Methylprednisolone for acute spinal cord injury: an increasingly philosophical debate

Following publication of NASCIS II, methylprednisolone sodium succinate (MPSS) was hailed as a breakthrough for patients with acute spinal cord injury (SCI). MPSS use for SCI has since become very controversial and it is our opinion that additional evidence is unlikely to break the stalemate amongst clinicians. Patient opinion has the potential to break this stalemate and we review our recent findings which reported that spinal cord injured patients informed of the risks and benefits of MPSS reported a preference for MPSS administration. We discuss the implications of the current MPSS debate on translational research and seek to address some misconceptions which have evolved. As science has failed to resolve the MPSS debate we argue that the debate is an increasingly philosophical one. We question whether SCI might be viewed as a serious condition like cancer where serious side effects of therapeutics are tolerated even when benefits may be small. We also draw attention to the similarity between the side effects of MPSS and isotretinoin which is prescribed for the cosmetic disorder acne vulgaris. Ultimately we question how patient autonomy should be weighed in the context of current SCI guidelines and MPSS′s status as a historical standard of care

Patients with Spinal Cord Injuries Favor Administration of Methylprednisolone.

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

Using chronic recordings from a closed‐loop neurostimulation system to capture seizures across multiple thalamic nuclei

Abstract We report the case of a patient with unilateral diffuse frontotemporal epilepsy in whom we implanted a responsive neurostimulation system with leads spanning the anterior and centromedian nucleus of the thalamus. During chronic recording, ictal activity in the centromedian nucleus consistently preceded the anterior nucleus, implying a temporally organized seizure network involving the thalamus. With stimulation, the patient had resolution of focal impaired awareness seizures and secondarily generalized seizures. This report describes chronic recordings of seizure activity from multiple thalamic nuclei within a hemisphere and demonstrates the potential efficacy of closed‐loop neurostimulation of multiple thalamic nuclei to control seizures

Chronic SCI Patients Favor Administration of Methylprednisolone for Acute SCI.

<p>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 (<b>A</b>), (<b>B</b>), (<b>C</b>), (<b>D</b>) and (<b>E</b>) were 69, 68, 74, 69 and 44 respectively. MPSS = methylprednisolone sodium succinate, SCI = spinal cord injury.</p

A Hype Cycle of Methylprednisolone for Acute Spinal Cord Injury.

<p>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.</p

Improved Surgical Safety via Intraoperative Navigation for Transnasal Transsphenoidal Resection of Pituitary Adenomas

Objectives Intraoperative navigation during neurosurgery can aid in the detection of critical structures and target lesions. The safety and efficacy of intraoperative, stereotactic computed tomography (CT) in the transnasal transsphenoidal resection of pituitary adenomas were explored. Design Retrospective chart review Setting Tertiary care hospital Participants Patients who underwent transsphenoidal resection of pituitary adenomas from February 2002 to May 2017. Intraoperative stereotactic CT navigation was used for all patients after mid-October 2013. Main Outcome Measures Operative time, estimated blood loss, gross total resection rate. Results Of 634 patients included, 175 underwent surgery with intraoperative navigation and 444 had no intraoperative navigation during surgery. There was no difference in mean age, sex, tumor type, or tumor size between the two groups. Operative time, endoscope use, cerebrospinal fluid diversion, and estimated blood loss were also similar. Two patients showed intraoperative, iatrogenic misdirection in the absence of stereotactic CT navigation ( p = 0.99) but similar numbers of patients having navigated and non-navigated surgery returned to the operating room, underwent gross total resection, and showed endocrinological normalization. Conclusions These results suggest that intraoperative navigation can reduce injury without resulting in increased operative time, estimated blood loss, or reduction in gross total resection

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

<p>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.</p