Personal Health : New Hope for Care of Spinal Injuries

TIMES HEALTH WRITER

As usual this summer, long days and warm weather ideal for recreational pursuits will usher in dozens of serious accidents that result in paralysis.

But the fate of individuals who suffer spinal cord injuries this summer (and throughout the decade) could differ slightly from people paralyzed in the past.

In what is described as a modest but important advance, health professionals in trauma units in Los Angeles and across the country say they are preparing or have begun to use a new drug for some types of spinal cord injuries in an attempt to limit the extent of paralysis.

About 10,000 people become paralyzed each year and the federal government provides more than $4 billion annually to care for the lifelong injured.

While doctors agree that the potential benefits of the drug are small--for example, someone with an injury that usually produces complete paralysis of the arms and legs might recover the use of a hand--the drug is important because it represents the first effective treatment for spinal cord injuries and shatters the belief that medical experts are powerless to intervene between the point of the injury and the onset of paralysis.

"The exciting part is that this is the first positive result for spinal cord injuries that we're seeing," said Dr. Michael D. Walker of the National Institute of Neurological Disorders and Stroke, which funded the recent study showing the drug--a steroid called methylprednisolone--to be effective. The drug is sold under the brand name Solu-Medrol.

"This has opened a series of research questions that need to be addressed," he said. "We want to develop newer, better drugs. Since there was only modest improvement in these patients, that leaves the door open for wanting to do more."

Spokesmen for the 13 Los Angeles-area trauma centers say they are prepared to use methylprednisolone for spinal cord injuries, and some have already used the drug, which must be administered in high doses within eight hours of the injury. But several local physicians reflect skepticism over the perceived benefits of methylprednisolone and say they fear the public will expect miracles from the treatment.

"It is a small step on a extraordinarily long walk," said Dr. Martin Weiss, chief of neurosurgery at the County-USC Medical Center, where a majority of Los Angeles-area spinal cord injuries are initially treated.

"It is important because the difference between quadriplegics who can use their hands or can't use their hands is immense. Their lives will be improved. But these are small, incremental advances," he said.

The announcement of the drug's success created controversy last March when officials at the National Institute of Neurological Disorders and Stroke announced the findings of a study demonstrating methylprednisolone's benefits before the study was published in a medical journal, the traditional manner in which new findings are presented.

At a press conference, study leaders and federal health officials justified the early announcement based on the drug's "immediate effect on a major national public health problem that has been extraordinarily resistant to treatment."

But many neurosurgeons and trauma-center directors said they had questions about the drug and waited for publication of the study in the May 17 New England Journal of Medicine before establishing a policy to use methylprednisolone.

Reluctance to use methylprednisolone has concerned officials at the American Paralysis Assn., which funded some of the preliminary research on the drug.

Margaret Brown, director of research for the APA, said that recent medical meetings, in which the authors of the study have explained the discovery, have cleared up much of the confusion.

"Many physicians and researchers have been trained in a tradition where skepticism about the ability of the central nervous system to be protected from damage after injury has been built into the curriculum," she said. "It's reasonable you would have a conservative stand toward results such as this."

But, she added, the use of methylprednisolone demands that physicians view spinal cord injuries in a new light.

The results of the methylprednisolone study--which involved leading spinal cord injury researchers at 10 institutions--were communicated in terms that many doctors consider vague, Brown said.

The study concluded that patients receiving methylprednisolone showed "significant improvement" in both muscle function and touch sensations over patients not receiving methylprednisolone. For example, the researchers said, a quadriplegic might retain use of a hand while a paraplegic might have enough limb sensation to use crutches to move from a wheelchair to a chair.

"It's a little hard to communicate that except through example," Brown says. "It wasn't translated into functional (statistical) terms."

Experts agree that future studies to test even more promising drugs for spinal cord injury must include a better system to grade the outcome.

"You need to come up with appropriate measures that will make for a stronger set of evidence," she said. "So when we have this natural kind of hesitation by physicians that we have gained something with this drug, we can fight it with better data."

With specifics lacking in the methylprednisolone study, many physicians are taking a wait-and-see attitude.

Dr. Barry Ceverha, a neurosurgeon at Memorial Medical Center of Long Beach, has used high doses of methylprednisolone on five patients but said it's too early to determine whether the patients have benefited.

"This would not be the first time when an exciting possibility has arisen on the medical scene but subsequent studies have shown it to be ineffective," he said. "It is critical to maintain a cautious attitude on methylprednisolone. It's an important study. But I don't know in the long run if it will hold up."

And, said Dr. John C. Johnson, an Indiana physician and president-elect of the College of Emergency Physicians: "Right now there is only one research study to lend credence to its use. That's not enough for everyone to jump on the bandwagon. It worked OK in this study, but what's going to happen when someone has a related but not identical study? Is the data going to come out the same?"

Research is already under way to improve the understanding of how methylprednisolone works, said Walker of the National Institute of Neurological Disorders and Stroke.

In most spinal cord injuries, the cord is not severed but is bruised or crushed. The blood supply to the damaged area is reduced and toxic substances are released, depriving cells of needed nutrients. The nerve cells die and scar tissue forms.

Methylprednisolone appears to inhibit this process by stabilizing the cord so that cells release fewer toxic substances after the injury.

The drug might be hazardous to some people with pre-existing health problems but no serious side effects were associated with patients treated in the study. The treatment is unusual because it is thought to work only if started within eight hours of the injury. It is administered for 24 hours only.

"One would like to know the mechanism of action of extremely high doses of methylprednisolone," Walker said. "We don't understand that well.

"And if you don't treat within eight hours, you don't get a positive result. There is something going on in the spinal cord very early. What is this cascade of biochemical events going on in the first eight hours in which this drug has its impact? A 24-hour treatment is a very short drug treatment, yet it has pretty profound impact on the life of this patient."

Whatever the eventual benefits of methylprednisolone, researchers hope that the drug is stepping stone to better drugs that might reduce paralysis.

"We've had a success which has shown that some of the things we'd like to do in the central nervous system are doable," said Brown of the American Paralysis Assn. "And therefore other things become more feasible."

Tracy Thomas contributed research to this story.

CAUSES OF SPINAL CORD INJURY Motor Vehicle Accidents: 47.7% Falls: 20.8% Acts of Violence: 14.6% Sports: 14.2% Other: 2.7%

Source: National Spinal Cord injury Statistical Center University of Alabama

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