Subject: Spinal cord steroids in children....
Date: Thu, 13 Nov 2003 11:44:44 -0500
From: Perry W. Stafford
Please forgive the following preamble, but I'm in the midst of preparing for a deposition concerning a 2 month old unrestrained child in an MVC who unfortunately had a severe CHI and was transported to us 7 hours postinjury intubated with sedation and paralysis and well resuscitated with adequate cervical spine stabilization (well taped to towel rolls and on a peds spine board aligned appropriately)....we were concerned about the baby's minimal movement of the extremities as the baby began to wake up here....cervical spine xrays and a CTScan of the cervical spine were normal....SCIWORA (spinal cord injury without radiographic abnormality) was suspected, and spinal steroids were ordered and finally started 9 hours post-injury (2 hours after arrival here)....an MRI showed a ligamentous injury with a cord contusion....despite good resuscitation of the baby, the brain, and the spinal cord, the baby is paraplegic...I'm being deposed in a suit alledging that the 2 hour delay in the start of spinal steroids after transfer from the outlying hospital contributed to the child's eventual outcome.....nonsense, but does anyone know the final outcome of the ongoing neurosurgical discussions about the Bracken protocol...I recall that we have been told that the neurosurgeons were thinking of changing their protocol suggestions concerning the use of steroids in non-penetrating spinal cord injury, but I cannot find what if anything came out of this....there is very little/nothing in our pediatric literature reflecting the efficacy of spinal steroids, and we have been extrapolating the indications and protocol from the adult literature, which has been controversial and somewhat contentious....anyone have any updates on the adult literature concerning spinal cord steroid protocols...appreciate your comments...
Perry Stafford, MD
Children's Hospital of Philadelphia
From: William SLyons MD
Date: Thu, 13 Nov 2003 14:12:58 -0500
PS, argue that steroids cause the retention of salt and water, promoting edema, probably the worst thing for a cord contusion. Of secondary importance, is that the inflammatory aspects of the trauma would not be diminished after the seven hour delay with which you were faced. Besides, the establishment of failure to comply with the standard of care, has got to take into account the fact or probability that at least 20% or more of practitioners would have done it your way; in which case it is a variant of acceptable care .
WS Lyons
From: Andrew J Bowman
Date: Thu, 13 Nov 2003 15:07:00 -0500
It is amazing to me how steroids for spinal cord injury became "the standard of care". Pre-released data before the study was completed to a gullible public who does not understand the science and that improvement to a twitching finger is "a miracle in a bag of steroids".
Andrew Bowman
Date: Thu, 13 Nov 2003 15:07:16 -0500
From: Hall, John R
Perry,
We would have done as you did.
The steroid study was in adults. There is NO Data that it works or does not in kids and as you know, even the adult data is questionable.
I think that your defense is also that your cervical spine films were normal. It was not until the child started to awaken that you suspected SCIWORA, worked it up and started treatment. That is the standard of care. I don't believe anyone would have started steroids, adult or child, without the appropriate workup that you did.
Good luck
Date: Thu, 13 Nov 2003 14:25:46 -0800
From: cbella
For a start I've pasted an abstract from J Neurosurg 2000.
-- A medline search for Hurlbert will provide more updated info and additional references.
-- Also Spine Journal summary statement (year 2000 vs 2001, written by Michael Fehlings) mirroring the AANS recommendation that based on questionable benefits, use of steroids be considered an "option" rather than a "standard of care."
J Neurosurg (Spine 1) 93:1-7, 2000
Methylprednisolone for acute spinal cord injury: an inappropriate standard of care*
Object. Since publication in 1990, results from the National Acute Spinal Cord Injury Study II (NASCIS II) trial have changed the way patients suffering an acute spinal cord injury (SCI) are treated. More recently, recommendations from NASCIS III are being adopted by institutions around the world. The purpose of this paper is to reevaluate carefully the results and conclusions of these studies to determine the role they should play in influencing decisions about care of the acutely spinal cord-injured patient.
