Methylprednisolone is the Corticosteroid Used for Acute Spinal Cord Injury
High-dose methylprednisolone is the only corticosteroid shown to have efficacy in acute spinal cord injury when administered within 8 hours of injury, though its use is controversial and no longer routinely recommended in current guidelines. 1, 2, 3
Evidence for Methylprednisolone in Spinal Cord Injury
Dosing Protocol
When methylprednisolone is used for spinal cord injury, the established protocol is:
- Initial bolus: 30 mg/kg IV administered over 15 minutes
- Followed by: 5.4 mg/kg/hour as a continuous infusion for 23 hours 4, 2
- If treatment begins between 3-8 hours after injury, extending the infusion to 48 hours may provide additional benefit 2, 3
Clinical Trial Evidence
The National Acute Spinal Cord Injury Studies (NASCIS) provided the primary evidence for methylprednisolone use:
- NASCIS II showed modest improvement in motor scores at 6 months when administered within 8 hours of injury 2
- NASCIS III suggested extending treatment to 48 hours if started between 3-8 hours after injury 3
- Japanese trials replicated these findings, while a French trial did not 2
Current Guideline Recommendations
Despite historical use, current guidelines have moved away from routine methylprednisolone administration:
- The 2020 French clinical guidelines strongly recommend against routine use of steroids in acute spinal cord injury 1
- The Canadian guidelines state there is insufficient evidence to support high-dose methylprednisolone as a treatment standard or guideline, considering it only a "treatment option" with weak clinical evidence 5
Risks and Complications
The potential benefits of methylprednisolone must be weighed against significant risks:
- Increased risk of infectious complications, including pulmonary and urinary infections 1
- Higher rates of complications with 48-hour regimens compared to 24-hour regimens 3
- Potential for serious adverse effects including psychosis and gastric ulcers 6
Alternative Management Approaches
Current guidelines emphasize other aspects of spinal cord injury management:
- Transfer to specialized spinal cord injury units 1
- Hemodynamic management maintaining mean arterial pressure > 70 mmHg 1
- Early imaging diagnosis with MRI for unexplained neurological deficits 1
Important Distinction
It's crucial to distinguish between traumatic spinal cord injury and spinal cord compression from other causes:
- Dexamethasone is the preferred corticosteroid for malignant spinal cord compression 6, 1
- Methylprednisolone is specifically studied for traumatic spinal cord injury 2, 3
Conclusion
While methylprednisolone is the only corticosteroid with demonstrated efficacy in clinical trials for acute spinal cord injury, its routine use is no longer recommended by current guidelines due to limited benefit and significant risks of complications. Management should focus on specialized care, hemodynamic stability, and early diagnosis.