In Germany, every year about 2000 people with a mean

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1 SPINE Volume 38, Number 11, pp E669 E , Lippincott Williams & Wilkins HEALTH SERVICES RESEARCH Current Practice of Methylprednisolone Administration for Acute Spinal Cord Injury in Germany A National Survey Claudia Druschel, MD, * Klaus-Dieter Schaser, MD, and Jan M. Schwab, MD, PhD * Study Design. Written mail-out survey. Objective. To determine current practice in high-dose methylprednisolone succinate (MPSS) administration for treatment of acute spinal cord injury (SCI) in Germany. Summary of Background Data. Reanalysis of the National Acute Spinal Cord Injury Studies (NASCIS) resulted in criticism of the use of high-dose MPSS for treatment of acute SCI. Subsequently, SCI treatment guidelines were revised leading to a reduction in MPSS use across North America. The impact of these revisions on SCI treatment in Germany is not known. Methods. A questionnaire was sent to all trauma, orthopedic and neurosurgical departments of German university centers, affiliated teaching hospitals, and specialized SCI care centers. Survey included 6 questions about the administration of MPSS after acute SCI. Results. Three hundred seventy-two r espondents completed the survey (response rate: 51% overall, 76% university hospitals, 85% specialized SCI care centers). Overall, 55% of departments that treat SCI prescribe MPSS. Among them, 73% are frequent users administering MPSS to more than 50% of their patients. Ten percent prescribe according to NASCIS I, 43% NASCIS II, 33% NASCIS III, and 13% generic protocols. As justification for MPSS treatment, From the * Clinical and Experimental Spinal Cord Injury Research Laboratory (Neuroparaplegiology) ; Department of Musculoskeletal Surgery; and Department of Neurology and Experimental Neurology, CHARITÉ Campus Mitte and Campus Virchow CHARITÉ - University Medicine Berlin, Germany. Acknowledgment date: September 20, First revision date: November 7, Second revision date: January 17, Third revision date: February 8, The manuscript submitted does not contain information about medical device(s)/drug(s). German Ministry of Science and Education/Berlin - Brandenburg Center for Regenerative Therapies and Wings for Life Spinal Cord Research Foundation (No ) funds were received in support of this work. Relevant financial activities outside the submitted work: board membership, consultancy, grants. Address correspondence and reprint requests to Jan Schwab, MD, PhD, Department of Neurology and Experimental Neurology, Clinical & Experimental Spinal Cord Injury Research (Neuroparaplegiology) or Claudia Druschel, MD, Department of Musculoskeletal Surgery, CHARITÉ - University Medicine Berlin CHARITÉplatz 1, D Berlin; jan.schwab@ charite.de or claudia.druschel@charite.de DOI: /BRS.0b013e31828e4dce effectiveness ranked before common practice and medicolegal reasons. Specialized SCI care centers differ in that (1) MPSS is administered less frequently, (2) NASCIS I doses are not used, and (3) during the past several years, practice patterns are more likely to have shifted away from the treatment of SCI with MPSS. Conclusion. About one-half of the institutions continue to prescribe MPSS in the setting of acute SCI. A need for further education in almost one-fourth of German departments treating acute SCI is demonstrated through responses indicating use of the outdated NASCIS I protocol, a legal need or unchanged MPSS application during the last years. Specialized SCI centers are more likely to change their practice in accordance with evolving literature. Key words: methylprednisolone, NASCIS, spinal cord injury, standard of care. Level of Evidence: 3 Spine 2013 ;38:E669 E677 In Germany, every year about 2000 people with a mean age of 35 years experience a spinal cord injury (SCI). 1, 2 Improved field resuscitation and transportation, intensive care medicine, and surgical and rehabilitative care have all contributed to a highly improved rate of survival. 3 Whereas in % of patients died shortly after SCI from its direct consequences, 4 the current mortality rate rests at 6%. 