Methods. Published results from NASCIS II and III were reviewed in the context of the original study design, including primary outcomes compared with post-hoc comparisons. Data were retroconverted from tabular form back to raw form to allow direct inspection of changes in treatment groups. These findings were further analyzed with respect to justification of practice standards.
Although well-designed and well-executed, both NASCIS II and III failed to demonstrate improvement in primary outcome measures as a result of the administration of methylprednisolone. Post-hoc comparisons, although interesting, did not provide compelling data to establish a new standard of care in the treatment of patients with acute SCI.
Conclusions. The use of methylprednisolone administration in the treatment of acute SCI is not proven as a standard of care, nor can it be considered a recommended treatment. Evidence of the drug's efficacy and impact is weak and may only represent random events. In the strictest sense, 24-hour administration of methylprednisolone must still be considered experimental for use in clinical SCI. Forty-eight-hour therapy is not recommended. These conclusions are important to consider in the design of future trials and in the medicolegal arena.
From: ecthompson
Date: Thu, 13 Nov 2003 19:59:54 -0600
Let's all say it together - THIS IS WHY MEDICAL CARE COSTS SO MUCH,
Stupid nonsense suits like this.
This is an excellent paper - Methylprednisolone for acute spinal cord injury: an inappropriate standard of care* J Neurosurg (Spine 1) 93:1-7, 2000 R. JOHN HURLBERT, M.D.
Perry, I know that there was a lot of talk at one of the neurosurgical meeting 2 years ago. In spite of all of the talk I don't think that the actual recommendations have changed.
Errington C. Thompson, MD
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx
Date: Fri, 14 Nov 2003 08:00:18 -0500
From: James Carr
I still don't know how this paper made it into "standard of care" with its NEJM article, other than Dan Rather thought it was pretty cool. One strategy would the one you have asked about. Another would be to look at the age groups treated in the Bracken study- I don't recall if they involved children. Therefore, the paper isn't applicable to that age group. And finally, recommendations (such as the Bracken protocol) are merely guidelines to which the individual MD can tailor treatment for the specific patient.
I trained at Northwestern, and we saw >200 spine injuries a year. At the beginning of my training in the early 80's, we were using steroids (probably not at the Bracken doses), and quit as they were seeing too many GI ulcers, infection, etc. Also, Paul Meyer noted a big decrease in complete injuries just from early reduction and medical stabilization alone. He refers to those issues in his book.
I know someone else can add a bit more science to my sentiments. Sorry Chip .
James B. Carr, MD
Palmetto Health Orthopedics
Date: Fri, 14 Nov 2003 08:55:38 -0500
From: Hall, John R
While we all agree that the data is weak, unfortunately, IT IS published as the present standard of care in ADULTS
Date: Fri, 14 Nov 2003 08:33:12 -0600
From: Joseph Murphy
steroids in a 2 month old for spine injury?
there is absolutely no data for this rx.
get yourself a better lawyer, you're getting screwed.
Date: Fri, 14 Nov 2003 09:52:48 -0500
From: Jeffrey Salomone .
ATLS (1997) does recommend methylprednisolone "in the same dosages" for adults for non-penetrating spinal cord injuries, but admits the use of steroids in children "remains controversial."
If I were being deposed one such a cash, in addition to emphasizing the lack of data for steroids in children, I would also stress the several studies that document the infectious complications of steroid use for SCI, and thus emphasize that, like many decisions in medicine, the decision to use steroids is a risk / benefit analysis, and not one that should be made arbitrarily and capriciously in the absence of good data.
Jeff Salomone
From: ecthompson
Date: Fri, 14 Nov 2003 09:21:50 -0600
IT IS published as the present standard of care in ADULTS
Here's my point - there are several published papers which say that it is garbage. So, isn't it in your patient's best interest for you to do the "right" thing?
