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Three Part Question

[In patients presenting to the emergency department with neck pain following a rear end RTA] are [steroids better than placebo] at [decreasing time off work, relieving pain, incresing mobility]

Clinical Scenario

A 34 year old ED nurse presents to the ED following a minor rear impact RTA. She is complaining of minor neck movement limitation. There are no indications for X-Ray. She has no neurological signs. You grade her as having a Grade II neck sprain as classified by the Quebec classification of whiplash associated disorders (WAD).
She tells you that she has been recruiting for the CRASH head injury trial and wonders if steroids are good for neck injuries as well. You decide to find out.

Search Strategy

In Medline 1966-September 2004.
In Cochrane edition 3 2004.
Medline:
[exp steroids/ or "steroid".mp. or exp adrenal cortex hormones/ or "adrenal cortex hormones".mp. or exp adrenal cortex hormones/ or "corticosteroids".mp. or exp methylprednisolone/ or "methylprednisolone".mp. or exp hydrocortisone/ or "hydrocortisone".mp. or exp dexamethasone/ or "dexamethasone".mp. or exp prednisone/ or "prednisone".mp. or prednisolone.mp. or exp PREDNISOLONE/ or glucocorticoid.mp. or exp GLUCOCORTICOIDS/] AND [exp WHIPLASH INJURIES/ or whiplash.mp. or exp Cervical Vertebrae/ or exp NECK PAIN/ or exp NECK INJURIES/ or exp NECK MUSCLES/] AND [RTA.mp.or exp Accidents, Traffic/ or exp Automobile Driving/ or exp Automobiles/ or car.mp.]
Cochrane
[Neck and steroids]
[Cervical and steroids]

Search Outcome

Medline:
8 papers found of which one was relevant to the three part question.
Cochrane
119 citations found of which one was relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Pettersson, Kurt MD, PhD; Toolanen, Göran MD, PhD 1998 Sweden	40 patients. 22 men, 18 women. All types of car impact included. Grade I and grade IV injuries were excluded.	PRCT. Patients were randomised to either placebo or high dose methylprednisolone (30mg/Kg then 5.4mg/Kg/hour).	Number of patients on sick leave at 6 months	1/20 for steroids vs. 4/20 in the placebo group. p=0.047	The authors report no patients on sick leave at 6 months for steroids. However, one patient was on sick leave for lower back pain. I have included this as a positive in the BET. The p value given is that in the paper (assuming 0/20 for steroids) so may not be accurate. Pilot study. Confounding factors relating to incident or psychological profile not taken into account.
			daily analgesic use at 6 months	0/20 for steoids vs. 4/20 for placebo.
			number of sick days taken	4.7 average for steroids vs. 51.7 for placebo. p=0.0097.

Comment(s)

There is much interest in the use of steroids for spinal cord injury which may be where the idea for this paper came from. The use of such high dose steroids must come with caveats. The long term sequalae and or complications of such therapy have not been discussed in this paper. The lack of consideration of confounding factors makes the data difficult to interpret. In addition the apparent size of the treatment effect seems remarkable. From a personal perspective the group treated with placebo seem to do considerably worse than most of the patients I see in the the UK making me suspicious that they are not reflective of my practice. In addition the need to retain patients in hospital to deliver the steroids would mean a significant change in current practice.

Clinical Bottom Line

There is insufficient evidence to recommend the use of high dose steroids for Grade II or III whiplash injuries.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Pettersson, Kurt MD, PhD; Toolanen, Göran MD, PhD High-Dose Methylprednisolone Prevents Extensive Sick Leave After Whiplash Injury: A Prospective, Randomized, Double-Blind Study Spine 1998; 23(9):984-989