Dexamethasone Should NOT Be Used for Acute Cervical Spinal Cord Injury
Dexamethasone (Dexona) is not recommended for acute management of cervical spinal cord injury, including cases presenting with unilateral lower-limb weakness. The highest quality evidence demonstrates no neurological benefit and significant risk of harm from corticosteroid use in this setting.
Evidence Against Dexamethasone Use
Guideline Recommendations
The 2013 Guidelines for Management of Acute Cervical Spine and Spinal Cord Injuries downgraded methylprednisolone (and by extension, other corticosteroids like dexamethasone) from Class I to Class III evidence because primary outcome measures in major trials were negative, with any positive results coming only from post-hoc analyses rather than pre-planned endpoints 1.
The guidelines explicitly state that methylprednisolone is "only a treatment option" with weak clinical evidence, not a standard of care 1, 2.
Dexamethasone specifically is not recommended based on the European Stroke Organisation's position against corticosteroids in acute central nervous system injury 1, 3.
Clinical Evidence of Harm
A retrospective study of 254 spinal gunshot wound patients found no neurological benefits from dexamethasone (initial doses 10-100 mg), but demonstrated significantly increased gastrointestinal complications (P = 0.021) 4.
Patients receiving dexamethasone had higher rates of infectious complications, gastrointestinal bleeding, and delayed wound healing compared to controls 4, 5, 6.
In patients with complete spinal cord injury treated with corticosteroids, 87% (14/16) experienced steroid-related complications, including one death from sepsis related to perforated peptic ulcer 7.
Why This Matters for Your Patient
Your patient with unilateral lower-limb weakness from cervical cord injury requires:
Immediate Management Priorities
Maintain systolic blood pressure > 110 mmHg to ensure adequate spinal cord perfusion, as hypotension worsens neurological outcomes 1.
Obtain CT cervical spine without contrast immediately to identify fractures and bony injuries (>98% sensitive for clinically significant injuries) 1.
Perform MRI cervical spine to assess cord compression, ligamentous injury, and cord signal changes that guide surgical decision-making 1, 8.
Surgical Considerations
Early surgical decompression within 24 hours of acute neurological deficit is associated with improved neurological recovery compared to delayed intervention 8, 9.
Surgical intervention is strongly indicated when neurological symptoms are present with evidence of cord compression on imaging 8.
Common Pitfalls to Avoid
Do not delay imaging or surgical consultation while considering steroid administration - time to decompression is the critical factor for neurological recovery 8, 9.
Do not use dexamethasone based on older literature from the 1990s 5, 6 - these studies have been superseded by higher quality evidence and current guidelines that demonstrate no benefit and significant harm 1, 4, 7.
Recognize that unilateral symptoms can progress to bilateral involvement - this represents evolving cord compression requiring urgent intervention 9.
Alternative Evidence-Based Management
Instead of corticosteroids, focus on:
Hemodynamic optimization with vasopressors (phenylephrine, norepinephrine) to maintain spinal cord perfusion pressure 1.
Urgent neurosurgical consultation for potential decompression, as 91% of patients with cord compression experience complete or partial recovery after surgical intervention 8.
Continuous neurological monitoring with neuro checks every 4 hours to detect early deterioration 9.
Prevention of secondary injury through proper immobilization, avoiding hypotension and hypoxia 1.