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‡ Bin Guan, Guoyu Li, and Ruiyuan Zheng contributed equally to this work.
Bin Guan
Footnotes
‡ Bin Guan, Guoyu Li, and Ruiyuan Zheng contributed equally to this work.
Affiliations
Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
‡ Bin Guan, Guoyu Li, and Ruiyuan Zheng contributed equally to this work.
Guoyu Li
Footnotes
‡ Bin Guan, Guoyu Li, and Ruiyuan Zheng contributed equally to this work.
Affiliations
Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
‡ Bin Guan, Guoyu Li, and Ruiyuan Zheng contributed equally to this work.
Ruiyuan Zheng
Footnotes
‡ Bin Guan, Guoyu Li, and Ruiyuan Zheng contributed equally to this work.
Affiliations
Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China
Department of Orthopaedics, Tianjin Medical University General Hospital, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin, 300052, P.R. China
† Hengxing Zhou, Shiqing Feng, and Lingxiao Chen were designated as co-corresponding authors.
Lingxiao Chen
Correspondence
Corresponding author. Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China. Faculty of Medicine and Health, The Back Pain Research Team, Sydney Musculoskeletal Health, The Kolling Institute, University of Sydney, Sydney, Australia. Tel.: (61) 0466965326; fax: (86) 053182169114.
† Hengxing Zhou, Shiqing Feng, and Lingxiao Chen were designated as co-corresponding authors.
Affiliations
Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. ChinaFaculty of Medicine and Health, The Back Pain Research Team, Sydney Musculoskeletal Health, The Kolling Institute, University of Sydney, Sydney, Australia
† Hengxing Zhou, Shiqing Feng, and Lingxiao Chen were designated as co-corresponding authors.
Shiqing Feng
Correspondence
Corresponding author. Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China. Tel.: (86) 13920286292; fax: (86) 0531-82169114.
† Hengxing Zhou, Shiqing Feng, and Lingxiao Chen were designated as co-corresponding authors.
Affiliations
Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. ChinaDepartment of Orthopaedics, Tianjin Medical University General Hospital, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin, 300052, P.R. China
† Hengxing Zhou, Shiqing Feng, and Lingxiao Chen were designated as co-corresponding authors.
Hengxing Zhou
Correspondence
Corresponding author. Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. China. Tel.: (86) 13612051681; fax: (86) 0531-82169114.
† Hengxing Zhou, Shiqing Feng, and Lingxiao Chen were designated as co-corresponding authors.
Affiliations
Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, P.R. ChinaDepartment of Orthopaedics, Tianjin Medical University General Hospital, International Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin Key Laboratory of Spine and Spinal Cord, Tianjin, 300052, P.R. China
‡ Bin Guan, Guoyu Li, and Ruiyuan Zheng contributed equally to this work. † Hengxing Zhou, Shiqing Feng, and Lingxiao Chen were designated as co-corresponding authors.
Spinal cord injury (SCI) is a serious health problem which carries a heavy economic burden. Imaging technologies play an important role in the diagnosis of SCI. Although several organizations have developed guidelines for diagnostic imaging of SCI, their quality has not yet been systematically assessed.
PURPOSE
We aim to conduct a systematic review to appraise SCI guidelines and summarize their recommendations for diagnostic imaging of SCI.
STUDY DESIGN
Systematic review.
METHODS
We searched Embase, Medline, Web of Science, Cochrane, some guideline-specific databases (eg, Scottish Intercollegiate Guidelines Network) and Google Scholar from January 2000 to January 2022. We included guidelines developed by nationally recognized organizations. If multiple versions could be obtained, we included the latest one. We appraised included guidelines using the Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument which contains six domains (eg, scope and purpose). We also extracted recommendations and assessed their supporting evidence using levels of evidence (LOE). The evidence was categorized as A (the best quality), B, C, and D (the worst quality).
