Letters to the Editor: Evaluation and Treatment of Spinal Injuries in the Patient with Polytrauma

To the Editor: We would like to congratulate the authors on their detailed review of the evaluation and treatment of spinal injuries in their article titled: “Evaluation and Treatment of Spinal Injuries in the Patient with Polytrauma” by RV Patel, W DeLong Jr., and EJ Vresilovic.1 We would, however, like to make a comment concerning steroids in spinal cord injury. The authors recommend the administration of methylprednisolone in case of neurological deficit, and base their recommendation on the NASCIS II and III guidelines.2,3 Since these guidelines were published, the euphoria for this therapy was gradually replaced by the realization that the evidence available for efficacy, let alone safety, does not justify clinical usage. Much has been written regarding the unsatisfactory methods and therefore results of NASCIS, that steroids improve neurological outcome.4 The main criticism of the validity of these trails is directed towards the use of subgroup analysis. In NASCIS II, there was no benefit overall in the methylprednisolone-treated group; however, subgroup analyses detected a small gain in the total motor and sensory score in a subgroup of 62 patients who had received the drug within 8 hours of injury. The arm of the treatment group is reduced from approximately 160 patients who received methylprednisolone within a time window of 12 hours, to 62 patients in the subgroup alone. In addition to the smaller sample size, the benefits of randomization are lost when performing such analyses, yet another reason to be cautious when interpreting subgroup analysis results.5 This type of analysis carries an inherent risk of finding a difference where it actually does not exist and should be used primarily as a source of hypotheses to be tested by future research and not to change clinical policy. Additional problem with NASCIS is that it ignores the effect of surgical decompression of the spinal cord on neurological recovery. An animal study showed that surgical decompression with steroids resulted in improved neurological recovery when compared to steroids or surgery alone.6 The American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section of Disorders of the Spine and Peripheral Nerves recently published guidelines for the management of acute cervical spine and spinal cord injuries.7 The most controversial part of the guidelines is the conclusion to recommend the use of methylprednisolone only as an option without demonstrated clinical benefit8 rather than a standard of care, due to insufficient evidence. The Canadian Neurosurgical Society published similar recommendations regarding the use of methylprednisolone in spinal cord injury,9 in which this agent is considered only as a therapeutic option. More recently, the early anecdotal evidence of adverse effects has been supported by scientific evidence that this treatment can be positively harmful, such as giving rise to acute myopathy.10 Perhaps both sides of this controversy should have been discussed. Readers are encouraged to read these guidelines and the relevant associated literature to establish their own perspective on this issue. Eitan Melamed, MD Dror Robinson, MD, PhD Department of Orthopedic Surgery, Rabin Medical Center, Petach-Tikva, Israel

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