Errington C. Thompson, MD
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx
From: Davis, Thomas P. (CDR)
Date: Fri, 14 Nov 2003 10:33:00 -0500
Dr. Stafford,
At the Clinical Congress in Chicago, I attended the Neurosurgery session on Spinal Trauma. It was specifically mentioned that there is no standard and not even a guideline for steroids in spinal cord trauma because of the lack of evidence. It remains an option, nothing more.
CDR Thomas P. Davis, MC(SW), USNR, FACS
Trauma Surgery/General Surgery/Critical Care
Naval Medical Center, Portsmouth, VA 23708
Date: Fri, 14 Nov 2003 11:13:52 -0500
From: Hall, John R
Perry
from the March 2002 "Guidelines for treatment of spinal cord injury" RECOMMENDATIONS
CORTICOSTEROIDS:
Standards:There is insufficient evidence to support treatment standards.
Guidelines:There is insufficient evidence to support treatment guidelines.
Options:Treatment with methylprednisolone for either 24 or 48 hours is recommended as an option in the treatment of patients with acute spinal cord injuries that should be undertaken only with the knowledge that the evidence suggesting harmful side effects is more consistent than any suggestion of clinical benefit.
GM-1 GANGLIOSIDE:
Standards:There is insufficient evidence to support treatment standards.
Guidelines:There is insufficient evidence to support treatment guidelines.
Options:Treatment of patients with acute spinal cord injuries with GM-1 ganglioside is recommended as an option without demonstrated clinical benefit. (Neurosurgery 50: 63-72, 2002)
From: carl hauser
Perry:
As everyone here has pointed out, you did everything absolutely right. The NASCIS II trial (I prefer to call it the "Lawyer's relief act of 1990") was a terrible study. It proved nothing, as I have said for >10 years and many times before on this list (I can send you all the posts if it'll be any help).
1) The only effects seen were in post-hoc subset analyses for which the study was underpowered.
2) The differences were only seen because the control group did worse than published historic controls, and
3) Those effects that were measured were statistically rather than clinically significant (unless the preservation of pilo-erection over one more dermatome is important to you).
So SCI steroids were never proved effective, they were simply foisted upon the medical community by an aggressive, self promoting research group that played (quite openly and shamelessly) on our national fear of malpractice litigation. To my knowledge, SCI steroids were never accepted as effective anywhere else in the world. The recent spate of editorial re-assessments (Hurlbut is only one of several) are simply belated admissions that this particular Emperor was never actually wearing clothes. Unfortunately though, we live in a 'pro-active' society. And in this case, we have allowed Society to pressure us into accepting the all-American, lay, "can-do" approach that something can and must always be done, rather than obeying our better judgment and the more generally successful medical concept that we should 'first do no harm'. So we need to accept, as a group, that SCI steroids are in fact a totally unproved treatment with enormous potential for harm.
I personally do not treat any SCI's with steroids. The full-time spine surgeons here are all in agreement. I write a note (personally) when I do not give steroids saying specifically that they are unproven and frankly dangerous. In groups like this (children, penetrating injuries, multiple trauma) I point out that they were specific exclusions of NASCIS II, and thus the intervention has even less support (if possible). I cite literature in the note. Nobody's ever come after me, and my SCI's stay just as paralyzed as everybody else's. The idea that you gave steroids late is also nonsense. Does the plaintiff have an expert who is saying that trauma surgeons should be giving steroids to everyone who doesn't move, without any diagnosis? Well they may, but that 'expert' can and should be shot down.
No, the only real weakness in your defense is that you gave the steroids at all. What you need to establish at the earliest possible point in your defense is that you gave the steroids in desperation, clearly knowing that they were of no proven value. Otherwise, your testimony will be used as prima facie evidence that you think (or thought) they were of value, and will be used to discredit you later in the case.