RESULTS
Seven guidelines (2008–2020) were included. They all received the lowest scores in the domain of applicability. All guidelines (7/7, 100%) recommended magnetic resonance imaging (MRI) in patients with SCI or SCI without radiographic abnormality (SCIWORA). A total of 12 recommendations involving patient age (eg, adult and child patients), timing of MRI (eg, as soon as possible and in the acute period), symptoms indicated for MRI (eg, a stiff spine and midline tenderness, suspected disc and posterior ligamentous complex injury, and neurological deficit), and types of MRI (eg, T2-weighted imaging and diffusion tensor imaging) were extracted. Among them, the LOE was C in nine (75%) recommendations and D in three (25%) recommendations.
CONCLUSIONS
Seven guidelines were included in the present systematic review, and all of them showed the worst applicability scores in the Appraisal of Guidelines for Research and Evaluation, 2nd edition instrument. They all weakly recommended MRI for patients with suspected SCI or SCIWORA based on a low LOE.
]. According to the Global Burden of Disease Study, there were 20.64 million (95% uncertainty interval: 18.93–23.61 million) prevalent cases of SCI recorded globally in 2019 [
]. According to the National Spinal Cord Injury Statistical Center, the average yearly expenses for patients with SCI ranged from $0.04 million to $1.08 million in the United States [
]. Magnetic resonance imaging (MRI) is effective in detecting slight changes in soft tissues, supporting a better diagnosis of SCI and proper management [
]. Although clinical practice guidelines for the diagnostic imaging of SCI have been published by some authoritative organizations, the consistency of the recommendations and the overall quality of the guidelines remain unclear. In 2021, Liang et al. [
Critical appraisal of paralyzed veterans of America Guidelines in spinal cord injury: an International Collaborative Study Using the Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II).
] appraised the guidelines for SCI published in the Paralyzed Veterans of America; however, not all available guidelines were included or focused on diagnostic imaging.
Therefore, the purpose of this study is to critically appraise existing guidelines on diagnostic imaging of SCI, and to present recommendations based on an assessment of the supporting evidence.
Methods
Study design
According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [
], we conducted a systematic review and registered it on PROSPERO (CRD42022350091). The systematic review team consisted of two attendings, one epidemiologist, one guideline methodologist, two interns, and two medical students.
Search strategy
Guidelines developed in the past may not apply to current clinical practice. Based on the recommendations of a study published in Annals of Internal Medicine [
], the publication time of clinical practice guidelines was limited to January 2000 to January 2022. Using search strategies (Appendix 1) formulated by a professional librarian, we searched Embase, Medline, Cochrane, and Web of Science for clinical practice guidelines related to SCI. We also searched Google Scholar and some guideline-specific databases (eg, Scottish Intercollegiate Guidelines Network, Congress of Neurological Surgeons, National Institute for Health and Care Excellence, etc.) (Appendix 2) to supplement the results. We restricted the results to English-language.
Selection of guidelines
After the removal of duplicates, the titles and abstracts of the literature were reviewed independently by three reviewers to exclude documents which were not guidelines or were not related to SCI. Before reviewing full-text articles, we increased consistency by selecting 5% of the selected documents as a pilot test [
], our inclusion criteria were as follows: (1) developed by nationally recognized committees, medical societies, or publicly funded institutions that formulated recommendations on SCI; (2) included specific methodological sections (for example, literature review, review of the evidence, and the methodology of the forming recommendations); and (3) was the latest version if several versions were available.
Quality assessment of guidelines
The included guidelines were appraised by three reviewers independently according to the Appraisal of Guidelines for Research and Evaluation, 2nd edition (AGREE II) instrument (www. agreetrust. org). The AGREE II instrument contains 23 items split into six different domains: scope and purpose (regarding aims, target population, and health problems of guidelines), stakeholder involvement (regarding appropriate stakeholders and intended users in the process of the guideline development), rigor of development (regarding the gathering of evidence and formulation or revisions of recommendations), clarity of presentation (regarding organizations and formats of guidelines and language), applicability (regarding potential barriers to, facilitators factors of, and possible resource impact of the practical application of guidelines), and editorial independence (regarding conflicts of interest in the process of formulating recommendations) [
]. Further, the AGREE II instrument contains an overall rating item that indicates the general quality of appraised guidelines.
