Skip to main content

Steroids in Spinal Injury...waiting more evidence



The Use of steroids in Spinal cord trauma/injury is controversial topic ,some still belief it is helpful, and surely there are opponents who belief the opposite..the question what is the evidence?
here were we are putting some of the literature findings...some findings support and another don't..

The original NASCIS trial (NASCIS I) found no difference in motor function or pinprick/sensation from baseline with IV methylprednisolone use, but the doses used were much lower than the doses used in the animal studies that first suggested a possible benefit. 

Therefore, NASCIS II was performed to look at high dose methylprednisolone in acute spinal cord injury.  Patients received either methylprednisolone, naloxone, or placebo within the first twelve hours of injury.  The methylprednisolone was high dose and given for 24 hours.  Overall there was no benefit in the methylprednisolone group, but sub-group analysis showed a small benefit in motor function in the patients that received the IV steroids within the first 8 hours. 

After that study, many began to define high dose methylprednisolone as standard of care after acute spinal cord injury. 

A Japanese study  attempted to repeat the NASCIS II using the 8 hour timeline as the main outcome, and it showed a benefit. 

 However, the opponents of steroids in acute spinal cord injury noted that the randomization was not defined and only 3/4 of the patients enrolled were listed in the data. 

NASCIS III attempted to compare a 24 hour regiment with a 48 hour regimen and found no benefit.

In the US, a survey of spine surgeons reported 91% of them use steroids in acute spinal cord injury, although only 24% of them believe there is a clinical benefit.  Once the label of “standard of care” is attached, it’s hard to remove. 

The Cochrane review reported that high-dose methylprednisolone is the only approved pharmacologic treatment of acute spinal cord injury that has been proven by prospective, randomized studies.  The review admitted the treatment must be started within 8 hours to see the benefit, but it didn’t mention the post-hoc analysis aspect. 

The Canadians no longer define steroids as a standard of care but instead call it a treatment option. 

 Until better data emerge, we’re still forced to decide between a possible benefit from post-hoc analysis vs going against a “standard of care.


Bracken, 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; 322:1405-1411.

Young, Bracken, et al.  The Second National Acute Spinal Cord Injury Study.  J Neurotrauma.  1992, 9 Suppl 1:S397-405.

Bracken, et al.  Administration of Methylprednisolone for 24 or 48 Hours or Tirilazad Mesylate for 48 Hours in the Treatment of Acute Spinal Cord Injury.  JAMA.  1997;277(20):1597-1604
Labels:

Comments

Post a Comment

Popular posts from this blog

power injectable peripherally inserted central catheters

Clinical experience with power injectable peripherally inserted central catheters in intensive care patients     Introduction In intensive care units (ICU), peripherally inserted central catheters (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters . Method We have retrospectively reviewed all the power injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance. Results We have collected 89 power injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related blood stream infection. Non-infective complications ...
1 comment
Read more

The 12 decision making steps for post dural puncture headache treatment

Treatment decision-making algorithm for postdural puncture headache. 1. When diagnosis is made, all patients should receive supportive measures (reassurance, bed rest, analgesics, hydration, quiet environment). 2. Severity of symptoms should be classified using VAS scale (mild 1–3, moderate 4–6, severe 7–10). 3. Virtually all patients will improve in time even without additional therapy. (dashed lines) 4. Symptoms worsen or fail to resolve within 5 days. 5. Patient preference dictates the choice between pharmacologic (less effective) and epidural blood patch (EBP). 6. In patients with severe symptoms, EBP is strongly suggested. 7. The most common pharmacologic measure is  caffeine  prescription. 8. The failure, worsening, or recurrence of symptoms after pharmacologic measures favors the use of EBP. 9. In addition to EBP, other epidural treatment options can be considered in select patients (eg,  dextran , saline). 10. A period of 24 h should lapse before repeating EBP. 11...
1 comment
Read more

Things to Avoid in Anesthesia for Pregnant with Pulmonary hypertension

Anesthesia for Pregnant woman with Pulmonary Hypertension is a real challenge for anesthesiologist. It is very crucial to remember the pathophysiology of pulmonary hypertension in pregnant women and to avoid some practices that will worsen the cardiac status. 1-Avoid single shot spinal anesthesia. Some authorities consider pulmonary hypertension as absolute contraindication for single shot spinal anesthesia specially in patients with NYHA III ,IV. Spinal anesthesia causes major hemodynamic instability(decrease SVR, decrease VR, decrease in CO) The preferred neuroaxial techniques are (epidural anesthesia and CSE with minimal spinal dose) 2-Avoid PAC. Pulmonary Artery catheters insertion may lead to pulmonary artery rupture or thrombosis. TEE is better cardiac monitor/Arteial line is mandatory. 3-Avoid Nitrous oxide in gas mixture.N2O increase the PVR 4-If MV to be started, avoid High TV and PEEP 5-Avoid Oxytocin Boluses, or rapid administration of Pitocin. Oxytocin causes ...
Post a Comment
Read more