Current Guidelines for Corticosteroid Use in Spinal Cord Injury
Methylprednisolone is not recommended as standard treatment for acute spinal cord injury based on current evidence, and the complication profile—particularly increased infectious complications—should be carefully considered if administration is contemplated. 1, 2, 3
Evidence Quality and Guideline Recommendations
The Congress of Neurological Surgeons provides a Grade Insufficient recommendation for methylprednisolone in thoracolumbar spine trauma with spinal cord injury, explicitly stating that the complication profile must be carefully weighed. 1 This represents a significant downgrade from previous recommendations.
The American Association of Neurological Surgeons has downgraded methylprednisolone from Class I to Class III evidence due to methodological flaws in the NASCIS trials. 1, 2, 3 The primary outcome measures in NASCIS II and NASCIS III were all negative—any positive results came from post hoc analysis rather than pre-planned endpoints, which fundamentally changes the evidence classification. 1
French guidelines for spinal cord injury management explicitly state that steroids are not recommended after post-traumatic spinal cord injury to improve neurological prognosis (Grade 1 recommendation with strong agreement). 3
Key Problems with the NASCIS Evidence
The NASCIS trials contained significant scientific irregularities that undermine their conclusions: 1, 2
NASCIS I compared two steroid doses and found no neurological difference between groups, but documented a 3-times higher rate of wound infection in the high-dose group. 1
NASCIS II showed only modest motor score improvement 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). 3
NASCIS III compared 24-hour versus 48-hour administration and found no better motor improvement in the 48-hour group but higher rates of infectious complications. 3
Documented Harms Without Clear Benefits
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. 2, 3 This real-world data contradicts the limited post hoc findings from NASCIS.
High-dose methylprednisolone (30 mg/kg) has shown detrimental effects in patients with traumatic brain injury (increased mortality) and patients with spinal cord injury (increased risk of infection). 1
Current Management Algorithm for Acute Spinal Cord Injury
Instead of administering steroids, focus on:
Maintain adequate spinal cord perfusion pressure with mean arterial pressure >70 mmHg. 2, 3
Arrange prompt transfer to a specialized spinal cord injury center to avoid delays that place patients outside therapeutic windows for effective interventions. 2, 3
Consider early MRI to guide surgical management when feasible without delaying treatment. 2, 3
Prioritize early surgical decompression within 24 hours when indicated, which has been associated with superior neurological recovery. 2
Critical Pitfalls to Avoid
Do not administer high-dose steroids based on outdated protocols that are no longer supported by current evidence. 3 The focus of acute spinal cord injury management has shifted toward maintaining adequate spinal cord perfusion pressure and prompt surgical decompression when indicated. 2, 3
If methylprednisolone is administered despite current evidence (perhaps due to institutional protocols or medicolegal concerns), recognize that treatment initiated more than 8 hours after injury may actually be harmful. 4 The time-dependent nature means any potential benefit (which remains unproven in properly analyzed trials) exists only in the immediate post-injury window. 1, 5
The complication profile includes increased rates of sepsis, severe pneumonia, wound infections, and urinary tract infections without demonstrated functional neurological benefit. 1, 3, 5