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  1. #1

    Question about methylpredisolone.

    I just read my medical reports and found out that I was not given methylpredisolone. Given all the benefits that I have read about I wonder if my condition did not merit it.

    I was a victim of an accidental shooting at the T7 level. I have a complete injury. My t7 was fractured and I received instrumataion from t4-t9 with the whole section being fused. I read Dr's report and it stated "there is no indication at this point for Solu-Medrol (methypredisolone) given that there was a penetrating spinal cord injury. this patient has a t7 complete spinal cord injury and he will not likely recover any function of the lower extremities."

    This is from the first assestment after xrays and no MRI done yet.

    I know that it is too late to cry about it now, but I was just curious since there are no dangerous side effects why not give it too all spinal cord injuries? Nothing to lose.

    I was treated at UCI Irvine one of Californias top spincal cord hospitals.

  2. #2
    I will ask Dr. Young to comment, since he is an MP expert. In my experience it is generally not used in penetrating injuries like GSW because of the risk of infection from such injuries, and the MP supression of your immune response.

    (KLD)

  3. #3
    Quote Originally Posted by POPO367
    I just read my medical reports and found out that I was not given methylpredisolone. Given all the benefits that I have read about I wonder if my condition did not merit it.

    I was a victim of an accidental shooting at the T7 level. I have a complete injury. My t7 was fractured and I received instrumataion from t4-t9 with the whole section being fused. I read Dr's report and it stated "there is no indication at this point for Solu-Medrol (methypredisolone) given that there was a penetrating spinal cord injury. this patient has a t7 complete spinal cord injury and he will not likely recover any function of the lower extremities."

    This is from the first assestment after xrays and no MRI done yet.

    I know that it is too late to cry about it now, but I was just curious since there are no dangerous side effects why not give it too all spinal cord injuries? Nothing to lose.

    I was treated at UCI Irvine one of Californias top spincal cord hospitals.
    The Second National Acute Spinal Cord Injury Study (NASCIS 2) showed that very high-dose methylprednisolone (30 mg/kg bolus followed by 5.4 mg/kg/hour) significantly improved recovery by 6 and 12 months after injury by about 20%, compared to placebo-treated subjects. At the time NASCIS 2 was designed, people with gunshot wound induced spinal cord injuries were excluded from the study because of worries by doctors that such high-dose steroids would increase the likelihood of infective complications in penetrating injuries, particularly ones that involve the gut. NASCIS 2 was reported in May 2000. No randomized clinical trial has been carried out on people with gunshot wounds since.

    Several retrospective studies (Heary, et al. 1997; Levy, et al. 1996; Gerndt, et al., 1997), however, have been done, comparing recovery of patients with and without methylprdnisolone. These studies did not show significant difference of recovery between those treated with methylprednisolone and those who did not. However, non-randomized studies may give misleading results. For example, because the treatment was not randomized, the giving of methylprednisolone may depend on factors such as the severity of injury. For example, several studies have shown that doctors are more likely to give methylprednisolone to people with complete spinal cord injury and less likely to give the drug to people with incomplete spinal cord injury. Given the large difference of recovery between those with complete and incomplete spinal cord injury, even a slight bias in giving methylprednisolone to more severely injured patients may give the impression that methylprednisolone has no beneficial effect on spinal cord injury.

    So, we simply don't have reliable clinical trial data for methylprednisolone effects on gunshot wounds. So, the decision to give the steroids is generally left up to the doctors. It is an "option" for treatment. In the 1990's, hundreds of people that had gunshot wounds received methylprednisolone. For example, at Bellevue Hospital in New York, where I worked, we routinely gave methylprednisolone to people with gunshot wounds, even of the gut. If you gave covering antibiotics, which doctors should doing anyway, we did not see any major complications. Unfortunately, many doctors have interpreted absence of randomized clinical trial data as being indicative of no treatment efficacy. Thus, many hospitals recommend against giving of methylprednisolone to people with gunshot wounds.

