Are steroids, specifically methylprednisolone, indicated for treatment of central cord syndrome?

Steroids for Central Cord Syndrome

Do not administer steroids for central cord syndrome or any traumatic spinal cord injury, as current evidence shows no proven neurological benefit and significant risk of infectious complications. 1, 2

Evidence Against Steroid Use in Traumatic Spinal Cord Injury

The recommendation against steroids is based on multiple lines of high-quality evidence:

• French national 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

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

• The Congress of Neurological Surgeons concluded there is insufficient evidence to recommend methylprednisolone use in spinal cord injury, emphasizing that the complication profile should be carefully considered. 3, 1

Why the NASCIS Trials Failed to Support Steroid Use

The three major NASCIS trials that historically drove steroid use all failed their primary endpoints:

• NASCIS I compared two steroid doses and found no neurological difference between groups, but noted higher infectious complications in the high-dose group (3-times higher wound infection rate). 3

• NASCIS II showed only modest motor score improvement at 6 months in a post-hoc subgroup analysis of patients treated within 8 hours—this was not a pre-specified outcome, and the steroid group had higher infection rates (7% vs 3%). 1

• NASCIS III compared 24-hour versus 48-hour infusions and found no better motor improvement in the 48-hour group, but significantly higher rates of infectious complications. 1

• A large Canadian propensity score analysis demonstrated no beneficial effect on one-year motor function while finding more infectious pulmonary and urinary complications in steroid-treated patients. 1

Complications of Steroid Administration

The risk profile is substantial and well-documented:

• Higher rates of wound infections, pneumonia, and urinary tract infections. 1, 2
• Gastrointestinal complications including ulcers and perforations. 3
• No offsetting neurological benefit to justify these risks. 1

Recommended Management Algorithm for Central Cord Syndrome

Instead of steroids, focus on these evidence-based interventions:

1. Maintain adequate spinal cord perfusion with mean arterial pressure >70 mmHg. 1, 4

2. Arrange prompt transfer to a specialized spinal cord injury center. 1, 4

3. Obtain early MRI to guide surgical decision-making without delaying treatment. 1, 4

4. Consider early surgical decompression (within 24 hours) when indicated, as this has been associated with superior neurological recovery. 4

Critical Pitfall to Avoid

Do not administer high-dose steroids based on outdated protocols from the 1990s that are no longer supported by current evidence. 1 The focus of acute spinal cord injury management has shifted toward maintaining adequate perfusion pressure and prompt surgical decompression when indicated, not pharmacologic neuroprotection with steroids. 1, 4

Important Distinction: Malignancy-Related Cord Compression

Note that this recommendation applies specifically to traumatic spinal cord injury including central cord syndrome. In contrast, malignancy-related epidural spinal cord compression requires immediate high-dose dexamethasone (typically 16 mg/day) along with radiotherapy. 2 This is a completely different clinical scenario with different pathophysiology and evidence base.