  5. Dizon JM, Machingaidze S, Grimmer K (2016) To adopt, to adapt, or to contextualise? The big question in clinical practice guideline development. BMC research notes 9(1):442. https://doi.org/10.1186/s13104-016-2244-7

    Article  PubMed  PubMed Central  Google Scholar 

  6. Fehlings MG, Tetreault LA, Wilson JR, Aarabi B, Anderson P, Arnold PM et al (2017) A Clinical practice guideline for the management of patients with acute spinal cord injury and central cord syndrome: recommendations on the timing (</=24 hours versus >24 hours) of decompressive surgery. Global spine journal 7(3 Suppl):195S–202S. https://doi.org/10.1177/2192568217706367

    Article  PubMed  PubMed Central  Google Scholar 

  7. Gagliardi AR, Brouwers MC (2012) Integrating guideline development and implementation: analysis of guideline development manual instructions for generating implementation advice. Implementation science : IS 7:67. https://doi.org/10.1186/1748-5908-7-67

    Article  PubMed  PubMed Central  Google Scholar 

  8. GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators (2019) Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 18(1):56–87. https://doi.org/10.1016/S1474-4422(18)30415-0

  9. Ghajarzadeh M, Saberi H (2019) Transportation mode and timing of spinal cord decompression and stabilization in patients with traumatic spinal cord injury in Iran. Spinal Cord 57(2):150–155. https://doi.org/10.1038/s41393-018-0189-5

    Article  PubMed  Google Scholar 

  10. Ghodsi Z, Jazayeri SB, Pourrashidi A, Sadeghi-Naeini M, Azadmanjir Z, Baigi V, Maroufi SF, Azarhomayoun A, Faghih-Jouybari M, Amirjamshidi A, Naghdi K, Habibiarejan R, Shabani M, Sepahdoost A, Dehghanbanadaki H, Habibi R, Mohammadzadeh M, Bahreini M, O’Reilly GM, Vaccaro AR, Harrop JS, Davies BM, Yi L, Ghodsi SM, Rahimi-Movaghar V (2023) Development of a comprehensive assessment tool to measure the quality of care for individuals with traumatic spinal cord injuries. Spinal Cord Ser Cases 9(1). https://doi.org/10.1038/s41394-023-00569-3  

  11. Graham ID, Harrison MB (2005) Evaluation and adaptation of clinical practice guidelines. Evidence-based nursing 8(3):68–72. https://doi.org/10.1136/ebn.8.3.68

    Article  PubMed  Google Scholar 

  12. Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 362(9391):1225–1230. https://doi.org/10.1016/S0140-6736(03)14546-1

    Article  PubMed  Google Scholar 

  13. Gupta DK, Vaghani G, Siddiqui S, Sawhney C, Singh PK, Kumar A et al (2015) Early versus delayed decompression in acute subaxial cervical spinal cord injury: a prospective outcome study at a Level I trauma center from India. Asian journal of neurosurgery 10(3):158–165. https://doi.org/10.4103/1793-5482.161193

    Article  PubMed  PubMed Central  Google Scholar 

  14. Haghnegahdar A, Behjat R, Saadat S, Badhiwala J, Farrokhi MR, Niakan A et al (2020) A randomized controlled trial of early versus late surgical decompression for thoracic and thoracolumbar spinal cord injury in 73 patients. Neurotrauma reports 1(1):78–87. https://doi.org/10.1089/neur.2020.0027

    Article  PubMed  PubMed Central  Google Scholar 

  15. Hejrati N, Moghaddamjou A, Pedro K, Alvi MA, Harrop JS, Guest JD et al (2022) Current practice of acute spinal cord injury management: a global survey of members from the AO spine. Global spine journal:21925682221116888. https://doi.org/10.1177/21925682221116888

  16. Jug M, Kejžar N, Vesel M, Al Mawed S, Dobravec M, Herman S et al (2015) Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience. J Neurotrauma 32(18):1385–1392. https://doi.org/10.1089/neu.2014.3767

    Article  PubMed  Google Scholar 

  17. Lee BJ, Jeong JH (2023) Early decompression in acute spinal cord injury: review and update. Journal of Korean Neurosurgical Society 66(1):6–11. https://doi.org/10.3340/jkns.2022.0107

