What is the role of methylprednisolone (MPS) in the management of traumatic spinal cord injury (SCI) more than 48 hours after injury?

Methylprednisolone in Traumatic Spinal Cord Injury After 48 Hours

Methylprednisolone (MPS) has no role in the management of traumatic spinal cord injury (SCI) when more than 48 hours have passed since the injury, and its administration at this late stage is not recommended due to lack of evidence for benefit and potential for harm. 1

Current Evidence on MPS in SCI

Timing of Administration

• The original NASCIS trials only showed modest potential benefit when MPS was administered within 8 hours of injury 2, 3
• No evidence supports MPS administration beyond the 8-hour window post-injury 1
• When administered after 8 hours, MPS has been associated with worse motor function recovery compared to placebo 4

Evidence Quality and Guidelines

• The Congress of Neurological Surgeons (CNS) has downgraded the evidence for MPS from Class I to Class III, citing methodological flaws in the original NASCIS studies 1
• The 2019 CNS guidelines state there is "insufficient evidence to make a recommendation" for MPS use in thoracolumbar spine trauma with SCI 5
• The US Food and Drug Administration does not approve MPS for SCI treatment 5

Risk-Benefit Analysis

• MPS administration in SCI is associated with significant complications:

  • Higher rates of wound infections (3 times higher in high-dose groups) 1
  • Increased risk of pneumonia 6
  • Higher rates of sepsis and severe pneumonia with 48-hour regimens 2
  • Potential for psychosis and gastric ulcers 1

• Studies have failed to consistently demonstrate neurological improvement:

  • A prospective study found no evidence supporting high-dose MPS for neurologic improvement 6
  • Some studies showed poorer discharge mobility in MPS-treated patients 7

Management Recommendations for SCI Beyond 48 Hours

Since MPS is not indicated beyond 48 hours post-injury, management should focus on:

1. Transfer to specialized care: Patients should be managed in specialized spinal cord injury units to reduce long-term morbidity and mortality 1

2. Hemodynamic management: Maintain mean arterial pressure (MAP) > 70 mmHg, which correlates with better neurological outcomes 1

3. Comprehensive imaging: Obtain MRI of the spine in cases of post-traumatic neurological deficit that cannot be explained by CT findings 1

4. Early rehabilitation: Focus on preventing complications and maximizing functional recovery

Common Pitfalls to Avoid

• Administering MPS based on outdated protocols: The NASCIS protocols have been criticized for methodological flaws, selective reporting, and ad hoc analyses 5
• Assuming any benefit beyond the 8-hour window: Evidence suggests potential harm when MPS is administered after 8 hours 4
• Overlooking the risk-benefit ratio: The modest potential benefits of MPS (even within the 8-hour window) must be weighed against significant risks of complications 1, 6

The routine use of MPS in acute SCI is no longer recommended due to limited benefit and significant risks of complications, particularly when administered beyond the initial 48 hours post-injury.