What is the role of methylprednisolone (MP) in treating a patient with a suspected spinal injury and pre-existing conditions such as osteoporosis or spinal stenosis?

Methylprednisolone in Spinal Injury

Do not administer methylprednisolone to patients with acute traumatic spinal cord injury, regardless of pre-existing conditions such as osteoporosis or spinal stenosis. 1, 2

Current Guideline Recommendations

The French guidelines explicitly state that steroids are not recommended after post-traumatic spinal cord injury to improve neurological prognosis (Grade 1 recommendation with strong agreement). 1, 2 This represents the strongest level of recommendation against steroid use. 1

The Congress of Neurological Surgeons provides insufficient evidence to recommend methylprednisolone use in thoracolumbar spine trauma with spinal cord injury, emphasizing that the complication profile should be carefully considered. 1, 2

The American Association of Neurological Surgeons has downgraded methylprednisolone from Class I to Class III evidence due to methodological flaws in the foundational NASCIS studies. 1, 2

Why the Evidence Fails to Support Methylprednisolone

Critical Flaws in NASCIS Trials

The NASCIS II and III trials, which established methylprednisolone as a "standard of care" in 1990, contained remarkable scientific irregularities. 1

• Both studies were negative on their primary preplanned comparisons - they failed to show benefit when analyzed as originally designed. 1
• NASCIS II reported motor improvements from only the right half of the body, using only 17 methylprednisolone and 22 control patients from a total population of 487 patients. 1
• The positive results in NASCIS III's 48-hour treatment group were lost at 1-year follow-up. 1
• Post-hoc sub-subgroup analyses without multi-test corrections produced the "positive" findings, which current statistical interpretation considers random effects without clinical significance. 3

Contemporary Evidence Against Methylprednisolone

A 2023 reanalysis of the NASCIS2 and Sygen studies using contemporary statistical methods and case-matched pooled data (increasing the methylprednisolone group from 106 to 431 patients) found that administration of methylprednisolone did not enhance motor score improvement at 26 weeks. 3 This analysis excluded patients with injury levels caudal to T10, lower-extremity motor scores ≥46, Glasgow Coma Scale scores ≤11, and age <15 or >75 years to meet contemporary criteria. 3

A propensity score analysis of a large Canadian cohort demonstrated no beneficial effect of steroids on one-year motor function. 1, 2

Significant Complications of Methylprednisolone

Infectious complications are consistently higher in steroid-treated patients. 1, 2

• NASCIS I found a 3-times higher rate of wound infection in the high-dose group. 1
• NASCIS II reported 7% infections in the steroid group versus 3% in placebo (though not statistically significant). 1
• NASCIS III found higher rates of infectious complications in the 48-hour group. 1
• The Canadian cohort analysis found more infectious pulmonary and urinary complications in steroid-treated patients. 1, 2

Additional Concerns in Patients with Osteoporosis or Spinal Stenosis

While the evidence does not specifically address these subpopulations, high-dose corticosteroids cause:

• Increased calcium excretion 4
• Potential for HPA axis suppression and Cushing's syndrome 4
• Immunosuppression with increased infection risk 4

These effects would be particularly problematic in patients with pre-existing osteoporosis, who already have compromised bone health and would face additional fracture risk from steroid-induced calcium loss. 4

Evidence-Based Management Algorithm for Acute Spinal Cord Injury

Immediate Priorities (First 8 Hours)

1. Maintain mean arterial pressure ≥70 mmHg during the first week post-injury to limit risk of worsening neurological deficit. 1, 2

   • Target spinal cord perfusion pressure >50 mmHg, which correlates with better neurological status at 6 months. 1
   • Use continuous arterial catheter monitoring as MAP is below target 25% of the time. 1

2. Arrange immediate transfer to a specialized spinal cord injury center to decrease morbidity and long-term mortality (Grade 2+ recommendation). 1, 2

3. Consider early MRI to guide surgical management when feasible without delaying treatment. 2, 5

4. Prioritize early surgical decompression (within 24 hours) when indicated, which has been associated with superior neurological recovery. 5

What NOT to Do

• Do not administer methylprednisolone at any time point - neither within 8 hours nor after 8 hours of injury. 1, 2
• Do not extend treatment beyond 24 hours if methylprednisolone was already initiated (though initiation itself is not recommended). 1, 6
• Do not use high-dose steroids based on outdated protocols that are no longer supported by current evidence. 2

Critical Pitfalls to Avoid

The most common pitfall is administering methylprednisolone based on fear of medicolegal consequences rather than current evidence. 7 In Czech spinal surgery centers, 63% use methylprednisolone solely due to fear of sanctions, despite lack of evidence for benefit. 7

Recognize that the focus of acute spinal cord injury management has shifted from pharmacological neuroprotection to maintaining adequate spinal cord perfusion pressure and prompt surgical decompression when indicated. 2, 5

Do not confuse traumatic spinal cord injury with malignancy-related spinal cord compression - dexamethasone IS recommended for malignancy-related compression (16-96 mg/day) but NOT for traumatic injury. 8