Current Practice of Methylprednisolone Administration For Acute Spinal Cord Injury in Germany

SPINE Volume 38, Number 11, pp E669E677
2013, Lippincott Williams & Wilkins
HEALTH SERVICES RESEARCH
Current Practice of Methylprednisolone

Administration for Acute Spinal
Cord Injury in Germany
A National Survey
Claudia Druschel, MD,* Klaus-Dieter Schaser, MD, and Jan M. Schwab, MD, PhD*
Study Design. Written mail-out survey.

Objective. To determine current practice in high-dose
methylprednisolone succinate (MPSS) administration for treatment
of acute spinal cord injury (SCI) in Germany.
Summary of Background Data. Reanalysis of the National
Acute Spinal Cord Injury Studies (NASCIS) resulted in criticism of
the use of high-dose MPSS for treatment of acute SCI. Subsequently,
SCI treatment guidelines were revised leading to a reduction in
MPSS use across North America. The impact of these revisions on
SCI treatment in Germany is not known.
Methods. A questionnaire was sent to all trauma, orthopedic
and neurosurgical departments of German university centers, affiliated
teaching hospitals, and specialized SCI care centers. Survey included
6 questions about the administration of MPSS after acute SCI.
Results. Three hundred seventy-two respondents completed the
survey (response rate: 51% overall, 76% university hospitals, 85%
specialized SCI care centers). Overall, 55% of departments that
treat SCI prescribe MPSS. Among them, 73% are frequent users
administering MPSS to more than 50% of their patients. Ten percent
prescribe according to NASCIS I, 43% NASCIS II, 33% NASCIS III,
and 13% generic protocols. As justification for MPSS treatment,
From the *Clinical and Experimental Spinal Cord Injury Research Laboratory
(Neuroparaplegiology); Department of Musculoskeletal Surgery; and
Department of Neurology and Experimental Neurology, CHARIT Campus
Mitte and Campus Virchow CHARIT - University Medicine Berlin, Germany.
Acknowledgment date: September 20, 2012. First revision date: November 7,
2012. Second revision date: January 17, 2013. Third revision date: February
8, 2013.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
German Ministry of Science and Education/Berlin - Brandenburg Center for
Regenerative Therapies and Wings for Life Spinal Cord Research Foundation
(No. 60-2012) funds were received in support of this work.
Relevant financial activities outside the submitted work: board membership,
consultancy, grants.
Address correspondence and reprint requests to Jan Schwab, MD, PhD,
Department of Neurology and Experimental Neurology, Clinical &
Experimental Spinal Cord Injury Research (Neuroparaplegiology) or Claudia
Druschel, MD, Department of Musculoskeletal Surgery, CHARIT - University
Medicine Berlin CHARITplatz 1, D-10117 Berlin; E-mail: jan.schwab@
charite.de or claudia.druschel@charite.de
DOI: 10.1097/BRS.0b013e31828e4dce
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effectiveness ranked before common practice and medicolegal

reasons. Specialized SCI care centers differ in that (1) MPSS is
administered less frequently, (2) NASCIS I doses are not used, and
(3) during the past several years, practice patterns are more likely to
have shifted away from the treatment of SCI with MPSS.
Conclusion. About one-half of the institutions continue to prescribe
MPSS in the setting of acute SCI. A need for further education in
almost one-fourth of German departments treating acute SCI is
demonstrated through responses indicating use of the outdated
NASCIS I protocol, a legal need or unchanged MPSS application
during the last years. Specialized SCI centers are more likely to
change their practice in accordance with evolving literature.
Key words: methylprednisolone, NASCIS, spinal cord injury,
standard of care.
Level of Evidence: 3
Spine 2013;38:E669E677
n Germany, every year about 2000 people with a mean

