Is methylprednisolone (steroid) recommended for traumatic spinal cord injury?

Steroids in Traumatic Spinal Cord Injury

Do not administer methylprednisolone for traumatic spinal cord injury—the evidence does not support neurological benefit and the drug significantly increases infectious complications. 1, 2

Current Guideline Position

• The Congress of Neurological Surgeons states there is insufficient evidence to recommend methylprednisolone, but explicitly emphasizes that the complication profile should be carefully considered when making treatment decisions 3
• The French guidelines provide a Grade 1 recommendation (strong agreement) explicitly stating that steroids are not recommended after traumatic spinal cord injury to improve neurological prognosis 1
• The American Association of Neurological Surgeons has downgraded methylprednisolone from Class I to Class III evidence due to methodological flaws in the foundational studies 1, 4

Why the Evidence Fails to Support Steroid Use

The widely cited NASCIS trials that established methylprednisolone as "standard of care" in the 1990s have critical flaws:

• NASCIS I compared two steroid doses and found no difference in neurological improvement between groups, but noted higher infectious complications in the low-dose group 1
• NASCIS II showed only modest improvement in motor scores 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) 1
• NASCIS III found no better motor improvement with 48-hour versus 24-hour administration but documented higher rates of infectious complications 1
• All three trials failed to demonstrate improvement in their primary outcome measures—the reported benefits came only from post-hoc analyses that were not part of the original study design 5, 6, 7, 8

Documented Harms Without Proven Benefit

• A large Canadian propensity score analysis demonstrated no beneficial effect of steroids on one-year motor function while finding more infectious pulmonary and urinary complications in steroid-treated patients 1
• High-dose methylprednisolone is associated with significant systemic adverse effects and its administration is strongly discouraged 2
• The presumed minimal benefits from subgroup analyses have been inappropriately extended to all acute spinal cord injured patients despite lack of clinically significant treatment effects 5

What to Do Instead: Evidence-Based Management Algorithm

Immediate priorities:

• Maintain adequate spinal cord perfusion with mean arterial pressure >70 mmHg 1, 9
• Arrange prompt transfer to a specialized spinal cord injury center 1, 9
• Consider early MRI to guide surgical management when feasible without delaying treatment 1, 9

Surgical intervention:

• Prioritize early surgical decompression within 24 hours when indicated, which has been associated with superior neurological recovery 9, 2
• The clinical evidence favors performing early surgical decompression and spine stabilization within 24 hours regardless of severity or location of injury 2

Critical Pitfalls to Avoid

• Do not administer steroids based on outdated protocols from the 1990s that are no longer supported by current evidence 1
• Recognize that methylprednisolone must be considered experimental (unproven) for clinical spinal cord injury use, and 48-hour therapy is specifically not recommended 6, 8
• The focus has appropriately shifted toward maintaining adequate spinal cord perfusion pressure (>50 mmHg) and prompt surgical decompression when indicated 1, 9
• Time-dependent interventions mean that delays in transfer to specialized care may result in patients arriving outside the therapeutic window for effective interventions 9

Important Distinction: Malignancy-Related Compression

Note that this recommendation applies only to traumatic spinal cord injury. In contrast, dexamethasone is recommended for malignancy-related epidural spinal cord compression, where randomized trials have demonstrated improved ambulation 4