Full text of DOI:10.1017/S0317167100002006

ORIGINALARTICLE
Why Do You Prescribe
Methylprednisolone for Acute Spinal
Cord Injury? A Canadian Perspective
and a Position Statement
R.J. Hurlbert, R. Moulton
ABSTRACT: Objective: To determine the practice patterns for methylprednisolone administration for
patients with acute spinal cord injury (SCI) within the spinal surgery community across Canada, and the
reasons behind these patterns. Methods: Canadian neurological and orthopedic spine surgeons were
surveyed at their respective annual meetings with a questionnaire asking seven questions with respect to
their practice standards. Results: Sixty surgeons completed the survey representing approximately two-
thirds of surgeons treating acute SCI within Canada. The NASCIS III dosing regimen is the most
commonly prescribed steroid protocol. However, one-quarter of surgeons do not administer steroids at
all. Of those who administer methylprednisolone, most do so because of peer pressure or out of fear of
litigation. Conclusions: The vast majority of spine surgeons in Canada either do not prescribe
methylprednisolone for acute SCI, or do so for what might be considered the wrong reasons. These
results demonstrate the need for an evidence-based practice guideline. The Candian Spine Society and
the Canadian Neurosurgical Society fully endorse the recommendations of the steroid task force (see
preceding paper).
RÉSUMÉ: Pourquoi prescrire de la méthylprednisolone dans les cas de lésion aiguë de la moelle épinière?
Perspective canadienne et déclaration de principe. Objectif: Déterminer les modalités d’administration de la
méthylprednisolone chez les patients présentant une lésion aiguë de la moelle épinière (LMÉ) en chirurgie de la
moelle épinière au Canada et les raisons sous-jacentes à ces pratiques. Méthodes: Nous avons fait un sondage auprès
des neurochirurgiens et des orthopédistes lors de leur congrès annuel respectif au moyen d’un questionnaire incluant
sept questions sur leurs standards de pratique. Résultats: Soixante chirurgiens ont complété le sondage, soit environ
les deux tiers des chirurgiens qui traitent des LMÉ au Canada. Le régime posologique NASCIS III est le protocole
d’administration de stéroïdes le plus couramment prescrit. Cependant, le quart des chirurgiens ne prescrivent pas du
tout de stéroïdes. Parmi ceux qui administrent de la méthylprednisolone, la plupart le font à cause de la pression des
pairs ou par crainte d’une poursuite. Conclusions: La grande majorité des chirurgiens qui traitent des traumatisés de
la moelle au Canada ne prescrivent pas de méthylprednisolone pour une LMÉ ou le font pour ce qui pourrait être
considéré comme de mauvaises raisons. Ces résultats démontrent qu’il existe un besoin quant à l’établissement de
lignes directrices basées sur des données probantes. La Canadian Spine Society et la Canadian Neurosurgical Society
appuient entièrement les recommandations du groupe de travail sur les stéroïdes (voir l’article précédent).
Can. J. Neurol. Sci. 2002; 29: 236-239
In 1990, the results of a multicentre prospective randomized
double-blind controlled trial (NASCIS II) were published,
investigating the administration of high-dose methylpredniso-
lone in the treatment of acute spinal cord injury (SCI).1 Within a
very short time, the medical community embraced routine
administration of this steroid protocol for patients with acute,
nonpenetrating, spinal cord trauma. More recent publications by
the same investigators have provided longer follow-up of the
original study patients and results from another trial (NASCIS
III) investigating a modified dosing strategy of the same drug for
the same indication.2-4 The results of these trials have led the
investigators to conclude that high dose methylprednisolone
should be routinely administered for either 24 or 48 hours
depending on the acuity of the injury (<3 hrs, 3-8 hrs).
From the Department of Clinical Neurosciences, Foothills Hospital and Medical
Centre, Calgary AB (RJH); Department of Neurosurgery, St. Michael’s Hospital,
Toronto, ON (RM) Canada.
RECEIVED JANUARY 16, 2002. ACCEPTEDIN FINALFORM MARCH 27, 2002.