age of 35 years experience a spinal cord injury (SCI).1,2
Improved field resuscitation and transportation, intensive
care medicine, and surgical and rehabilitative care have all
contributed to a highly improved rate of survival.3 Whereas
in 1989 25% of patients died shortly after SCI from its direct
consequences,4 the current mortality rate rests at 6%.1 To date,
only methylprednisolone succinate (MPSS) succinate, tirilazad
mesylate, naloxone, and GM-1 ganglioside have been tested
in large phase III randomized controlled trials using neurological function5 as primary endpoint. In the 1990s, corticosteroids provided an intuitive therapeutic concept because they
reduced the secondary spinal cord damage in experimental
SCI models.6 The randomized, placebo-controlled National
Acute Spinal Cord Injury Study (NASCIS) II 7 purportedly
demonstrated a neuroprotective effect of MPSS and thus
led to the transient establishment of the NASCIS protocol as
a standard therapy for patients with spinal cord injury.8
However, doubts were spawned by a critical reappraisal
of the NASCIS trials that identified limitations in its study
design and statistical value5 as well as evidence of detrimental
adverse effects in the NASCIS III trial.916 In Germany,
international critical re-evaluation was incorporated in the
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Methylprednisolone Admninistration for Acute SCI in Germany Druschel et al
TABLE 1. Panel of the Questionnaire Content

Question
Possible Answers
In what percentage of acute spinal cord injured

patients do you implement a high dose
methylprednisolone treatment after National Acute
Spinal Cord Injury Studies (NASCIS) scheme?
> 50%
< 50%
None
No treatment of
acute spinal cord
injuries
Treatment regimen
NASCIS I
NASCIS II
NASCIS III
Generic protocol
Medical specialty
Trauma surgery
Orthopedic surgery
Neurosurgery
Others
Number of patients with acute spinal cord injury

treated per year
Administration
n < 10
Believe in
effectiveness
Has the application changed in the past 5-10 years

with you?
n = 1040
Legally binding
(malpractice)
Yes
n > 40
Standard practice in most centers
No
Modified from the study of Hurlbert et al.20,21

NASCIS indicates National Acute Spinal Cord Injury Studies.
updated multidisciplinary surgical (S3/consensus finding

group) Polytrauma Guideline in 2011,17 where the administration of MPSS was no longer considered as the standard treatment. The second valid guideline derives from the
German Society of Neurologists, which in 2008 indicated that
MPSS treatment (NASCIS III) may be applied.18 The recent
update of this guideline states however that MPSS is no longer
recommended due to a higher risk of side effects.19 No information is available as to whether the treatment of patients
with acute has changed accordingly.
In this study, we survey the current status of SCI treating departments with regard to the use of high-dose MPSS
in therapy after acute SCI in Germany (treatment reality).
Our aim was to analyze (1) how the German medical community responded to the evolution and demise of a treatment
standard, (2) whether a treatment consensus currently
exists, and (3) how current German practice compares with
that in North America.
MATERIALS AND METHODS

A modified, standardized questionnaire was sent to the clinical directors of Trauma, Orthopedic, and Neurological Surgery departments in Germany in January 2011. University
departments were selected according to the website of the
German Association of University Hospitals (VUD, http://
www.uniklinika.de/) and the respective teaching hospitals
according to the universities. Furthermore specialized hospitals were included indicated by the website of the German
Society of Paraplegia (DMGP, www.dmgp.at).
The survey was directed to the department directors,
responsible for the type of treatment, to detail the use of
high-dose MPSS after traumatic SCI representative for their
department. It was ensured that multiple answers per department from different physicians were excluded and the institutional practice was stated. To allow for comparability the
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survey was modeled after prior similar reports.20,21 Items 1, 2,

