急性頸椎頸髄損傷 : ガイドラインから(<特集>神経外傷治療の最新動向) Management of Acute Cervical Spine and Spinal Cord Injury using Clinical Guidelines(<SPECIAL ISSUE>Current Trends of the Treatment of Neurotrauma)

急性頸椎頸髄損傷の臨床ガイドラインが,米国および日本でも出版された.しかし,脊椎脊髄損傷の治療に関してエビデンスレベルの高い臨床研究はきわめて少なく,明確な指標を示すというよりは,治療optionの提示となっている.本論文では,わが国における頸椎頸髄損傷の実際と治療の問題点に関して,ガイドラインの記載を基にエビデンスのレビューを行った.日本では,高齢者での骨損傷のない頸髄損傷は,北米に比べて高い頻度でみられるが,この病態に対する治療方針は,いまだ標準化されていない.また,ガイドラインは,メチルプレドニゾロンの大量療法に関しては,注意深い使用を促している.これは,根拠となったランダム化臨床試験での分析方法に問題があることや,ステロイドによる合併症のためである.急性脊椎脊髄損傷に対して現在行われている治療手段の有効性を判断し,さらに明確なガイドラインを作成していくためには,今後もエビデンスの積み重ねが必要と考える.

Clinical guidelines for the management of acute cervical spine and spinal cord injuries were published in the USA and also in Japan. However, because of the paucity of clinical studies with a high evidence level in the field of spinal cord injury, most of the descriptions are options of treatment rather than definite guidelines. In this paper, we reviewed evidences regarding clinical features and problems in the management of acute cervical spine and spinal cord injuries in our country from the perspective of these guidelines. In Japan, acute cervical cord injury without fracture or dislocation of the cervical spine in the elderly population is more common than in North America. However, management of this clinical entity including the role of surgical decompression has not been standardized. Intravenous administration of large-dose methylprednisolone has been commonly utilized for acute spinal cord injury. Both guidelines recommend the careful use of methylprednisolone in spite of results of randomized clinical trials, since there were inconsistent results from other studies, analysis flaws of the randomized trials and statistically significant complications associated with steroids. Further accumulation of clinical evidence will be needed to clarify the effectiveness of the known treatment modalities and bring about the development of definitire guidelines for acute spine and spinal cord injury.