High-dose methylprednisolone for acute traumatic spinal cord injury

Liu, Zhongyu; Yang, Yang; He, Lei; Pang, Mao; Luo, Chunxiao; Liu, Bin; Rong, Limin

doi:10.1212/wnl.0000000000007998

Cited by 141 publications

(100 citation statements)

References 39 publications

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“…Several trials of neuroprotective agents for TSCI have failed, despite evidence from different TSCI animal models that the drugs are neuroprotective [49][50][51]. In 3 TSCI patients, we injected intravenously a 4-mg bolus of dexamethasone and found that little (~0.64%, based on area under the curve calculations) dexamethasone entered the injury site [52].…”

Section: Enhancing Drug Deliverymentioning

confidence: 99%

Targeted Perfusion Therapy in Spinal Cord Trauma

Saadoun

Papadopoulos

2020

Neurotherapeutics

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We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. Key concepts are discussed such as intraspinal pressure and spinal cord perfusion pressure (SCPP) at the injury site, respectively, analogous to intracranial pressure and cerebral perfusion pressure for traumatic brain injury. The concept of spinal cord autoregulation is introduced and quantified using spinal pressure reactivity index (sPRx), which is analogous to pressure reactivity index for traumatic brain injury. The Ushaped relationship between sPRx and SCPP defines the optimum SCPP as the SCPP that minimizes sPRx (i.e., maximizes autoregulation), and suggests that not only ischemia but also hyperemia at the injury site may be detrimental. The observation that optimum SCPP varies between patients and temporally in each patient supports individualized management. We discuss multimodality monitoring, which revealed strong correlations between SCPP and injury site metabolism (tissue glucose, lactate, pyruvate, glutamate, glycerol), monitored by surface microdialysis. Evidence is presented that the dura is a major, but unappreciated, cause of spinal cord compression after TSCI; we thus propose expansion duroplasty as a novel treatment. Monitoring spinal cord blood flow at the injury site has revealed novel phenomena, e.g., 3 distinct blood flow patterns, local steal, and diastolic ischemia. We conclude that monitoring from the injured spinal cord in the intensive care unit is a safe technique that appears to enable optimized and individualized spinal cord perfusion.

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Section: Enhancing Drug Deliverymentioning

confidence: 99%

Targeted Perfusion Therapy in Spinal Cord Trauma

Saadoun

Papadopoulos

2020

Neurotherapeutics

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“…Liu et al 6 have brought to attention the use of methylprednisolone in acute traumatic SCI and concluded that high-dose methylprednisolone does not improve neurologic outcomes in acute traumatic SCI and may increase the risk of adverse events. They recommend against the use of this corticosteroid early after injury.…”

Section: Discussionmentioning

confidence: 99%

“…Confounding occurs when the true association between an exposure and an outcome is distorted by the presence of another variable (i.e., the confounder). 16 Another strength of the Liu et al 6 meta-analysis was that an assessment of study quality was performed, although the quality score was not used in the meta-analysis. There are several techniques for incorporating quality scores in metaanalyses, including excluding studies of a certain quality, subgroup analyses by study quality, and incorporating quality scores as weights in the meta-analysis.…”

Section: Study Strengths and Limitationsmentioning

confidence: 99%

Journal Club: High-dose methylprednisolone for acute traumatic spinal cord injury

