Methylprednisolone in Spinal Cord Injury Due to Hanging
Methylprednisolone is not recommended for routine use in suspected spinal cord injury due to hanging due to insufficient evidence of benefit and significant risk of complications.
Current Evidence on Methylprednisolone in Spinal Cord Injury
The Congress of Neurological Surgeons (CNS) guidelines from 2019 state there is "insufficient evidence to make a recommendation" for methylprednisolone use in thoracolumbar spine trauma with spinal cord injury, emphasizing that the complication profile should be carefully considered when deciding on administration 1.
The routine use of methylprednisolone in acute spinal cord injury is no longer recommended due to:
- Limited evidence of clinical benefit
- Significant risks of complications, including:
- Increased wound infections
- Infectious complications
- Psychosis
- Gastric ulcers 2
Historical Context
The National Acute Spinal Cord Injury Studies (NASCIS) initially provided the primary evidence for methylprednisolone use:
- NASCIS II (1990) showed modest improvement in motor scores at 6 months when administered within 8 hours of injury 3
- NASCIS III (1997) suggested that extending treatment from 24 to 48 hours might provide additional benefit if started 3-8 hours after injury 4
However, subsequent critical analysis revealed significant methodological concerns:
- The NASCIS II and III studies contained scientific irregularities
- There were no significant differences in the primary preplanned comparisons
- The reported motor improvements were from only a small subset of patients
- The positive results reported in the 48-hour treatment group were lost at 1-year follow-up 1
Current Recommendations for Spinal Cord Injury Management
Instead of methylprednisolone administration, current management should focus on:
- Rapid transfer to specialized spinal cord injury units
- Hemodynamic management, including maintaining mean arterial pressure > 70 mmHg
- Early imaging diagnosis, including MRI of the spine in cases of post-traumatic neurological deficit 2
Specific Considerations for Hanging-Related Spinal Cord Injury
While the evidence specifically addressing hanging-related spinal cord injuries is limited, the general principles for traumatic spinal cord injury management apply. The mechanism of injury in hanging (distraction and flexion-extension) may cause different patterns of injury compared to other traumatic mechanisms, but the fundamental approach to neuroprotection remains the same.
Conclusion
Based on the most recent and highest quality evidence, methylprednisolone should not be routinely administered for suspected spinal cord injury due to hanging. The risks of complications outweigh the uncertain benefits, and management should instead focus on specialized care, hemodynamic stability, and early diagnosis.