What is the dose of methylprednisolone (steroids) in traumatic spinal cord injury?

Methylprednisolone in Traumatic Spinal Cord Injury

Steroids are not recommended for routine use in traumatic spinal cord injury due to insufficient evidence of benefit and significant risk of complications. 1, 2

Current Guideline Recommendations

• The Congress of Neurological Surgeons provides a "Grade Insufficient" recommendation for methylprednisolone in thoracolumbar spine trauma with spinal cord injury, emphasizing that the complication profile should be carefully considered 3
• The American Association of Neurological Surgeons has downgraded methylprednisolone from Class I to Class III evidence due to methodological flaws in previous studies 1
• 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

Historical Context of Methylprednisolone Use

• The NASCIS trials initially suggested benefit but contained scientific irregularities and were ultimately considered negative Class I medical evidence when meticulously examined 2
• NASCIS II protocol involved a bolus of 30 mg/kg IV over 15 minutes, followed by 5.4 mg/kg/hour for 23 hours 4, 5
• NASCIS III suggested that extending infusion to 48 hours might benefit patients treated between 3-8 hours post-injury 5
• Multiple subsequent studies have failed to show consistent neurological benefit from methylprednisolone in traumatic spinal cord injury 1, 6

Risks of Methylprednisolone Administration

• Higher rates of infectious complications have been documented in steroid-treated spinal cord injury patients 1, 2
• Propensity score analyses found more infectious pulmonary and urinary complications in steroid-treated patients without beneficial effects on one-year motor function 1
• Serious adverse effects include severe psychosis, gastric ulcers, gastrointestinal hemorrhage, and perforation 7
• Cardiac arrhythmias and/or cardiac arrest have been reported following rapid administration of large intravenous doses 8

Current Management Recommendations for Traumatic SCI

• Focus on maintaining adequate spinal cord perfusion (MAP >70 mmHg) rather than administering steroids 1, 2
• Arrange for prompt transfer to a specialized spinal cord injury center 1, 2
• Consider early MRI to guide surgical management when feasible without delaying treatment 1
• If surgical decompression is indicated, prioritize early intervention (within 24 hours) which has been associated with superior neurological recovery 2

Important Caveats and Pitfalls

• Avoid administering high-dose steroids in trauma based on outdated protocols that are no longer supported by current evidence 1
• Recognize that the focus of acute spinal cord injury management has shifted toward maintaining adequate spinal cord perfusion pressure and prompt surgical decompression when indicated 1, 2
• Do not confuse recommendations for traumatic SCI with those for malignancy-related spinal cord compression, where dexamethasone is still recommended 7
• The time-dependent nature of interventions in spinal cord injury means that prompt transfer to specialized care is critical 2

Historical Dosing Protocol (No Longer Recommended)

• If a clinician still chooses to use methylprednisolone despite current recommendations against it, the NASCIS II protocol involved: 4, 5
  • Bolus dose: 30 mg/kg IV over 15 minutes
  • Maintenance: 5.4 mg/kg/hour for 23 hours
  • Must be started within 8 hours of injury
• The Canadian guidelines previously stated there was insufficient evidence to support extending methylprednisolone infusion beyond 23 hours 9