I think this is an important test case, and the real issue is who decides on standards of care - us or lawyers? I will be happy to appear pro-bono as an expert on the issue, and my suggestion is that as many other senior surgeons on this list as can should step forward to do the same. Such a united front will create a strong precedent on an issue that affects us all. We need to remove the fear of litigation from our valid scientific discussions of the appropriate management of these unfortunate individuals. This is as good a time as any to put the bell on this cat.
CJH
Date: Sat, 15 Nov 2003 07:31:00 +0530
From: rajesh
Well said.
Dr. K. R. Rajesh, MS, Dip NB, FRCS, FRCS(Orth)
Consultant Orthopaedic Surgeon
Lords Hospital & Cosmopolitan Hospital
Trivandrum India.
Date: Fri, 14 Nov 2003 14:56:12 -0500
Carl: Superb and logical synopsis. Blaine
From: Joseph Murphy
Carl, et al.
It would be of enormous benefit if the relevant literature that's been cited in this thread of discussion be listed for all to review.
Already cited:
JTM
Date: Fri, 14 Nov 2003 15:26:58 -0600
Of interest in the legal aspects of this case, what is happening to the child's caregivers? Specifically, the one(s) that had a 2 month old infant unrestrained in a MVC? It is interesting - and disturbing - that the person(s) that work the hardest to reverse what another irresponsible adult does are the ones that are "called on the carpet".
J. Pufahl, RN, BAN, CEN, CFRN, Flight Nurse
Date: Fri, 14 Nov 2003 16:35:20 -0500
Reminds me of a case I was part of several years ago. Toddler in front seat, unrestrained and sitting on mom's lap (also unrestrained, passenger). Driver ran a railroad crossing and car hit by train. Child suffered spinal cord injury at C6. Mom sued railroad and won! Crazy!
Andrew Bowman, RN, NREMTP
Date: Fri, 14 Nov 2003 18:07:04 -0500
From: carl hauser
Here's another.
Nesathurai S., J Trauma. 1998 Dec;45(6):1088-93.
Steroids and spinal cord injury: revisiting the NASCIS 2 and NASCIS 3 trials.
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.
From: jjake
Date: Fri, 14 Nov 2003 18:12:33 -0500
Please publish the name of the plaintiffs 'Expert'. Even better put his deposition on line. It is hard to blame Juries when our own act as a Lawyer's Bitch Whore.
Brian Shapiro MD FACS
Trauma Director
Genesys Health System
Date: Sat, 15 Nov 2003 20:34:34 -0600
From: R. Burton
The one thing that you will have to argue is that you did use steroids but didn't get them in until 2 hours after the patient's arrival. This would weaken your argument that they were not needed at all or that it was a medical decision not to use them. Not that I disagree with any of the arguments already given - will just be harder to stand on when you did use them.
From: ecthompson
Date: Sun, 16 Nov 2003 02:28:10 -0600
I did a literature search. Here's a couple more articles
*****AMERICAN SURGEON*****
(REFERENCE 1 OF 23)
95344102
George ER, Scholten DJ, Buechler CM, Jordan-Tibbs J, Mattice C,
Albrecht RM
Failure of methylprednisolone to improve the outcome of spinal cord
injuries.
In: Am Surg (1995 Aug) 61(8):659-63; discussion 663-4
ISSN: 0003-1348
The infusion of methylprednisolone (MP) within 8 hours of injury for
spinal cord injuries (SCI) has been advocated to improve the motor
function of patients after this catastrophic injury. However,
clinical improvement in the outcome of SCI has not been consistently
identified, despite the use of MP. We reviewed the outcome of SCI
patients with MP to those without MP (No-MP) at two Level I Trauma
Centers from 1989-1992. Acute SCI patients were identified from the
trauma registries with trauma demographics and hospital data obtained
from registry and medical records. Rehabilitation data for Functional
Independence Measure (FIM) was obtained from the rehabilitation
institute database. Primary outcome parameters were mortality, and
for survivors, patient mobility (6 point scale) and FIM scores. There
were 145 acute SCI patients: 80 treated with MP and 65 with No-MP.