Reprint requests to: R.J. Hurlbert, University of Calgary Spine Program, Department
of Clinical Neurosciences, Foothills Hospital and Medical Centre, 1403, 29th St. NW,
Calgary AB T2N 2T9 Canada.
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During the same time period, not only has methylpredniso-
lone enjoyed widespread use in spinal cord trauma, but experts
have come forward to declare it a standard of care. Legal
precedents have been set.5 At the same time, independent review
of published NASCIS data have led certain authors to form their
own conclusions about safety and efficacy, that are quite in
contrast to the conclusions championed by the principal
investigators.6-8
40
36%
30
29%
24%
20
Against this background, the front-line physicians treating
patients with acute spinal cord injury are left exposed. Do they
prescribe steroids because they have read and understand the
NASCIS study results; do they prescribe steroids out of fear of
litigation; do they prescribe steroids because everyone else does;
or do they prescribe nothing? On behalf of the Canadian
Neurosurgical Society and the Canadian Spine Society, we
undertook a national survey to try to answer these questions.
10
7%
5%
0
NASCIS I NASCISII
NASCISIII
generic
none
Administration of Steroid Protocol
60 Canadian Surgeons Treating Acute SCI
METHODS
At the annual meetings of the Canadian Neurosurgical
Association and Canadian Spine Society for the year 2001, we
conducted a survey of neurosurgeons and orthopedic surgeons
who treat acute spinal cord injured patients with the questions
posed above, in mind. Surgeons were confronted with the
questionnaire during scientific sessions throughout the venue of
both meetings. They were asked to complete the questionnaire
only once, and only if they were responsible for treating patients
with acute spinal cord injuries. Results were tabulated and
expressed as a percentage of physicians completing the
questionnaire. To estimate the number of spinal surgeons treating
acute SCI across Canada, we contacted physician specialists at
each of 10 University tertiary care centers that routinely manage
this disorder.
Figure 2: Steroid protocol administered to patients with acute spinal
cord injury.
other physicians treating this condition (n=2). All 10 University
tertiary care centers provided details about the number of
neurosurgeons and orthopedic surgeons managing patients with
acute SCI in their geographic region. Subsequently we were able
to estimate that, within Canada at the time of this survey,
approximately 65 neurosurgeons and 25 orthopedic surgeons
were active in treating this disorder. Hence, the results of this
survey represent the opinion of roughly two-thirds of all
surgeons treating acute SCI in this country.
Of the 60 respondents, 48% report treating on average <10
patients with acute spinal cord injuries per year. Forty-one
percent treat between 10-40 injuries per year, and 11% more than
40 per year. When asked about their knowledge of the literature,
73% of those surveyed indicated that they have read in detail and
understand the results of the NASCIS II study, the NASCIS III
study, or both (Figure 1). Implied in these findings is that the
majority of surgeons feel adequately informed about prescribing
methylprednisolone as a treatment for acute SCI. Just over one-
quarter of the respondents admitted to being unfamiliar with
either study.
Practice patterns were elucidated through a question
examining steroid prescription. Twenty-four percent of Canadian
surgeons treating SCI do not prescribe methylprednisolone at all.
NASCIS II recommendations are followed by 29%, while
NASCIS III recommendations are followed by 36% (Figure 2).
Seven surgeons (12%) indicated that they prescribed steroids
(such as methylprednisolone or decadron) according to some
other regimen. Of those surgeons who prescribe steroids, almost
half (47%) follow NASCIS III recommendations.
RESULTS
Sixty surgeons responded to the questionnaire that either treat
acute spinal cord injuries (n=58) or routinely provide advice to
40
30
28%
27%
23%
22%
20
10
0
Those physicians who prescribe steroids for patients with
acute SCI were asked to respond to a subsequent question
exploring the reason for this practice (Figure 3). The two most
common reasons for prescribing methylprednisolone are
“because everyone else does” (35%) or out of fear of litigation
(35%). Only 17% of those prescribing steroids do so primarily
NASCISII
NASCISIII
both
neither
Detailed Understanding
Figure 1: Although most surgeons treating acute SCI reported a detailed
understanding of NASCIS II and/or NASCIS III, just over 1⁄
did not feel
comfortable with the literature.
