The guideline development process adopted by the Consortium for Spinal Cord Medicine consists of twelve steps, leading to panel consensus and organizational endorsement. After the steering committee chooses a topic, a panel of experts is selected. Panel members must have demonstrated leadership in the topic area through independent scientific investigation and publication. Following a detailed explication and specification of the topic by select steering committee and panel members, consultant methodologists review the international literature, prepare evidence tables that grade and rank the quality of research, and conduct statistical meta-analyses and other specialized studies, as needed. The panel chair then assigns specific sections of the topic to the panel members based on their area of expertise. Writing begins on each component using the references and other materials furnished by the methodology support group.
After panel members complete their sections, a draft document is generated during the first full meeting of the panel. The panel incorporates new literature citations and other evidence-based information not previously available. At this point, charts, graphs, algorithms, and other visual aids, as well as a complete bibliography, are added, and the full document is sent to legal counsel for review.
Grading the Guideline Recommendations
After panel members had drafted their sections of the guideline, each recommendation was graded according to the level of scientific evidence supporting it. The framework used by the methodology team is outlined in "Rating Scheme for the Strength of the Recommendations." It should be emphasized that these ratings, like the evidence table ratings, represent the strength of the supporting evidence, not the strength of the recommendation itself. The strength of the recommendation is indicated by the language describing the rationale.
If the literature supporting a recommendation comes from two or more levels, the number and level of the studies are reported (e.g., in the case of a recommendation that is supported by two studies, one a level III, the other a level V, the "Scientific evidence" is indicated as "III/V"). In situations in which no published literature exists, consensus of the panel members and outside expert reviewers was used to develop the recommendation and is indicated as "Expert consensus."
Grading of Panel Consensus
The level of agreement with the recommendation among panel members was assessed as either low, moderate, or strong. Each panel member was asked to indicate his or her level of agreement on a 5-point scale, with 1 corresponding to neutrality and 5 representing maximum agreement. Scores were aggregated across the panel members and an arithmetic mean was calculated. This mean score was then translated into low, moderate, or strong. A panel member could abstain from the voting process for a variety of reasons, including, but not limited to, lack of expertise associated with the particular recommendation.