Guidelines for neuroprognostication in adults with traumatic spinal cord injury

Neurocritical Care Society · 2023 · USA

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Authors: Dea Mahanes, Susanne Muehlschlegel, Katja E Wartenberg et al.
Title: Guidelines for neuroprognostication in adults with traumatic spinal cord injury
Journal: Neurocritical Care, 2023
DOI: 10.1007/s12028-023-01845-8
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC10959804

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Outcome: Mortality (Acute, in-Hospital)

RecommendationWhen counseling patients, family members, and/or surrogates of adults with acute tSCI, we suggest that older age alone not be considered a reliable predictor of acute in-hospital mortalityweak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the Quality in Prognostic Studies (QUIPS) domains of study participation, prognostic factor measurement, confounding, statistical analysis and reporting, and self-fulfilling prophecy. Many studies had high risk of bias in the domain of confounding because treatment effect was not considered, and in statistical analysis and reporting because the studies were underpowered, or the analysis was not well described. Most studies also had moderate to high risk of bias in the domain of self-fulfilling prophecy because death was either preceded by withdrawal of life-sustaining treatment or this information was not reported. The quality of evidence was not limited by inconsistency or indirectness but was limited by imprecision. Only one study found no significant impact of age on acute in-hospital mortality, and this study had methodologic limitations, primarily related to study participation and statistical reporting [34]. While the body of evidence was consistent in identifying older age as a predictor of acute in-hospital mortality in patients with cervical injury [35–38] and when patients with all levels of injury were included [39–41], the panel could not recommend the use of age alone as a reliable or moderately reliable predictor because, irrespective of age, the majority of individuals survive to hospital discharge. In one of the largest studies (n=3,389 patients with all levels and severity of injury), 528/668 patients (79%) ≥ 65 years survived to discharge [40].
RecommendationWhen counseling patients, family members, and/or surrogates of adults with acute tSCI, we suggest that comorbidities alone not be considered a reliable predictor of acute in-hospital mortalityweak recommendation, low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study participation, prognostic factor measurement (assessment of comorbidities through retrospective chart review), confounding (potential impact of treatment factors), and self-fulfilling prophecy (withdrawal of life-sustaining treatment not considered or not reported). The quality of evidence was not limited by imprecision or indirectness, but inconsistency did downgrade the quality of evidence. The presence of two or more comorbid conditions compared to no comorbidities was associated with increased mortality in two large studies that included a total of more than 6,000 patients [39, 40]. However, even with ≥ 3 comorbidities, most patients in these two studies survived to hospital discharge (in-hospital mortality rate 16.9–22.8%). In one smaller study (n = 297) that utilized both the CCI and number of comorbidities, the number of comorbidities did not impact in-hospital mortality, although the study population included a large proportion (60.9%) of patients with AIS D SCI [42]. Across studies, the body of literature demonstrated substantial variation in study population and in prognostic factor measurement. The panel was unable to recommend the use of comorbidities as a reliable or moderately reliable predictor of mortality because most patients will survive despite the presence of multiple comorbidities.
