Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Cochrane and a Significantly Biased Review of Steroids for acute spinal cord injury


An interesting relic of trauma care is the use of steroids for the treatment of acute spinal cord injury. As with The Golden Hour, there are people still promoting this idea. In the words of Monty Python, it’s not quite dead, yet.

Who is promoting this idea? The Cochrane Collaboration.

Here is a list of the papers evaluated in this 2012 update of the 2009 Cochrane Review, which was an update of the 2002 Cochrane Review. There has been no change in the references, since the most recent paper reviewed is from 2000.


1. Bracken MB, Aldrich EF, Herr DL et al. Clinical measurement, statistical analysis and risk benefit: controversies from trials of spinal injury. J Trauma 2000; 48:558-61.

2. Bracken MB. Methylprednisolone and spinal cord injury. J Neurosurg Spine 2000; 93:175-8.

3. Bracken MB, Shepard MJ, Collins WF et al. A randomized controlled trial of methylprednisolone or naloxone in the treatment of acute spinal cord injury: results of the second national acute spinal cord injury study. New Engl J Med 1990; 322:1405-11.

4. Bracken MB, Shepard MJ, Holford TR et al. Methylprednisolone administered for 24 or 48 hours, or 48 hour tirilazad mesylate, in the treatment of acute spinal cord injury; results of the third national acute spinal cord injury randomized controlled trial. JAMA 1997; 277:1597-1604.

5. Hall ED. The neuroprotective pharmacology of methylprednisolone. J Neurosurg 1992; 76:13-22.

6. Oudega M, Vargas CA, Weber AB et al. Long-term effects of methylprednisolone following transection of adult rat spinal cord. Eur J Neurosci 1999; 11:2453-64.

7. Banik NL, Matzelle D, Terry E et al. A new mechanism of methylprednisolone and other corticoids action demonstrated in vitro: inhibition of a proteinase (calpain) prevents myelin and cytoskeletal protein degradation. Brain Res 1997; 748:205-10.

8. Xu J, Fan G, Chen S et al. Methylprednisolone inhibition of TNF-alpha expression and NF-KB activation after spinal cord injury.[1]

Highlighting is mine.

Who wrote this Cochrane Review, and the previous Cochrane Review, and the Cochrane Review before that?

I’ll give you three guesses. Looking at the names of the authors of the papers, maybe I should give you four guesses, because the author has written four of the eight papers he is reviewing.

Does Michael Bracken lacks objectivity?

Dr. Bracken evaluated all of the studies for risk of bias. He only found four studies, out of the eight, that he considered in his Author’s judgement to have a Low risk for bias in every category.

Can you guess which papers Dr. Bracken judged to to be at the least risk for bias?

Dr. Michael Bracken considers Dr. Michael Bracken to be at low risk of bias. Who could be more objective in reviewing Dr. Michael Bracken’s papers?

It was a little before my time, but this does suggest the dispute between Gottfried Leibnitz and Isaac Newton over who invented calculus. That disagreement was settled by the objective people at the Royal Society in favor of Newton. A pure coincidence, and completely irrelevant, is that the Royal Society’s opinion was written anonymously by somebody named Isaac Newton.[2]

Dr. Michael Bracken may not have been compared to Isaac Newton before, but it is one of Newton’s flaws that is relevant, not Newton’s genius.

Was Newton objective? No. Is this what we remember Isaac Newton for? No. Dr. Bracken may not be remembered for anything else.

Image credit.


[1] Steroids for acute spinal cord injury.
Bracken MB.
Cochrane Database Syst Rev. 2012 Jan 18;1:CD001046.
PMID: 22258943 [PubMed – in process]

Free Full Text Download in PDF format of the 2009 version is available here

Leibniz–Newton calculus controversy

Bracken MB (2012). Steroids for acute spinal cord injury. Cochrane database of systematic reviews (Online), 1 PMID: 22258943