The new recommendation, one of 112 evidence-based recommendations, was recently issued by the American Congress of Neurological Surgeons (CNS) and the American Association of Neurological Surgeons (AANS) regarding the first clear indication that steroids are not recommended early after an acute spinal cord injury. Daniel K. Resnick, professor of neurosurgery at the University of Wisconsin-Madison School of Medicine and Public Health, president of the Association of Neurological Surgeons, said previous recommendations on steroid hormone use said they could be used as long as physicians recognized that the odds of damage from their use outweighed the benefits of their use. we now have to go back to the raw data and fundamentally correct some of the practices that were incorrect in the past.” These recommendations, including the latest research as well as previous studies, are published in the March supplement of the journal Neurosurgery. Introduction to the new guidelines The guidelines are an updated version of the original guidelines, which were published in 2002 with only 76 recommendations. The new version of the guideline has 19 Class I recommendations, each supported by Class I evidence. There are also 16 Level II recommendations based on Class II evidence and 77 Level III recommendations based on Class III evidence. However, due to a lack of evidence, the new guidelines do not include information on the use of hypothermia or other treatments for spinal cord injury (SCI) patients with this type of injury. Unlike the old guidelines, the recommendation in the chapter on “Pharmacologic Treatment of Acute Spinal Cord Injury” is that methylprednisolone (MP) should not be used within the first 24 to 48 hours of acute spinal cord injury. The standard was revised because of the lack of clinical medical evidence supporting the benefit of these drugs. In fact, the report also includes conclusive evidence indicating harmful adverse effects from high doses of steroids. Studies have shown that steroid use in this population leads to higher rates of infection, higher rates of sepsis, longer stays in the intensive care unit, and increased complications, sometimes resulting in death. This new recommendation appears to provide clear direction for neurosurgeons. It will provide an immediate and beneficial impact on patient care, said Dr. Langston Holly of the University of California, Los Angeles Medical Center. The 2012 edition of the guidelines clearly states that methylprednisolone is not recommended in acute spinal cord injury, and there is no Level I or Level II evidence to support its use,” he said. In stark contrast, there is Level I to Level III evidence that this treatment has harmful side effects.” Another significant change in the guidelines relates to vertebral artery injury. dr. Resnick said the new guidelines recommend imaging screening for most patients with significant spinal cord injury, which was not recommended in the old guidelines. In addition, the new guidelines include additional recommendations regarding assessment of functional prognosis, assessment of pain after spinal cord injury, imaging assessment, diagnosis of atlanto-occipital dislocation, and assessment of pediatric spinal cord injury. The new guidelines also include an easy-to-use summary table that explains the differences between the older and newer versions of the guidelines. Readers can see at a glance if the guidelines have changed and which parts of the guidelines are being presented for the first time. Dr. Resnick says, “For surgeons who have a lot of information coming in all the time, the kind of table that succinctly explains what new things are most useful is most appropriate.” As mentioned earlier, there are still some issues left unclear in the new version of the guidelines because of the lack of clear evidence in the medical literature. For example, the guidelines do not address the use of hypothermia or the timing of surgery after an acute traumatic cervical medullary injury. There are also no guidelines regarding the use of electrophysiological monitoring during surgery for spinal cord injury. says Dr. Resnick, “Because the literature on trauma is so sparse. there may be 100 traumas in 1,000 patients, so trying to figure out how to interpret data on trauma patients is very difficult.”