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Thu Apr 24 12:19:25 BST 2008

It would be extremely useful if ATLS has reviewed its current stance.
Whether this is the case or not I can provide a current consensus update
on this and related topics for UK clinicians at least. 

In the UK the initial and lifetime management of people with SCI is a
recognised specialist service which incorporates standards for the
initial management before transfer to a specialist care centre. The
department of health SCI service definition includes the following:
"Spinal cord injury (SCI) care incorporates the core components of acute
care, restorative rehabilitation, reintegration into the community and
long term follow-up into a seamless clinical service. Of necessity in
the context of acute spinal trauma, other providers are involved in
acute spinal trauma activity; these include specialised spinal surgery,
major trauma and critical care services. Emergency cover requires
co-ordinated integration of these to be resource efficient and
clinically effective". Thanks to work by the British Trauma Society A&E
consultants have been most accepting of the benefits of early referral
to specialist centres where conflict with ATLS guidelines occurs and
emergent work under the umbrella of the National Service Framework for
Long-Term Neurological Conditions is advancing the standard that patient
referral should be from A&E within maximum 4 hours of diagnosis or
within maximum 4 hours of recognition if late onset / diagnosis occurs. 

More detail into how health commissioners expect a high standard of
collaboration within defined specialised care pathways is also evolving
for example 8 of the UK health regions are working towards a single set
of care standards initially developed for the South of England:
http://www.mascip.co.uk/pdfs/standardssci.PDF

There are currently 11 regional spinal cord injury centres in the UK:
Belfast, London, Salisbury, Stoke Mandeville, Cardiff, Sheffield,
Wakefield, Middlesbrough,Glasgow, Oswestry, Southport. Because of a lack
of funding, and the low priority given to the national SCI service over
many years, the
service is now in crisis. In many areas this crisis is severe,
especially where the centre has not received any developmental funding.
The SCI population has increased, along with the increase in their
general life
expectancy, but beds in these specialist centres have been reduced or
closed (or at best remained static). This has led to newly injured SCI
people and those who have an existing injury being treated in general
hospitals, where staff do not have the expertise or experience to
address their unique and complex needs. Concerns over how inadequate
some parts of current service delivery are when measured against these
standards has lead to the development of a campaign to create an
All-Party Parliamentary Working Party to identify and drive through the
necessary changes and resourcing neccesary to achieve a 'Model Service'.
This campaign achieved its goal in a record time and the Working Party
will be launched next week.

UK expert consensus opinion on the use of steroids was originally
derived from a statement from the British Association of Spinal Cord
Injury Specialists following a systematic review of the evidence which
showed no significant clinical advantage in the routine use of
high-dose, short duration methylprednisolone for acute SCI patients
(See: Short D T, El Masri W S, Jones P W. High Dose Methylprednisolone
in the Management of Acute Spinal Cord Injury - A Systematic. Review
from a Clinical Perspective. Spinal Cord (2000) 38, 273-286). Dated 8th
June 2000 the statement reads "The use of methylprednisolone in the
acute management of SCI remains controversial and advice should be
sought from your local spinal injuries unit". At this time the option
remained for an individual SCI consultant to retain the option for the
use of methylprednisolone in exceptional individual case scenarios. 

This recommendation was carried forward when the BASCIS Best Practice
guidelines were published with the launch of their website
www.bascis.pwp.blueyonder.co.uk: "Highly publicised studies have
suggested that high dose Methylprednisolone therapy is an essential
treatment in most cases of spinal cord injury in spite of important
related clinical complications.  In common with clinicians in other
countries BASCIS has carefully evaluated the information now available.
The published evidence does not support the use of high dose
Methylprednisolone as a standard treatment in acute spinal cord injury".

These guidelines brought UK specialist consensus to any clinician
seeking web-based information and became standard practice for all UK
SCI centres  pre-transfer management in advice given at patient referral
to general trauma services. See below for example:
http://www.spinal.org.uk/pdf/guidelines/NSICPositionStatementOnMPInSCI.p
df

In 2006 the British Orthopaedic Association in collaboration with BASCIS
and others, published its own set of Clinical Guidelines on The Initial
Management and Transfer of Patients with Spinal Cord Injuries
(http://www.boa.ac.uk/site/showpublications.aspx?ID=59)
"to assist health care professionals in Accident and Emergency and in
Orthopaedic and Neurosurgical departments in the initial assessment and
management of the patient prior to transfer to the Spinal Injuries
Centre". 

On steroid manaagement: "The question of steroid administration has been
debated by the British Association of Spinal Cord Injuries Specialists
who concluded that the use of high dose steroid in the management of
acute spinal cord injury could not be recommended or supported on the
current evidence".

The production of these and future guidelines for Critical Care and
Neuroscience practice does not guarantee a standard of clinical action -
that remains the preserve of the individual clinician - but it does make
it apparent how far away from a published expert or peer consensus an
individual's knowledge and practice can be measured to. In the event
that in a claim for compensation a suggestion is made that
'inappropriate' administration of steroids led to 'avoidable' clinical
complications which subsequently affected an individual's health,
survivability or quality of life afterwards it can prove very difficult
to find an expert peer witness to speak in support of the defendant. 

Perhaps a roll-call of current advice from professional medical
associations around the world would further add to list-members
appreciation of how this topic is being addressed? In the US peer
colleagues are waiting to see how this issue will be addressed in the
PVA's forthcoming 'Early Acute Management in Adults with Spinal Cord
Injury: A Clinical Practice Guideline for Health-Care Professionals':
(http://www.pva.org/site/PageServer?pagename=pubs_main#CPG)

The gate remains open for continued research into current and future use
of steroids in relation to SCI but scientists need to know that
international trial standards have been created including the standard
of patient informed consent to participate in trials involving steroids:

http://www.spinal-research.org/downloads/Experimental_treatment_for_SCI.
pdf

Paul Harrison
Clinical Development Officer
Princess Royal Spinal Injuries Centre
Sheffield UK

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of
bensonblues at comcast.net
Sent: 24 April 2008 05:46
To: trauma-list at trauma.org
Subject: Steroids in Spinal Cord Injury

This is the philosophy that guides my practice in the ED:

Steroids are most likely insalubrious in the patient with spinal cord
transection. Steroids may have a role in the acutely contused spinal
cord, but mild local hypothermia is probably better. The NIH study in
rats that led to this mess is probably not reproducible. Likewise,
steroids are most likely insalubrious in the patient with CNS axonal
disruption, and probably contusion, and most certainly hemorrhage. 

I only give steroids in any of the above situations if the consulting
specialist tells me to. Not many of them tell me to. It is a waste of
money and nursing resource, and wastes time.

DB
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Steroids in Spinal Cord Injury