    On the other hand, high-dose methylprednisolone has long been used for multi-trauma victims and patients with severe respiratory distress syndrome in patients with trauma and surgical complications (Koontz, et al. 2006), despite fears that such treatment may increase infections and reduce wound healing (Goforth & Gudas, 1980). Dentists often use methylprednisolone to treat the sequelae of molar surgery (Esen, et al., 1999; Hyrkas, et al., 1994). Many surgeons use high-dose methylprednisolone to treat patients undergoing surgery (Sauerland, et al., 2000). I am particularly influenced by the work of Jan Svennevig (1987), a leading trauma surgeon in Norway who used high-dose 24-hour methylprednisolone to treat patients with severe closed chest injuries, a condition that is often associated with high mortality rates. He showed that methylprednisolone reduced mortality from 23.3% to 11.3% even though the injury severity score were higher in patients treated with methylprednisolone.

    Wise.

    References
    1. Heary RF, Vaccaro AR, Mesa JJ, Northrup BE, Albert TJ, Balderston RA and Cotler JM (1997). Steroids and gunshot wounds to the spine. Neurosurgery 41: 576-83; discussion 583-4. OBJECTIVE: The second National Acute Spinal Cord Injury Study demonstrated that there were neurological benefits from "spinal cord injury" doses of methylprednisolone for blunt spinal cord injuries. In this review, we examined the relative risk/benefit ratio of intravenously treating spinal gunshot wound victims with steroids. METHODS: A retrospective review was conducted of 254 consecutive patients who were treated between 1979 and 1994 for gunshot wounds to the spine (C1-L1) and a spinal cord injury. Three subgroups were established based on the administration of the steroids methylprednisolone (National Acute Spinal Cord Injury Study 2 protocol), dexamethasone (initial dose, 10-100 mg), and no steroids. All patients who received steroids were initially treated at another hospital and then transferred. No patients received steroids at our institution. The data analyzed included neurological outcome and infectious and noninfectious complications. RESULTS: No statistically significant neurological benefits were demonstrable from the use of steroids (methylprednisolone, dexamethasone). Infectious complications were increased in both groups receiving steroids (not statistically significant). Gastrointestinal complications were significantly increased in the dexamethasone group (P = 0.021), and pancreatitis was significantly increased in the methylprednisolone group (P = 0.040). The mean duration of follow-up was 56.3 months. CONCLUSION: In this retrospective, nonrandomized review, no neurological benefits were detectable from intravenously administered steroids after a gunshot wound to the spine. Both infectious and noninfectious complication rates were higher in the groups receiving steroids. Patients who sustain a spinal cord injury secondary to a gunshot wound to the spine should not be treated with steroids until the efficacy of such treatment is proven in a controlled study. Division of Neurological Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, USA. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=9310974
    2. Gerndt SJ, Rodriguez JL, Pawlik JW, Taheri PA, Wahl WL, Micheals AJ and Papadopoulos SM (1997). Consequences of high-dose steroid therapy for acute spinal cord injury. J Trauma 42: 279-84. OBJECTIVE: High-dose Solu-Medrol (Upjohn, Kalamazoo, Mich) therapy has become standard care in the management of acute spinal cord injury (ASCI). This study attempts to define the adverse effects that Solu-Medrol therapy has on these patients. DESIGN: Retrospective review with historical control. MATERIALS AND METHODS: From May 1990 to April 1994, all patients with ASCI admitted within 8 hours of injury received high-dose Solu-Medrol per the National Acute Spinal Injury Study (NASCIS-2) protocol. Their demographic and outcome parameters were compared with those of a group admitted from March 1986 to December 1993 with an associated ASCI who received no steroid therapy. MEASUREMENTS AND MAIN RESULTS: Steroid therapy was associated with a 2.6-fold increase in the incidence of pneumonia and an increase in ventilated and intensive care days. However, it was associated with a decrease in duration of rehabilitation and had no significant impact on other outcome parameters, including mortality. CONCLUSIONS: Although the NASCIS-2 protocol may promote early infectious complications, it has no adverse impact on long-term outcome in patients with ASCIs. Division of Trauma, Burn, and Emergency Surgery, University of Michigan, Ann Arbor, USA. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=9042882
