From the Guidelines
Intravenous steroids should not be administered to improve neurological outcomes in patients with acute spinal cord injury. The use of IV steroids in this context has been extensively studied, and the most recent and highest quality evidence suggests that it does not provide significant neurological benefits 1. The French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury, published in 2020, state that early administration of steroids is not recommended to improve post-traumatic neurological outcomes, with a strong agreement and a GRADE 1 recommendation 1.
The rationale behind this recommendation is based on the results of several randomized controlled trials, including the NACSIS 1, 2, and 3 trials, which investigated the role of methylprednisolone in patients with traumatic spinal cord injury 1. These trials found no significant difference in neurologic improvement between patients treated with steroids and those who were not, and also reported a higher rate of infectious complications in the steroid group. A recent propensity score analysis of a large Canadian cohort also found no beneficial effect of steroids on one-year motor function, and instead reported more infectious pulmonary and urinary complications in patients treated with steroids 1.
Key points to consider in the management of acute spinal cord injury include:
- Early surgical decompression when indicated
- Blood pressure management to maintain adequate spinal cord perfusion
- Specialized rehabilitation
- Careful consideration of potential risks and benefits if steroids are considered in select cases The initial enthusiasm for IV steroids has not been supported by subsequent analysis and real-world experience, and most major spine surgery and neurosurgical societies now recommend against routine administration of high-dose steroids for acute spinal cord injury 1.
From the FDA Drug Label
The desired dose may be administered intravenously over a period of several minutes In general, high dose corticosteroid therapy should be continued only until the patient’s condition has stabilized; usually not beyond 48 to 72 hours When high dose therapy is desired, the recommended dose of methylprednisolone sodium succinate for injection is 30 mg/kg administered intravenously over at least 30 minutes.
The role of intravenous (IV) steroid administration, specifically methylprednisolone, in the management of acute spinal cord injury is to administer high-dose corticosteroid therapy for a limited period, typically not beyond 48 to 72 hours. The recommended dose is 30 mg/kg administered intravenously over at least 30 minutes, which may be repeated every 4 to 6 hours for 48 hours 2.
From the Research
Role of Intravenous (IV) Steroid Administration
The administration of intravenous (IV) steroids, specifically methylprednisolone, plays a significant role in the management of acute spinal cord injury. The key aspects of this treatment are:
- Methylprednisolone sodium succinate has been shown to improve neurologic outcome up to one year post-injury if administered within eight hours of injury 3, 4, 5.
- The recommended dose regimen is a bolus of 30mg/kg administered over 15 minutes, followed by a maintenance infusion of 5.4 mg/kg per hour infused for 23 hours 3, 4, 5.
- Extending the maintenance dose from 24 to 48 hours may provide additional improvement in motor neurologic function and functional status, particularly if treatment cannot be started until between three to eight hours after injury 3, 4, 5.
Efficacy and Safety
The efficacy of high-dose methylprednisolone steroid therapy has been demonstrated in Phase Three randomized trials when administered within eight hours of injury 3, 4, 5. However, there is insufficient evidence to support the use of high-dose methylprednisolone as a treatment standard or guideline for treatment 6. The risk of bias was low in the largest methylprednisolone trials, and there was no evidence of significantly increased complications or mortality from the 23 or 48 hour therapy 3.
Clinical Practice
Despite the availability of guidelines, the use of methylprednisolone in clinical practice may be inconsistent. A retrospective audit found poor documentation of prescription orders and timing of administration, with only a small percentage of patients receiving the steroid regime according to the recommended protocol 7. Therefore, it is essential to ensure that healthcare providers are aware of the recommended treatment guidelines and adhere to them to maximize the potential benefits of IV steroid administration in acute spinal cord injury.