What is the role of steroids, specifically methylprednisolone, in the management of spinal cord injury?

Role of Steroids in Spinal Cord Injury

Based on current evidence, methylprednisolone is not recommended for routine use in acute spinal cord injury due to insufficient evidence of benefit and significant risk of complications. 1, 2

Current Guideline Recommendations

• The Congress of Neurological Surgeons (CNS) concluded there is insufficient evidence to recommend methylprednisolone in thoracolumbar spine trauma with spinal cord injury, emphasizing that the complication profile should be carefully considered 2
• The American Association of Neurological Surgeons has downgraded methylprednisolone from Class I to Class III evidence due to methodological flaws in previous studies 2
• The French guidelines 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 Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) explicitly recommend against corticosteroid use in major trauma (conditional recommendation, low quality of evidence) 3

Evidence Analysis

Historical Context

• Methylprednisolone became widely used after the NASCIS II trial in 1990, which reported modest improvements in motor scores in patients treated within 8 hours of injury 4
• Subsequent critical examination revealed significant methodological flaws in the NASCIS trials: 2
  • Primary outcome measures were negative in both NASCIS II and III studies 2
  • Positive results were only found in post hoc analyses rather than pre-planned analyses 2
  • Motor improvements in NASCIS II were oddly reported from only the right half of the body 2
  • The positive findings were based on a small subset of patients (17 MP and 22 control patients from a total population of 487) 2

Risk-Benefit Assessment

• Multiple studies have shown higher rates of infectious complications in steroid-treated patients 1, 3
• 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 1
• Meta-analysis data showed similar mortality rates between corticosteroid and placebo groups in trauma patients (26.9% vs 23.4%) 3

Clinical Management Algorithm

1. For patients with acute traumatic spinal cord injury, do not administer methylprednisolone as standard treatment 1, 2
2. Focus instead on:
   • Maintaining adequate spinal cord perfusion (MAP >70 mmHg) 1
   • Early surgical decompression when indicated 1
   • Prompt transfer to a specialized spinal cord injury center 1
   • Consider early MRI to guide surgical management 1

Important Distinctions and Caveats

• While steroids are not recommended for traumatic spinal cord injury, they are indicated in malignancy-related spinal cord compression 5
• For malignancy-related compression, dexamethasone (typically 16 mg/day) should be administered promptly when clinical suspicion is high 5
• The molecular effects of methylprednisolone in SCI suggest it may have greatest effect at 8-12 hours post-injury on immune response, but also has side effects on metabolism and cannot address neurological system processes 6

Common Pitfalls to Avoid

• Administering high-dose steroids in trauma based on outdated protocols that are no longer supported by current evidence 1, 3
• Failing to recognize that while the Cochrane review from 2012 suggested some benefit of methylprednisolone 7, more recent guidelines and analyses have not supported this conclusion 2, 1
• Delaying more effective interventions (such as surgical decompression or blood pressure management) while debating steroid administration 1