From the Guidelines
No corticosteroid is recommended for the treatment of cervical cord edema in trauma due to the lack of evidence showing improvement in neurological outcomes and the potential for increased complications. The use of corticosteroids, such as methylprednisolone, in spinal cord injury has been investigated in several studies, including the NACSIS trials 1. These trials found no significant difference in neurologic improvement between patients treated with steroids and those who were not, and in some cases, found a higher rate of infectious complications in the steroid group. A recent propensity score analysis of a large Canadian cohort also found no beneficial effect of steroids on one-year motor function and more infectious pulmonary and urinary complications in patients treated with steroids 1. The French recommendations for the management of patients with spinal cord injury or at risk of spinal cord injury also state that it is not recommended to administer steroids early on to improve the neurological prognosis, with a strong agreement and a GRADE 1 recommendation 1.
Some of the key points to consider when evaluating the use of corticosteroids in spinal cord injury include:
- The lack of evidence showing a significant improvement in neurological outcomes with steroid treatment
- The potential for increased complications, such as infections, hyperglycemia, and gastrointestinal bleeding
- The importance of closely monitoring patients for adverse effects and considering appropriate prophylaxis
- The need for further research to fully understand the risks and benefits of corticosteroid treatment in spinal cord injury.
Given the current evidence, the best course of action is to prioritize other aspects of trauma care, such as stabilization of the spine, management of other injuries, and supportive care, rather than administering corticosteroids 1.
From the Research
Corticosteroid Options for Cervical Cord Edema in Trauma
- Methylprednisolone is currently used due to its ability to reduce inflammation, but more recent studies question its clinical benefits 2
- High-dose methylprednisolone steroid therapy has been shown to improve neurologic outcome up to one year post-injury if administered within eight hours of injury 3, 4
- The dose regimen of methylprednisolone is: bolus 30mg/kg over 15 minutes, with maintenance infusion of 5.4 mg/kg per hour infused for 23 hours 3, 4
- Extending the maintenance dose from 24 to 48 hours may provide additional improvement in motor neurologic function and functional status, especially if treatment cannot be started until between three to eight hours after injury 3, 4
- However, some studies suggest that high-dose methylprednisolone may not improve neurological recovery and may even have a deleterious effect on early mortality and morbidity 5
- The use of steroids, including methylprednisolone, is not recommended as a routine treatment for cervical spine trauma 6
Key Considerations
- The timing of treatment is crucial, with optimal benefits seen when methylprednisolone is administered within eight hours of injury 3, 4
- The dose and duration of methylprednisolone treatment may need to be individualized based on the severity of the injury and the patient's response to treatment 3, 4
- More research is needed to fully understand the benefits and risks of corticosteroid treatment for cervical cord edema in trauma 2, 3, 4, 5, 6