Methylprednisolone Should NOT Be Used Routinely in Acute Spinal Cord Injury
Do not administer methylprednisolone as standard treatment for acute spinal cord injury due to lack of proven neurological benefit, significant complications including increased infections and mortality, and methodological flaws in supporting studies. 1, 2, 3, 4
Current Guideline Position
The Congress of Neurological Surgeons provides a Grade Insufficient recommendation for methylprednisolone in spinal cord injury, explicitly emphasizing its unfavorable complication profile. 1, 2, 3 The American Association of Neurological Surgeons has downgraded methylprednisolone from Class I to Class III evidence because all primary (a priori) outcome measures in the NASCIS trials were negative—any positive results came from post-hoc analysis rather than preplanned endpoints. 1, 4
Why the Evidence Fails
The NASCIS I trial showed no neurological difference between high-dose and low-dose methylprednisolone groups, but documented 3 times higher wound infection rates in the high-dose group. 1
The NASCIS II and III trials showed no long-lasting neurological benefit, with benefits only appearing through retrospective data mining rather than predefined outcomes. 1
Independent studies (Pointillart et al) demonstrated no benefit of methylprednisolone. 1
Propensity score analyses found more infectious pulmonary and urinary complications in steroid-treated patients without beneficial effects on one-year motor function. 3, 4
Documented Harms
Higher rates of infectious complications consistently documented across multiple studies. 3, 4, 5
Increased mortality associated with methylprednisolone administration. 1
No pharmacologic agent, including methylprednisolone, has been shown to improve neurological outcomes in acute spinal cord injury despite 30 years of research. 1
What to Do Instead: Evidence-Based Management Algorithm
Immediate priorities (within first 7 days):
Maintain mean arterial pressure ≥70 mmHg continuously using arterial catheter monitoring—this is the only intervention proven to limit neurological deterioration. 2, 3, 4
Avoid hypotension (systolic BP <110 mmHg) as it is associated with increased mortality. 2
Arrange prompt transfer to specialized spinal cord injury center without delay—waiting for "stability" causes patients to arrive outside therapeutic windows. 2, 3
Within 24 hours:
Perform early surgical decompression when indicated, as this has been associated with superior neurological recovery. 2, 3
For upper cervical injuries (C2-C5), plan early tracheostomy within 7 days to improve respiratory outcomes. 2
Ongoing management:
Implement thromboprophylaxis early (venous thromboembolism incidence reaches 4-100% without prophylaxis). 2
Begin early mobilization once spine is stabilized to prevent pressure ulcers. 2
Initiate intermittent urinary catheterization rather than indwelling catheters. 2
Critical Pitfalls to Avoid
Do not administer methylprednisolone based on outdated protocols—the focus has shifted to maintaining adequate spinal cord perfusion pressure and prompt surgical decompression. 3, 4
Do not delay transfer waiting for "stability"—early intervention is time-dependent and delays result in missed therapeutic windows. 2, 3
Do not use methylprednisolone after 8 hours of injury or for more than 24 hours—this is not justified by any evidence. 5
The Controversial Exception (Not Recommended)
One 2017 guideline suggested offering (not recommending) a 24-hour methylprednisolone infusion within 8 hours as a "treatment option" based on modest motor score improvements at 6-12 months. 6 However, this contradicts the most recent and authoritative Congress of Neurological Surgeons guidelines (2019) which found insufficient evidence and emphasized the unfavorable complication profile. 1, 2, 3 A 2000 Cochrane review supported methylprednisolone, but this predates the critical reanalysis showing methodological flaws and the downgrading to Class III evidence. 7
Given the lack of functional neurological benefits, high complication rates including death, and reliance on post-hoc analysis, methylprednisolone should not be used in acute spinal cord injury. 1, 2, 3, 4