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Role of Steroids in Spinal Cord Inj

Rob Ojala Rob.Ojala at cdhb.govt.nz
Fri Nov 5 01:41:40 GMT 2010


Thank you I am familiar with NASCIS 2 and 3 and their 1984 predecessor
in JAMA. Each trial had around 160ish patients in each arm - a
substantial number but not what I'd call very big - given the
heterogeneous nature of SCI. I have no argument that the trials failed
to scientifically prove lack of benefit, and as I have indicated we
stopped this therapy many years ago for this reason. 
My point however, remains unchanged
Rob Ojala

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Smith
Sent: Friday, 5 November 2010 12:43 a.m.
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Role of Steroids in Spinal Cord Inj

When people say the evidence isn't all that clear it makes me crazy. At
the risk of sounding like an arrogant jerk, every time we have this
discussion, I get the feeling that many of us have not actually read the
NASCIS studies. If you can, please do so. They're not that long or
difficult. I guarantee it will be an epiphany. Like, "all this
controversy is base on THIS???" These were very big trials btw. Everyone
wanted there to be a benefit. But there wasn't. It's not like there is
some pro and some con. They don't do anything beneficial. Period. Unless
you want to count the non clinically relevant scale Bracken made up in
NACSIS 2 to justify their use, that no one has ever used before or
since.
>From CMAJ, 2003 by Hugenholtz.

Three well-designed, large, randomized clinicaltrials (the National
Acute Spinal Cord Injury Studies [NASCIS I, II and III]) examined the
effect of steroid administration in patients with acute spinal cord
injury.6,7,8,9,10,11

NASCIS I examined the change in motor function in specific muscles and
changes in light touch and pinprick sensation from baseline.6,7 The
study detected no benefit from methylprednisolone, but the dose was
considered to be below the therapeutic threshold determined from animal
experiments. Therefore, NASCIS II used a much higher dose, and patients
were randomly assigned to receive a 24-hour infusion of
methylprednisolone, naloxone or placebo within 12 hours after acute
spinal cord injury.8,9 Again, there was no benefit overall in the
methylprednisolone group; however, post hoc analyses detected a small
gain in the total motor and sensory score in a subgroup of patients who
had received the drug within 8 hours after their injury. As a result,
this 24-hour, high-dose methylprednisolone infusion, if started within 8
hours afterinjury, quickly became an implied standard of care despite
considerable criticism of the validity of such a post hoc analysis.



Rob Smith





On Nov 4, 2010, at 1:23 AM, Rob Ojala wrote:

> I fear my point is lost by my inability to convey it accurately.  My
point is nobody REALLY knows the answer - we only know that it doesn't
appear to be beneficial in the balance of the very limited research thus
far. that's not the same as an emphatic "no role for steriods period".
> 
> For the record - we haven't used steroids in SCI for >10 years.
> 
> ________________________________
> 
> From: trauma-list-bounces at trauma.org on behalf of Errington Thompson
> Sent: Thu 4/11/2010 5:46 p.m.
> To: 'Trauma-List [TRAUMA.ORG]'
> Subject: RE: Role of Steroids in Spinal Cord Inj
> 
> 
> 
> Ron is correct. There are only 2 studies done by the same guy which
supports
> using steroids. There are tons of small prospective studies and
> retrospective studies which show anything from no benefit to harm.
Yet, it
> is a therapy which continues to hang on.
> 
> There is a small subset of patients who get an overwhelming pneumonia
when
> given high dose steroids. These patients die bigger than Dallas in
spite of
> maximal medical care.
> 
> Errington C. Thompson, MD, FACS, FCCM
> Trauma/Critical Care
> Talk Show Host - Podcasts
> Twitter
> www.whereistheoutrage.net
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Rob Ojala
> Sent: Wednesday, November 03, 2010 8:02 PM
> To: Trauma-List [TRAUMA.ORG]
> Subject: RE: Role of Steroids in Spinal Cord Inj
> 
> Perhaps that should read - there is no proven role for steroids?
> Rob
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
> Sent: Wednesday, 3 November 2010 4:46 p.m.
> To: 'Trauma-List [TRAUMA.ORG]'; Paramedicine at yahoogroups.com;
> EMS-L at EMS-L.org; ems_research at yahoogroups.com
> Subject: RE: Role of Steroids in Spinal Cord Inj
> 
> Simply put - there is NO ROLE for steroids.  Period.
> 
> Ron
> 
> 
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org] On Behalf Of James Richardson
> Sent: Tuesday, November 02, 2010 10:09 PM
> To: Paramedicine at yahoogroups.com; 'Trauma-List [TRAUMA.ORG]';
> EMS-L at EMS-L.org; ems_research at yahoogroups.com
> Subject: Role of Steroids in Spinal Cord Inj
> 
> I know it's opening Pandora's box again but can someone share what the
> current standard is regarding use of steroids' in spinal cord injury?
> 
> Case is a 13 year old male ice hockey injury stable with t-spine
> tenderness
> and weakness in one leg being transferred from a rural level 3 to an
> urban
> level 1 neuro / spine center about 4 hours ground inter-facility
> transport.
> 
> ER physician and the trauma surgeon at the level 3 were against
starting
> steroids prior to the transfer but the Neurologist at the receving
level
> 1
> "required" a solu-medrol drip be started for the transfer which we did
> and
> upon arriving at the receiving center we were asked by the ER doc
there
> "why
> is the child on a solu-medrol drip?"
> 
> I thought my most recent readings were no benefit found, but have
things
> changed again?
> 
> Thanks Jim<
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