What is the role of methylprednisolone (corticosteroid) in the treatment of suspected spinal cord injury due to hanging?

Methylprednisolone in Hanging-Related Spinal Cord Injury

Methylprednisolone is not recommended for routine use in suspected spinal cord injury due to hanging because of limited benefits and significant risks of complications. 1

Current Evidence and Recommendations

The use of methylprednisolone (MP) in spinal cord injury (SCI) has evolved significantly over time:

• The 2019 Congress of Neurological Surgeons (CNS) guidelines state there is "insufficient evidence to make a recommendation" for MP use in traumatic SCI 1
• The original NASCIS (National Acute Spinal Cord Injury Study) trials, which initially promoted MP use, have been downgraded from Class I to Class III evidence due to methodological flaws 2, 1
• The FDA does not approve methylprednisolone for SCI treatment 1

Historical Context

The promotion of methylprednisolone for SCI began with the NASCIS trials:

• NASCIS II (1990) initially reported improved motor function when MP was administered within 8 hours of injury 3
• However, detailed examination revealed significant scientific irregularities in both NASCIS II and III studies 2
• The reported motor improvements in NASCIS II were oddly reported from only the right half of the body, using only a small cohort of 17 MP and 22 control patients from a total population of 487 patients 2
• Positive results reported in the 48-hour MP treatment group were lost at 1-year follow-up 2

Risks Associated with Methylprednisolone Use

MP 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 1
• Higher rates of sepsis with 48-hour regimens 1
• Potential for psychosis and gastric ulcers 1
• Possible development of acute corticosteroid myopathy (ACM) 4

A 2005 study found that muscle biopsies from SCI patients who received 24 hours of MP showed muscle damage consistent with ACM in four out of five cases, while patients who had SCI but did not receive MP had normal muscle biopsies 4.

Current Management Recommendations

Instead of methylprednisolone, current guidelines emphasize:

1. Rapid transfer to specialized spinal cord injury units to reduce long-term morbidity and mortality 1

2. Hemodynamic management:

   • Maintaining mean arterial pressure (MAP) > 70 mmHg
   • This correlates with better neurological outcomes at 6 months 1

3. Early imaging diagnosis:

   • MRI of the spine in cases of post-traumatic neurological deficit that cannot be explained by CT findings 1

Important Considerations for Hanging-Related SCI

Hanging-related SCI presents unique challenges:

• Often involves cervical spine injuries
• May be complicated by hypoxic brain injury
• Can involve multiple trauma if the hanging was from a height

Pitfalls to Avoid

• Do not administer methylprednisolone based solely on the historical NASCIS protocols, as these have been scientifically questioned 2, 1
• Do not delay transfer to a specialized SCI center while initiating steroid therapy
• Do not overlook hemodynamic management, which is more critical than steroid administration
• Do not assume any benefit of MP beyond the 8-hour window, as this is not supported by evidence 1

In summary, focus on rapid transfer to specialized care, hemodynamic stability, and early diagnosis rather than methylprednisolone administration for suspected spinal cord injury due to hanging.