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Friday, May 23, 2014
Corticosteroid Use in Acute Spinal Cord Injury: The Pendulum Continues to Swing

The use of high dose steroids in acute spinal cord injury (SCI) remains one of the most controversial topics in the spine world. While there was initial enthusiasm for the possibility of improving outcomes pharmacologically following publication of the NASCIS II trial, further scrutiny of the NASCIS data has prompted the spine community to reconsider the risks and benefits of the treatment. The reported benefit (about 5 points on the ASIA motor and sensory scales) is of limited clinical importance, and some have suggested it is a statistical anomaly related to the poor performance of the placebo subgroup included in the analysis of patients who were treated within 8 hours of injury. Additionally, while the NASCIS trials glossed over the complications of steroids, review of that trial and others indicate the rate of infection and GI bleeding is up to twice as high in the patients receiving steroids. These revelations prompted the American Association of Neurological Surgeons (AANS) to conclude that the “administration of methylprednisolone for the treatment of acute SCI is not recommended.”1 Given these changes in the perception of the role of steroids in SCI, Dr. Schroeder and colleagues performed a survey of members of the Cervical Spine Research Society to determine current practices and attitudes surrounding the use of steroids. They received responses from 84 spine surgeons, including 71 orthopaedic surgeons, 12 neurosurgeons, and one who did not identify their training. In the hypothetical case of an incomplete cervical SCI patient presenting 4 hours after injury, 56% of respondents reported they would use high dose steroids, with 44% avoiding them. This is down from the 89% who stated they would have used steroids in a survey of NASS members in 2006. Of those still using steroids, only 25% believe that they lead to better outcomes, while 25% use them due to medicolegal concerns and 19% due to an institutional policy. Over 70% of respondents indicated they had observed complications related to the use of steroids, and 13% reported firsthand knowledge of a lawsuit related to the use or non-use of steroids in acute SCI. This study provides a nice depiction of how practice has changed over a relatively short period of time.

 

Surveys are helpful in capturing practice patterns and attitudes, though they do not necessarily indicate what the best pattern of care would be. History is replete with examples of how the medical establishment supported a treatment that was subsequently found to be useless or even harmful (i.e. therapeutic bleeding, IDET). In the case of steroids for SCI, the trend away from steroids certainly seems to be in-line with our current understanding of the issue, though the fact that so many CSRS members who responded to the survey indicate they still use steroids despite not believing they are indicated for clinical reasons is concerning. If high dose steroids caused no harm, then using them for medicolegal purposes or in order to comply with a policy would be ethically sound as they might help some patients to some degree. However, given the evidence that they increase the rate of infection, GI bleeding, and possibly death, using them for non-clinical purposes (i.e. medicolegal protection) is clearly wrong. The current situation in which physicians are providing a treatment that they believe causes more harm than good will only change if other large practice organizations (i.e. NASS, AAOS, ASIA, etc.) follow the lead of the AANS and provide clinical practice guidelines that support not using high dose steroids in acute SCI. For those concerned about medicolegal issues, the current situation in which some institutions have policies supporting the use of high dose steroids while the AANS recommends not using steroids is the worst case scenario as malpractice attorneys can argue that physicians have acted negligently whether they gave steroids or not. This survey and comparison to past surveys provides a nice snapshot into actual practice around a controversial topic. As surgeons become more aware of how practice is changing outside their institution, some may be willing to alter their practice in line with what they believe is truly best for the SCI patient.

Please read Dr. Schroeder’s article on this topic in the May 20 issue. Do you use high dose steroids in acute SCI patients? Let us know by leaving a comment on The Spine Blog.

Adam Pearson, MD, MS

Associate Web Editor

 

 

REFERENCE

1.            Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery 2013;72 Suppl 2:93-105.

 

 

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Spine Journal
This Blog provides a forum for discussion about high impact articles published in Spine, including the bi-annual publication of "Evidenced-Based Recommendations for Spine Surgery." Website users can use this forum to discuss how the articles have affected their practice and query the authors about their findings and recommendations.