1 To date, only methylprednisolone succinate (MPSS) succinate, tirilazad mesylate, naloxone, and GM-1 ganglioside have been tested in large phase III randomized controlled trials using neurological function 5 as primary endpoint. In the 1990s, corticosteroids provided an intuitive therapeutic concept because they reduced the secondary spinal cord damage in experimental SCI models. 6 The randomized, placebo-controlled National Acute Spinal Cord Injury Study (NASCIS) II 7 purportedly demonstrated a neuroprotective effect of MPSS and thus led to the transient establishment of the NASCIS protocol as a standard therapy for patients with spinal cord injury. 8 However, doubts were spawned by a critical reappraisal of the NASCIS trials that identified limitations in its study design and statistical value 5 as well as evidence of detrimental adverse effects in the NASCIS III trial In Germany, international critical re-evaluation was incorporated in the Spine E669

2 TABLE 1. Panel of the Questionnaire Content Question In what percentage of acute spinal cord injured patients do you implement a high dose methylprednisolone treatment after National Acute Spinal Cord Injury Studies (NASCIS) scheme? Possible Answers > 50% < 50% None No treatment of acute spinal cord injuries Treatment regimen NASCIS I NASCIS II NASCIS III Generic protocol Medical specialty Trauma surgery Orthopedic surgery Neurosurgery Others Number of patients with acute spinal cord injury treated per year n < 10 n = n > 40 Administration Believe in Legally binding Standard practice in most centers effectiveness (malpractice) Has the application changed in the past 5-10 years with you? Yes No 20, 21 Modified from the study of Hurlbert et al. NASCIS indicates National Acute Spinal Cord Injury Studies. updated multidisciplinary surgical (S3/consensus finding group) Polytrauma Guideline in 2011, 17 where the administration of MPSS was no longer considered as the standard treatment. The second valid guideline derives from the German Society of Neurologists, which in 2008 indicated that MPSS treatment (NASCIS III) may be applied. 18 The recent update of this guideline states however that MPSS is no longer recommended due to a higher risk of side effects. 19 No information is available as to whether the treatment of patients with acute has changed accordingly. In this study, we survey the current status of SCI treating departments with regard to the use of high-dose MPSS in therapy after acute SCI in Germany ( treatment reality ). Our aim was to analyze (1) how the German medical community responded to the evolution and demise of a treatment standard, (2) whether a treatment consensus currently exists, and (3) how current German practice compares with that in North America. MATERIALS AND METHODS A modified, standardized questionnaire was sent to the clinical directors of Trauma, Orthopedic, and Neurological Surgery departments in Germany in January University departments were selected according to the website of the German Association of University Hospitals (VUD, ) and the respective teaching hospitals according to the universities. Furthermore specialized hospitals were included indicated by the website of the German Society of Paraplegia (DMGP, ). The survey was directed to the department directors, responsible for the type of treatment, to detail the use of high-dose MPSS after traumatic SCI representative for their department. It was ensured that multiple answers per department from different physicians were excluded and the institutional practice was stated. To allow for comparability the survey was modeled after prior similar reports. 20, 21 Items 1, 2, 4, and 6 consisted of single-choice answers; items number 3 and 5 allowed for multiple answers ( Table 1 ). Survey requests were directed toward 3 target groups. In order of increasing specialization, the first group consisted of trauma, orthopedic, and neurological surgeons practicing within university-affiliated teaching hospitals located off campus. The second group comprised similar surgeons practicing in university hospitals. Lastly, questionnaires were sent to directors in specialized SCI treatment centers (third group) indicated by the DMGP forming a core group in this study. As an extended core group classical university hospitals (second group) were added to this group. If a teaching hospital was among the DMGP hospitals, responses were allocated to the DMGP group. Besides stratification according to degree of SCI specialization, we also grouped answers of SCI treating departments according to the frequency of SCI care that ranged from sporadic ( < 10 patients/yr) to frequent ( > 40 patients/yr). A reply envelope was sent with each questionnaire to expedite the response procedure. A reminder and second copy of the questionnaire were sent to all nonresponders after a lapse of 4 weeks. The threshold for freedom from bias was assumed to be a 70% response rate according to Fillion. 