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Steroids in Spinal Injury...waiting more evidence



The Use of steroids in Spinal cord trauma/injury is controversial topic ,some still belief it is helpful, and surely there are opponents who belief the opposite..the question what is the evidence?
here were we are putting some of the literature findings...some findings support and another don't..

The original NASCIS trial (NASCIS I) found no difference in motor function or pinprick/sensation from baseline with IV methylprednisolone use, but the doses used were much lower than the doses used in the animal studies that first suggested a possible benefit. 

Therefore, NASCIS II was performed to look at high dose methylprednisolone in acute spinal cord injury.  Patients received either methylprednisolone, naloxone, or placebo within the first twelve hours of injury.  The methylprednisolone was high dose and given for 24 hours.  Overall there was no benefit in the methylprednisolone group, but sub-group analysis showed a small benefit in motor function in the patients that received the IV steroids within the first 8 hours. 

After that study, many began to define high dose methylprednisolone as standard of care after acute spinal cord injury. 

A Japanese study  attempted to repeat the NASCIS II using the 8 hour timeline as the main outcome, and it showed a benefit. 

 However, the opponents of steroids in acute spinal cord injury noted that the randomization was not defined and only 3/4 of the patients enrolled were listed in the data. 

NASCIS III attempted to compare a 24 hour regiment with a 48 hour regimen and found no benefit.

In the US, a survey of spine surgeons reported 91% of them use steroids in acute spinal cord injury, although only 24% of them believe there is a clinical benefit.  Once the label of “standard of care” is attached, it’s hard to remove. 

The Cochrane review reported that high-dose methylprednisolone is the only approved pharmacologic treatment of acute spinal cord injury that has been proven by prospective, randomized studies.  The review admitted the treatment must be started within 8 hours to see the benefit, but it didn’t mention the post-hoc analysis aspect. 

The Canadians no longer define steroids as a standard of care but instead call it a treatment option. 

 Until better data emerge, we’re still forced to decide between a possible benefit from post-hoc analysis vs going against a “standard of care.


Bracken, et al.  A Randomized, Controlled Trial of Methylprednisolone or Naloxone in the Treatment of Acute Spinal-Cord Injury — Results of the Second National Acute Spinal Cord Injury Study.  N Engl J Med.  1990; 322:1405-1411.

Young, Bracken, et al.  The Second National Acute Spinal Cord Injury Study.  J Neurotrauma.  1992, 9 Suppl 1:S397-405.

Bracken, et al.  Administration of Methylprednisolone for 24 or 48 Hours or Tirilazad Mesylate for 48 Hours in the Treatment of Acute Spinal Cord Injury.  JAMA.  1997;277(20):1597-1604

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