Methylprednisolone Should Not Be Used as Standard Treatment for Acute Spinal Cord Injury
Do not administer methylprednisolone as standard treatment for acute spinal cord injury. The evidence base has been thoroughly discredited, with the landmark NASCIS II and III trials downgraded from Class I to Class III evidence due to fundamental methodological flaws, post-hoc analysis manipulation, and lack of clinically meaningful benefit, while the treatment carries significant infectious complications 1.
Why Methylprednisolone Failed as a Treatment
The scientific foundation for methylprednisolone collapsed under scrutiny:
NASCIS II and III were negative studies when examined by their pre-planned primary endpoints—both failed to show significant differences in their original comparisons 1.
Statistical manipulation undermined credibility: NASCIS II reported motor improvements using only 39 patients (17 methylprednisolone, 22 control) from a total population of 487 patients, and bizarrely reported results from only the right half of the body 1.
Benefits disappeared over time: Any positive results reported in the 48-hour methylprednisolone group in NASCIS III were lost at 1-year follow-up 1.
The American Association of Neurological Surgeons/Congress of Neurological Surgeons downgraded all NASCIS publications to Class III evidence due to flaws in study design, data presentation, interpretation, and analysis 1.
Documented Harms Outweigh Unproven Benefits
The complication profile is substantial and well-documented:
Three-fold higher wound infection rates in high-dose methylprednisolone groups 1.
Increased infectious pulmonary and urinary complications without beneficial effects on one-year motor function, demonstrated in propensity score analyses of large Canadian cohorts 2, 3.
Higher overall complication rates including death associated with methylprednisolone administration 1.
Current Guideline Consensus Against Use
Multiple authoritative bodies have rejected methylprednisolone:
The Congress of Neurological Surgeons provides a Grade Insufficient recommendation for methylprednisolone in thoracolumbar spine trauma with spinal cord injury, emphasizing the unfavorable complication profile 2, 4.
French guidelines explicitly state steroids are not recommended after post-traumatic spinal cord injury to improve neurological prognosis (Grade 1 recommendation with strong agreement) 3.
No pharmacologic agent has been shown to improve neurological outcomes in acute spinal cord injury despite intense research over 30 years 1.
What to Do Instead: Evidence-Based Management Algorithm
Focus on interventions with proven benefit:
Immediate Hemodynamic Management
- Maintain mean arterial pressure ≥70 mmHg continuously for the first 7 days to optimize spinal cord perfusion 4, 3.
- Use arterial catheter for continuous MAP monitoring as target levels are difficult to maintain 4.
- Avoid hypotension (systolic BP <110 mmHg) as it increases mortality 4.
Urgent Transfer and Surgical Considerations
- Arrange prompt transfer to a specialized spinal cord injury center—delays may result in patients arriving outside the therapeutic window for effective interventions 2, 4, 3.
- Consider early surgical decompression within 24 hours when indicated, as this has been associated with superior neurological recovery 2, 4.
- Obtain early MRI to guide surgical management when feasible without delaying treatment 2, 3.
Prevention of Secondary Complications
- Implement thromboprophylaxis early, as venous thromboembolism incidence can reach 4-100% without prophylaxis 4.
- Begin early mobilization as soon as the spine is stabilized to prevent pressure ulcers 4.
- For upper cervical injuries (C2-C5), consider early tracheostomy within 7 days to improve respiratory outcomes 4.
Critical Pitfalls to Avoid
Do not delay transfer waiting for "stability"—early intervention is time-dependent and delays compromise outcomes 2, 4, 3.
Do not administer methylprednisolone based on outdated protocols from the 1990s that are no longer supported by current evidence 3.
Do not confuse "option" with "recommendation"—even when methylprednisolone was listed as an "option" by AANS/CNS, this reflected insufficient evidence, not endorsement 1.
Recognize that the focus has shifted from pharmacologic neuroprotection to maintaining adequate spinal cord perfusion pressure and prompt surgical decompression when indicated 2, 3.