Letter

Methylprednisolone treatment for acute spinal cord injury is a polarizing topic. Methylprednisolone was introduced as an off-label treatment for acute spinal cord injuries (SCI) in the 1980s in the NASCIS I trial.1-4 At that time, the treatment did not demonstrate neurological improvement in comparison with the control group, and infectious complications were documented. The NASCIS II trial was published in 1990, and the results and wide publication of the neurological benefits in both the lay press and scientific journals ushered in an era of strong support and a purported “Standard of Care” designation for the use of methylprednisolone in the treatment of SCI.5,6 However, subsequent concerns over the validity of the data interpretation of the NASCIS II and NASCIS III studies have been reported. Specific concerns raised are the post hoc methodology of determining neurological benefit from methylprednisolone treatment in NASCIS II and the underreporting of infectious and life-threatening complications associated with methylprednisolone use in trauma patients.7,8 In 2002, the first “Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries” was published as a supplement to Neurosurgery.9 At that time, the guideline authors did not feel that there was enough evidence to support a treatment standard. Methylprednisolone treatment was designated as a treatment option. In 2013, an update of the guidelines was published in which a more definitive level I recommendation was made, stating, “administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended.”10 Guideline development is a labor-intensive and sometimes contentious pursuit. However, guidelines can be beneficial not only for highlighting appropriate treatments for various conditions, but also for identifying deficiencies in data. The purpose of this survey-based study was to determine whether published guidelines are associated with changes in physician behavior. Therefore, our hypothesis was that the newly published guideline recommendations would have a high impact on the use of methylprednisolone and lead to a practice change of decreased use of methylprednisolone for the treatment of acute SCI. METHODS The entire membership of the Congress of Neurological Surgeons was sent an email requesting that they fill out a survey regarding their use of methylprednisolone in the treatment of acute SCI. The survey request was distributed 15 months after the publication of the 2013 guidelines. The survey request was sent to 6857 members via an email link to the Survey Monkey Web site. Four hundred sixty-six members (7%) responded to the survey request. Because of the design of the survey, not all of the questions were answered by respondents. Respondents who answered that they do not treat acute SCIs (19%) were excluded from evaluation. The survey asked 8 questions (see Survey Questions, Supplemental Digital Content 1, https://links.lww.com/NEU/A882). Questions 1, 3, and 7 had specified responses in Likert style (eg, likely–less-likely). The remainder of the survey questions were open ended, allowing free text responses. Demographic and practice type data were also collected. RESULTS The results will be presented with the questions in italics. Results are displayed as (number, percentage). “How often do you currently use methylprednisolone in the treatment of acute spinal cord injury?” Four hundred forty-seven responses were obtained: always (68, 15%), often (54, 12%), sometimes (61, 13%), rarely (96, 21%), never (176, 39%) (Figure 1).FIGURE 1: Survey results of current use of methylprednisolone for the treatment of acute spinal cord injury. Note that 73% of respondents use methylprednisolone sometimes, rarely, or never.“Within the past year, has there been a change in your usage of methylprednisolone in the treatment of acute cervical spinal cord injury?” Four hundred thirty-six responses were obtained: more likely (9, 2%), no change (161, 61%), less likely (266, 37%) (Figure 2).FIGURE 2: Responses to the question, “Within the past year, has there been a change in your usage of methylprednisolone in the treatment of acute cervical spinal cord injury?” Thirty-seven percent of the respondents answered less likely.“Have you encountered barriers that impact your use of methylprednisolone?” Four hundred twelve responses: yes (58, 14%), no (354, 86%). “Do you recall reading or hearing about any guidelines for the management of acute cervical spine and spinal cord injuries in the last year or so?” Four hundred thirteen responses: yes (296, 72%), no (117, 28%). “Do you recall the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries from the March 2013 journal NEUROSURGERY?” Three hundred eighty-seven responses: yes (288, 74%), no (99, 26%). “How much impact have these guidelines had on your practice?” Three hundred seventy-two responses: a great deal (73, 20%), a moderate amount (133, 37%), not much (99, 27%), none at all (57, 16%) (Figure 3).FIGURE 3: Responses to the question, “How much impact have these guidelines had on your clinical practice?” Fifty-seven percent of the respondents felt that the guidelines had a great to moderate amount of impact on their clinical practice.Demographics Self-Description Three hundred eighty-two responses: neurosurgeon (in practice) (84%), neurosurgeon retired (<1%), neurosurgery resident/fellow (15%), non-neurosurgeon (2, <1%), other (2, <1%). Areas of Practice Three hundred eighty-three responses (respondents were able to choose multiple answers): cerebrovascular surgery (82, 21.4%), neurotrauma and critical care (177, 46%), pain surgery (40, 10%), pediatric surgery (64, 17%), peripheral nerve surgery (45, 12%), spine surgery (304, 79%), stereotactic and functional surgery (46, 12%), tumor surgery (174, 45%), and general (193, 50%). Practice Setting Three hundred eighty-two responses: solo practice (26, 7%), group practice–single specialty (56, 15%), group practice–multispecialty (56, 15%), private practice with academic (41, 11%), full-time academic (129, 34%), research (1, 0.2%), hospital employee (54, 14%), military/government (12, 3%), other (7, 1.8%). Fellowship Training (Multiple Responses Allowed) Three hundred seventy-eight responses: no fellowship (165, 44%), spine (135, 36%), peripheral nerve (7, 2%), tumor (38, 10%), trauma (12, 3%), vascular (44, 12%), functional (21, 6%), pediatric (33, 9%). Years in Practice Three hundred eighty-two responses: less than 5 years (107, 28%), 5 to 9 years (76, 20%), 10 to 14 years (54, 14%), 15 to 19 years (47, 12%), 20 years or longer (98, 26%). Do you practice in the United States or another country? Three hundred eighty-four responses: United States (258, 67%), other country (126, 33%). In which types of hospitals do you practice? Two hundred fifty-seven responses (multiple responses allowed): teaching hospital (139, 54%), community hospital (114, 44%), level I trauma center (110, 43%), level II trauma center (84, 33%), level III trauma center (26, 10%), urban (97, 37%), suburban (50, 19%), rural (17, 7%). Age Groups Three hundred eighty responses: under 35 (53, 14%), 35 to 44 (141, 37%), 45 to 54 (94, 25%), 55 to 64 (75, 20%), 65 or older (17, 4%). Free text commentary made by the respondents gave some suggestion of the following types of physician practice. 