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Thu Feb 19 10:27:12 GMT 2004

As a healthcare worker we all must do what we feel is in the best
interest of our patients.  We can't deliver a therapy that we know or
feel is harmful.  This is ethically wrong.  

Here are some articles to help you feel better about NOT giving
steroids. 

*****ANNALS OF SURGERY*****

(REFERENCE 1 OF 5)
94029215

Galandiuk S,  Raque G,  Appel S,  Polk HC  
The two-edged sword of large-dose steroids for spinal cord trauma.

In: Ann Surg (1993 Oct) 218(4):419-25; discussion 425-7

ISSN: 0003-4932

OBJECTIVE: In 1990, large-dose steroid administration was advocated
  in spine-injured patients to lessen neurologic deficits. The authors
  undertook both prospective and retrospective studies to evaluate the
  response of such profound pharmacologic intervention. SUMMARY
  BACKGROUND DATA: Of all sources of nonfatal injury, spinal cord
  trauma remains the most devastating in both cost and impact on the
  quality of the patient's life. One study found that routine large-
  dose steroid administration after injury lessened the extent of
  neurologic injury. After uncommonly prompt and broad lay press
  publicity, this practice was widely accepted. Biased by knowledge of
  the known immunosuppressive effects of steroids, the authors
  suspected that pneumonia was both more frequent and severe in steroid-
  treated patients. METHODS: Thirty-two patients with cervical or upper
  thoracic spinal injuries (C3-6, 20 patients; C6-7, 6 patients; and T1-
  6, 6 patients) were studied at an urban level I trauma center from
  January 1987 to February 1993. Complete spinal cord injury was
  present in 22 of 32 patients; 14 patients received steroids
  postinjury. There was no difference in mean age, cord level, age-
  adjusted injury severity score, or the percent of injury severity
  score caused by the spinal injury. RESULTS: The length of hospital
  stay was longer in steroid-treated patients (S) than in nonsteroid
  (NS) patients, that is, 44.4 days versus 27.7 days, respectively (p =
  0.065). Seventy-nine per cent of S patients had pneumonia compared
  with 50% of NS patients (p = 0.614). There was no statistical
  difference in the episodes of pneumonia per patient between the two
  groups (p > 0.05). Prospectively, the authors evaluated sequentially
  several parameters known to be important in human immune responses to
  bacterial challenges in nine S and five NS patients. In S patients,
  both the per cent and density of monocyte class II antigen expression
  and T-helper/suppressor cell ratios were lower than in NS patients.
  However, S patients did have an initially higher, earlier boost in
  some host defense parameters that rapidly declined, and their
  subsequent response was both blunted and delayed. These differences
  became even clearer when stratified according to cord level and
  incomplete versus complete cord status. Not surprisingly, infected
  patients, whether S or NS, had lower levels of monocyte antigen
  expression, CR3, and helper/suppressor ratios. CONCLUSIONS: These
  data do not permit a judgment to be made whether neurologic status
  was improved by S administration. It is known that vital immune
  responses were adversely affected, that pneumonia was somewhat more
  prevalent, and that hospitalization was prolonged and costs therefore
  increased by an average of $51,504 per admission. Further clinical
  studies will be needed to determine to what extent these observations
  offset the putative benefits of large-dose steroids in the treatment
  of spinal trauma.

Registry Numbers:      83-43-2(Methylprednisolone)

Institutional address: 
     Department of Surgery
     Division of Neurosurgery
     University of Louisville School of Medicine
     Kentucky.

*****CURRENT OPINION IN NEUROLOGY*****

(REFERENCE 2 OF 5)
21579585

Short D  
Is the role of steroids in acute spinal cord injury now resolved?

In: Curr Opin Neurol (2001 Dec) 14(6):759-63

ISSN: 1350-7540

Steroids have long been used in the context of acute spinal cord
  injury but the evidence for doing so is limited. The second National
  Acute Spinal Cord Injury Study trial had the potential to provide
  such evidence for the first time, as this was a placebo controlled,
  prospective, randomized trial. From the outset, however, some
  clinicians found the methodology and consequently the results
  unsatisfactory. This concern has been revisited within the evidence-
  based framework of critical appraisal of the accumulation of clinical
  studies. High-dose methylprednisolone cannot be justified as a
  standard treatment in acute spinal cord injury within current medical
  practice.

Registry Numbers:      83-43-2(Methylprednisolone)

Institutional address: 
     Midlands Centre for Spinal Injuries
     Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS
Trust
     Oswestry
     Shropshire SY10 7AG
     UK. debbie.short at rjahoh-tr.wmids.nhs.uk

*****JOURNAL OF TRAUMA*****

(REFERENCE 3 OF 5)
99082943

Nesathurai S  
Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3
  trials.

In: J Trauma (1998 Dec) 45(6):1088-93

ISSN: 0022-5282

The National Acute Spinal Cord Injury Study (NASCIS) 2 and 3 trials
  are often cited as evidence that high-dose methylprednisolone is an
  efficacious intervention in the management of acute spinal cord
  injury. Neither of these studies convincingly demonstrate the benefit
  of steroids. There are concerns about the statistical analysis,
  randomization, and clinical end points. Even if the putative gains
  are statistically valid, the clinical benefits are questionable.
  Furthermore, the benefits of this intervention may not warrant the
  possible risks. This paper comments on these two clinical trials.