FIM data was available on 45 MP and 25 No-MP patients. There was no
difference in the admission trauma score, ICU length of stay (LOS),
or hospital LOS between the two groups. The MP patients were
significantly younger (30 years vs 38 years, P = < 0.05) and had
lower ISS scores (24 vs 31, P = < 0.05). There was no statistically
significant difference in mortality (MP, 3.8% vs No-MP, 10.7%)
between the two groups. Although admission mobility was not
statistically different (MP, 5.99 vs No-MP, 5.90), there was a
significantly poorer discharge mobility in the MP group when compared
to the No-MP group (MP, 5.16 vs No-MP, 4.67, P = < 0.05).(ABSTRACT
TRUNCATED AT 250 WORDS)
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
Department of Surgery
Butterworth Hospital
Grand Rapids
Michigan
USA.
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.
Hugenholtz H, Cass DE, Dvorak MF, Fewer DH, Fox RJ, Izukawa DM,
Lexchin J, Tuli S, Bharatwal N, Short C
High-dose methylprednisolone for acute closed spinal cord injury--
only a treatment option.
In: Can J Neurol Sci (2002 Aug) 29(3):227-35
ISSN: 0317-1671
BACKGROUND: A systematic review of the evidence pertaining to
methylprednisolone infusion following acute spinal cord injury was
conducted in order to address the persistent confusion about the
utility of this treatment. METHODS: A committee of neurosurgical and
orthopedic spine specialists, emergency physicians and physiatrists
engaged in active clinical practice conducted an electronic database
search for articles about acute spinal cord injuries and steroids,
from January 1, 1966 to April 2001, that was supplemented by a manual
search of reference lists, requests for unpublished additional
information, translations of foreign language references and study
protocols from the author of a Cochrane systematic review and
Pharmacia Inc. The evidence was graded and recommendations were
developed by consensus. RESULTS: One hundred and fifty-seven
citations that specifically addressed spinal cord injuries and
methylprednisolone were retrieved and 64 reviewed. Recommendations
were based on one Cochrane systematic review, six Level I clinical
studies and seven Level II clinical studies that addressed changes in
neurological function and complications following methylprednisolone
therapy. CONCLUSIONS: There is insufficient evidence to support the
use of high-dose methylprednisolone within eight hours following an
acute closed spinal cord injury as a treatment standard or as a
guideline for treatment. Methylprednisolone, prescribed as a bolus
intravenous infusion of 30 mg per kilogram of body weight over
fifteen minutes within eight hours of closed spinal cord injury,
followed 45 minutes later by an infusion of 5.4 mg per kilogram of
body weight per hour for 23 hours, is only a treatment option for
which there is weak clinical evidence (Level I- to II-1). There is
insufficient evidence to support extending methylprednisolone
infusion beyond 23 hours if chosen as a treatment option.
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
QEII Health Sciences
Halifax
NS
St. Michael's Hospital
Faden AI, Jacobs TP, Patrick DH, Smith MT
Megadose corticosteroid therapy following experimental traumatic
spinal injury.
In: J Neurosurg (1984 Apr) 60(4):712-7
ISSN: 0022-3085
Corticosteroids are frequently used in the treatment of spinal
trauma, although neither experimental nor clinical evidence to
support their use is persuasive. Recently there have been claims that
extremely high doses ("megadoses") of corticosteroids (equivalent to
15 to 30 mg/kg of methylprednisolone) improve neurological recovery
compared to results with traditional steroid doses. The authors have
compared the effect of megadose dexamethasone and methylprednisolone
therapy to that of saline treatment following traumatic cervical
spinal injury in the cat. During 6 weeks postinjury, neurological
recovery did not differ significantly in corticosteroid-treated and
saline-treated animals. Moreover, histopathological changes in the
spinal cord were similar in methylprednisolone- and saline-treated
cats. Corticosteroid-treated animals had a higher mortality rate than
did control animals, with the predominant cause of death being
neurogenic pulmonary edema. It is concluded that megadose
corticosteroid treatment does not improve neurological recovery in
this experimental model of spinal injury, and is associated with
increased mortality.