We scored each item on a scale of 1 to 7 to indicate the degree of agreement between the criteria of AGREE II instrument and the content of the guidelines [
]. One indicates strong disagreement, and 7 indicates strong agreement. We calculated the score for each domain as follows: (obtained score-minimum possible score)/(maximum possible score-minimum possible score) [
]. If the scores of most domains (5–6 domains) were above 50%, the guideline would be evaluated as “recommended”; if the scores of some domains (1–4 domains) were above 50%, the guideline would be evaluated as “recommended with modifications”; if the scores of all domains were below 50%, the guideline would be evaluated as “not recommended” [
]. The interquartile range (IQR) and the median score of each domain were calculated. We also calculated the interrater agreement by the intraclass correlation coefficient with a corresponding 95% confidence interval (CI) to measure the reliability of the results. A score of 0.01 to 0.20 indicates poor agreement; a score of 0.21 to 0.40 indicates fair agreement; a score of 0.41 to 0.60 indicates moderate agreement; a score of 0.61 to 0.80 indicates substantial agreement; a score of 0.81 to 1.00 indicates very good agreement [
]. Any discrepancy was discussed. If necessary, senior scientists were available for consultation. All calculations in our study were performed by IBM SPSS Statistics 25.0 and Microsoft Excel 2016.
Recommendations on diagnostic imaging
One reviewer extracted recommendations on diagnostic imaging of SCI with supporting evidence from guidelines which were evaluated as “recommended with modification” and “recommended.” Two reviewers checked the work. Any differences were resolved through discussion [
Given the lack of high-quality supporting evidence such as randomized controlled trials (RCTs), we evaluated the quality of supporting evidence of extracted recommendations by levels of evidence (LOE) based on a prior study whose quality of included supporting evidence was similar to ours [
]. LOE was categorized as A, B, C or D. Grade A refers to individual RCTs and systematic reviews of RCTs; Grade B refers to systematic reviews of cohort/case-control studies, case-control studies, and cohort studies; Grade C refers to case report/series and poor-quality case-control studies or cohort studies; Grade D refers to troublingly inconsistent or inconclusive studies. Additionally, LOE will be assessed as D if one recommendation is an expert opinion formulated without explicit critical appraisal of evidence (Appendix 3).
Results
Selection of guidelines
In total, 12,017 articles were available after the removal of duplicates. Seven guidelines from 2008 to 2020 were included after reviewing titles, abstracts, and full texts (Fig. 1). They were developed by AO Spine [
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction
Fehlings et al.
2017
Spinal cord injury
AO Spine
GRADE system
For
Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care providers
Paralyzed Veterans of America
2008
Spinal cord injury
Paralyzed Veterans of America
Guidance from Canadian Medical Association
For
French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury
Roquilly et al.
2020
Spinal cord injury
French Society of Anesthesia and Intensive Care Medicine
GRADE system
For
Outcomes of spinal cord injury: WFNS Spine Committee Recommendations
Parthiban et al.
2020
Cervical spinal cord injury
WFNS Spine Committee
Delphi method
For
An expert consensus on the evaluation and treatment of acute thoracolumbar spine and spinal cord injury in China
Zhang et al.
2013
Thoracolumbar spine cord injury
Chinese Association of Spine and Spinal Cord Injury
Delphi method
For
Pediatric cervical spine injuries and SCIWORA: WFNS Spine Committee Recommendations
Konovalov et al.
2020
Pediatric cervical spinal cord injury/SCIWORA
WFNS Spine Committee
Delphi method
For
Spinal cord injury without radiographic abnormality (SCIWORA)
Rozzelle et al.
2013
SCIWORA
AANS/CNS Joint Guidelines Committee
Modified North American Spine Society criteria
For
AANS/CNS, American Association of Neurological Surgeons and Congress of Neurological Surgeons; GRADE, Grading of Recommendations Assessment, Development and Evaluation; MRI, magnetic resonance imaging; SCIWORA, Spinal Cord Injury Without Radiographic Abnormality; WFNS, World Federation of Neurosurgical Societies.
