Steroids in acute spinal cord injury

CAEP Position Statements

CJEM 2003;5(1):7-9

Summary | Review of evidence | References

Position Statement: Methylprednisolone for acute spinal cord injury is not a standard of care; it is only a treatment option.

Summary

Confusion persists about the utility of high-dose methylprednisolone infusion for acute spinal cord injury. This treatment was widely adopted following the report of the Second National Acute Spinal Cord Injury Study (NASCIS II) in 1990 and became an implied standard of care.¹ Despite the fact that subsequent clinical studies and critical reviews have challenged the validity of the recommendations that followed the NASCIS studies, failure to administer steroids in acute spinal cord injury has been cited in litigation against physicians.^2-10 A survey of attendees at the First Annual Canadian Spine Society Meeting in Mont Tremblant, Que., on Mar. 23, 2001, revealed that 75% of respondents were using methylprednisolone either "because everyone else does" or out of fear of litigation for failing to do so.

A systematic review of this treatment (see Table 1^11-18) was conducted at the request of the Canadian Spine Society and the Canadian Neurosurgical Society in order to provide current, evidence-based recommendations about its utility for practising physicians.¹⁹ A committee of neurosurgeons, orthopedic surgeons, emergency physicians and physiatrists, some with a Masters in Clinical Epidemiology reviewed the evidence and concluded the following.

1. There is insufficient evidence to support the use of high-dose methylprednisolone within 8 h following an acute closed spinal cord injury as a treatment standard or as a guideline for treatment.
2. Methylprednisolone prescribed as a bolus intravenous infusion of 30 mg/kg of body weight over 15 min within 8 h of acute closed spinal cord injury, followed 45 min later by an infusion of 5.4 mg/kg of body weight per hour for 23 h is a treatment option for which there is weak clinical evidence (Level II, III).
3. There is insufficient evidence to support extending methylprednisolone infusion beyond 23 h if chosen as a treatment option.¹⁹ These recommendations were then presented to the annual meetings of the two sponsoring societies and adopted.

Review of evidence

Because of the controversy surrounding the use of methylprednisolone in acute spine cord injury, a systematic review of this treatment (see Table 1) was conducted at the request of the Canadian Spine Society and the Canadian Neurosurgical Society in order to provide current, evidence-based recommendations about its utility for practising physicians. A committee of neursurgeons, orthopedic surgeons, emergency physicians and physiatrists (Appendix 1) critically reviewed the available literature and assigned levels of evidence based upon established criteria.

The committee identified serious methodological deficiencies in the NASCIS II and NASCIS III studies as well as Otani and colleagues' study.¹² The committee also concluded that the apparent a priori intent of the original NASCIS protocol to conduct the post hoc analyses that led to the recommendations for methylprednisolone within 8 h of acute spinal cord injury could not be substantiated.¹⁹ Otani and colleagues' study, which reported improved neurological outcome as a consequence of high-dose methylprednisolone administered within 8 h of acute spinal cord injury, is the only clinical study that attempted to replicate the under-8-hour subgroup of patients in the NASCIS II study. Unfortunately, Ortani and colleagues' subjects were not properly randomized, and the investigators were not blinded to the treatments.¹² Furthermore, the recommendations from the subsequent Cochrane review of this treatment (which was written by the principal author of the NASCIS studies) were based on the questionable post hoc analyses described above and on Otani and colleagues' study, which was not properly randomized and blinded.¹¹

Patients with acute spinal cord injuries are a desperate group for whom any neurological recovery can have a major impact on their subsequent functional independence. A return of antigravity strength to even a single muscle at or immediately below a zone of injury is particularly significant to a tetraplegic patient, while a return of a flicker of movement to several muscles below a zone of injury is of little functional value unless antigravity strength can be attained.²⁰ There may be some utility for methylprednisolone in tetraplegics and in incomplete conus injuries, but only if the results from the post hoc analyses of the NASCIS II study and Otani and colleagues' study can be substantiated in future randomized, blinded trials.

A treatment such as high-dose methylprednisolone infusion should only be considered if its potential benefit outweighs the risk of associated complications. In well designed studies, high-dose methylprednisolone therapy has not caused a statistically significant increase in major complications. However, the trend to a higher incidence of sepsis and hyperglycemia cannot be ignored in the absence of Level I evidence of benefit for this treatment.^21-24

Physicians should not feel intimidated into prescribing high-dose methylprednisolone for acute spinal cord injuries. The utility of high-dose methylprednisolone infusion within 8 h following acute spinal cord injury has not been adequately tested.

