EBQ:High Dose Steroids in Cord Injury

Under Review Journal Club Article

Tsutsumi S. et al.. "Effects of the Second National Acute Spinal Cord Injury Study of high-dose methylprednisolone therapy on acute cervical spinal cord injury-results in spinal injuries center.". Spine. 2006 Dec 15. 31(26):2992-6.
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Clinical Question

Does high-dose methylprednisolone treatment of acute cervical spinal cord injury within 8 hours of injury improve neurologic motor function outcomes?

Conclusion

High dose methylprednisolone sodium succinate (MPSS) should be administered to patients with incomplete cervical spinal cord injury according to the Second National Acute Spinal Cord Injury Study protocol.

Major Points

• In patients with incomplete paralysis at admission, American Spinal Injury Association motor scores in the MPSS group were significantly improved compare to the non-MPSS group at 6 weeks and 6 months post-injury.
• In patients with complete paralysis at admission, there was no significant difference in improvement between the two groups.
• No significant difference was noted in improvement of myotomal level, or in early complications in the two groups.

Study Design

• Retrospective single-center study conducted at the Spinal Injuries Center in Fukuoka, Japan
• Patients in the MPSS group were treated with MPSS within 8 hours of their injury according to the Second National Acute Spinal Cord Injury Study protocol
  • Bolus of 30mg/kg of actual body weight, followed by infusion of 5.4mg/kg for 23 hours
• Patients assessed at 6 weeks and 6 months post-injury with ASIA impairment scale and ASIA motor scale (0-100)
  • Improvements in the American Spinal Injury Association motor score compared
  • In patients with complete motor loss, improvements of myotomal levels (most caudal level of intact motor function) compared
• Sensory function not evaluated

Population

Patient Demographics

'MPSS group vs. non-MPSS group' Men: 86% vs. 91% Mean age: 50.2 years vs. 51.6 years ASIA A: 49% vs. 76% ASIA B: 8% vs. 6% ASIA C: 24% vs. 3% ASIA D: 19% vs. 15%

• There were significant differences in ASIA impairments between groups, P=0.02

Inclusion Criteria

• Patient with acute mid-to-lower cervical spinal cord injury admitted to center between 1998 to 2002
• Admitted to center within 7 days of injury and were followed for 6 months.

Exclusion Criteria

• Patients with partially flawed medical records
• Follow-up less than 6 months
• Admission to study center later than 7 days after injury
• Administration of MPSS non-conforming to NASCIS-2 protocol
• Bone fracture of extremities
• Death with complications
• Brain injury
• Multiple spinal cord injury
• Mental disturbance
• Peripheral nerve injury
• Spine injury without paralysis

Outcomes

N=70 patients Patients with complete motor loss in MPSS group (n=15) and non-MPSS group (n=21)

Criticisms & Further Discussion

• Low powered study
• More recent papers have shown evidence that high dose steroids are associated with harmful side effects including death