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) 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

Reply at: AAST Trauma List
Reply at: Orthopaedic Trauma Association forum

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


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."

Carlo Bellabarba
Harborview Medical Center
University of Washington
Seattle, WA

J Neurosurg (Spine 1) 93:1-7, 2000

Methylprednisolone for acute spinal cord injury: an inappropriate standard of care*

University of Calgary Spine Program, Foothills Hospital and Medical Centre,
Calgary, Alberta, Canada

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


from the March 2002 "Guidelines for treatment of spinal cord injury"   RECOMMENDATIONS


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.


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)

Date: Fri, 14 Nov 2003 14:35:50 -0500

From: carl hauser


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.


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.

From: Enderson, Blaine L.

Date: Fri, 14 Nov 2003 14:56:12 -0500

Carl:  Superb and logical synopsis.  Blaine

Date: Fri, 14 Nov 2003 13:54:17 -0600

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:


From: Pufahl, Jo

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

From: Andrew J Bowman

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



George ER,  Scholten DJ,  Buechler CM,  Jordan-Tibbs J,  Mattice C,  
  Albrecht RM  
Failure of methylprednisolone to improve the outcome of spinal cord

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

Registry Numbers:      83-43-2(Methylprednisolone)

Institutional address: 
     Department of Surgery
     Butterworth Hospital
     Grand Rapids

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

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
     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
     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

Comment in:  Spine. 2003 Jan 1;28(1):39

Registry Numbers:      83-43-2(Methylprednisolone)

Institutional address: 
     Department of Orthopaedic Surgery
     Atlanta Medical Center

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


Hope this helps.

Errington C. Thompson, MD
Trauma Surgeon
Trinity Mother Frances
Tyler, Tx