RecommendationWhen counseling patients, family members, and/or surrogates of adults with acute tSCI, we suggest that concomitant injury alone not be considered a reliable predictor of acute in-hospital mortalityweak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of prognostic factor measurement, confounding, statistical analysis and reporting, and self-fulfilling prophecy. Prognostic factor measurement varied between studies, including a count of body systems injured [40], total ISS [39, 41], and measures of the severity of associated TBI [35, 39, 41]. Most studies did not describe or control for the potential impact of treatment variables, descriptions of statistical analysis lacked detail, and the impact of withdrawal of life-sustaining treatment was not addressed. The quality of evidence was not limited by inconsistency or indirectness but was decreased by imprecision. Studies found increased risk of in-hospital mortality in patients with multisystem injury (hazard ratio 1.46–1.85) [40] and patients with higher total ISS [39, 41]. One study used the Trauma Score and ISS (TRISS) and found no significant association with acute in-hospital mortality [36]. Concomitant TBI was associated with higher acute in-hospital mortality, although TBI was defined differently across studies [35, 38, 39, 41]. However, in those studies in which mortality rates were separately reported, more than 80% of patients with TBI or other multisystem trauma survived to hospital discharge [40, 41]. The panel was unable to recommend the use of concomitant injury alone as a reliable or moderately reliable predictor of mortality because most patients will survive despite the presence of concomitant injuries.
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that NLI alone not be considered a reliable predictor of acute in-hospital mortality.weak recommendation; very low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study participation, prognostic factor measurement, study confounding, statistical analysis and reporting, and self-fulfilling prophecy. In addition, several studies included limited or no information about the timing of prognostic factor measurement and decisions about withdrawal of life-sustaining treatment. The quality of evidence was not limited by indirectness but was limited by inconsistency and imprecision. Most studies included only patients with cervical injuries. In the only study that included patients with all levels of injury, the majority of the population (83.5% of 6,827 patients) had cervical injury [41]. There were no significant differences in mortality based on NLI when comparing cervical, thoracic, or cauda equina to lumbar levels of injury [41]. Among studies focused on cervical injury, mortality was higher in patients with upper cervical injury, which was defined as C4 or higher in two studies [34, 35] and C5 or higher in the largest study [43]. In contrast, Martin and colleagues found no significant difference in mortality between patients with C1–4 and C5–8 injuries [36]. Across all studies, the vast majority of patients (approximately 80–90%) survived to hospital discharge. Additional limitations that favor not considering the predictor include the potential for withdrawal bias among patients with cervical injury and the likelihood that patients with complete injury at C1 or C2 do not survive to reach the hospital.
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that severity of injury (complete versus incomplete) alone not be considered a reliable predictor of acute in-hospital mortalityweak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study participation, study attrition, prognostic factor measurement, study confounding, statistical analysis and reporting, and self-fulfilling prophecy. In several studies, the population was either selective or was poorly described, and some studies did not consider treatment effect, the impact of polytrauma, or withdrawal of life-sustaining treatments. Limited descriptions of statistical analysis also contributed to risk of bias. The quality of evidence was not limited by inconsistency or indirectness, but was impacted by imprecision with wide confidence intervals in one large study [43]. Mortality risk appears increased with complete injury when compared to incomplete injury, especially at the cervical level, but variability in comparison groups and statistical analysis make the risk difficult to quantify [34, 36, 38–41, 43]. Even among patients with complete cervical injury, early survival is consistently reported to exceed 75% [34, 38, 39, 43].

Outcome: Long-Term Mortality (Cumulative, Measured After Discharge)

RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest increased age at time of injury alone not be considered a reliable predictor of long-term mortality (cumulative mortality measured at any time point after hospital discharge).weak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study participation, outcome measurement, confounding, statistical analysis and reporting, and self-fulfilling prophecy. The quality of evidence was not limited by inconsistency or indirectness, but was limited by imprecision with wide confidence intervals throughout. While there is low quality evidence that suggests that the risk of longer-term all-cause mortality (at least 1 year after tSCI) increases with age [44–48], the age at which this increase is seen varies substantially between studies, follow-up periods vary, confidence intervals are wide, and comparator groups vary. Survival at a year or more postinjury remains > 50% for almost all age groups [44, 45, 47], although one study [45] reported a five-year survival of 40.4% among those individuals aged 75 or older. With one exception [46], acute in-hospital mortality was included in the cumulative mortality rates reported at later intervals.
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that comorbidities alone not be considered a reliable predictor of long-term mortalitycumulative mortality measured at any time point after hospital discharge; weak recommendation; low quality evidence
Rationale: Three studies [45, 46, 49] evaluated the predictive value of comorbid conditions at the time of acute hospitalization for long-term cumulative mortality. Moderate risk of bias was present, with potential bias in at least one study for all QUIPS domains. The quality of evidence was not limited by imprecision or indirectness but was limited by inconsistency. One study assessed all-cause mortality 5 years post injury in patients with all levels and varying severity of tSCI, and found no correlation with CCI during acute hospitalization [45]. Similarly, Esmoris-Arijón and colleagues (2021) found no association between CCI during acute hospitalization and death at 1 year [49]. The third and largest (n=2,685) study evaluated the association between number of comorbidities and mortality after discharge from acute hospitalization. This study followed patients for variable periods (longest follow-up > 10 years) and found that patients with two or more comorbid conditions were at increased risk for death. However, 84% of patients remained alive at last follow-up [46].
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that concomitant injury alone not be considered a reliable predictor of long-term mortalitycumulative mortality measured at any time point after hospital discharge; weak recommendation; moderate quality evidence
Rationale: The evidence was downgraded for risk of bias in the QUIPS domains of study participation, prognostic factor measurement, confounding, and self-fulfilling prophecy. The quality of evidence was not limited by inconsistency, imprecision, or indirectness. All studies reported cumulative mortality, encompassing in-hospital and post-discharge mortality. Concomitant injury was defined by chest trauma [44], ISS [45], or GCS [45, 47], and patient population also varied by level and severity of injury. None found a significant impact of concomitant injury on long-term survival after tSCI.
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that NLI alone not be considered a reliable predictor of long-term mortality (cumulative mortality measured at any time point after hospital discharge).weak recommendation; very low quality evidence
Rationale: Four studies addressed the impact of NLI on long-term outcomes, with follow-up intervals varying from 1 year to almost 12 years. The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study participation, prognostic factor measurement, study confounding, statistical analysis and reporting, and self-fulfilling prophecy. The quality of evidence was not limited by indirectness but was limited by inconsistency and imprecision. One study reported 5-year mortality for 426 patients with cervical, thoracic, and lumbar injury of variable severity and found no significant impact of NLI on multivariate analysis [45]. Another found no significant difference in cumulative mortality at 1 year for cervical versus thoracolumbar injury [47]. The remaining two studies found increased mortality in patients with upper cervical injury (C1-C4); the comparison group was patients with lower cervical injury in one study [44] and all levels of injury in the other [46]. Even among patients with injuries at C4 or above, approximately 60–70% were still alive 8 to 10 years post injury [44, 46], limiting the utility of NLI as a predictor of long-term mortality.
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that severity of injury alone (defined by complete versus incomplete injury or by ASIA motor score) not be considered a reliable predictor of long-term mortalitycumulative mortality measured at any time point after hospital discharge; weak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study participation, prognostic factor assessment, study confounding, statistical analysis and reporting, and self-fulfilling prophecy. The quality of evidence was not limited by inconsistency or indirectness but was impacted by imprecision. Although increased severity of injury (defined by lower ASIA motor score or worse AIS/Frankel grade) appeared to be associated with increased mortality risk, the evidence was limited by variation in study methodology, and lack of information regarding the timing of assessment of injury severity. The largest study reported a hazard ratio of 0.3–0.6 for incomplete injury (Frankel grades B-E) versus complete injury (Frankel grade A) with overall mortality (across all grades) of 16.2% [46]. Although follow-up intervals varied and severity of injury did impact mortality, survival rates at final follow-up remained above 60 percent across studies even for patients with the most severe injuries. Casper et al. (2018) grouped patients by ASIA motor score and found that lower motor scores were associated with higher mortality; however, 5-year survival was 68.2% even among the group with the most severe injury (ASIA motor score 0–20) [45].

Outcome: Functional Outcome (at Discharge from Rehabilitation or Beyond)

RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that age alone not be considered a reliable predictor of functional outcome at 1-year follow-upweak recommendation; moderate quality evidence
Rationale: Functional outcome was assessed with the FIM score in studies that met our criteria. Evidence was downgraded for the overall risk of bias with potential bias in the QUIPS domains of participation, study attrition, confounding, statistical analysis and reporting and self-fulfilling prophecy. The quality of evidence was not limited by inconsistency, indirectness, or imprecision. Available data from four large prospective databases suggested that age at time of the injury was independently and inversely associated with functional outcome at 1 year. Age could not be considered a reliable, or moderately reliable predictor, because these effects were weak [28, 47, 50, 51]—albeit statistically significant—and an age threshold that reliably predicted poor outcome could not be identified. In one study, advanced age impacted functional outcome and recovery after tSCI as assessed by the motor score of the FIM. This effect varied across the spectrum of injury severity. Potential for improvement generally diminished with completeness or incompleteness of the injury. Age was particularly relevant for AIS grade B/C patients, with patients < 65 years demonstrating better functional outcomes [51].
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that NLI alone not be considered a reliable predictor of poor functional outcome at 1-year follow-up. However, patients and surrogates should be counseled that a higher level of injury is associated with more functional deficits and greater dependenceweak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study attrition, confounding, statistical analysis and reporting, and self-fulfilling prophecy. Imprecision was present. In a multivariate analysis thoracolumbar injuries independently predicted better functional outcome than cervical injuries [51]. The study was limited however by a relatively low proportion (<10%) of thoracic and lumbar SCI. In thoracic SCI the NLI based on the sensory exam was also an independent predictor of functional outcome. The analysis of 400 patients enrolled in the SCIMS database revealed better FIM motor scores at 1-year follow-up in patients with low (T10–T12) as opposed to high (T2–T9) NLI [28]. This predictor could not be recommended as a reliable (or moderately reliable) predictor in isolation because a substantial number of patients with higher NLI with mitigating factors such as incomplete injury achieve functional independence.
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that initial severity of injury as measured by the ASIA impairment score alone not be considered a reliable predictor for future motor outcome at 1-year follow-up. However, patients and surrogates should be counseled that motor incomplete injury is associated with a higher probability of functional improvementweak recommendation; moderate quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating potential bias in the QUIPS domains of study attrition, confounding, statistical analysis and reporting, and self-fulfilling prophecy. The quality of evidence was not limited by inconsistency, indirectness, or imprecision. Evidence was from prospective registries and study data sets revealed a strong relationship between initial ASIA grade and functional outcome as measured by the motor score of the FIM. As independent predictors of functional outcome, the AIS and NLI are most consistently included in clinical prediction models. Patients with motor complete injuries (AIS A and B) were least likely to achieve functional independence, compared with patients with AIS C and D injuries [50, 51]. As previously outlined, these studies primarily included patients with cervical tSCI, about half with motor complete injuries. However, an analysis by Lee et al. (2016) confirmed these results in a population with thoracic tSCI, in which 90% of patients had motor complete injuries [28]. This predictor could not be recommended as a reliable (or moderately reliable) predictor in isolation because a substantial number of patients with motor complete injuries demonstrate AIS grade conversion and variable functional independence at long-term follow-up.