4, and 6 consisted of single-choice answers; items number 3
and 5 allowed for multiple answers (Table 1).
Survey requests were directed toward 3 target groups. In
order of increasing specialization, the first group consisted
of trauma, orthopedic, and neurological surgeons practicing
within university-affiliated teaching hospitals located off campus. The second group comprised similar surgeons practicing in university hospitals. Lastly, questionnaires were sent to
directors in specialized SCI treatment centers (third group)
indicated by the DMGP forming a core group in this study.
As an extended core group classical university hospitals
(second group) were added to this group. If a teaching hospital was among the DMGP hospitals, responses were allocated
to the DMGP group.
Besides stratification according to degree of SCI specialization, we also grouped answers of SCI treating departments
according to the frequency of SCI care that ranged from sporadic (<10 patients/yr) to frequent (>40 patients/yr). A
reply envelope was sent with each questionnaire to expedite
the response procedure. A reminder and second copy of the
questionnaire were sent to all nonresponders after a lapse of 4
weeks. The threshold for freedom from bias was assumed to
be a 70% response rate according to Fillion.22
Descriptive statistics were used for the survey analysis.
Results were given in absolute and relative percentages. The
data were assembled in such a way that single- and multispecifications were considered. To exclude irrelevant answers,
only answers from SCI-treating practitioners were considered
(Figure 1). A differential analysis with regard to several medical specializations (trauma, orthopedic, neurological surgeons,
and others) was conducted. For comparison of proportions,
the Fisher exact test was applied with a significance level of
P < 0.05. Statistical testing was performed using PASW Statistics 18 (SPSS Inc, Chicago, IL).
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730 questionnaires
DMGP: 26
university hospitals: 86
teaching hospitals: 618
358 non responders (49%)

372 responders (51%)
DMGP hospitals:
22 (84.6%)
university hospitals: 65 (75.6%)
teaching hospitals: 285 (46.1%)
94 no SCI treatment
(25.3%)
278 SCI treatment

(74.7%)
DMGP hospitals:
16 (72.7%)
124 no MPSS usage (44.5%)

change in MPSS
application
75 (60.5%)
154 MPSS usage (55.4%)

DMGP hospitals:
9 (56.2%)
DMGP hospitals:
university hospitals:
teaching hospitals:
MPSS > 50 of
patients
113 (73.4%)
DMGP hospitals:
university hospital:
teaching hospitals:
DMGP hospitals:
university hospital:
teaching hospitals:
0
3 (9.7%)
11 (9.7%)
4 (44.5%)
11 (35.5%)
26 (22%)
NASCIS III
51 (33.1%)
6 (66.7%)
14 (45.2%)
47 (41.3%)
litigation
17 (11%)
4 (44.5%)
14 (45.2%)
37 (32.4%)
2 (22.3%)
8 (25.8%)
41 (35.4%)
practice
45 (29.2%)
1 (11.1%)
1 (3.2%)
15 (13.1%)
change in MPSS application

40 (25.3%)
DMGP hospitals:
university hospitals:
teaching hospitals:
1 (14.3%)
9 (31%)
35 (39.7%)
MPSS < 50 of
patients
41 (26.6%)
NASCIS II
67 (43.4%)
believe
55 (35.7%)
DMGP hospitals:
university hospitals
teaching hospitals:
6 (85.7%)
19 (65.5%)
50 (56.8%)
5 (55.5%)
20 (64.5%)
88 (74.6%)
NASCIS I
14 (9.7%)
no change in MPSS application

42 (33.8%)
5 (55.6%)
9 (29%)
26 (22.8%)
2 (22.2%)
8 (25.8%)
35 (30.7%)
generic
21 (13.4%)
abstention
1 (0.6%)
1 (11%)
6 (19.3%)
14 (12.3%)
combination
32 (20.8%)
1 (0.9%)
abstention
7 (4.5%)
2 (22.2%)
5 (16.1%)
25 (21.9%)
3 (9.7%)
4 (3.5%)
no change in MPSS application