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.
Pollard ME, Apple DF
Factors associated with improved neurologic outcomes in patients with
incomplete tetraplegia.
In: Spine (2003 Jan 1) 28(1):33-9
ISSN: 1528-1159
STUDY DESIGN: Retrospective review of 412 patients with traumatic,
incomplete, cervical spinal cord injuries, and an average follow-up
period of 2 years. OBJECTIVES: To determine what patient
characteristics, injury variables, and management strategies are
associated with improved neurologic outcomes. In particular, the
effects of intravenous steroids (NASCIS II protocol), early
definitive surgery (<24 hours after injury), early anterior
decompression for burst fractures or disc herniations (<24 hours
after injury), and surgical decompression for stenosis without
fracture were assessed. SUMMARY OF BACKGROUND DATA: Controversy
surrounds the pharmacologic and surgical management of patients with
spinal cord injuries. METHODS: Neurologic data were collected
retrospectively and classified using American Spinal Injury
Association guidelines. This information was recorded at the time of
injury, on admission to rehabilitation, on discharge from
rehabilitation, and at 1, 2, and final year of follow-up evaluation.
Outcome measures included change in motor score, change in sensory
score, final motor score, and final sensory score. The SPSS v10.0.7
statistical software package was used for data analysis. RESULTS:
Neurologic recovery was not related to the following factors: gender,
race, type of fracture, or mechanism of injury. Neurologic recovery
also was not related to the following interventions: high-dose
methylprednisolone administration, early definitive surgery, early
anterior decompression for burst fractures or disc herniations, or
decompression of stenotic canals without fracture. Improved
neurologic outcomes were, however, noted in younger patients ( =
0.002), and those with either a central cord or Brown-Sequard
syndrome ( = 0.019). CONCLUSIONS: The most important prognostic
variable relating to neurologic recovery in a patient with a spinal
cord injury is the completeness of the lesion. When an incomplete
cervical spinal cord lesion exists, younger patients and those with
either a central cord or Brown-Sequard syndrome have a more favorable
prognosis for recovery. In this study, no evidence was found to
support high-dose steroid administration, routine early surgical
intervention, or surgical decompression in stenotic patients without
fracture.
Comment in: Spine. 2003 Jan 1;28(1):39
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
Department of Orthopaedic Surgery
Atlanta Medical Center
Atlanta
Georgia
USA. matthewandelizabeth@msn.com
Faillace WJ
Management of childhood neurotrauma.
In: Surg Clin North Am (2002 Apr) 82(2):349-63, vii
ISSN: 0039-6109
A summary of some of the more important aspects of brain, spinal,
peripheral nerve and sport injuries of childhood is presented.
Guidelines for the treatment of severe brain injury have been
developed for adults, are currently employed with success to treat
children, but much information still needs to be acquired about
childhood brain injury so that better age specific treatment
modalities could be implemented. The unique anatomy of the spine
during childhood predisposes to cervical spinal injury without
radiographic abnormality; immobilization is the primary treatment and
a minority of cases require surgery. Peripheral nerve injuries are
uncommon, often missed, and require skillful evaluation and early
treatment by physical therapy and oftentimes surgery. Appreciation of
the sequelae of cerebral concussion, education on proper sport
techniques, body conditioning, and equipment upkeep are the mainstay
of vigilant sport injury treatment and prevention.
Registry Numbers: 83-43-2(Methylprednisolone)
Institutional address:
University of Florida/Jacksonville
Department of Neurosurgery
32209
USA. Walter.Faillace@jax.ufl.edu
-------------------
Hope this helps.
Errington C. Thompson, MD
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx