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Treating Spinal Cord Injuries: Lessons from Neurosurgeons

The Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) has recently updated their guidelines for the treatment of acute cervical spine and spinal cord injuries. Most noteworthy is their recommendation against using certain steroids immediately after spinal cord trauma. This has long been used to treat spinal cord injuries because there was a widespread, though not universal, belief that it reduced the possibility of paralysis in the immediate aftermath of a spinal cord injury. While the guidelines are not binding requirements for surgeons, they are reflective of what the best practices might be and they offer helpful insight to surgeons facing tough choices in matters of life and death. Additionally, these new guidelines have been published in the wake of the meningitis outbreak that started in late 2012. That case and the updating of the guidelines are both relevant to victims of spinal cord injuries, their loved ones and personal injury attorneys who focus on spinal cord injury cases. Steroids loom large in both stories.

Prior to the new guidelines, doctors were encouraged to weigh the risks of using certain steroids. Of course surgeons should always be doing what is best for their patients but the new suggestions may play a role in their decision making after the prestigious body made the first changes to the guidelines since 2002. The amended guidelines are included in a recent edition of the journal Neurosurgery.

In 2002, the authors of the guidelines seemed to differ on whether or not steroids were, generally, a feasible option for back injury patients. Now the evidence is much more obvious that steroids should be discouraged except in rare circumstances or where the surgeon believes the benefits far outweigh the risks. Steroid use for people with spinal cord injuries has been associated with infections and sepsis. For a significant number of patients suffering spinal trauma, longer intensive care unit stays have also been necessary when compared to people with similar injuries who were not given the steroid treatment.

Though perhaps coincidental, these new guidelines arrive on the heels of the latest news on the meningitis outbreak that started in September of 2012. The outbreak was linked to the same steroid and the company that compounded the medicine for particular patient's needs. The company that compounded the contaminated methylprednisolone acetate has since filed for bankruptcy protection. The contaminated steroid treatment has thus far resulted in 51 deaths and has made over 700 more people seriously ill ("As officials investigate, patients fear the future"). Many of the people injected with the steroid suffered as the result of spinal trauma and had chronic back pain. The meningitis issues are related to sterility at the compounding facility in New England that produced it and the CNS and AANS guidelines do not directly reflect on that current case. However, both issues do remind us of the many steps, and the many possibilities for error, in the treatment of a spinal cord injury.

In an emergency, doctors are flooded with choices. Their job is to quickly wade through the flood and make the right decisions. Injury victims rely on their surgeon's training, experience and knowledge of best practices to make the most prudent choices in the vital moments after a trauma. On one hand, the revised guidelines demonstrate the positive truth that medical knowledge is always expanding. But on the other hand, it suggests that some current guideline will inevitably be revised in the future as new information becomes available. For many, the neurosurgeon's credibility is bolstered by their willingness to critique and change their guidelines in light of new information. The pharmaceutical compounding industry may want to follow suit and demonstrate that they have the ability to learn.

Struggling with a severe back injury induces enough anxiety. The safety observed in the facilities where patients' prescriptions are compounded should not further complicate that anxiety. Perhaps it is time for compounding facilities to follow the lead of the CNS and AANS and release guidelines that will affirm to the public that they have learned from the meningitis outbreak. Recent news about compounding facilities is not reassuring, however. New guidelines from the compounding industry will surely only be part of the resolution and lawsuits are pending, congressional hearings are ongoing, and investigators from multiple agencies are probing the facts. A resolution cannot come fast enough for those who suffer with catastrophic injuries or chronic back pain. The resolution should include signs that the compounding industry has learned from their colleagues in the medical field who perform surgery.

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