22 Descriptive statistics were used for the survey analysis. Results were given in absolute and relative percentages. The data were assembled in such a way that single- and multispecifications were considered. To exclude irrelevant answers, only answers from SCI-treating practitioners were considered ( Figure 1 ). A differential analysis with regard to several medical specializations (trauma, orthopedic, neurological surgeons, and others) was conducted. For comparison of proportions, the Fisher exact test was applied with a significance level of P < Statistical testing was performed using PASW Statistics 18 (SPSS Inc, Chicago, IL). E670 May 2013

3 730 questionnaires DMGP: 26 university hospitals: 86 teaching hospitals: non responders (49%) 372 responders (51%) DMGP hospitals: 22 (84.6%) university hospitals: 65 (75.6%) teaching hospitals: 285 (46.1%) 278 SCI treatment (74.7%) DMGP hospitals: 16 (72.7%) university hospitals: 60 (92.3%) teaching hospitals: 202 (70.4%) 94 no SCI treatment (25.3%) 124 no MPSS usage (44.5%) 154 MPSS usage (55.4%) DMGP hospitals: 9 (56.2%) university hospitals: 31 (51.6%) teaching hospitals: 114 (56.4%) change in MPSS application 75 (60.5%) no change in MPSS application 42 (33.8%) DMGP hospitals: 6 (85.7%) 1 (14.3%) university hospitals: 19 (65.5%) 9 (31%) teaching hospitals: 50 (56.8%) 35 (39.7%) MPSS > 50 of patients 113 (73.4%) MPSS < 50 of patients 41 (26.6%) DMGP hospitals: 5 (55.5%) 4 (44.5%) university hospital: 20 (64.5%) 11 (35.5%) teaching hospitals: 88 (74.6%) 26 (22%) NASCIS I 14 (9.7%) NASCIS II 67 (43.4%) NASCIS III 51 (33.1%) generic 21 (13.4%) abstention 1 (0.6%) DMGP hospitals: 0 6 (66.7%) 2 (22.3%) 1 (11%) university hospital: 3 (9.7%) 14 (45.2%) 8 (25.8%) 6 (19.3%) teaching hospitals: 11 (9.7%) 47 (41.3%) 41 (35.4%) 14 (12.3%) 1 (0.9%) believe 55 (35.7%) litigation 17 (11%) practice 45 (29.2%) combination 32 (20.8%) abstention 7 (4.5%) DMGP hospitals: 4 (44.5%) 1 (11.1%) 2 (22.2%) 2 (22.2%) university hospitals 14 (45.2%) 1 (3.2%) 8 (25.8%) 5 (16.1%) 3 (9.7%) teaching hospitals: 37 (32.4%) 15 (13.1%) 35 (30.7%) 25 (21.9%) 4 (3.5%) change in MPSS application 40 (25.3%) no change in MPSS application 114 (74.6%) DMGP hospitals: 5 (55.6%) 4 (44.4%) university hospitals: 9 (29%) 22 (70.9%) teaching hospitals: 26 (22.8%) 88 (77.2%) Figure 1. Methylprednisolone succinate (MPSS) administration by departments in Germany that treat SCI Recruitment algorithm. Respective survey answers are given in numbers and percentages, stratified into specialized SCI care units (DMGP) forming the German Society of Paraplegia, university hospitals, and affiliated teaching hospitals. SCI indicates spinal cord injury; NASCIS, National Acute Spinal Cord Injury Studies; DMGP, German Society of Paraplegia. RESULTS In total, 372 of 730 departments (112 extended core group and 618 teaching hospitals) responded to the questionnaire, signifying a 51% overall response rate ( Figures 1 and 2 ). Within the extended core group of university hospitals und DMGP departments, 78% (n = 87) responded to the questionnaire. Questionnaires were returned by 44% (n = 162) of the orthopedic/trauma departments, 25% (n = 91) of the neurosurgical departments, 19% (n = 70) of departments with multiple medical specialties, and 1% (n = 3) of departments with other specialties. Another 12% (n = 46) did not specify their medical subspecialization. Overall, 25% (n = 94) of the responders did not treat spinal cord injured patients; this group was not considered for further analysis. Spine E671

