High dose methylprednisolone in the management of acute spinal cord injury- a systematic review from a clinical perspective

Study design: Systematic literature review for primary data using predefine d inclusion, exclusion and validity criteria. Primary outcome measure was s tandardised neurological examination or neurological function. Secondary ou tcomes; acute mortality, early morbidity. Objectives: To access the literature available to clinicians systematically and evaluate the evidence for an effect of high dose methylprednisolone (M PSS) on neurological improvement following acute spinal cord injury (ACSI). Methods: Information retrieval was based on Medline search (1966 through De cember 1999) using the strategy 'spinal cord injury' and 'methylprednisolon e' (or 'dexamethasone') with no other restrictions. Primary data publicatio ns using high dose steroids given within 12 h following spinal cord injury and reporting outcome measures separately for steroid and nonsteroid treate d groups were selected. Evaluation followed the guides of Guyatt et al(7) ( for the Evidence Based Working Group in Canada). Studies with questionable validity were excluded. Level of evidence and treatment recommendation util ised the Canadian Task Force on the Periodic Health Examination criteria.(6 ) Experimental spinal cord injury studies on larger animals were included; small mammal experiments were considered beyond evaluation. Results: Three clinical trials and six cohort study publications were found to satisfy the review criteria. The evidence they provide supports 'the re commendation that the manoeuvre (high dose methylpredisolone) be excluded f rom consideration as an intervention for the condition'(10) (acute spinal c ord injury). Twelve larger animal publications were detailed. Validity and the functional significance of results was of concern in many. The weight o f evidence lay with those studies demonstrating no definite effect of MPSS on functional outcome. In cat experiments with higher level cord damage, de aths in the MPSS treated groups were notable. Conclusion: The evidence produced by this systematic review does not suppor t the use of high dose methylprednisolone in acute spinal cord injury to im prove neurological recovery. A deleterious effect on early mortality and mo rbidity cannot be excluded by this evidence.