    Article  PubMed  Google Scholar 

  18. Leidinger A, Kim EE, Navarro-Ramirez R, Rutabasibwa N, Msuya SR, Askin G et al (2019) Spinal trauma in Tanzania: current management and outcomes. J Neurosurg Spine 31(1):103–111. https://doi.org/10.3171/2018.12.spine18635

    Article  PubMed  Google Scholar 

  19. Leidinger A, Zuckerman SL, Feng Y, He Y, Chen X, Cheserem B et al (2023) Predictors of spinal trauma care and outcomes in a resource-constrained environment: a decision tree analysis of spinal trauma surgery and outcomes in Tanzania. Journal of neurosurgery. Spine. 1-9. https://doi.org/10.3171/2022.11.spine22763

  20. Mac-Thiong JM, Feldman DE, Thompson C, Bourassa-Moreau E, Parent S (2012) Does timing of surgery affect hospitalization costs and length of stay for acute care following a traumatic spinal cord injury? J Neurotrauma 29(18):2816–2822. https://doi.org/10.1089/neu.2012.2503

    Article  PubMed  Google Scholar 

  21. Magogo J, Lazaro A, Mango M, Zuckerman SL, Leidinger A, Msuya S et al (2021) Operative treatment of traumatic spinal injuries in Tanzania: surgical management, neurologic outcomes, and time to surgery. Global spine journal 11(1):89–98. https://doi.org/10.1177/2192568219894956

    Article  PubMed  Google Scholar 

  22. Penney GC. Adopting and adapting clinical guidelines for local use. The Obstetrician & Gynaecologist 2007;9(1):48-52. doi: https://doi.org/https://doi.org/10.1576/toag.9.1.048.27296.

  23. Rahimi-Movaghar V, Moradi-Lakeh M, Rasouli MR, Vaccaro AR (2010) Burden of spinal cord injury in Tehran. Iran Spinal cord 48(6):492–497. https://doi.org/10.1038/sc.2009.158

    Article  CAS  PubMed  Google Scholar 

  24. Rahimi-Movaghar V, Niakan A, Haghnegahdar A, Shahlaee A, Saadat S, Barzideh E (2014) Early versus late surgical decompression for traumatic thoracic/thoracolumbar (T1-L1) spinal cord injured patients. Primary results of a randomized controlled trial at one year follow-up. Neurosciences (Riyadh, Saudi Arabia) 19(3):183–191

    PubMed  Google Scholar 

  25. Rahimi-Movaghar V, Rasouli MR (2012) Spinal cord decompression: is country of surgery a predictor of outcome? Surg Neurol Int 3:36. https://doi.org/10.4103/2152-7806.94034

    Article  PubMed  PubMed Central  Google Scholar 

  26. Rogers WK, Todd M (2016) Acute spinal cord injury. Best Pract Res Clin Anaesthesiol 30(1):27–39. https://doi.org/10.1016/j.bpa.2015.11.003

    Article  PubMed  Google Scholar 

  27. Sánchez JAS, Sharif S, Costa F, Rangel J, Anania CD, Zileli M (2020) Early management of spinal cord injury: WFNS Spine Committee recommendations. Neurospine. 17(4):759–784. https://doi.org/10.14245/ns.2040366.183

    Article  PubMed  PubMed Central  Google Scholar 

  28. Schunemann HJ, Oxman AD, Fretheim A (2006) Improving the use of research evidence in guideline development: 6. Determining which outcomes are important. Health research policy and systems 4:18. https://doi.org/10.1186/1478-4505-4-18

    Article  PubMed  PubMed Central  Google Scholar 

  29. Stein DM, Sheth KN (2015) Management of acute spinal cord injury. Continuum (Minneapolis, Minn) 21(1 Spinal Cord Disorders):159–187. https://doi.org/10.1212/01.CON.0000461091.09736.0c

    Article  PubMed  Google Scholar 

  30. Ter Wengel PV, De Witt Hamer PC, Pauptit JC, van der Gaag NA, Oner FC, Vandertop WP (2019) Early surgical decompression improves neurological outcome after complete traumatic cervical spinal cord injury: a meta-analysis. J Neurotrauma 36(6):835–844. https://doi.org/10.1089/neu.2018.5974