4 Figure 2. Nationwide character of the study. Distribution of responding institutions spans all German states. The responses are subdivided according to the medical specialties into trauma/orthopedic, neurosurgeons, combination of specialties and other specialties. Of the departments treating patients with spinal cord injuries, 47% (n = 131) defined themselves as orthopedic/trauma surgeons, 32% (n = 88) as neurosurgeons, 0.4% (n = 1) as other specialists, and 21% (n = 57) reported a combination of specialties ( Figure 3 ). Of the 372 respondents, 75% (n = 278) reported treating patients with acute blunt SCI. Among those, 53% (n = 146) reported a mean of fewer than 10 patients treated per year ( sporadic SCI care unit); 42% (n = 115) treated between 10 to 40 injuries per year and only 5% (n = 15) more than 40 per year ( frequent SCI care unit) ( Figure 4 ). Notably, a significant correlation ( P < 0.05) was evident between the level of institutional SCI specialization and the number of patients treated. In the extended core group 79% (n = 60) of treating departments are medium to frequent SCI units, whereas only 35% (n = 70) of departments in teaching hospitals treat more than 10 patients with SCI per year ( P < 0.05). Similarly, only 11% of hospitals treating fewer than 10 patients/ yr ( sporadic SCI units) belonged to the extended core group. Interestingly, the majority (53%) of institutions treating SCI are located in sporadic SCI units, whereas only 5% are located in frequent SCI units ( Figure 4 ). Fifty-five percent (n = 154) of German hospitals that treat SCI still prescribe MPSS ( Figure 1 ). Of those, 74% (n = 113) apply MPSS in more than 50% of patients with SCI and 27% (n = 41) in under 50%. Forty-five percent (n = 124) do not prescribe MPSS at all ( Figures 5, 6 ). A trend toward reduced MPSS administration exists in comparing sporadic ( < 10 patients), middle (10 40 patients), and frequent ( > 40 patients) SCI units. This does not reach statistical significance E672 May 2013

5 HEALTH SERVICES RESEARCH Figure 3. Representation of medical specialties of departments treating SCI patients in Germany. Almost two-thirds of the responders were orthopedic/trauma departments, whereas only one-third designated themselves as neurosurgical departments. According to the German Federal Chamber of Physicians the ratio presented reflects the recent distribution of medical specialists in Germany, with three-quarters fewer neurosurgeons than orthopedic/trauma surgeons. Subdivision according to the DMGP, university and teaching hospitals illustrates a higher proportion of trauma/orthopedic departments in DMGP hospitals. DMGP indicates German Society of Paraplegia; SCI, spinal cord injury. (Figure 5A). Similarly MPSS administration tends to decrease on the basis of the degree of institutional SCI specialization; teaching hospitals prescribe the drug most frequently, university hospitals less frequently, and specialized (DMGP) hospitals least frequently (Figure 5B). There was no evidence of geographical segregation in terms of differences in northsouth or east-west practice patterns (Figure 6). Among institutions administrating MPSS for acute SCI, 10% (n = 14) follow NASCIS I recommendations, 43% (n = 67) follow NASCIS II recommendations, and 33% (n = 51) dose according to NASCIS III (Figure 7). A generic Figure 4. Treating departments in sporadic, medium, and frequent SCI care units. Fifty-three percent (n = 146) of the treating institutions reported treating a mean of fewer than 10 patients per year ( sporadic SCI care unit) that points to a fragmentalized acute SCI care in Germany. DMGP indicates German Society of Paraplegia; SCI, spinal cord injury. Spine Figure 5. (A) MPSS usage in sporadic and frequent SCI care units. MPSS applying departments show a tendency to use MPSS more specifically (<50% of the patients) in frequent SCI care units (>40 patients/yr) than in sporadic SCI care units (<10 patients/yr). Thus, as a trend, MPSS usage is reduced in frequent SCI care units but this does not reach statistical significance. (B) MPSS usage in DMGP, university and teaching hospitals. Specialized DMGP departments show a tendency to use MPSS more specifically than in university or teaching hospitals. DMGP indicates German Society of Paraplegia; SCI, spinal cord injury; MPSS, methylprednisolone succinate. protocol (modified steroid administration not matching any particular NASCIS study) is prescribed by 13% (n = 21) of treating departments (Figure 7). More