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Steroids in Spinal Cord Injury

 The use of steroids, particularly high-dose methylprednisolone (MP), in the treatment of acute spinal cord injury (SCI) has been extensively studied and remains a topic of debate. The primary goal of administering steroids post-injury is to mitigate secondary damage by reducing inflammation and oxidative stress. However, the efficacy and safety of this approach have been questioned.



Key Clinical Trials and Findings:

  1. National Acute Spinal Cord Injury Study (NASCIS) II (1990): This randomized controlled trial evaluated the effects of high-dose MP administered within 8 hours of injury. A subgroup analysis suggested a modest improvement in motor function scores for patients treated within this time frame. However, the clinical significance of this improvement has been debated, and concerns about methodological limitations were raised.

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  2. NASCIS III (1997): This study compared 24-hour and 48-hour MP infusion protocols. The results did not demonstrate a significant benefit in neurological outcomes with extended MP administration. Additionally, there was an observed increase in severe pneumonia cases in the 48-hour MP group, raising concerns about potential harms associated with prolonged steroid use.

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  3. Cochrane Review (2012): An updated systematic review concluded that high-dose MP administered within 8 hours of acute SCI resulted in a small improvement in motor function. However, the review also highlighted the lack of significant long-term benefits and the increased risk of complications, leading to a recommendation against the routine use of MP in acute SCI.

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  4. TheNNT.com Analysis: A review of multiple trials indicated no clear benefit of steroid use in acute SCI and noted an increased incidence of complications such as infections and gastrointestinal issues. The analysis concluded that the potential harms of high-dose MP likely outweigh any benefits, advising against its routine use.

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Current Clinical Recommendations:

Based on the available evidence, several professional organizations, including the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, recommend against the routine use of high-dose MP in the treatment of acute SCI due to the lack of definitive benefit and the potential for significant adverse effects.

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Conclusion:

While early studies suggested a potential role for high-dose steroids in improving outcomes following acute spinal cord injury, subsequent analyses and reviews have not demonstrated consistent or clinically significant benefits. Moreover, the increased risk of serious complications associated with steroid use has led to a consensus against their routine administration in this context. Clinicians are advised to consider alternative therapeutic strategies and to focus on supportive care measures that have a more established efficacy and safety profile.

The latest ATLS 10th edition Guidelines say there is insufficient data to recommend for or against the usage of steroids in acute spinal trauma.

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