    Article  PubMed  Google Scholar 

  31. The ADAPTE Collaboration. The ADAPTE process: resource toolkit for guideline adaptation. Version 2.0. 2009. Available from: https://g-i-n.net/wp-content/uploads/2021/05/ADAPTE-Resource-toolkit-V2.1-March-2010-updated-disclaimer.pdf. Accessed 7 July 2022

  32. Yazdani S, Shirvani A, Nejati M, Heydarpour P, Ahmadi A (2015) Clinical practice guideline adaptation model in IR. Iranian Ministry of Health and Medical Education, Iran

    Google Scholar 

  33. Yusuf AS, Mahmud MR, Alfin DJ, Gana SI, Timothy S, Nwaribe EE et al (2019) Clinical characteristics and challenges of management of traumatic spinal cord injury in a trauma center of a developing country. Journal of neurosciences in rural practice 10(3):393–399. https://doi.org/10.1055/s-0039-1695696. Accessed 7 July 2022

Download references

Funding

This work was funded by Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences [grant number 98-01-38-41355].

Author information

Authors and Affiliations

  1. Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran

    Seyed Farzad Maroufi, Sina Azadnajafabad, Seyed Behnam Jazayeri, Zahra Ghodsi, Farzin Farahbakhsh, Amir Azarhomayoun & Vafa Rahimi-Movaghar

  2. Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

    Sina Azadnajafabad

  3. Department of Neurosurgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Ahmad Pour-Rashidi

  4. Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

    Zahra Ghodsi & Vafa Rahimi-Movaghar

  5. Neuropsychology Division, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran

    Heshmatollah Ghawami

  6. National Board in Community and Preventive Medicine, Treatment Department, Ministry of Health and Medical Education, Tehran, Iran

    Maryam Kheyri

  7. Sports Medicine Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran

    Farzin Farahbakhsh

  8. Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Farzin Farahbakhsh

  9. Tehran University of Medical Sciences, Tehran, Iran

    Maryam Bahreini

  10. Director, Defence Health Research C, Tehran, Iran

    Jalil Arab Kheradmand

  11. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

    Morteza Faghih Jouibari & Vafa Rahimi-Movaghar

  12. Department of Orthopedic Surgery, Tehran University of Medical Sciences, Tehran, Iran

    Mohammad Zareh

  13. Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada

    Michael G Fehlings

  14. Division of Neurosurgery, University Health Network, Toronto Western Hospital, Toronto, ON, Canada

    Michael G Fehlings

  15. Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada

    Michael G Fehlings

  16. Universal Scientific Education and Research Network (USERN), Tehran, Iran

    Vafa Rahimi-Movaghar

  17. Institute of Biochemistry and Biophysics, University of Tehran, Tehran, Iran

    Vafa Rahimi-Movaghar

  18. Visiting Professor, Spine Program, University of Toronto, Toronto, Canada

    Vafa Rahimi-Movaghar

Authors
  1. Seyed Farzad Maroufi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sina Azadnajafabad
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ahmad Pour-Rashidi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Seyed Behnam Jazayeri
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zahra Ghodsi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Heshmatollah Ghawami
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Maryam Kheyri
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Farzin Farahbakhsh
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Amir Azarhomayoun
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Maryam Bahreini
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Jalil Arab Kheradmand
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Morteza Faghih Jouibari
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Mohammad Zareh
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Michael G Fehlings
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Vafa Rahimi-Movaghar
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

The study was designed and conceptualized by VRM. SFM and SA prepared the material and primary draft. SFM, SA, APR, SBJ, ZG, HG, MK, FF, AA, MB, JAK, MFJ, MZ, MF, and VRM provided critical comments on the methodology, study results, and the explanations in the discussion section. All authors commented on the draft and approved the final manuscript. VRM was the corresponding author and supervised all study stages.

Corresponding author

Correspondence to Vafa Rahimi-Movaghar.

Ethics declarations

Ethical approval

The Ethics Committee of Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, approved the study, and the reference number is 98-01-38-362.

Informed consent

Not applicable

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Seyed Farzad Maroufi and Sina Azadnajafabad are the first authors equally.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Maroufi, S.F., Azadnajafabad, S., Pour-Rashidi, A. et al. Adopting and adapting clinical practice guidelines for timing of decompressive surgery in acute spinal cord injury from a developed world context to a developing region. Acta Neurochir 165, 1401–1406 (2023). https://doi.org/10.1007/s00701-023-05591-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-023-05591-w

Keywords

Search

Navigation