than two-thirds of specialized SCI institutions dose patients with SCI according to NASCIS II guidelines, whereas fewer than half of patients with SCI receive this protocol in university and teaching hospitals (Figure 7). Conversely NASCIS III guidelines are used proportionately more frequently in non-dmgp institutions. Administration of MPSS according to NASCIS I doses was claimed only in university and teaching hospitals, noticeably absent in specialized DMGP hospitals. Similar trends were evident when comparing sporadic to frequent SCI centers where the highest percentage of departments prescribing NASCIS I were observed in the sporadic group (Figure 7). Approximately one-third (36%, n = 55) of the respondents who prescribe MPSS for SCI cite effectiveness (in promoting neurological recovery) as their main reason. Almost an equal proportion (29%, n = 45) do so because it is the usual practice at their institution or by their colleagues. Only 11% (n = 17) prescribe MPSS in fear of litigation. Twentywww.spinejournal.com E673 BRS indd E673 14/05/13 6:02 AM

6 Figure 6. MPSS succinate application routine of treating departments in Germany. The graphical representation of MPSS usage in the individual German federal states relative to the number of responses according to each federal state does not indicate a north-south or an east-west gradient. The MPSS usage is divided into 50% or more of the patients, less than 50% of the patients, and no application at all. DMGP indicates German Society of Paraplegia; MPSS, methylprednisolone succinate. one percent of respondents indicated a combination of these reasons while 5% (n = 7) abstained from this issue ( Figure 8 ). Only one-quarter (n = 40) of institutions that administer MPSS have modified their routine in the past decade, whereas three-quarters (n = 114) have not altered their prescribing technique ( P < 0.05). Institutions currently not prescribing steroids for SCI were more likely to have converted from MPSS-use to nonuse (60%, n = 75) than they were to have maintained a nonprescribing status (34%, n = 42). Departments in specialized SCI units converted more frequently to being non-mpss users (56%) than did departments in university (29%) or teaching hospitals (23%). In summary, although specialized SCI units house fewer treating physicians they care for more patients with acute SCI and administer MPSS less frequently compared with university and teaching hospitals. However, the majority of departments treating SCI in Germany still use MPSS primarily because they think it is effective in treating the neurological injury. An almost equally large group does so because it is their routine. Specialized DMGP hospitals are more likely to have stopped prescribing steroids within the past 10 years, as are the physicians who work in them. DISCUSSION 20, 21 With a structured, formerly published, modified questionnaire the present nationwide survey investigated the practice and role of MPSS in the acute treatment of SCI in Germany. The survey was sent to all medical institutions involved in treatment of acute SCIs including all associated medical disciplines, such as trauma surgery, orthopedic, and neurosurgical departments. The overall response rate was 51%. As the included hospitals are not securely involved in the treatment of patients with E674 May 2013

7 Figure 7. NASCIS protocol subtype in sporadic and frequent SCI care units. Steroid protocols applied by prescribers in the treatment of acute spinal cord injury. Overall, mainly NASCIS II and III regimen are used, but modified personalized protocols, referred to as generic protocols, were prescribed by 13% of the MPSS users. Surprisingly, the outdated NASCIS I protocol is also used in 10%. The inverse correlation of NASCIS I application with hospital specialization and number of treated patients noticeably shows that this is not the case in DMGP hospitals and hospitals treating more than 40 patients per year. It is noteworthy that neither frequent SCI care units nor specialized SCI care units (DMGP) apply NASCIS I protocols. Departments that frequently administer MPSS (50% or more), use NASCI II more frequently than those that rarely apply than 50% MPSS. NASCIS indicates National Acute Spinal Cord Injury Studies; DMGP, German Society of Paraplegia; SCI, spinal cord injury; MPSS, methylprednisolone succinate; Generic, MPSS application not matching NASCIS I-III. SCI, the target population may be overestimated and thus the response rate is underestimated. However, the response rate from university hospitals (76%) and specialized SCI care units (85%) where the majority of patients with SCI receive their care reached or exceeded the 70% benchmark. 