4
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THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES
Table: Joint CNS/CSS Steroid and SCI Committee
40
Chair
35%
35%
H Hugenholtz
Division of Neurosurgery, Dalhousie University,
Halifax NS
30
20
10
0
Committee Members
DE Cass*
MF Dvorak
DH Fewer
RJ Fox
Department of Emergency Medicine, University of
Toronto, Toronto ON
Department of Orthopedic Surgery, University of
British Columbia, Vancouver BC
Division of Neurosurgery, University of Manitoba,
Winnipeg, MN
17%
13%
Division of Neurosurgery, University of Alberta,
Edmonton AB
Beneficial
Litigation
Everyone
Else Does
All of the
Above
DMS Izukawa
J Lexchin*
S Tuli*
Division of Neurosurgery, Mississauga General
Hospital, Mississauga ON
Department of Emergency Medicine, University of
Toronto, Toronto ON
Division of Neurosurgery, University of Toronto,
Toronto ON
Reason for Using Methylprednisolone
(Of 46 respondents who routinely use steroids for SCI)
Figure 3: Of those who routinely prescribe methylprednisolone for
acute SCI, 70% do so out of fear of litigation or from peer pressure,
while another 13% admit that litigation and peer pressure influence
their decision.Only 17% prescribe steroids primarily for patient benefit.
N Bharatwal
C Short
Department of Physical and Rehabilitation
Medicine, University of Toronto, Toronto ON
Department of Physical and Rehabilitation
Medicine, Dalhousie University, Halifax NS
because they believe in the benefit to their patients. Thirteen
percent indicated their practice to be based on a combination of
reasons.
*Master’s preparation in Clinical Epidemiology
CONCLUSIONS
In summary, 3/4 of surgeons treating acute SCI in Canada
prescribe steroids. This suggests that at face value, steroids for
acute SCI represent a national standard of care. The NASCIS III
dosing schedule is currently the most widely prescribed steroid
protocol in this setting. This is concerning, in that there is the
least amount of evidence for this protocol and the most potential
for patient harm (see preceding paper by Hugenholtz et al.).
When one examines the reasons for steroid administration,
70% of surgeons are prescribing methylprednisolone because of
peer pressure or out of fear of litigation, while only 17% are
convinced of the therapeutic benefit. Including those who do not
prescribe methylprednisolone, 87% of surgeons treating acute
SCI are either not using methylprednisolone, or are using it for
what might be considered undesirable reasons. These results
argue strongly against methylprednisolone as a standard of care,
and raise serious concerns about the influence of misguided
medicolegal pressures on practice patterns. Further underscored
is the need for an unbiased evidence-based national position
statement structured from available literature.
tions with respect to the use of methylprednisolone in acute
spinal cord injury. In April, the entire committee met for three
days in Toronto to undertake this process. Their
recommendations were finalized over the ensuing weeks.
Subsequently they have been formally presented to several
national special interest groups including the Canadian
Orthopedic Association, Emergency Physician Association of
Canada, Physical and Rehabilitation Medicine Society of
Canada, the Canadian Paraplegic Association, and the Rick
Hansen Society.
OUTCOME
Both sponsoring organizations have formally accepted the
recommendations of the committee. It is the hope of these two
societies that the committee’s report will help clear up the
confusion surrounding the use of steroids in acute SCI. In
particular, the document will provide care-givers in Canada with
enough information to make an informed choice based on
objective review of scientific evidence, without fear of peer
pressure or litigation.
AN EVIDENCE-BASED PROCESS
In January of 2001, a committee was struck consisting of
recognized experts in the field of acute spinal cord injury,
emergency medicine, and/or epidemiology (Table). A mandate
was provided by the sponsoring societies to undertake an
evidence-based review of available literature and through a
formal guidelines process, to formulate a set of recommenda-
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