India-OrthCurrent Recommendation by Academic Bodies
1. AAOS
AAOS article in 2010 by Dr Ranjan Gupta [26] holds that – “Because of an increased complication rate with steroid treatment and the lack of evidence corroborating the NASCIS results, treatment with MPSS has become largely a clinical decision to be made by the treating physician based on each individual case.”
2. American Association of Neurological Surgeons Recommend (2001) - There is insufficient evidence to support treatment standards. 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 [27].
3. Cochrane Review 2012 [28] - High-dose methylprednisolone steroid therapy is the only pharmacologic therapy shown to have efficacy in a phase three randomized trial when administered within eight hours of injury. One trial indicates additional benefit by extending the maintenance dose from 24 to 48 hours, if start of treatment must be delayed to between three and eight hours after injury. There is an urgent need for more randomized trials of pharmacologic therapy for acute spinal cord injury
Future Trends in SCI Treatment: Following injury, the mammalian central nervous system fails to adequately regenerate due to intrinsic inhibitory factors expressed on central myelin and the extracellular matrix of the posttraumatic gliotic scar. Regenerative approaches to block inhibitory signals including Nogo and the Rho-Rho–associated kinase pathways have shown promise and are in early stages of clinical evaluation. Cell-based strategies including using neural stem cells to remyelinate spared axons are an attractive emerging approach.[23]
Conclusion
Though steroids are rampantly used worldwide in acute treatment of SCI, extensive research has failed to signify the advantages of its use for Long term benefit. The present regimes of MPSS use for 24/48 Hrs if started within 8 Hrs of injury are simply considered as ‘an Option’ in non- contraindicated situations & cannot be compelled as ‘protocol’. It is now more based on the decision of the treating Surgeon and not a decision based on concrete evidence. In this respect we would like to quote a paragraph from 2008 article by Dr Irene Rozet [29] – “How often is our treatment choice guided by belief based on experimental research, but not supported by level-1 evidence? Sometimes the “faith” is so strong that we consider a placebo unethical (like in NASCIS I), or we do not want to participate in randomized trials. How many of us still consider mild hypothermia to be neuroprotective during temporary occlusion of cerebral arteries, despite negative results of the IHAST trial? [30] “Theoretical advantage” of medication often is confronted by the lack of clinical evidence. There is a long list of “routine” and/or “standard” everyday medical practices, which lack level-1 evidence from double-blind randomized trials. Triple-H therapy in cerebral vasospasm, and use of steroids in septic shock and severe ARDS represent examples in this list. Unfortunately, neither NASCIS II nor NASCIS III trials reveal level-1 evidence of the beneficial effect of methylprednisolone in SCI. Nevertheless, some improvement of motor scores in patients treated by methylprednisolone cannot be ignored. Let us not forget that even minimal improvement in control of sphincters or motor function of fingers, reported by NASCIS trials, can have a crucial impact on the patient's lifestyle. The question is: “To give or not to give” 24-hour methylprednisolone protocol to a 30-year-old college physician, who was admitted to emergency room with numbness of hands and C4 fracture just 2 hours after a skiing accident? The dilemma of choosing a potentially beneficial drug, versus nothing, is pretty straightforward in favor of the drug.”
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