114 (74.6%)
4 (44.4%)
22 (70.9%)
88 (77.2%)
Figure 1. Methylprednisolone succinate (MPSS) administration by departments in Germany that treat SCIRecruitment algorithm. Respective survey answers are given in numbers and percentages, stratified into specialized SCI care units (DMGP) forming the German Society of Paraplegia,
university hospitals, and affiliated teaching hospitals. SCI indicates spinal cord injury; NASCIS, National Acute Spinal Cord Injury Studies; DMGP,
German Society of Paraplegia.
RESULTS
In total, 372 of 730 departments (112 extended core group
and 618 teaching hospitals) responded to the questionnaire,
signifying a 51% overall response rate (Figures 1 and 2).
Within the extended core group of university hospitals und
DMGP departments, 78% (n = 87) responded to the questionnaire. Questionnaires were returned by 44% (n = 162)
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of the orthopedic/trauma departments, 25% (n = 91) of the

neurosurgical departments, 19% (n = 70) of departments
with multiple medical specialties, and 1% (n = 3) of departments with other specialties. Another 12% (n = 46) did
not specify their medical subspecialization. Overall, 25%
(n = 94) of the responders did not treat spinal cord injured
patients; this group was not considered for further analysis.
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Figure 2. Nationwide character of the study. Distribution of responding institutions spans all German states. The responses are subdivided according to the medical specialties into trauma/orthopedic, neurosurgeons, combination of specialties and other specialties.
Of the departments treating patients with spinal cord injuries, 47% (n = 131) defined themselves as orthopedic/trauma
surgeons, 32% (n = 88) as neurosurgeons, 0.4% (n = 1) as
other specialists, and 21% (n = 57) reported a combination
of specialties (Figure 3).
Of the 372 respondents, 75% (n = 278) reported treating
patients with acute blunt SCI. Among those, 53% (n = 146)
reported a mean of fewer than 10 patients treated per year
(sporadic SCI care unit); 42% (n = 115) treated between
10 to 40 injuries per year and only 5% (n = 15) more than 40
per year (frequent SCI care unit) (Figure 4). Notably, a significant correlation (P < 0.05) was evident between the level
of institutional SCI specialization and the number of patients
treated. In the extended core group 79% (n = 60) of treating departments are medium to frequent SCI units, whereas
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only 35% (n = 70) of departments in teaching hospitals treat

more than 10 patients with SCI per year (P < 0.05). Similarly, only 11% of hospitals treating fewer than 10 patients/
yr (sporadic SCI units) belonged to the extended core
group. Interestingly, the majority (53%) of institutions treating SCI are located in sporadic SCI units, whereas only 5%
are located in frequent SCI units (Figure 4).
Fifty-five percent (n = 154) of German hospitals that treat
SCI still prescribe MPSS (Figure 1). Of those, 74% (n = 113)
apply MPSS in more than 50% of patients with SCI and 27%
(n = 41) in under 50%. Forty-five percent (n = 124) do not
prescribe MPSS at all (Figures 5, 6). A trend toward reduced
MPSS administration exists in comparing sporadic (<10
patients), middle (1040 patients), and frequent (>40
patients) SCI units. This does not reach statistical significance
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Figure 3. Representation of medical specialties of departments treating

SCI patients in Germany. Almost two-thirds of the responders were orthopedic/trauma departments, whereas only one-third designated themselves as neurosurgical departments. According to the German Federal
Chamber of Physicians the ratio presented reflects the recent distribution of medical specialists in Germany, with three-quarters fewer neurosurgeons than orthopedic/trauma surgeons. Subdivision according to
the DMGP, university and teaching hospitals illustrates a higher proportion of trauma/orthopedic departments in DMGP hospitals. DMGP
indicates German Society of Paraplegia; SCI, spinal cord injury.
(Figure 5A). Similarly MPSS administration tends to decrease

on the basis of the degree of institutional SCI specialization; teaching hospitals prescribe the drug most frequently,
university hospitals less frequently, and specialized (DMGP)
hospitals least frequently (Figure 5B). There was no evidence
of geographical segregation in terms of differences in northsouth or east-west practice patterns (Figure 6).
Among institutions administrating MPSS for acute SCI,
10% (n = 14) follow NASCIS I recommendations, 43%
(n = 67) follow NASCIS II recommendations, and 33%
(n = 51) dose according to NASCIS III (Figure 7). A generic
Figure 4. Treating departments in sporadic, medium, and frequent

