Patients with Spinal Cord Injuries Favor Administration of Methylprednisolone

Abstract

Methylprednisolone sodium succinate (MPSS) for treatment of acute spinal cord injury (SCI) has been associated with both benefits and adverse events. MPSS administration was the standard of care for acute SCI until recently when its use has become controversial. Patients with SCI have had little input in the debate, thus we sought to learn their opinions regarding administration of MPSS. A summary of the published literature to date on MPSS use for acute SCI was created and adjudicated by 28 SCI experts. This summary was then emailed to 384 chronic SCI patients along with a survey that interrogated the patients' neurological deficits, communication with physicians and their views on MPSS administration. 77 out of 384 patients completed the survey. 28 respondents indicated being able to speak early after injury and of these 24 reported arriving at the hospital within 8 hours of injury. One recalled a physician speaking to them about MPSS and one patient reported choosing whether or not to receive MPSS. 59.4% felt that the small neurological benefits associated with MPSS were 'very important' to them (p<0.0001). Patients had 'little concern' for potential side-effects of MPSS (p = 0.001). Only 1.4% felt that MPSS should not be given to SCI patients regardless of degree of injury (p<0.0001). This is the first study to report SCI patients' preferences regarding MPSS treatment for acute SCI. Patients favor the administration of MPSS for acute SCI, however few had input into whether or not it was administered. Conscious patients should be given greater opportunity to decide their treatment. These results also provide some guidance regarding MPSS administration in patients unable to communicate.

Fig 1. Experts Adjudicated the Datasheet Provided to Spinal Cord Injured Patients as Being Neutral, With Minimal Bias and of High Quality.

The authors constructed a datasheet summarizing the literature informing the use of MPSS for SCI. To verify its acceptability prior to distributing to SCI patients we asked twenty eight experts in spinal cord injury to adjudicate the document. The three questions asked of the adjudicators and the frequency of responses is demonstrated above. 27 respondents answered each of the 3 questions. When asked to evaluate whether the information sheet favored (5) or discouraged steroid use (1), the median score was 3 and the mode was 3 (3 = neutral on 5-point Likert scale). Similarly, the median score indicating whether the sheet demonstrated bias was 1 and the mode was 1 (1 = no bias and 5 = extreme bias on a 5-point Likert scale), and the median score for quality of the created survey was 5 and mode was 5 (1 = poor and 5 = excellent on 5-point Likert scale). MPSS = methylprednisolone sodium succinate; SCI = spinal cord injury.

Fig 2. Patients Report Little Input into Decision to Administer Methylprednisolone.

Responses of spinal cord injured patients to survey questions related to MPSS discussion and administration. Data reflects the responses of patients who reported presenting to the hospital within 8h of injury conscious and able to talk to the physicians. In panels (A), (B), and (C) the number of respondents choosing each response is plotted. The sample size for (A), (B), (C), were 24, 24, and 23. MPSS = methylprednisolone sodium succinate.

Fig 3. Chronic SCI Patients Favor Administration of Methylprednisolone for Acute SCI.

Patient responses to survey questions related to MPSS use for acute SCI are shown. Chi-square testing revealed that responses to all questions differed significantly from expected responses in which all possible answers would have been selected with equal frequency. The sample size for (A), (B), (C), (D) and (E) were 69, 68, 74, 69 and 44 respectively. MPSS = methylprednisolone sodium succinate, SCI = spinal cord injury.

Fig 4. A Hype Cycle of Methylprednisolone for Acute Spinal Cord Injury.

The Gartner Hype Cycle describes a common pattern in the adoption of new technologies. Here we propose a Steroid Hype Cycle for Spinal Cord Injury. We contend that the press release of the NASCIS II data in advance of scientific review conforms to a “Peak of Inflated Expectations” while the 2013 Acute Spinal Cord Injury Guidelines are akin to a “Trough of Disillusionment”. This cycle predicts selective administration of methylprednisolone in the future. MPSS = methylprednisolone sodium succinate.