Do you give steroids in cases of cervical cord compression?

Steroid Administration in Cervical Cord Compression

Steroids should not be administered in cases of traumatic cervical cord compression due to lack of proven neurological benefit and significant risk of complications, but they are recommended in malignancy-related spinal cord compression. 1

Traumatic Cervical Cord Compression

Evidence Against Steroid Use

• After traumatic spinal cord injury, steroids are not recommended to improve neurological prognosis (Grade 1 recommendation with strong agreement) 1
• The 2013 guidelines for management of acute cervical spine and spinal cord injuries downgraded methylprednisolone from Class I to Class III evidence due to methodological flaws in previous studies 1
• Multiple randomized controlled trials have failed to show consistent neurological benefit:
  • NASCIS I trial compared two steroid doses with no difference in neurological improvement 1
  • NASCIS II trial showed only modest motor improvement in a subgroup analysis, which was considered post-hoc rather than pre-planned 1
  • NASCIS III trial showed no better motor improvement with 48-hour vs. 24-hour steroid administration 1

Complications of Steroid Use in Traumatic SCI

• Higher rates of infectious complications in steroid-treated patients 1
• A propensity score analysis of a large Canadian cohort found more infectious pulmonary and urinary complications in steroid-treated patients without any beneficial effect on one-year motor function 1

Malignancy-Related Cervical Cord Compression

Recommendation for Steroid Use

• In patients with malignancy-related epidural spinal cord compression (SCC), prompt treatment with high-dose dexamethasone and radiotherapy is recommended (Grade 1B) 1
• If there is significant clinical suspicion of SCC, steroids should be administered prior to radiographic confirmation 1
• Dexamethasone is the most frequently used drug, with doses ranging from moderate (16 mg/day) to high (36-96 mg/day) 1

Evidence Supporting Steroid Use in Malignancy-Related SCC

• A randomized trial demonstrated improved ambulation with administration of high-dose dexamethasone (96 mg/day); 81% of patients in the high-dose dexamethasone treatment arm who were ambulatory before treatment remained ambulatory after treatment, compared with 63% in the control arm 1
• In patients who are paretic or paraplegic before treatment, the addition of dexamethasone appears to improve the probability of regaining the ability to ambulate 1

Cautions and Complications

• High-dose dexamethasone can be associated with significant toxicity (11%) 1
• A retrospective study from the Norwegian Radium Hospital found 29% side effects, 14% serious (including fatal ulcer, rectal bleeding, GI perforation) with high-dose dexamethasone therapy 1
• GI perforation is a serious complication of steroid therapy in neurologic patients, occurring in approximately 2.8% of patients receiving 16 mg/day of dexamethasone for spinal cord compression 2
• Steroid-treated patients with GI perforation have fewer signs and symptoms of peritonitis, making diagnosis more difficult 2

Management Algorithm for Cervical Cord Compression

1. Determine etiology of compression:

   • Traumatic: Do not administer steroids 1
   • Malignancy-related: Administer steroids 1

2. For malignancy-related compression:

   • Administer dexamethasone immediately when clinical suspicion is high 1
   • Standard dose: 16 mg/day, though doses ranging from 8-96 mg/day have been used 1
   • Taper steroids over approximately 2 weeks 1
   • Arrange for prompt radiotherapy and/or surgical consultation 1
   • Implement preventive measures for GI complications (consider gastroprotection) 2
   • Monitor for and prevent constipation, which may help prevent GI perforation 2

3. Imaging:

   • Obtain sagittal T1-weighted MRI with or without gadolinium of the entire spine in patients with suspected cord compression 1

4. Additional treatment considerations:

   • Consider surgery for spinal instability, bony retropulsion, or in patients with paralysis for less than 2 days 1
   • Standard radiotherapy is 30 Gy in 10 fractions, though shorter fractionation schedules may be used in patients with poor performance status 1