SCI care units. Fifty-three percent (n = 146) of the treating institutions
reported treating a mean of fewer than 10 patients per year (sporadic SCI care unit) that points to a fragmentalized acute SCI care in
Germany. DMGP indicates German Society of Paraplegia; SCI, spinal
cord injury.
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Figure 5. (A) MPSS usage in sporadic and frequent SCI care units.
MPSS applying departments show a tendency to use MPSS more specifically (<50% of the patients) in frequent SCI care units (>40 patients/yr) than in sporadic SCI care units (<10 patients/yr). Thus, as
a trend, MPSS usage is reduced in frequent SCI care units but this
does not reach statistical significance. (B) MPSS usage in DMGP, university and teaching hospitals. Specialized DMGP departments show a
tendency to use MPSS more specifically than in university or teaching
hospitals. DMGP indicates German Society of Paraplegia; SCI, spinal
cord injury; MPSS, methylprednisolone succinate.
protocol (modified steroid administration not matching any

particular NASCIS study) is prescribed by 13% (n = 21) of
treating departments (Figure 7). More than two-thirds of specialized SCI institutions dose patients with SCI according to
NASCIS II guidelines, whereas fewer than half of patients
with SCI receive this protocol in university and teaching hospitals (Figure 7). Conversely NASCIS III guidelines are used
proportionately more frequently in non-DMGP institutions.
Administration of MPSS according to NASCIS I doses was
claimed only in university and teaching hospitals, noticeably
absent in specialized DMGP hospitals. Similar trends were
evident when comparing sporadic to frequent SCI centers where the highest percentage of departments prescribing
NASCIS I were observed in the sporadic group (Figure 7).
Approximately one-third (36%, n = 55) of the respondents who prescribe MPSS for SCI cite effectiveness (in promoting neurological recovery) as their main reason. Almost
an equal proportion (29%, n = 45) do so because it is the
usual practice at their institution or by their colleagues. Only
11% (n = 17) prescribe MPSS in fear of litigation. Twentywww.spinejournal.com
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Figure 6. MPSS succinate application routine of treating departments in Germany. The graphical representation of MPSS usage in the individual
German federal states relative to the number of responses according to each federal state does not indicate a north-south or an east-west gradient.
The MPSS usage is divided into 50% or more of the patients, less than 50% of the patients, and no application at all. DMGP indicates German
Society of Paraplegia; MPSS, methylprednisolone succinate.
one percent of respondents indicated a combination of these

reasons while 5% (n = 7) abstained from this issue (Figure 8).
Only one-quarter (n = 40) of institutions that administer
MPSS have modified their routine in the past decade, whereas
three-quarters (n = 114) have not altered their prescribing
technique (P < 0.05). Institutions currently not prescribing
steroids for SCI were more likely to have converted from
MPSS-use to nonuse (60%, n = 75) than they were to have
maintained a nonprescribing status (34%, n = 42). Departments in specialized SCI units converted more frequently to
being non-MPSS users (56%) than did departments in university (29%) or teaching hospitals (23%).
In summary, although specialized SCI units house fewer
treating physicians they care for more patients with acute
SCI and administer MPSS less frequently compared with
university and teaching hospitals. However, the majority of
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departments treating SCI in Germany still use MPSS primarily

