Methylprednisolone for Acute Spinal Cord Injury: Not Recommended
Methylprednisolone is NOT recommended for acute spinal cord injury, as current high-quality guidelines conclude it does not improve neurological prognosis and increases infectious complications. 1
Primary Recommendation
The 2020 French guidelines for spinal cord injury management provide a GRADE 1 recommendation with STRONG AGREEMENT: do not administer steroids early after post-traumatic spinal cord injury to improve neurological prognosis. 1
Evidence Behind This Recommendation
Why Methylprednisolone Fails
The guideline panel reviewed all three NASCIS trials and found critical flaws:
NASCIS I compared two steroid doses (1g vs 100mg bolus) without a placebo control group, found no neurological difference, and documented higher infection rates in the low-dose group 1
NASCIS II showed only modest motor score improvement at 6 months in a subgroup treated within 8 hours, without standardized long-term assessment, and reported more infections (7% vs 3% in placebo, though not statistically significant) 1
NASCIS III compared 24-hour vs 48-hour administration without a control group, found no additional motor improvement with longer duration, and documented significantly higher infectious complications in the 48-hour group 1
Real-World Outcomes Are Worse
A recent large Canadian propensity score analysis found no beneficial effect of steroids on one-year motor function and documented significantly more infectious pulmonary and urinary complications in steroid-treated patients. 1
Historical Context: The NASCIS Protocol (Now Obsolete)
For historical reference only, the previously used regimen was:
- Loading dose: 30 mg/kg IV bolus over 15 minutes 2, 3, 4
- Maintenance: 5.4 mg/kg/hour continuous infusion for 23-24 hours 2, 3, 4
- Extended regimen: 48 hours total if treatment started 3-8 hours post-injury 4
This protocol is no longer recommended based on current evidence. 1
Critical Pitfalls to Avoid
Timing Window Misconception
While older research suggested an 8-hour therapeutic window 2, 3, 4, animal studies demonstrate the actual neuroprotective window may be as short as 10-30 minutes, with delayed treatment potentially increasing lesion volumes 5
Harm from Late Administration
Methylprednisolone administered more than 8 hours after injury is not just ineffective—it may be actively harmful, increasing complications without neurological benefit 6, 4
Infection Risk Is Substantial
All three NASCIS trials and subsequent real-world data consistently show increased rates of:
What to Do Instead
Focus on proven interventions that actually improve morbidity and mortality:
Hemodynamic optimization: Maintain MAP > 70 mmHg for 2-3 days post-injury using continuous arterial monitoring 1
Early surgical decompression: Operate within 24 hours when indicated, as this demonstrates superior neurological recovery at 6 months 1
Specialized center transfer: Transfer all patients (including those with transient neurological recovery) to specialized spinal cord injury units to decrease morbidity and long-term mortality (GRADE 2+ recommendation) 1
Bottom Line
The evidence is clear and the guideline recommendation is unequivocal: do not use methylprednisolone for acute spinal cord injury. The modest and questionable neurological benefits from decades-old trials do not outweigh the documented infectious complications and potential harm, particularly when treatment is delayed beyond the immediate post-injury period. 1