What is the role of methylprednisolone (corticosteroid) in the treatment of acute spinal cord injury?

Methylprednisolone in Acute Spinal Cord Injury: Not Recommended as Standard Treatment

Methylprednisolone should not be used as standard treatment for acute spinal cord injury due to insufficient evidence of benefit, significant methodological flaws in supporting studies, and a concerning complication profile that includes increased infection rates and mortality risk. 1, 2, 3

Current Guideline Recommendations

The Congress of Neurological Surgeons provides a Grade Insufficient recommendation for methylprednisolone in both thoracolumbar and cervical spinal cord injuries, explicitly stating that the complication profile must be carefully considered before any decision to administer this medication. 1

• The American Association of Neurological Surgeons/Congress of Neurological Surgeons downgraded methylprednisolone from Class I to Class III evidence due to fundamental flaws in the NASCIS II and NASCIS III trials. 1
• All primary (pre-planned) outcome measures in both NASCIS II and NASCIS III were negative—any reported benefits came only from post-hoc analysis, which constitutes Class III evidence regardless of the randomized trial design. 1
• Methylprednisolone is listed only as a "treatment option" with weak clinical evidence, not as a standard or guideline for treatment. 4

Critical Problems with the NASCIS Studies

The foundational studies supporting methylprednisolone contain remarkable scientific irregularities that invalidate their conclusions:

• NASCIS II reported motor improvements from only 39 patients (17 methylprednisolone, 22 control) out of 487 total patients, and oddly only from the right half of the body. 1
• Motor improvements were reported as "change scores" rather than clinically meaningful absolute measures of motor function. 1
• NASCIS III showed positive results in the 48-hour treatment group that were completely lost at 1-year follow-up, indicating no sustained benefit. 1
• No subsequent study has replicated these findings with Class I or Class II evidence. 1

Documented Harms and Complications

The risks of methylprednisolone administration are well-established and clinically significant:

• Three times higher rate of wound infections in high-dose methylprednisolone groups. 1
• Increased infectious pulmonary and urinary complications without beneficial effects on one-year motor function. 3
• Higher mortality rates associated with methylprednisolone treatment. 1
• Propensity score analyses consistently demonstrate more complications in steroid-treated patients. 3

What Should Be Done Instead

Focus on proven interventions that actually improve outcomes:

• Maintain mean arterial pressure ≥70 mmHg continuously for the first 7 days using arterial catheter monitoring, as hypotension (systolic BP <110 mmHg) is associated with increased mortality. 2
• Arrange immediate transfer to a specialized spinal cord injury center—delays result in patients arriving outside the therapeutic window for effective interventions. 2, 3
• Perform early surgical decompression within 24 hours when indicated, as this has been associated with superior neurological recovery. 2, 3
• Avoid hypotension aggressively, as this is a modifiable factor with clear impact on outcomes. 2

If Methylprednisolone Is Still Being Considered

If, despite the evidence, methylprednisolone is being considered (perhaps due to institutional protocols or medicolegal concerns):

• Only consider it if treatment can begin within 8 hours of injury—administration beyond 8 hours is not justified. 5, 6, 7
• Use the NASCIS II protocol: 30 mg/kg bolus over 15 minutes, followed by 5.4 mg/kg/hour infusion for 23 hours. 5, 7, 4
• Do not extend treatment beyond 24 hours—the 48-hour regimen is not justified. 6
• Carefully weigh the documented increased risk of infections, wound complications, and mortality against the questionable and non-sustained neurological benefits. 1, 3

Common Pitfalls to Avoid

• Do not delay transfer to a specialized center while administering methylprednisolone—early intervention with proven therapies (MAP management, surgical decompression) is time-dependent and more important. 2, 3
• Do not use methylprednisolone in pre-hospital settings—there is no justification for high-dose administration by emergency crews at the injury site. 6
• Do not confuse "standard of care" with "evidence-based practice"—methylprednisolone became widely used based on flawed studies and media attention, not robust evidence. 1
• Recognize that 63% of spinal surgery centers report using methylprednisolone primarily due to fear of sanctions, not belief in efficacy. 6