because they think it is effective in treating the neurological
injury. An almost equally large group does so because it is
their routine. Specialized DMGP hospitals are more likely to
have stopped prescribing steroids within the past 10 years, as
are the physicians who work in them.
DISCUSSION
With a structured, formerly published, modified questionnaire20,21
the present nationwide survey investigated the practice and role
of MPSS in the acute treatment of SCI in Germany. The survey
was sent to all medical institutions involved in treatment of
acute SCIs including all associated medical disciplines, such as
trauma surgery, orthopedic, and neurosurgical departments.
The overall response rate was 51%. As the included hospitals are not securely involved in the treatment of patients with
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Figure 7. NASCIS protocol subtype in sporadic and frequent SCI care units. Steroid protocols applied by prescribers in the treatment of acute
spinal cord injury. Overall, mainly NASCIS II and III regimen are used, but modified personalized protocols, referred to as generic protocols,
were prescribed by 13% of the MPSS users. Surprisingly, the outdated NASCIS I protocol is also used in 10%. The inverse correlation of NASCIS
I application with hospital specialization and number of treated patients noticeably shows that this is not the case in DMGP hospitals and hospitals treating more than 40 patients per year. It is noteworthy that neither frequent SCI care units nor specialized SCI care units (DMGP) apply
NASCIS I protocols. Departments that frequently administer MPSS (50% or more), use NASCI II more frequently than those that rarely apply than
50% MPSS. NASCIS indicates National Acute Spinal Cord Injury Studies; DMGP, German Society of Paraplegia; SCI, spinal cord injury; MPSS,
methylprednisolone succinate; Generic, MPSS application not matching NASCIS I-III.
SCI, the target population may be overestimated and thus

the response rate is underestimated. However, the response
rate from university hospitals (76%) and specialized SCI care
units (85%) where the majority of patients with SCI receive
their care reached or exceeded the 70% benchmark.22 This
argues against bias due to inadequate sample size.23 In addition, the geographical distribution of responding institutions
fairly covered the whole of Germany without excluding any
particular area/state (Figure 2). Our observed response rate
Figure 8. Underlying reason for MPSS application. In Germany, approximately one-third (36%, n = 55) of these responders stated the
belief in the effectiveness as the main cause for using MPSS. The second most common motivation (29%, n = 45) was the usual practice
also of other colleagues. 11% (n = 17) prescribe methylprednisolone
out of fear of litigation. Twenty-one percent (n = 32) chose a combination of the response options, whereas 5% (n = 7) abstained from this
issue. MPSS indicates methylprednisolone succinate.
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also corresponds to similar studies where 66%21 to 75%23,24

of questionnaires were returned. Almost two-thirds of our
responders were surgeons representing orthopedic/trauma
departments; only one-third declared themselves as surgeons
representing neurosurgical departments. This proportion
matches the ratio of medical specialists in Germany, where
the number of neurological surgeons is three-quarters lower
than the number of orthopedic/trauma surgeons.25 This is an
interesting contrast compared with the study of Hurlbert and
Moulton21 which reports a higher proportion of neurological surgeons treating acute SCI in Canada than orthopedic/
trauma surgeons.
In Germany, the majority of departments that treat acute
SCI (52%) are units that see fewer than 10 injured patients
per year. By contrast, only 5% are specialized SCI units that
are more likely to treat 40 or more patients per year. This suggests that acute SCI care is currently fragmented throughout
the country, perhaps in an undesirable way considering evidence that supports early treatment of these patients in specialized SCI centers.26 Such specialization has been linked to
a reduction in (1) hospitalization time; (2) overall mortality,
and (3) the number and severity of complications.
Other studies estimated that in the early to mid-2000s
MPSS was prescribed for acute SCI by 75%23 to 95%27 of
trauma centers, dropping to 68%24 and 32%28 by 2009.
Working with a different retrospective study design focusing
on treated patients rather than perceptions of treating departments, a recent single-center Swiss investigation reports a
similar dynamic drop from 96% to 23% in MPSS treatment
of SCI 8 during a 10-year period. These authors report that
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European specialized SCI care units are already adhering to