The characteristics of all seven guidelines are outlined in Table 1. This includes their names, authors, edition years, target population, development committees/ agencies/ associations, methods used in recommendation development, recommendation on MRI respectively.
For all included guidelines, the scores for each domain were as follows: scope and purpose (range: 51.3%–86.7%, IQR: 56.9%–69.3%, median: 57.2%), stakeholder involvement (range: 17.9%–84.1%, IQR: 25.0%–53.9%, median: 34.3%), rigor of development (range: 41.3%–75.7%, IQR: 45.1%–61.8%, median: 55.1%), clarity of presentation (range: 77.8%–91.2%, IQR: 84.1%–88.0%, median: 87.0%), applicability (range: 5.8%–38.3%, IQR: 7.7%–15.7%, median: 9.7%), editorial independence (range: 22.2%–100%, IQR: 46.7%–84.4%, median: 50.0%), and overall rating (range: 3.5–5.4, IQR: 3.7–4.5, median: 3.7; Table 2, Fig. 2). The range of intraclass correlation coefficients was between 0.838 (95% CI: 0.707–0.921) and 0.975 (95% CI: 0.951–0.988), indicating that the consistency among the three raters was very good. Two guidelines [
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
] scored over 50% in 1 to 4 domains and were evaluated as “recommended with modification.” Therefore, we extracted recommendations from all included guidelines.
Table 2Appraisal of guidelines through AGREE II instrument
Guideline
Intraclass correlation coefficient (95% CI)
Scope and purpose (%)
Stakeholder involvement (%)
Rigor of development (%)
Clarity of presentation (%)
Applicability (%)
Editorial independence (%)
Overall rating
Fehlings et al. 2017
0.838 (0.707–0.921)
86.7
84.1
68.3
91.2
38.3
100.0
5.4
Paralyzed Veterans of America 2008
0.890 (0.795–0.948)
63.7
54.8
75.7
83.0
13.9
22.2
4.4
Roquilly et al. 2020
0.900 (0.812–0.952)
74.8
53.0
55.1
87.0
17.5
96.7
4.5
Parthiban et al. 2020
0.939 (0.883–0.972)
51.3
17.9
55.3
88.9
7.9
50.0
3.7
Zhang et al. 2013
0.894 (0.802–0.950)
56.7
34.3
43.2
77.8
7.5
72.2
3.7
Konovalov et al. 2020
0.868 (0.756–0.937)
57.2
18.0
46.9
85.2
5.8
43.3
3.5
Curtis et al. 2013
0.975 (0.951–0.988)
57.0
32.0
41.3
87.0
9.7
50.0
3.6
95% CI, 95% confidence interval; AGREE II, Appraisal of Guidelines for Research and Evaluation, 2nd edition.
The results of appraisals of all seven guidelines through the AGREE II instrument are outlined in Table 2. This includes six domains: scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence, and overall rating with intraclass correlation coefficient companied with 95% CI.
Twelve recommendations were extracted from the included guidelines. We described all included recommendations in detail in Appendix 4 and summarized them in Table 3. LOE was C in nine recommendations and D in three recommendations.
Table 3Recommendations on MRI in the diagnosis of spinal cord injury from guidelines and LOE of recommendations
Fehlings et al. 2017
Paralyzed Veterans of America 2008
Roquilly et al. 2020
Parthiban et al. 2020
Zhang et al. 2013
Konovalov et al. 2020
Rozzelle et al. 2013
SCI
Patient age
Adult
++
Children
++
Timing of MRI
As soon as possible
++
Acute period
++
Symptoms indicated for MRI
Neurological deficit
++
+
Suspected disc and posterior ligamentous complex injury
DTI sequences may be promising to predict outcome in both acute and chronic SCI patients. +, recommended for with LOE D; ++, recommended for with LOE C; +++, recommended for with LOE B; ++++, recommended for with LOE A. Grade A refers to individual RCTs and systematic reviews of RCTs; Grade B refers to systematic reviews of cohort/case-control studies, case-control studies, and cohort studies; Grade C refers to case report/series and poor-quality case-control studies or cohort studies; Grade D refers to troublingly inconsistent or inconclusive studies. LOE will also be assessed as D if one recommendation is an expert opinion formulated without explicit critical appraisal of evidence.