    3. Levy ML, Gans W, Wijesinghe HS, SooHoo WE, Adkins RH and Stillerman CB (1996). Use of methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis. Neurosurgery 39: 1141-8; discussion 1148-9. OBJECTIVE: Since the results of the Second National Acute Spinal Cord Injury Study were published in 1990, methylprednisolone has become a mainstay in the treatment of nonpenetrating spinal cord injury. Although potential significant relationships between the prompt administration of high-dose methylprednisolone after blunt spinal cord injury and outcome have recently been addressed, the relationship between the prompt administration of high-dose methylprednisolone after penetrating spinal cord injury and outcome remain unanswered. METHODS: To explore this relationship, we performed a retrospective nonrandomized study on a series of 252 patients with penetrating missile injuries to the spine who presented to our institution from March 1980 to July 1993. One hundred eighty-one patients (71%) were treated conventionally without adjunctive steroid therapy before 1990. Sixteen patients followed up during the 13-year study period received steroid protocols that were not consistent with the Second National Acute Spinal Cord Injury Study protocol and were excluded from the study. Since 1990, 55 patients (21%) were treated with intravenous methylprednisolone according to the Second National Acute Spinal Cord Injury Study protocol. All patients were subsequently transferred for rehabilitative care, and prospective evaluations of their neurological status were performed at admission and discharge. RESULTS: The study included 236 men and 16 women (mean age, 25.6 yr). The mean duration of stay for initial hospitalization was 94.6 days, and the mean duration of stay in rehabilitation was 78.6 days. Frankel scores were used to assess outcome (P < 0.05) and were assessed at admission and at the time of definitive discharge from the Spinal Cord Injury Care System. The hypothesis that methylprednisolone therapy significantly improves functional outcomes in patients with gunshot wound injuries to the spine was rejected. Only the total number of days in rehabilitation and the degree of neurological injury at admission contributed significantly to explaining outcome at discharge. CONCLUSION: The administration of methylprednisolone did not significantly improve functional outcomes in patients with gunshot wound injuries to the spine or increase the number of complications experienced by patients during their hospitalizations. Department of Neurological Surgery, University of Southern California School of Medicine, Los Angeles, USA. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=8938768
    4. Heary RF, Vaccaro AR, Mesa JJ, Northrup BE, Albert TJ, Balderston RA and Cotler JM (1997). Steroids and gunshot wounds to the spine. Neurosurgery 41: 576-83; discussion 583-4. OBJECTIVE: The second National Acute Spinal Cord Injury Study demonstrated that there were neurological benefits from "spinal cord injury" doses of methylprednisolone for blunt spinal cord injuries. In this review, we examined the relative risk/benefit ratio of intravenously treating spinal gunshot wound victims with steroids. METHODS: A retrospective review was conducted of 254 consecutive patients who were treated between 1979 and 1994 for gunshot wounds to the spine (C1-L1) and a spinal cord injury. Three subgroups were established based on the administration of the steroids methylprednisolone (National Acute Spinal Cord Injury Study 2 protocol), dexamethasone (initial dose, 10-100 mg), and no steroids. All patients who received steroids were initially treated at another hospital and then transferred. No patients received steroids at our institution. The data analyzed included neurological outcome and infectious and noninfectious complications. RESULTS: No statistically significant neurological benefits were demonstrable from the use of steroids (methylprednisolone, dexamethasone). Infectious complications were increased in both groups receiving steroids (not statistically significant). Gastrointestinal complications were significantly increased in the dexamethasone group (P = 0.021), and pancreatitis was significantly increased in the methylprednisolone group (P = 0.040). The mean duration of follow-up was 56.3 months. CONCLUSION: In this retrospective, nonrandomized review, no neurological benefits were detectable from intravenously administered steroids after a gunshot wound to the spine. Both infectious and noninfectious complication rates were higher in the groups receiving steroids. Patients who sustain a spinal cord injury secondary to a gunshot wound to the spine should not be treated with steroids until the efficacy of such treatment is proven in a controlled study. Division of Neurological Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, USA. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=9310974