Comment in:  J Trauma. 2000 Mar;48(3):558-61

Comment in:  J Trauma. 2001 Aug;51(2):421-3

Registry Numbers:      83-43-2(Methylprednisolone)

Institutional address: 
     Boston University School of Medicine and New England Regional
Spinal Cord Center
     Boston Medical Center
     Massachusetts 02118-2393
     USA.

(REFERENCE 4 OF 5)
95018411

Prendergast MR,  Saxe JM,  Ledgerwood AM,  Lucas CE,  Lucas WF  
Massive steroids do not reduce the zone of injury after penetrating
  spinal cord injury.

In: J Trauma (1994 Oct) 37(4):576-9; discussion 579-80

ISSN: 0022-5282

The National Acute Spinal Cord Injury Study II concluded in 1990 that
  high-dose methylprednisolone (MP) improved neurologic recovery after
  acute spinal cord injury (ASCI). We tested this conclusion by
  analysis of 54 patients with ASCI; 25 patients were treated without
  MP before 1990 whereas 29 patients were treated with MP after 1990.
  Neurologic deficit was assessed regularly, in most cases daily. Motor
  and sensory scores on admission, and best results at one-half week
  (days 2 to 4), 1 week (days 6 to 10), 2 weeks (days 11 to 21), 1
  month, and 2 months were noted for both groups. Motor assessment was
  recorded in 22 muscle segments on a scale of 0 (complete deficit) to
  5 (normal); the range, thus, was 0 to 110. The 23 patients with
  closed injuries demonstrated no difference in improvement with or
  without MP. In contrast, MP was associated with impaired improvement
  in the patients with penetrating wounds; the 15 patients with no MP
  therapy had an admission motor score of 49, which increased by 6.9 at
  one-half week, whereas the 16 patients treated with MP had an
  admission motor score of 48, which decreased by 0.3 at one-half week
  (p = 0.03). The neural status seen by day 4 persisted throughout the
  next 2 months. Changes in sensation paralleled the changes in motor
  function. We conclude that MP therapy for penetrating ASCI may impair
  recovery of neurologic function.

Registry Numbers:      83-43-2(Methylprednisolone)

Institutional address: 
     Department of Surgery
     Wayne State University
     Detroit
     MI 48201.

*****SPINE*****

(REFERENCE 5 OF 5)
21665377

Hurlbert RJ  
The role of steroids in acute spinal cord injury: an evidence-based
  analysis.

In: Spine (2001 Dec 15) 26(24 Suppl):S39-46

ISSN: 0362-2436

STUDY DESIGN: Literature review. OBJECTIVES: The purpose of this
  article is to review the available literature and formulate evidence-
  based recommendations for the use of methylprednisone in the setting
  of acute spinal cord injury (SCI). SUMMARY OF BACKGROUND DATA: Since
  the early 1990s, methylprednisolone has become widely prescribed for
  the treatment of acute SCI. Arguably, it has become a standard of
  care. METHODS: Through an electronic database search strategy and by
  cross-reference with published literature, appropriate clinical
  studies were identified. They were reviewed in chronologic order with
  respect to study design, outcome measures, results, and conclusions.
  RESULTS: Nine studies were identified that attempted to evaluate the
  role of steroids in nonpenetrating (blunt) spinal cord injury. Five
  of these were Class I clinical trials, and four were Class II
  studies. All of the studies failed to demonstrate improvement because
  of steroid administration in any of the a priori hypotheses testing.
  Although post hoc analyses were interesting, they failed to
  demonstrate consistent significant treatment effects. CONCLUSIONS:
  From an evidence-based approach, methylprednisolone cannot be
  recommended for routine use in acute nonpenetrating SCI. Prolonged
  administration of high-dose steroids (48 hours) may be harmful to the
  patient. Until more evidence is forthcoming, methylprednisolone
  should be considered to have investigational (unproven) status only.

Comment in:  Spine. 2001 Dec 15;26(24 Suppl):S55

Registry Numbers:      83-43-2(Methylprednisolone)

Institutional address: 
     Department of Clinical Neurosciences
     University of Calgary
     Foothills Hospital
     1403 29th Street NW
     Calgary
     Alberta T2N 2T9
     Canada. jhurlber at ucalgary.ca

Questions?

E

Errington C. Thompson, MD
Trauma/Surgical Critical Care
Trinity Mother Frances
Tyler, Tx
ecthompson at tyler.net

Don't think you are
Know you are
                            - Morpheus (The Matrix)

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Sherry, Scott :LPH
Trauma
Sent: Thursday, February 19, 2004 1:59 AM
To: trauma-list at trauma.org
Subject: Changing behavior...

Recent case of central cord syndrome, steroids given. I know the list's
argument and agree they dont have proven benefit and probably do more
harm.
But my question is this... as we were discussing the fact that the above
may
be true it was pointed out that steroid administration in spinal injury
has
become a "standard of care" and not doing it has reporcussions as well
(ie
neglegence, substandard care etc)

Is this true? ( I cant imagine it is). References 
How does one change the behavior if it is true?

Thanks. 

I will be away at a conference for a week and look forward to the flurry
of
emails and lively discusion when I get home...

Scott...

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