A previously fit and well 46 year-old was admitted via the emergency department having sustained a neck injury whilst horse riding. She was unable to move her arms and legs immediately after the fall. On arrival to the Emergency Department, she was alert and orientated. Examination of the cardiovascular and respiratory system was unremarkable although there was evidence of diaphragmatic breathing.
Examination of her neurological system revealed:
•A sensory level at C6
•Absent upper limb reflexes except for brisk bicep reflex bilaterally
•⅖ power in shoulder abductors bilaterally
•Flaccid paralysis of her lower limbs
•No anal tone
She was initially managed in a hard neck collar with full spinal immobilisation. CT brain was reported to be normal. CT neck showed an obviously displaced fracture of C5 and C6 vertebral bodies. She was transferred to the intensive care unit for cardiovascular, respiratory and neurological monitoring while a definitive treatment plan was being considered. After discussions with the orthopaedic surgeons, it was decided not to commence high-dose steroids. This decision was reinforced after discussion with the local neurosurgical and spinal units. It was also decided not to surgically stabilise the c-spine due to the higher risk of respiratory complications. She was transferred to the spinal rehabilitation unit after 2 days.
What is the role of steroids in cervical spine injury?
Adrian Wong
Acute cervical spine injury mostly affects young adults and has a profound impact on their quality of life. It is a devastating injury not just to the individual and their families but also to society. In the UK, an average of 2 adults per week are admitted to spinal units following traumatic spinal cord injury.
Corticosteroids have been used in the treatment of acute spinal cord injury for over three decades. The precise mode of steroid therapy is uncertain but in animal models. high-dose steroids reduce lipid peroxidation, protein degradation and metabolic dysfunction. The reduction in lipid peroxidation reduces the breakdown of cellular membranes and the release of vasoactive substances.
The first large human study was the National Acute Spinal Cord Injury Study (NASCIS) established to evaluate pharmacological therapies in the first hours after injury (1). The NASCIS 2 and subsequent NASCIS 3 trial concluded that patients started on high dose methylprednisolone (30mg/kg bolus followed by 5.4mg/kg/hr infusion) within 3 hours of injury had a better neurological outcome (2-3).
There have been many criticisms of the NASCIS trials (4,5,6). In the NASCIS 2 trial, any potential benefit of methylprednisolone may have been due to weakness in randomisation. In NASCIS 3, poor randomisation led to a higher number of patients with no motor deficit being allocated to the low dose group. When corrected, any benefit of methylprednisolone disappears. Furthermore, only NASCIS 3 made an assessment of functional improvement which was found to be non-significant. Hence neither NASCIS 2 nor 3 demonstrated any meaningful benefit to patients. These trials were also criticised for the high incidence of complications. NASCIS 3 had a 6 fold increase in death from respiratory complications in the treatment group compared to control. Gerndt et al (4) reported that steroid therapy was associated with a 2.6 fold increase in the incidence of pneumonia and increase in ventilated and intensive care days.
A recent meta-analysis carried out under the Cochrane Group of available trials (7) concluded that therapy starting within 8 hours of injury using a protocol similar to the NASCIS trials protocol resulted in sustained neurological recovery. It recommended commencing steroids within 8 hours with a continual infusion for between 24 and 48 hours. However this meta-analysis was heavily influenced by the NASCIS series of trials and acknowledged that whilst methylprednisolone was the only pharmacological therapy studied in large randomised controlled trials, further studies were needed and any neurological recovery did not necessarily translate to any functional recovery for the patient.
A survey of UK emergency departments8 found considerable variation in practice with regards to commencing high-dose steroids in spinal cord injuries. The majority of departments would not start therapy immediately but rather consult a specialist spinal unit. A survey of North American spine surgeons showed that whilst 91% of respondents would commence steroids, only 24% believed that they were of clinical benefit (9).
Lessons learnt
The mainstay of the immediate management of acute spinal cord injury is still airway control with c-spine immobilisation, respiratory and circulatory support. Despite the result of a recent meta-analysis pointing towards improved neurological recovery in patients treated with high-dose steroids, this did not translate to functional improvement to the patient overall. High-dose steroid therapy was also associated with a significant increase in complication rates. Future clinical trials must focus on functional improvement as an outcome measure.
References
ICM Case Summaries 