1) Most commonly, the physician who already agrees with the guidelines and uses them to support his/her practice decisions: a. “Reinforced my practice of not utilizing methylprednisolone.” b. “My practice was already to avoid usage of methylprednisolone, therefore this article did not change my feelings, only strengthened them.” 2) The physician who reads the guidelines and changes his/her practice based on the guideline recommendations: a. “I discontinued use of methylprednisolone for SCI.” b. “Our team [has] changed according to the new guidelines.” 3) The physician who is told by outside parties (hospital or other services) that he/she may no longer perform a treatment based on the data. a. “No proof that it works, and our institution decided to remove it from our protocols.” 4) The physician who is continuing to use methylprednisolone for legal reasons despite feeling that it is not beneficial. a. “I never thought steroids significantly helped, but for legal reasons felt obligated to use them.” 5) The physician who feels that there is a benefit to methylprednisolone therapy despite the evidence. a. “I see better and faster response to the injury.” b. “It has clear effect which improves outcome of spinal cord injuries.” c. “For high cervical spine injuries, I would want it done on myself or a loved one if needed, G-d forbid.” DISCUSSION The published guidelines do have an impact on physician practice, as evidenced by a high level of awareness, a self-reported impact on physician practice, and self-reported steroid use literature that is consistent with more recently published reports.1,3,4 There is a high level of awareness of the published guidelines, with 72% of respondents having read or heard about the 2013 guidelines. The demographics show that the survey has a broad representation in age, practice type, hospital type, and US and international respondents. These survey data suggest that published treatment guidelines have a moderate to good impact on physician practice and lead to a decrease in use of methylprednisolone for acute SCI. This is evidenced by the data demonstrating that 57% of respondents stated the impact on their practice was “a great deal” or a “moderate amount” and 43% of respondents stated “not much” or “none at all.” In addition, 37% of respondents noted that they were “less likely” to use methylprednisolone in the past year (2014) and only 2% stated that they were “more likely.” This moderate effect may be explained by the fact that significant change in practice patterns (such as the use of methylprednisolone) occurs over many years and is changed gradually and incrementally through published reports and presentations. Guidelines are published infrequently and represent a distillation of published and presented data that may have incrementally changed practice patterns over the years leading up to a guideline's publication. The free text commentary elicited in this survey suggests that many respondents already knew about the data regarding methylprednisolone treatment, had already changed their practice, and viewed the current guidelines as supportive information as well as transformative. The survey responses suggest there is a trend toward a decreased use of methylprednisolone. Within the year before the survey, respondents were overall stable to less likely to use methylprednisolone. Seventy-three percent of respondents use methylprednisolone sometimes, rarely, or never. We do not have historical data from this population to compare. Previously published results from Molloy et al1 in 2001 (European Cervical Spine Society), Eck et al3 in 2006 (NASS), and Hurlbert and Hamilton4 in 2008 (Canadian Neurosurgery and Canadian Spine Society) showed that 25%, 9.5%, and 75% of surgeons, respectively, were not using methylprednisolone. These survey findings are consistent with the findings of Hurlbert that methylprednisolone use continues to decline. Weaknesses There were a limited number of responses, which allows the possibility of sampling error. There is a potential for self-report bias of a median of 27% when physicians are asked about guideline compliance.11 Therefore, this type of survey data can overrepresent compliance. However, survey methodology is the first stage in assessing compliance with published evidence-based guidelines. Further Improving Compliance External factors may influence the use of methylprednisolone. Anecdotally, the concern over the use or disuse of methylprednisolone can be related to the malpractice environment in a particular region. Guideline adherence has been shown to vary regionally based on practice patterns and the culture of institutions.12 Adherence improves with practice implementation rather than relying on individual practitioners.13 Continuous improvement in compliance with published evidence-based guidelines is likely to require a concerted effort through education and system change locally, nationally, and internationally. These survey data should serve as a stepping-off point for further research. Further study could include retrospective review of prospectively collected data in level I trauma center registry databases to assess compliance with this published guideline and changes in practice patterns over time. CONCLUSION Evidence-based guidelines can lead to change in practice among neurosurgical providers. These survey data suggest that over half of the neurosurgeons surveyed felt that the guidelines had an impact on their use of methylprednisolone for acute SCI. Further dissemination and easy access to guidelines may further improve adoption of future guidelines. Disclosures Nathaniel Brooks, MD: Teaching Honorarium from Medtronic and Depuy/Synthes. Eric Potts, MD: None. John O'Toole, MD, MS: Consultant & Royalties: Globus Medical, RTI surgical, FDA; Stock ownership: Theracell, Inc. The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Acknowledgment The authors would like to thank the members of the CNS Office for their assistance in survey development, distribution, and data collection.

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