What is the role of steroids, such as methylprednisolone (methylprednisolone), in the treatment of acute spinal cord injury?

Role of Steroids in Spinal Cord Injury

Steroids are not recommended for the treatment of acute traumatic spinal cord injury due to insufficient evidence of neurological benefit and significant risk of infectious complications. 1

Evidence Against Steroid Use in Traumatic SCI

• Multiple randomized controlled trials have investigated methylprednisolone in traumatic spinal cord injury with inconsistent results and significant methodological concerns 1
• The NASCIS I trial compared two doses of steroids (1g vs 100mg bolus) and found no difference in neurological improvement between groups, but noted higher infectious complications in the low-dose group 1
• The NASCIS II trial showed only modest improvement in motor scores at 6 months in patients treated within 8 hours, without standardized long-term assessment, while reporting more infections in the steroid group (7% vs 3% in placebo) 1
• The NASCIS III trial compared 24-hour vs 48-hour administration of steroids and found no better motor improvement in the 48-hour group but higher rates of infectious complications 1
• A propensity score analysis of a large Canadian cohort demonstrated no beneficial effect of steroids on one-year motor function while finding more infectious pulmonary and urinary complications in steroid-treated patients 1

Current Guideline Recommendations

• The French guidelines for management of spinal cord injury explicitly state that steroids are not recommended after post-traumatic spinal cord injury to improve neurological prognosis (Grade 1 recommendation with strong agreement) 1
• The Congress of Neurological Surgeons concluded there is insufficient evidence to make a recommendation for methylprednisolone use in thoracolumbar spine trauma with spinal cord injury, but emphasized that the complication profile should be carefully considered 1
• The American Association of Neurological Surgeons has downgraded methylprednisolone from Class I to Class III evidence due to methodological flaws in previous studies 1, 2

Historical Context and Controversy

• Despite initial adoption based on the NASCIS trials, subsequent critical analysis has questioned the validity of these conclusions 3
• The Cochrane systematic review suggested methylprednisolone might improve neurologic outcome if administered within eight hours of injury using a specific dosing regimen (bolus 30mg/kg followed by 5.4mg/kg/hour for 23 hours) 4
• However, more recent evidence and guidelines have led to declining confidence in this treatment over the last decade 3, 5
• Some institutions continue using methylprednisolone not because of belief in its efficacy but due to fear of legal ramifications or perceived "non-lege artis" procedure 6

Clinical Decision Algorithm

1. For patients with acute traumatic spinal cord injury:

   • Do not administer steroids as standard treatment 1
   • Focus instead on maintaining adequate spinal cord perfusion (MAP >70 mmHg) 1
   • Arrange for prompt transfer to a specialized spinal cord injury center 1
   • Consider early MRI to guide surgical management when feasible without delaying treatment 1

2. For patients with malignancy-related spinal cord compression (different clinical scenario):

   • Steroids (dexamethasone) are recommended and should be administered promptly 2
   • Standard dose is typically 16mg/day, though higher doses may be considered 2

Important Caveats and Pitfalls

• Avoid administering high-dose steroids in trauma based on outdated protocols that are no longer supported by current evidence 7
• Be aware that while some clinicians still use methylprednisolone within 8 hours of injury, this practice is not supported by current guidelines and carries significant risk of complications 1, 8
• Recognize that the focus of acute spinal cord injury management has shifted toward maintaining adequate spinal cord perfusion pressure (>50 mmHg) and prompt surgical decompression when indicated 1
• Do not confuse recommendations for traumatic spinal cord injury with those for malignancy-related spinal cord compression, which do support steroid use 2