Outcome: AIS Improvement (Conversion) at Discharge from Rehabilitation or Beyond

RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest age at the time of injury alone not be considered a reliable predictor of AIS conversion assessed at 12–24 months follow-upweak recommendation; moderate quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating at least moderate bias in the QUIPS domains of study participation, study attrition, prognostic factor assessment, outcome measurement, study confounding, statistical analysis and reporting, and self-fulfilling prophecy. Three studies met inclusion criteria. In two studies, no effect of age at the time of injury on the rate of AIS conversion was observed. In a study of 14,433 patients with tSCI from the SCIMS database, neither age alone, nor the interaction of gender and age, was a significant predictor of AIS conversion [52, 53]. In one study of 57 patients with cervical tSCI who underwent surgical management, the median age was 37 years in the group that demonstrated AIS conversion, compared to a median age of 64 years in the group that did not [54].
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that the absence of pathological findings on MRI be considered a moderately reliable predictor of AIS conversion at 6–12 months follow-upweak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating at least moderate bias in the QUIPS domains of study participation and attrition, prognostic factor measurement, confounding, and self-fulfilling prophecy. Imprecision was present. In one study of 86 patients with cervical tSCI (AIS grades B-D), with improvement of at least one AIS grade in 77% of all patients at 12-month follow-up, intramedullary edema >36 mm and facet dislocation on MRI were independent predictors of the absence of AIS conversion regardless of initial AIS grade [55]. In another study, stepwise multiple logistic regression analysis demonstrated a 5% reduction in the probability of AIS conversion with each mm increment in intramedullary lesion length [56]. In a group of 55 patients who received definitive treatment for subaxial cervical fracture dislocations, AIS conversion was observed in 54% at follow-up. Maximal spinal cord compression >55.8% on MRI was an independent predictor of the absence of AIS conversion in this study [57].
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that NLI be considered a moderately reliable predictor of AIS conversion at 6–12 months follow-up. Patients and surrogates should be counseled that an improvement in AIS is more likely following lumbar and thoracolumbar injury than cervical or thoracic injuryweak recommendation; moderate quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating at least moderate bias in the QUIPS domains of study participation and attrition, prognostic factor and outcome measurement, confounding, statistical analysis and reporting, and self-fulfilling prophecy. In a retrospective study of 931 patients with motor complete (AIS A/B) tSCI NLI was an independent predictor of AIS improvement at 6–12 months. Patients with injury at the conus or below (lumbar) were more likely to demonstrate an improvement in AIS than patients with cervical or thoracic tSCI. [58]. In a study of 95 patients with thoracic and thoracolumbar injuries, an AIS conversion rate of 92.9% was observed following lumbar tSCI (conus, L1-S5) versus 22.4% for thoracic and thoracolumbar tSCI [59]. In a multivariate analysis of 86 surgically treated patients, compared with patients with cervical tSCI, patients with thoracolumbar and lumbar injury were significantly more likely to demonstrate AIS improvement (odds ratio [OR] 3.9), whereas patients with thoracic injury were less likely to improve (OR 0.5) [60].
RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest that severity of injury as assessed by the initial ASIA impairment score be considered a moderately reliable predictor of AIS conversion at 6–12 months follow-up. Patients and surrogates should be counseled that an improvement in AIS is more likely in the presence of incomplete injuryweak recommendation; low quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating at least moderate potential bias in the QUIPS domains of study participation and attrition, prognostic factor and outcome measurement, confounding, statistical analysis and reporting, and self-fulfilling prophecy. Imprecision was present. The body of evidence was consistent in demonstrating an independent association between severity of SCI as assessed by the initial ASIA impairment score and AIS conversion. Less than one third of patients with AIS A injuries demonstrate improvement at 1 year. AIS conversion is 4 to 8-fold more likely with AIS B–D injuries compared with AIS A injuries [53, 54, 58]. In a study of 931 patients with motor complete tSCI (AIS A/B) 21% of all patients with initial AIS A showed neurological improvement at 1-year follow-up compared to 69% with initial AIS B [58]. Among 86 patients with incomplete tSCI (AIS B–D), AIS improved by one or more grades in nearly 75%. Although incomplete injury was an independent predictor of AIS improvement in this study, AIS D was present in more than half of these patients at the time of initial evaluation [55]. In a study of 58 patients operated for thoracic or thoracolumbar tSCI, AIS conversion at 1-year follow-up occurred in 35% of patients with initial AIS A, 82% of patients with AIS B, 80% of patients with AIS C and 90% of patients with AIS D [61]. In a study of 86 patients with tSCI who underwent surgery only AIS B (OR 4.3, 95%CI 1.2–15.4) and AIS D (OR 5.2, 1.2–21.6) were independent predictors of AIS improvement [60].

Outcome: Independent Ambulation (at Discharge from Rehabilitation or Beyond)

RecommendationWhen counseling patients, family members, and/or surrogates of patients with acute tSCI, we suggest the Dutch Clinical Prediction Rule for ambulation (DCPR), with neurological assessment performed within 15 days following injury, be considered a moderately reliable predictor of the ability to walk 1-year following injuryweak recommendation; moderate quality evidence
Rationale: The body of evidence was downgraded for risk of bias, with various studies demonstrating bias in the Prediction model Risk Of Bias Assessmnent Tool (PROBAST) domains of analysis and self-fulfilling prophecy.
The DCPR was introduced in 2011 and is based on a patient sample set from the EMSCI. It was first validated internally and then externally in various international cohorts [19–22]. Excellent discrimination (AUC >0.95) was reported in most studies [18, 20]. Simplifying the rule by leaving out age (AUC 0.94) or leaving out one motor score (S1) and one sensory score (L3) (AUC 0.87) may yield acceptable discrimination [21]. Some recent studies suggest that prediction accuracy may vary based on injury severity (ASIA A+D > B+C) [22, 62]. Clinical utility may be greatest in patients with AIS B and C injuries since improvement to functional independence is inherently unlikely with AIS A injuries and inherently likely with AIS D injuries. Other studies suggest superior model performance with a lower age threshold than 65 years [63]. In a validation study using the SCIMS database dichotomization of age at 50 years yielded superior model performance, with both the original DCPR and a simplified (“3-variable”) version [22].