22 This argues against bias due to inadequate sample size. 23 In addition, the geographical distribution of responding institutions fairly covered the whole of Germany without excluding any particular area/state ( Figure 2 ). Our observed response rate Figure 8. Underlying reason for MPSS application. In Germany, approximately one-third (36%, n = 55) of these responders stated the belief in the effectiveness as the main cause for using MPSS. The second most common motivation (29%, n = 45) was the usual practice also of other colleagues. 11% (n = 17) prescribe methylprednisolone out of fear of litigation. Twenty-one percent (n = 32) chose a combination of the response options, whereas 5% (n = 7) abstained from this issue. MPSS indicates methylprednisolone succinate. also corresponds to similar studies where 66% 21 23, 24 to 75% of questionnaires were returned. Almost two-thirds of our responders were surgeons representing orthopedic/trauma departments; only one-third declared themselves as surgeons representing neurosurgical departments. This proportion matches the ratio of medical specialists in Germany, where the number of neurological surgeons is three-quarters lower than the number of orthopedic/trauma surgeons. 25 This is an interesting contrast compared with the study of Hurlbert and Moulton 21 which reports a higher proportion of neurological surgeons treating acute SCI in Canada than orthopedic/ trauma surgeons. In Germany, the majority of departments that treat acute SCI (52%) are units that see fewer than 10 injured patients per year. By contrast, only 5% are specialized SCI units that are more likely to treat 40 or more patients per year. This suggests that acute SCI care is currently fragmented throughout the country, perhaps in an undesirable way considering evidence that supports early treatment of these patients in specialized SCI centers. 26 Such specialization has been linked to a reduction in (1) hospitalization time; (2) overall mortality, and (3) the number and severity of complications. Other studies estimated that in the early to mid-2000s MPSS was prescribed for acute SCI by 75% 23 to 95% 27 of trauma centers, dropping to 68% 24 and 32% 28 by Working with a different retrospective study design focusing on treated patients rather than perceptions of treating departments, a recent single-center Swiss investigation reports a similar dynamic drop from 96% to 23% in MPSS treatment of SCI 8 during a 10-year period. These authors report that Spine E675

8 European specialized SCI care units are already adhering to the newer guidelines. However, our results indicate that withdrawal of MPSS as standard of care has not been fully implemented in Germany nonresolved role of MPSS Instead, our findings suggest that at least a quarter of all departments that treat SCI in Germany need further education about the risks and benefits of MPSS administration. Specifically these are the institutions that prescribe MPSS according to the outdated NASCIS I protocol and those that indicate worries about being sued or because everyone else does. The group of SCI departments that report having made no change in their MPSS application routine in the last 5 to 10 years (24%) represents another cohort that might benefit from exposure to updated literature. Finally, the 36% of steroid prescribers who cite benefit as the reason they give MPSS certainly have less firm ground to stand on in view of recently updated guidelines in Germany 17, 18 and around the world. The washout time of MPSS as a standard of care seems to be prolonged in Germany, especially in sporadic SCI care units. The effect of guidelines in changing physician behavior can be limited. 32 Furthermore, although guidelines require acknowledgement and adherence by treating physicians so that they are actually followed, they should not affect clinicians autonomy. 