New Neurosurgical Guidelines Warn of Harm from Steroids in Acute Spinal Injury

The Congress of Neurological Surgeons and the American Association of Neurological Surgeons released a revised version of the original 2002 evidence-based guidelines for management of acute cervical spine and spinal cord injuries (http://journals.lww.com/neurosurgery/toc/2013/03002). Of 112 recommendations (the previous version contained 76), 19 are classified as level I recommendations, 16 as level II, and 77 as level III. Due to lack of evidence, the panel offered no recommendations on certain topics of interest such as, for example, the benefit or harm of hypothermia in patients with spinal cord injury.

Changes most relevant to emergency medicine include:

• Methylprednisolone is not recommended for acute spinal cord injury, because no class I or II evidence supports its benefit. Class I, II, and III evidence indicate a higher incidence of infection, sepsis, complications, increased intensive care unit length of stay, and death with steroid use. (Level 1 recommendation)

• Computed tomography is the imaging study of choice for obtunded or un-evaluable patients with potential cervical spine injuries. (Level I)

• Computed tomographic angiography is recommended to assess for vertebral artery injury in selected patients who meet the modified Denver Screening Criteria after blunt cervical trauma. (Level I)

• Spinal immobilization and imaging are not recommended in patients with penetrating or blunt trauma who have normal mentation, no neck pain or tenderness, no focal neurologic findings, and no distracting injuries. (Level II)