    5. Levy ML, Gans W, Wijesinghe HS, SooHoo WE, Adkins RH and Stillerman CB (1996). Use of methylprednisolone as an adjunct in the management of patients with penetrating spinal cord injury: outcome analysis. Neurosurgery 39: 1141-8; discussion 1148-9. OBJECTIVE: Since the results of the Second National Acute Spinal Cord Injury Study were published in 1990, methylprednisolone has become a mainstay in the treatment of nonpenetrating spinal cord injury. Although potential significant relationships between the prompt administration of high-dose methylprednisolone after blunt spinal cord injury and outcome have recently been addressed, the relationship between the prompt administration of high-dose methylprednisolone after penetrating spinal cord injury and outcome remain unanswered. METHODS: To explore this relationship, we performed a retrospective nonrandomized study on a series of 252 patients with penetrating missile injuries to the spine who presented to our institution from March 1980 to July 1993. One hundred eighty-one patients (71%) were treated conventionally without adjunctive steroid therapy before 1990. Sixteen patients followed up during the 13-year study period received steroid protocols that were not consistent with the Second National Acute Spinal Cord Injury Study protocol and were excluded from the study. Since 1990, 55 patients (21%) were treated with intravenous methylprednisolone according to the Second National Acute Spinal Cord Injury Study protocol. All patients were subsequently transferred for rehabilitative care, and prospective evaluations of their neurological status were performed at admission and discharge. RESULTS: The study included 236 men and 16 women (mean age, 25.6 yr). The mean duration of stay for initial hospitalization was 94.6 days, and the mean duration of stay in rehabilitation was 78.6 days. Frankel scores were used to assess outcome (P < 0.05) and were assessed at admission and at the time of definitive discharge from the Spinal Cord Injury Care System. The hypothesis that methylprednisolone therapy significantly improves functional outcomes in patients with gunshot wound injuries to the spine was rejected. Only the total number of days in rehabilitation and the degree of neurological injury at admission contributed significantly to explaining outcome at discharge. CONCLUSION: The administration of methylprednisolone did not significantly improve functional outcomes in patients with gunshot wound injuries to the spine or increase the number of complications experienced by patients during their hospitalizations. Department of Neurological Surgery, University of Southern California School of Medicine, Los Angeles, USA. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=8938768
    6. Goforth P and Gudas CJ (1980). Effects of steroids on wound healing: a review of the literature. J Foot Surg 19: 22-8. Since some podiatric surgeons are using glucocorticosteroids to minimize postoperative edema and pain associated with traumatic procedures, the effects on wound healing should be understood as much as possible so that maximum results can be achieved with minimal risk to the patient. Considerable animal and human research has been done on the potential wound-healing effects of glucocorticosteroids. Current studies indicate a detrimental wound-healing effect with the use of glucocorticosteroids. Increased infection will also be discussed. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=7016965
    7. Esen E, Tasar F and Akhan O (1999). Determination of the anti-inflammatory effects of methylprednisolone on the sequelae of third molar surgery. J Oral Maxillofac Surg 57: 1201-6; discussion 1206-8. PURPOSE: The anti-inflammatory effect and adrenal suppressive side effect of methylprednisolone sodium succinate (MP) on the postoperative sequelae of third molar surgery were evaluated using objective methods in a double-blind, crossover study. PATIENTS AND METHODS: Twenty patients who were to undergo surgical removal of bilateral, symmetrically placed lower third molars were studied. Each patient was given 125 mg MP intravenously before surgery on one side, and a placebo before surgery on the opposite side on a random basis. Ultrasonographic and computed tomographic examinations were performed to determine the amount of facial edema. Trismus was evaluated by measuring maximal interincisal opening, and pain was evaluated by recording the number of standard analgesic tablets used on the day of surgery and the first postoperative day. Hypothalamic-pituitary-adrenal (HPA) axis function was tested by measuring basal plasma cortisol (hydrocortisone) levels preoperatively and postoperatively. The adrenocorticotropic hormone (ACTH) stimulation test also was performed before and after administration of MP, to evaluate adrenal function. RESULTS: Statistical analysis of the data indicated a significant decrease in edema, trismus, and pain in the MP group. Plasma cortisol levels showed a nonsignificant decrease in both the MP- and placebo-treated groups. The ACTH stimulation test indicated normal HPA axis function before and after MP administration. No clinically apparent infection, disturbance of wound healing, or other corticosteroid-related complications were noted. Eighteen patients (90%) indicated a preference for the overall postoperative course when MP was used. CONCLUSION: In the absence of contraindications for corticosteroid administration, preoperative use of MP appears to be a safe and effective method of reducing postoperative complications in third molar surgery. Department of Oral Surgery, Faculty of Dentistry, University of Cukurova, Adana, Turkey. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=10513866