References

1. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS, et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 1990;322(20):1405-11.
2. Coleman WP, Benzel D, Cahill DW, Ducker T, Geisler F, Green B, et al. A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury. J Spinal Disord 2000;13(3):185-99.
3. Hurlbert RJ. Methylprednisolone for acute spinal cord injury: an inappropriate standard of care. J Neurosurg 2000;93(1 suppl):1-7.
4. Hurlbert RJ. The role of steroids in acute spinal cord injury: an evidence-based analysis. Spine 2001;26(24 suppl):S39-46.
5. Nesathurai S. Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials. J Trauma 1998;45(6):1088-93.
6. Rosner MJ. Methylprednisolone for spinal cord injury. J Neurosurg 1992;77(2):324-5; discussion 325-7.
7. Short DJ, El Masry WS, Jones PW. High dose methylprednisolone in the management of acute spinal cord injury - a systematic review from a clinical perspective. Spinal Cord 2000;38(5):273-86.
8. Short D. Use of steroids for acute spinal cord injury must be reassessed. BMJ 2000;321(7270):1224.
9. Wilkinson HA. Spinal cord injury. J Neurosurg 2001;94(1 suppl):180-1.
10. 74 Cal. Rptr. 2d 550, 98 Cal. Daily Op. Serv. 3574, Daily Journal D.A.R. 4851 (Cal. App 2 Dist., May 08, 1998) (no. B088559).
11. Bracken MB. Pharmacological interventions for acute spinal cord injury. Cochrane Database Syst Rev 2000;(2):CD001046.
12. Otani K, Abe H, Kadoya S, Nagakawa H, Ikata T, Tominagu S, et al. Beneficial effect of methylprednisolone sodium succinate in the treatment of acute spinal cord injury. Sekitsui Sekizui J 1994;7:633-47.
13. Petitjean ME, Pointillart V, Dixmerias F, Wiart L, Sztark F, Lassie P, et al. Medical treatment of spinal cord injury in the acute stage. Ann Fr Anesth Reanim 1998;17(2):114-22.
14. Bracken MB, Collins WF, Freeman DF, Sheppard MJ, Wagner FW, Silten RM, et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA 1984;251(1):45-52.
15. Bracken MB, Shepard MJ, Hellenbrand KG, Collins WF, Leo LS, Freeman DF, et al. Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg 1985;63(5):704-13.
16. Bracken MB, Shepard MJ, Collins WF Jr, Holford TR, Baskin DS, Eisenberg HM, et al. Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg 1992;76(1):23-31.
17. Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, et al. Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study. JAMA 1997;277(20):1597-604.
18. Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M, et al. Methylprednisolone or tirilazad mesylate administration after acute spinal cord injury: 1-year follow up. Results of the third National Acute Spinal Cord Injury randomized controlled trial. J Neurosurg 1998;89(5):699-706.
19. Hugenholtz H, Cass DE, Dvorak MF, Fewer DH, Fox RJ, Izukawa DMS, et al. High-dose methylprednisolone for acute closed spinal cord injury: only a treatment option. Can J Neurol Sci 2002;29(3):227-35.
20. Ditunno JF Jr. Predicting recovery after spinal cord injury: a rehabilitation imperative. Arch Phys Med Rehab 1999;80:361-4.
21. Matsumoto T, Tamaki T, Kawakami M, Yoshida M, Ando M, Yamada H. Early complications of high-dose methylprednisolone sodium succinate treatment in the follow-up of acute cervical spinal cord injury. Spine 2001;26(4):426-30.
22. Galandiuk S, Raque G, Appel S, Polk HC Jr. The two-edged sword of large-dose steroids for spinal cord trauma. Ann Surg 1993;218(4):419-25; discussion 425-7.
23. Shepard MJ, Bracken MB. The effect of methylprednisolone, naloxone, and spinal cord trauma on four liver enzymes: observations from NASCIS 2. National Acute Spinal Cord Injury Study. Paraplegia 1994;32(4):236-45.
24. Gerndt SJ, Rodriguez JL, Pawlik JW, Taheri PA, Wahl WL, Micheals AJ, et al. Consequences of high-dose steroid therapy for acute spinal cord injury. J Trauma 1997;42(2):279-84.