Declining Rates of High-Dose Steroid Use for Acute Spinal Cord Injury
Use of high-dose steroids in the treatment of acute spinal cord injury significantly decreased between 2013 and 2006, according to survey of 78 Cervical Spine Research Society members published in the May issue of Spine.
“There has been a statistically significant decrease in the number of spine surgeons using high-dose methylprednisolone for the treatment of acute spinal cord injuries between 2006 and 2013 (89% vs. 56%); however, 30% of all respondents were still using high-dose steroids even though they did not believe in the efficacy of the treatment,” said lead author Gregory D. Schroeder, MD, a Resident in the Department of Orthopaedic Surgery at Northwestern University Feinberg School of Medicine in Chicago.
In this survey, 71% of respondents had observed complications from use of high-dose steroids for acute spinal cord injuries, and 76% believed that the complications were severe enough to limit steroid use. In addition, more than 80% of respondents reported that sepsis, active gastrointestinal bleeding, and spinal cord injury occurring earlier than 8 hours are contraindications to use of steroids.
Among respondents who used steroids in this setting, the following reasons were reported:
- 26% believed steroids improved neurological recovery
- 19.2% used steroids to adhere to their institutional protocol
- 25.6% used steroids because of medico-legal concerns, but did not believe that steroids were beneficial
Nearly half of surgeons who used high-dose steroids in this setting said they would not use these agents if there were no medico-legal concerns.
AANS/CNS Guidelines Recommend Against Steroid Use
In 2013, the American Association of Neurological Surgeons (AANS) and Congress of Neurological Surgeons (CNS) released guidelines recommending that methylprednisolone not be used in the first 24 to 48 hours after acute spinal cord injury given the lack of evidence supporting the benefit of this practice and strong evidence showing that use of high-dose steroids in this setting is associated with harmful side effects, including death.
“It is possible that the AANS/CNS guidelines will further decrease the number of surgeons using high dose steroids, as this survey was completed just prior to the publication of the new guidelines,” noted Dr. Schroeder. “More than 25% of respondents stated medico-legal concerns were the primary reason for their use of high-dose steroids, and with the new guidelines recommending against the use of steroids, it may alleviate some surgeons’ fears of litigation in cases which they choose not to administer high dose steroids,” he said.
Clinical Implications of the Findings
“The important findings were that the use of steroids has decreased significantly since 2006,” said CNS President Daniel K. Resnick, MD. “This is almost certainly the result of previous guidelines efforts and the well-publicized criticism of the National Acute Spinal Cord Injury Study studies referenced in the text. Steroids are still used with some frequency, however, and the survey reveals that the major driver of steroid use is persistent fear of medico-legal consequences if steroids are not used,” he noted.
“It is a distressing commentary on our medico-legal system that despite the majority of surgeons who prescribe steroids reporting that they don’t believe steroids are beneficial, these potentially dangerous drugs are being administered as part of a defensive medicine practice,” Dr. Resnick continued. “The analysis of belief patterns and steroid use in other countries clearly illustrates how bad the problem really is. Hopefully, with the new stronger recommendations against steroids in the 2013 CNS Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries, the use of steroids to avoid potential lawsuits will become less common. As we treat these seriously injured patients, it is important to continue to investigate any therapies with the potential to improve function. At the same time, we have all been charged to ‘first, do no harm,’” Dr. Resnick said.
Dr. Resnick also commented on limitations of the findings. “The number of surveys sent out is not reported so we do not know if this is a representative sample from the CSRS,” he said. “The responding population was largely made up of orthopedic surgeons, again raising the issue of whether the information has relevance to the entire community of spine surgeons at large…. These are all important methodological issues that decrease confidence in the relevance of the findings,” Dr. Resnick said.