What is the recommended dose of methylprednisolone (corticosteroid) in cases of hanging with potential spinal cord injury?

Methylprednisolone Dosing in Hanging with Potential Spinal Cord Injury

Methylprednisolone is no longer routinely recommended for acute spinal cord injury due to limited benefits and significant risks of complications. 1

Current Guidelines on Methylprednisolone Use

The use of high-dose methylprednisolone for acute spinal cord injury has become controversial over time, with recent guidelines moving away from its routine administration:

• The Congress of Neurological Surgeons (CNS) guidelines state there is "insufficient evidence to make a recommendation" for methylprednisolone use in thoracolumbar spine trauma with spinal cord injury 2
• Current Canadian and French clinical guidelines recommend against routine use of steroids in acute spinal cord injury 1
• The complication profile should be carefully considered when deciding on methylprednisolone administration 2

Historical Protocol (No Longer Standard of Care)

If methylprednisolone is considered in specific cases, the historical NASCIS protocol that was previously used included:

• Initial bolus: 30 mg/kg IV administered over 15 minutes 3, 4
• Maintenance infusion: 5.4 mg/kg/hour for 23 hours 3, 4
• If treatment is initiated between 3-8 hours after injury, some evidence suggested extending the maintenance infusion to 48 hours 4

Important Considerations

Timing

• The NASCIS studies only showed modest benefit when methylprednisolone was administered within 8 hours of injury 1, 5
• Administration beyond 8 hours after injury is not justified 6

Risks and Complications

• Significant risks include:
  • Increased infectious complications 1, 4
  • Psychosis and gastric ulcers 1
  • Higher rates of wound infections 2
  • Cardiac arrhythmias with rapid administration 3

Administration Precautions

• If administered, methylprednisolone should be given over at least 30 minutes to avoid cardiac arrhythmias 3
• Bradycardia has been reported during or after administration of large doses 3

Current Alternative Management Priorities

Instead of methylprednisolone, current management should focus on:

1. Early transfer to specialized spinal cord injury units 1
2. Hemodynamic management (maintaining mean arterial pressure > 70 mmHg) 1
3. Early imaging diagnosis including MRI in cases of post-traumatic neurological deficit 1

Conclusion

The historical high-dose methylprednisolone protocol (30 mg/kg IV bolus followed by 5.4 mg/kg/hour infusion) is no longer considered standard of care for acute spinal cord injury. Current evidence suggests focusing on specialized care, hemodynamic stability, and early diagnosis rather than routine methylprednisolone administration.