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Asian Intensive Care Conference, Hong Kong, November 21-22nd 2013

Reasons for giving methylprednisolone

• NASCIS II study showed an improved motor outcome in patients who were given methylprednisolone within 8 hours of spinal cord injury
• other less methodologically rigorous studies have also shown a benefit from steroids
• NASCIS III study showed greater benefit from 48 hour regime (compared with 24 hour regime) in patients treated between 3-8 hours
• adverse effects are not very marked
• there is no other definitive treatment for spinal cord injury

Reasons for not giving methylprednisolone

• no demonstrable benefit in NASCIS I
• only demonstrable benefit from NASCIS II study was in a post hoc analysis of patients treated within 8 hours
• demonstrated benefit was small, of dubious clinical significance and was smaller at 1 year than at 6 months
• NASCIS III did not involve a placebo group
• only demonstrable benefit from 48 hour regime was in a post hoc analysis, benefit was small and had disappeared by 1 year
• trend to more adverse effects (especially wound healing) in steroid group (vs placebo) and 48 hour group (vs 24 hour group)
• French randomized controlled trial showed worse outcome. May be due to increased hyperglycaemia in steroid group.
• other studies too methodologically flawed

Further reading

M. B. Braken. Methylprednisolone and acute spinal cord injury. Spine 26 (24 Suppl):S47-S54, 2001

M. B. Braken, M. J. Shepard, W. F. Collins et al. A randomized, controlled trial of methyprednisolone or naloxone in the treatment of acute spinal-cord injury: results of the second national acute spinal cord injury study. N Engl J Med 322:1405-1411, 1990

M. B. Braken, M. J. Shepard, W. F. Collins et al. Methylprednisolone or naloxone treatment after acute spinal cord injury:1-year follow-up data. J. Neurosurg 76:23-31, 1992

M. B. Braken, M. J. Shepard, T. R. Holford et al. Adminstration of methylprednisolone for 34 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. JAMA 277:1597-1604, 1997

M. B. Braken, M. J. Shepard, T. R. Holford et al. Methylprednisolone or tirilazad mesylate administration after acute spinal cord injury: 1-year follow-up. J Neurosurg 89:699-706, 1998

M. G. Fehlings. Editorial: recommendations regarding the use of methylprednisolone in acute spinal cord injury. Spine 26 (24 Suppl):S56-S57, 2001

R. J. Hurlbert. The role of steroids in acute spinal cord injury.An evidence-based analysis. Spine 26 (24 Suppl):S39-S46,2001

©Charles Gomersall, May, 2013 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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