    8. Hyrkas T (1994). Effect of preoperative single doses of diclofenac and methylprednisolone on wound healing. Scand J Plast Reconstr Surg Hand Surg 28: 275-8. Anti-inflammatory drugs should impair wound healing, which may explain why they have been used to only a limited extent to relieve pain. If they are to have maximal effect they must be started before the operation. In the present study, single doses of the non-steroidal anti-inflammatory agent diclofenac or of diclofenac and the corticosteroid methylprednisolone were given before operation, and the effects on wound healing after operative extraction of third molars were recorded. Patients developed 18 postoperative complications (5%), the most common of which was alveolar osteitis (n = 14), followed by bleeding (n = 3) and infection (n = 1). Pretreatment with diclofenac alone or in combination with methylprednisolone did not result in a notable increase in the incidence of complications as compared to placebo. Department of Oral and Maxillofacial Surgery, University of Helsinki, Finland. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=7899837
    9. Sauerland S, Nagelschmidt M, Mallmann P and Neugebauer EA (2000). Risks and benefits of preoperative high dose methylprednisolone in surgical patients: a systematic review. Drug Saf 23: 449-61. BACKGROUND: A single preoperative high dose of methylprednisolone (15 to 30 mg/kg) has been advocated in surgery, because it may inhibit the surgical stress response and thereby improve postoperative outcome and convalescence. However, these potential clinical benefits must be weighed against possible adverse effects. OBJECTIVE: To conduct a risk-benefit analysis using a meta-analysis, to compare complication rates and clinical advantages associated with the use of high dose methylprednisolone in surgical patients. METHODS: Randomised controlled trials of high dose methylprednisolone in elective and trauma surgery were systematically searched for in various literature databases. Outcome data on adverse effects, postoperative pain and hospital stay were extracted and statistically pooled in fixed-effects meta-analyses. RESULTS: We located 51 studies in elective cardiac and noncardiac surgery, as well as traumatology. Pooled data failed to show any significant increase in complication rates. In patients treated with corticosteroids, nonsignificantly more gastrointestinal bleeding and wound complications were observed; the 95% confidence interval boundaries of the numbers-needed-to-harm were 59 and 38, respectively. The only significant finding was a reduction of pulmonary complications (risk difference -3.5%; 95% confidence interval -1.0 to -6.1), mainly in trauma patients. CONCLUSION: For patients undergoing surgical procedures, a perioperative single-shot administration of high dose methylprednisolone is not associated with a significant increase in the incidence of adverse effects. In patients with multiple fractures, limited evidence suggests promising benefits of glucocorticoids on pulmonary complications. 2nd Department of Surgery, University of Cologne, Germany. S.Sauerland@uni-koeln.de http://www.ncbi.nlm.nih.gov/entrez/q..._uids=11085349
    10. Gerndt SJ, Rodriguez JL, Pawlik JW, Taheri PA, Wahl WL, Micheals AJ and Papadopoulos SM (1997). Consequences of high-dose steroid therapy for acute spinal cord injury. J Trauma 42: 279-84. OBJECTIVE: High-dose Solu-Medrol (Upjohn, Kalamazoo, Mich) therapy has become standard care in the management of acute spinal cord injury (ASCI). This study attempts to define the adverse effects that Solu-Medrol therapy has on these patients. DESIGN: Retrospective review with historical control. MATERIALS AND METHODS: From May 1990 to April 1994, all patients with ASCI admitted within 8 hours of injury received high-dose Solu-Medrol per the National Acute Spinal Injury Study (NASCIS-2) protocol. Their demographic and outcome parameters were compared with those of a group admitted from March 1986 to December 1993 with an associated ASCI who received no steroid therapy. MEASUREMENTS AND MAIN RESULTS: Steroid therapy was associated with a 2.6-fold increase in the incidence of pneumonia and an increase in ventilated and intensive care days. However, it was associated with a decrease in duration of rehabilitation and had no significant impact on other outcome parameters, including mortality. CONCLUSIONS: Although the NASCIS-2 protocol may promote early infectious complications, it has no adverse impact on long-term outcome in patients with ASCIs. Division of Trauma, Burn, and Emergency Surgery, University of Michigan, Ann Arbor, USA. http://www.ncbi.nlm.nih.gov/entrez/q...t_uids=9042882

  4. #4
    Thank you doc for the info. After my accident I didn't really want to know a who lot about my treatment. I figured the less I knew the better. I did not want my hope to be taken away right away.

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