2020

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Methylprednisolone is a corticosteroid medication used in acute traumatic spinal cord injury (SCI) to tackle secondary injury cascades. Its use in acute SCI has been the subject of controversy for over 30 years. The second National Acute Spinal Cord Injury Study (NASCIS-2) demonstrated a small benefit of methylprednisolone, 1 though this conclusion was derived from a post hoc subgroup analysis. 2 Studies that followed did not reach the same conclusion and reported potential adverse effects of the drug. 3 However, the 2017 AOSpine guideline continues to recommend high-dose methylprednisolone within 8 hours postinjury, 4 based on a meta-analysis with rigid inclusion criteria. 5 This Journal Club article reports on a study from Liu et al., 6 who have attempted to resolve this controversy. The study provides an elegant example of meta-analytic methods and has important implications for neurologic clinical practice. Hypotheses and design Does acutely administered methylprednisolone improve neurologic recovery following traumatic SCI? To answer this important question, Liu et al. 6 performed a meta-analysis of clinical trials and observational studies. The use of a meta-analysis is important here as it synthesizes all available evidence and provides the highest possible strength of recommendation for its use in clinical management. Methods This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses. 7 A comprehensive literature search was performed of PubMed and the Cochrane Library, and articles were further restricted to those published in journals included in the Science Citation Index. In addition to traditional database searches, manual searches of the reference lists of all of the relevant studies, review articles, and conference abstracts were also conducted. Searching multiple databases is recommended when conducting metaanalyses in order to identify all the relevant articles. For instance, the Cochrane Handbook suggests the use of MEDLINE (accessible through PubMed) and the Cochrane Central Register of Controlled Trials. 8 Other commonly used databases include the Web of Science and Google Scholar. 9

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“…The effectiveness of MP therapy in spinal cord injury patients has been clearly demonstrated. [23][24][25] Spinal cord injury can be divided into primary and secondary injuries-primary injury denotes the damage caused by external forces at the moment of insult 18 and secondary spinal cord injury denotes a cascade of damage after the primary injury including edema, ischemia, microcirculatory dysfunction, and severe inflammatory response; secondary injuries are usually more serious. 9 High-dose MP therapy can mitigate the secondary injuries by inhibition of inflammatory and pre-oxidative responses; although, high-dose MP therapy may carry a high risk for side effects including poor wound healing and/or gastrointestinal bleeding, the risk of such side-effects is not usually significant, 25 hence, high dose MP therapy carries a significant role in preventing further cord injury.…”

Section: Discussionmentioning

confidence: 99%

Acute traumatic quadriplegia: Predictors of in-hospital and six-month mortality

Alimohammadi

Ahadi

Rezaee

et al. 2020

Trauma

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Background Traumatic spinal cord injury is one of the most disastrous and devastating health burdens all over the world with a high mortality rate. The present study aimed to evaluate the predictors of in-hospital and six-month mortality in these patients. Methods The electronic medical records of 87 consecutive patients with acute complete traumatic quadriplegia were reviewed to extract clinical, radiological, and laboratory data. Simple and multiple logistic regression models were used to estimate crude and adjusted odds with 95% confidence interval (CI) ratios for the predictors of in-hospital mortality and six-month mortality. Results There were 48 males and the mean age was 38.67 ± 12.81; in-hospital and six-month mortality were 21.84% and 11.76%, respectively. Traffic road accidents (67.8%) and falls (12.6%) were the most common causes of injury. The univariate analysis demonstrated advanced age, level of injury, late surgery or no surgical intervention, the lack of methylprednisolone therapy, a higher Charlson comorbidity index, the Injury Severity Score, and the presence of respiratory failure or bradycardia on admission were predictors of in-hospital mortality ( p < 0.05). In the final multiple logistic regression model, the level of injury (OR = 0.02 (0.001,0.35), p = 0.008) and the presence of respiratory failure (OR = 2.37 (0.03,13.88), p = 0.024) were the only predictors of in-hospital mortality. The univariate model showed that the level of injury, respiratory failure on admission, and the Injury Severity Score were the predictors of six-month mortality; however, the level of injury was the only predictor of the six-month mortality (OR = 1.12 (0.99, 1.27), p = 0.028) according to the multiple logistic regression model. Conclusions Several factors could affect in-hospital and six-month mortality in patients with traumatic spinal cord injury. Our findings demonstrated the level of injury and respiratory failure on admission as independent predictors of in-hospital mortality in these patients. Furthermore, the level of injury was the only independent predictor of six-month mortality in the present study.

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High-dose methylprednisolone for acute traumatic spinal cord injury

Cited by 141 publications

References 39 publications

Targeted Perfusion Therapy in Spinal Cord Trauma

Targeted Perfusion Therapy in Spinal Cord Trauma

Journal Club: High-dose methylprednisolone for acute traumatic spinal cord injury

Acute traumatic quadriplegia: Predictors of in-hospital and six-month mortality

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