Today I silenced the room (something I have a proclivity for, usually when pointing out something painfully obvious) full of neuro people in a discussion on steroid use in TBI.
The long and short of the hour long discussion was that there is no evidence showing steroid use significantly decreases ICP or brain edema in TBI.
The current recommendations do not reflect its routine usage in TBI.
However, a rather well respected neuro clinician was defending his practice of using it with the argument that patients relate feeling better when it is used, so by some unknown mechanism not accounted for in the research it must work.
Having picked a neurologist's brain yesterday about CT scanning syncope, I was asked to return the favor, which is how I got involved.
My answer is not really why I am writing, the process behind my answer is.
I was once taught by an orthopaedic traumatologist that the worst and most common mistake nonorthopods make is to look at imaging and only think about what they see.
In xray and CT, the most obvious thing seen is bone. In a head CT, it is bone, brain, and ventricals.
We have a tremendous amount of soft tissue covering the bones of our body. None of it shows up on an x-ray. Very little of it shows up on a head CT.
When you injure your brain, or anything else for that matter from a trauma, you injure soft tissue. (even in a concussion, there is arachnoid, pia, and dura matter involved)
So when you deal with ortho trauma, don't forget about that soft tissue. In a rough estimate, not including blood vessles, there are at least 6 layers of soft tissue between the outside world and your brain. Some very thick layers in front of your central and axial skeletal bones.
When you break any bone you damage soft tissue. Especially when that bone is broken by an external force.
That tissue, even at microcirculation levels, bleeds, and like in any injury there is an inflammatory response. That tissue is no less important than the bone or organ underneath it.
It has been demonstrated that in spinal injury, it is soft tissue swelling that occludes spinal arteries which leads to cord ischemia in the affected regions.
In extremities, it is this inflammatory response and swelling of soft tissue that creates or potentiates compartment syndrome.
In addition to pain, soft tissue injury can be debilitating. It is an error to think a sprain, strain, or tendon rupture is somehow less serious if a bone underneath it is not broken because the force was not great enough.
As you recall, even the force required to break a bone is variable not only on the elasticity of the bone, but also the angle, and surface area.
So, in my expert, professional opinion. If studies show steroids do not reduce ICP or brain edema, why is there clinical improvement in TBI patient symptoms with steroids?
Because it mediates the inflammatory response of all the soft tissue. Including Bradykinin.
See the forest from the trees, when a bone is broken, so is everything else around it to some degree.
Don't forget.
The long and short of the hour long discussion was that there is no evidence showing steroid use significantly decreases ICP or brain edema in TBI.
The current recommendations do not reflect its routine usage in TBI.
However, a rather well respected neuro clinician was defending his practice of using it with the argument that patients relate feeling better when it is used, so by some unknown mechanism not accounted for in the research it must work.
Having picked a neurologist's brain yesterday about CT scanning syncope, I was asked to return the favor, which is how I got involved.
My answer is not really why I am writing, the process behind my answer is.
I was once taught by an orthopaedic traumatologist that the worst and most common mistake nonorthopods make is to look at imaging and only think about what they see.
In xray and CT, the most obvious thing seen is bone. In a head CT, it is bone, brain, and ventricals.
We have a tremendous amount of soft tissue covering the bones of our body. None of it shows up on an x-ray. Very little of it shows up on a head CT.
When you injure your brain, or anything else for that matter from a trauma, you injure soft tissue. (even in a concussion, there is arachnoid, pia, and dura matter involved)
So when you deal with ortho trauma, don't forget about that soft tissue. In a rough estimate, not including blood vessles, there are at least 6 layers of soft tissue between the outside world and your brain. Some very thick layers in front of your central and axial skeletal bones.
When you break any bone you damage soft tissue. Especially when that bone is broken by an external force.
That tissue, even at microcirculation levels, bleeds, and like in any injury there is an inflammatory response. That tissue is no less important than the bone or organ underneath it.
It has been demonstrated that in spinal injury, it is soft tissue swelling that occludes spinal arteries which leads to cord ischemia in the affected regions.
In extremities, it is this inflammatory response and swelling of soft tissue that creates or potentiates compartment syndrome.
In addition to pain, soft tissue injury can be debilitating. It is an error to think a sprain, strain, or tendon rupture is somehow less serious if a bone underneath it is not broken because the force was not great enough.
As you recall, even the force required to break a bone is variable not only on the elasticity of the bone, but also the angle, and surface area.
So, in my expert, professional opinion. If studies show steroids do not reduce ICP or brain edema, why is there clinical improvement in TBI patient symptoms with steroids?
Because it mediates the inflammatory response of all the soft tissue. Including Bradykinin.
See the forest from the trees, when a bone is broken, so is everything else around it to some degree.
Don't forget.