DTI sequences may be promising to predict outcome in both acute and chronic SCI patients. +, recommended for with LOE D; ++, recommended for with LOE C; +++, recommended for with LOE B; ++++, recommended for with LOE A. Grade A refers to individual RCTs and systematic reviews of RCTs; Grade B refers to systematic reviews of cohort/case-control studies, case-control studies, and cohort studies; Grade C refers to case report/series and poor-quality case-control studies or cohort studies; Grade D refers to troublingly inconsistent or inconclusive studies. LOE will also be assessed as D if one recommendation is an expert opinion formulated without explicit critical appraisal of evidence.
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
] (1/1, 100%) recommended that T2-weighted imaging (T2WI) was an acceptable method for the diagnosis of SCI (LOE: C) and diffusion tensor imaging (DTI) might be used to predict outcomes of patients with SCI (LOE: C).
Discussion
Seven guidelines regarding diagnostic imaging for patients with SCI were included in the systematic review. In the domains of clarity of presentation, scope and purpose, all included guidelines were above the minimum threshold. Over half of included guidelines were above the minimum threshold in the domains of rigor of development and editorial independence. In the domain of applicability, no guidelines reached the minimum threshold.
The following accounted for the low scores of the domain of applicability of the included guidelines: (1) Advice and tools for the application of the recommendations were lacking; (2) potential facilitators of and barriers to the application of the recommendations were not discussed; and (3) potential cost implications of the application of the recommendations were not considered. In the future, guideline developers should describe potential factors that may promote or hinder the application of the recommendations, such as advice and tools for the application (eg, a quick reference guide), potential barriers to the application (eg, insufficient skills of practitioners), potential facilitators of the application (eg, sufficient imaging equipment for diagnosis), and potential cost implications of the application (eg, imaging acquisition costs), to improve the applicability of the guidelines [
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
] recommended MRI for adult patients because the target population of most of the supporting evidence was adult patients. Notably, both recommendations were based on a low LOE. The other guidelines [
] did not describe the patient age in the recommendations. To some extent, these data indicates that there is no high-level evidence to prove that there is an age limit for the use of MRI. One possible reason is that MRI is a safe imaging modality with the use of non-ionizing electromagnetic radiation. With proper management and care, MRI can be performed safely for patients of all ages [
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
] recommended MRI in the “acute period”, which was defined as “within a week of injury.” Both guidelines lacked high-quality evidence to prove their reliability, which made their recommendations weak. Although the quality of the supporting evidence was low, the consistency of recommendations was high. One possible reason is that MRI performed in the acute setting can play an important role in the evaluation of patients with suspected SCI for an earlier diagnosis and a timely treatment, which are beneficial to the prognosis of neurological function [
]. Therefore, although the quality of the supporting evidence was low, the guidelines arrived at the consistent conclusions leading to the high consistency of the recommendations.
] recommended that T2WI was an acceptable method for the diagnosis of SCI and DTI might be used to predict outcomes of patients with SCI. In clinical practice, T2WI is the most important method for the detection of SCI [
]. DTI is a useful imaging method for detecting the microstructure of spinal cord, which is based on diffusion of water molecules in biological tissues [
]. However, the clinical utility of DTI is limited because susceptibility artifacts caused by cardiac and respiratory motions can affect its accuracy [
]. These may be reasons why DTI was not widely recommended in the other included guidelines. The limited availability of relevant clinical studies with a long-term follow-up might also contribute to the weak recommendation for DTI.
