BOOTStrap-SCI: Beyond One Option of Treatment for Spinal Trauma and Spinal Cord Injury: Consensus-Based Stratified Protocols for Intensive Care and Surgical Management

Abstract

OBJECTIVE: Spinal trauma (STx), with or without spinal cord injury (SCI), represents a significant global health burden, particularly in low- and middle-income countries (LMICs). International guidelines often assume the availability of resources for intensive care and surgical management, limiting their applicability in resource-constrained settings. A resource-adapted approach may improve management in these contexts. This study aimed to develop resource-tiered protocols for the intensive care and surgical management of STx and SCI, addressing LMIC-specific challenges with clinical evidence and expert-based practices. METHODS: A multidisciplinary Delphi consensus process combined international evidence-based guidelines with expert input. Iterative discussions and voting by healthcare providers from LMICs and high-income countries ensured context-sensitive and flexible protocols, tailored to varying levels of training, resource availability, and healthcare infrastructure. RESULTS: The resulting protocols address key aspects of intensive care and surgical management, including resuscitation, cardiopulmonary optimization, imaging, and surgical criteria and timing. Two protocols were developed for intensive care (postoperative recovery and general ICU setting) and 3 for surgical management, reflecting resource levels: basic facilities without imaging, intermediate facilities with X-ray, and advanced facilities with computed tomography and magnetic resonance imaging. CONCLUSIONS: The proposed protocols may bridge gaps in STx and SCI care in LMICs by providing adaptable frameworks for resource-limited contexts. The consensus-driven approach can foster protocolized care delivery in LMICs, emphasizing feasibility and local adaptability. Future efforts should focus on validating these protocols in clinical practice.