Abstract

Background: Traumatic spinal cord injury (tSCI) impacts patients and their families acutely and often for the long term. The ability of clinicians to share prognostic information about mortality and functional outcomes allows patients and their surrogates to engage in decision-making and plan for the future. These guidelines provide recommendations on the reliability of acute-phase clinical predictors to inform neuroprognostication and guide clinicians in counseling adult patients with tSCI or their surrogates.

Methods: A narrative systematic review was completed using Grading of Recommendations Assessment, Development, and Evaluation methodology. Candidate predictors, including clinical variables and prediction models, were selected based on clinical relevance and presence of an appropriate body of evidence. The Population/Intervention/Comparator/Outcome/Timing/Setting question was framed as “When counseling patients or surrogates of critically ill patients with traumatic spinal cord injury, should < predictor, with time of assessment if appropriate > be considered a reliable predictor of < outcome, with time frame of assessment >?” Additional full-text screening criteria were used to exclude small and lower quality studies. Following construction of an evidence profile and summary of findings, recommendations were based on four Grading of Recommendations Assessment, Development, and Evaluation criteria: quality of evidence, balance of desirable and undesirable consequences, values and preferences, and resource use. Good practice recommendations addressed essential principles of neuroprognostication that could not be framed in the Population/Intervention/Comparator/Outcome/Timing/Setting format. Throughout the guideline development process, an individual living with tSCI provided perspective on patient-centered priorities.

Results: Six candidate clinical variables and one prediction model were selected. Out of 11,132 articles screened, 369 met inclusion criteria for full-text review and 35 articles met eligibility criteria to guide recommendations. We recommend pathologic findings on magnetic resonance imaging, neurological level of injury, and severity of injury as moderately reliable predictors of American Spinal Cord Injury Impairment Scale improvement and the Dutch Clinical Prediction Rule as a moderately reliable prediction model of independent ambulation at 1 year after injury. No other reliable or moderately reliable predictors of mortality or functional outcome were identified. Good practice recommendations include considering the complete clinical condition as opposed to a single variable and communicating the challenges of likely functional deficits as well as potential for improvement and for long-term quality of life with SCI-related deficits to patients and surrogates.

Conclusions: These guidelines provide recommendations about the reliability of acute-phase predictors of mortality, functional outcome, American Spinal Injury Association Impairment Scale grade conversion, and recovery of independent ambulation for consideration when counseling patients with tSCI or their surrogates and suggest broad principles of neuroprognostication in this context.

Supplementary Information: The online version contains supplementary material available at 10.1007/s12028-023-01845-8.

Contents of the original publication

The section headings of the original.

Introduction
Scope, Purpose, and Target Audience
How to Use These Guidelines
Methods
Selection of Guideline Questions
Selection of Outcomes
Systematic Review Methodology
Evidence to Recommendation Criteria
Good Practice Statements
Recommendations: Clinical Variables as Predictors
Outcome: Mortality (Acute, in-Hospital)
Outcome: Long-Term Mortality (Cumulative, Measured After Discharge)
Outcome: Functional Outcome (at Discharge from Rehabilitation or Beyond)
Outcome: AIS Improvement (Conversion) at Discharge from Rehabilitation or Beyond
Outcome: Independent Ambulation (at Discharge from Rehabilitation or Beyond)
Recommendations: Clinical Prediction Models
Outcome: Independent Ambulation (at Discharge from Rehabilitation or Beyond)
Future Directions
Conclusions
Source of support
Ethical Approval

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