] recommended for MRI in the diagnosis of SCIWORA. SCIWORA is defined as the presence of clinical symptoms of traumatic myelopathy with no radiographic or computed tomographic features of spinal fracture or instability [
]. For this reason, MRI can be utilized to detect some characteristic pathomorphological changes in soft tissues of patients with SCIWORA, such as spinal cord hematomas and edema [
Referring to the suggestions of reviewers, this study did not include recommendations relevant to CT. CT is regarded as a first-line imaging modality after spinal trauma because it is sensitive to osseous abnormalities and can be performed rapidly [
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
In the future, more high-quality evidence (eg, data from RCTs) is expected to formulate strong recommendations. However, considering the particularity of studies for diagnostic strategies, this could be difficult and challenging. With synthesis of existing evidence, clinical experience, and expert opinions, the Appropriate Use Criteria (AUC) methodology could be expected to be utilized by a rating panel to determine the appropriateness of MRI in various clinical scenarios [
AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.
]. Additionally, more types of MRI for the diagnosis of SCI such as diffusion-weighted imaging and susceptibility-weighted imaging are expected to be studied and gradually introduced into future guidelines [
There were some strengths in our study. First, this study included seven available clinical practice guidelines on diagnostic imaging of SCI from 2008 to 2020 through a systematic search and critically appraised their qualities using the AGREE II instrument [
]. This strategy enabled an intuitive presentation of the qualities of existing available guidelines, which can help clinicians in selecting high-quality guidelines to facilitate consistent, efficient, and evidence-based practices in clinical conditions and provide guidance for future work for guideline developers. Second, to our knowledge, this study is the first time to summarize and analyze the recommendations on diagnostic imaging for SCI from existing available guidelines and evaluate the level of their supporting evidence by a unified evidence assessment system. The findings can help clinicians intuitively acquire similarities and differences of the recommendations in current existing guidelines and the quality of their supporting evidence.
Our study also had some limitations. First, considering that the AGREE II instrument has not defined a specific minimum threshold for the scores of each domain and defined the method for evaluating the overall quality of appraised guidelines, the minimum threshold (50%) set for each domain and evaluation methods of the overall quality might be limitations. However, we evaluated the overall quality of the included guidelines based on two commonly used methods: 1) number of domains reaching the minimum threshold and 2) overall rating score. The results were similar, indicating that the set minimum threshold and evaluation methods did not significantly affect the appraisal results of the overall quality of the included guidelines and the subsequent extraction results of the recommendations. Second, the inclusion criterion that literature must be published in English may have caused several available guidelines to be omitted.
In conclusion, seven guidelines were included in the present systematic review, and all of them showed the worst applicability scores in the AGREE II instrument. They all weakly recommended MRI for patients with suspected SCI or SCIWORA based on a low LOE.
Declarations of Competing Interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
Dr Zhou was funded by Taishan Scholars Program of Shandong Province-Young Taishan Scholars (tsqn201909197). We thank Ping Yu from Library of Tianjin Medical University for developing the search strategies. We thank Runhan Fu from Shandong University and Wei Wang from Shandong University for their contributions to this study. This study received no funding.
Critical appraisal of paralyzed veterans of America Guidelines in spinal cord injury: an International Collaborative Study Using the Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II).
A clinical practice guideline for the management of patients with acute spinal cord injury: recommendations on the role of baseline magnetic resonance imaging in clinical decision making and outcome prediction.
AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery.
Author disclosures: BG: Nothing to disclose. GL: Nothing to disclose. RZ: Nothing to disclose. YF: Nothing to disclose. LY: Nothing to disclose. LC: Nothing to disclose. SF: Nothing to disclose. HZ: Nothing to disclose.
DTI sequences may be promising to predict outcome in both acute and chronic SCI patients. +, recommended for with LOE D; ++, recommended for with LOE C; +++, recommended for with LOE B; ++++, recommended for with LOE A. Grade A refers to individual RCTs and systematic reviews of RCTs; Grade B refers to systematic reviews of cohort/case-control studies, case-control studies, and cohort studies; Grade C refers to case report/series and poor-quality case-control studies or cohort studies; Grade D refers to troublingly inconsistent or inconclusive studies. LOE will also be assessed as D if one recommendation is an expert opinion formulated without explicit critical appraisal of evidence.
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