33 The literature reveals that it takes several years until new scientific evidence is adopted in current practice, even when there is obvious impact in patients morbidity and mortality. 34 Thus, it cannot be predicted when the mentioned new guidelines (S3 multidisciplinary surgical polytrauma guideline and guideline from the German Society of Neurologists) will be fully implemented in current treatment strategies. In this context, this study could be seen as a starting point to follow-up on response rate with a repetition of the survey. The related Canadian analysis that served as a study model uses a similar approach 20 and thus shares the same limitations. The investigated study population SCI treating unit chairmen is not identical to the one investigated by the Hurlbert group individual surgeons and limits a direct comparability of the results. Nevertheless, it reports that only 24% of physicians treating SCI applied MPSS in 2006 compared with 76% in 2001, representing a reduction of more than 50%. In Germany only 25% of responding departments admit to changing their practice pattern in the past 10 years. We acknowledge there are limitations to our research. Due to the design of our study, we cannot exclude false-positive answers with regard to MPSS use, which might be higher in sporadic SCI units. Nevertheless, even false-positive answers underscore the need to change perception about the role of MPSS in SCI. This analysis might spur further discussion and prospective analysis in respective, SCI-treating medical societies. Furthermore, we focused on the most reliable and representative/ authoritative sources, the head of department. Here, we cannot and do not intend to detect diverging treatment perceptions of the chairmen and fellows in their respective SCI treating units. In this study, we cannot fully distinguish between noninformed MPSS use and informed autonomy of the SCI physician. Nonetheless, reasons provided by treating departments point to a high rate of a noninformed MPSS use. Despite the fact that current guidelines have largely abandoned MPSS in the treatment of acute SCI, our nationwide survey suggests that its continued, heterogeneous application is as a result of persisting insecurity within the majority of physicians treating this condition. CONCLUSION In conclusion, this study demonstrates a fragmented SCI care with a remarkable flux of SCI patients referred to nonspecialized centers. This, and the continued frequent administration of MPSS in acute SCI may result in an increase in overall mortality as well as number and severity of complications. Together, this leads to a need for further communication/ education concerning the treatment guidelines in spinal cord injured patients. Key Points The majority of German SCI treating departments see less than 10 injured patients per year, suggesting that acute SCI care is currently fragmented throughout the country. Unexpectedly, the majority of German SCI treating departments persistently applies MPSS, mostly based on the belief of in its effectiveness to ameliorate neurological injury. This survey indicates that withdrawal of MPSS as standard of care has not been fully implemented and that further education about the risks and benefits of MPSS administration is necessary. Acknowledgments The authors thank Dr. Niedeggen (Ukb Berlin), Dr. Kopp and Prof. Dr. Dirnagl (Experimental Neurology) for critically reading the manuscript, and Jörg Bongartz for help with graphics. Klaus-Dieter Schaser, MD, and Jan M. Schwab, MD, PhD, contributed equally as senior authors. The Department of Clinical and Experimental Spinal Cord Injury Research, Department of Experimental Neurology, CHARITÉ, is an associated member of the European Multi- Center Study on Spinal Cord Injury (EMSCI, org ). References 1. Thietje R, Kowald B, Hirschfeld S. What are the causes of death in patients with spinal cord injury today? a descriptive analysis of 102 cases. Rehabilitation (Stuttg) 2011 ; 50 : Schwab JM, Brechtel K, Mueller CA, et al. Experimentelle Therapiestrategien akuter Rückenmarkverletzung eine integrative Perspektive. Deutsches Aerzteblatt, 2004 ; 101 : A Ducker TB. Treatment of spinal-cord injury. N Engl J Med 1990 ; 322 : E676 May 2013

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