the newer guidelines. However, our results indicate that withdrawal of MPSS as standard of care has not been fully implemented in Germany nonresolved role of MPSS
Instead, our findings suggest that at least a quarter of all
departments that treat SCI in Germany need further education about the risks and benefits of MPSS administration.
Specifically these are the institutions that prescribe MPSS
according to the outdated NASCIS I protocol and those that
indicate worries about being sued or because everyone
else does. The group of SCI departments that report having made no change in their MPSS application routine in the
last 5 to 10 years (24%) represents another cohort that might
benefit from exposure to updated literature. Finally, the 36%
of steroid prescribers who cite benefit as the reason they
give MPSS certainly have less firm ground to stand on in view
of recently updated guidelines in Germany17,18 and around the
world.2931
The washout time of MPSS as a standard of care seems
to be prolonged in Germany, especially in sporadic SCI
care units. The effect of guidelines in changing physician
behavior can be limited.32 Furthermore, although guidelines
require acknowledgement and adherence by treating physicians so that they are actually followed, they should not affect
clinicians autonomy.33 The literature reveals that it takes
several years until new scientific evidence is adopted in current practice, even when there is obvious impact in patients
morbidity and mortality.34 Thus, it cannot be predicted when
the mentioned new guidelines (S3 multidisciplinary surgical
polytrauma guideline and guideline from the German Society
of Neurologists) will be fully implemented in current treatment strategies. In this context, this study could be seen as
a starting point to follow-up on response rate with a repetition of the survey. The related Canadian analysis that served
as a study model uses a similar approach20 and thus shares
the same limitations. The investigated study population SCI
treating unit chairmen is not identical to the one investigated by the Hurlbert group individual surgeons and limits
a direct comparability of the results. Nevertheless, it reports
that only 24% of physicians treating SCI applied MPSS in
2006 compared with 76% in 2001, representing a reduction
of more than 50%. In Germany only 25% of responding
departments admit to changing their practice pattern in the
past 10 years.
We acknowledge there are limitations to our research. Due
to the design of our study, we cannot exclude false-positive
answers with regard to MPSS use, which might be higher
in sporadic SCI units. Nevertheless, even false-positive
answers underscore the need to change perception about the
role of MPSS in SCI. This analysis might spur further discussion and prospective analysis in respective, SCI-treating
medical societies. Furthermore, we focused on the most reliable and representative/authoritative sources, the head of
department. Here, we cannot and do not intend to detect
diverging treatment perceptions of the chairmen and fellows
in their respective SCI treating units.
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In this study, we cannot fully distinguish between noninformed MPSS use and informed autonomy of the SCI physician. Nonetheless, reasons provided by treating departments
point to a high rate of a noninformed MPSS use. Despite the
fact that current guidelines have largely abandoned MPSS in
the treatment of acute SCI, our nationwide survey suggests
that its continued, heterogeneous application is as a result of
persisting insecurity within the majority of physicians treating
this condition.
CONCLUSION
In conclusion, this study demonstrates a fragmented SCI
care with a remarkable flux of SCI patients referred to nonspecialized centers. This, and the continued frequent administration of MPSS in acute SCI may result in an increase in
overall mortality as well as number and severity of complications. Together, this leads to a need for further communication/
education concerning the treatment guidelines in spinal cord
injured patients.
Key Points
The majority of German SCI treating departments
see less than 10 injured patients per year, suggesting
that acute SCI care is currently fragmented throughout the country.
Unexpectedly, the majority of German SCI treating departments persistently applies MPSS, mostly
based on the belief of in its eectiveness to ameliorate neurological injury.
This survey indicates that withdrawal of MPSS as
standard of care has not been fully implemented and
that further education about the risks and benefits of
MPSS administration is necessary.
Acknowledgments
The authors thank Dr. Niedeggen (Ukb Berlin), Dr. Kopp
and Prof. Dr. Dirnagl (Experimental Neurology) for critically
reading the manuscript, and Jrg Bongartz for help with
graphics. Klaus-Dieter Schaser, MD, and Jan M. Schwab, MD,
PhD, contributed equally as senior authors.
The Department of Clinical and Experimental Spinal Cord
Injury Research, Department of Experimental Neurology,
CHARIT, is an associated member of the European MultiCenter Study on Spinal Cord Injury (EMSCI, www.emsci.
org).
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Current Practice of Methylprednisolone Administration For Acute Spinal Cord Injury in Germany

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Current Practice of Methylprednisolone Administration For Acute Spinal Cord Injury in Germany

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SPINE Volume 38, Number 11, pp E669E677

2013, Lippincott Williams & Wilkins

HEALTH SERVICES RESEARCH