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Retrospective study comparing spinal cord injury (SCI) lesion characteristics in methylprednisolone (MPS) treated versus untreated patients as demonstrated by magnetic resonance (MR) imaging.Determine if the administration of MPS immediately following SCI affects lesion severity.The administration of MPS in the setting of acute SCI has become controversial. Since magnetic resonance imaging (MRI) is sensitive for the detection of spinal cord edema and hemorrhage, changes in lesion characteristics would support a biologic effect due to MPS.Patients with cervical spinal injury treated with the recommended dose of methylprednisolone (bolus 30 mg/kg + 5.4 mg/kg per hour over 24 hours) initiated within 8 hours of injury were compared to historical controls that did not receive steroids. All patients (n = 82) sustained clinically complete SCI (ASIA Grade A) and underwent MRI on the same 1.5 Tesla unit. The length of spinal cord edema, presence/absence of intramedullary hemorrhage, and length of intramedullary hemorrhage were measured on T2-weighted and gradient echo MR images. Comparisons of lesion severity were then made between untreated and treated subjects.Forty-eight of 82 patients with complete injuries received MPS therapy. After accounting for differences in the mean age of the treatment and control groups, multiple regression analysis demonstrated a persistent reduction in the mean length of intramedullary hemorrhage, 2.6 U in the treatment group versus 4.4 U in the control group (P = 0.04). Although there was a reduction in the number of patients exhibiting spinal cord hemorrhage in the treated group compared with the untreated group (65% vs. 91%), this result was not statistically significant (P = 0.16). There was no statistically significant effect of MPS treatment on the mean length of the spinal cord edema between treated versus untreated subjects (10.3 vs. 12.0, respectively,P = 0.85).MRI suggests MPS therapy in the acute phase of spinal cord injury may decrease the extent of intramedullary spinal cord hemorrhage.