Consider the Use of Steroids for Neurological Trauma in Blunt Spinal Cord Injury Only
Jacob T. Gutsche MD
Patrick K. Kim MD
Corticosteroids have been studied for decades as a treatment of traumatic central nervous system injury. The proposed mechanism of benefit is the reduction of inflammation and edema, leading to decreased ischemic injury and neuronal apoptosis. High-dose methylprednisolone was widely adopted as the standard of care for patients with blunt spinal cord injury following the publication of the National Acute Spinal Cord Injury Studies (NASCIS) II and III. These studies suggested that steroid treatment results in slight improvement in motor function at long-term follow-up. Subsequent clinical studies and critical reviews have challenged the validity of the results of the NASCIS II study. Despite its wide adoption, steroid therapy for spinal cord injury is still controversial.
Methylprednisolone (Solu-Medrol) is the steroid of choice based on NASCIS. Large doses are required, starting with a bolus intravenous infusion of 30 mg/kg of body weight over 15 minutes followed by an infusion of 5.4mg/kg per hour. If steroid treatment begins within 3 hours of injury, the duration of the infusion is 23 hours. If steroid treatment begins between 3 and 8 hours after injury, the duration of infusion is 47 hours. If the 8-hour window is missed, steroids should not be given. The use of steroids in blunt spinal cord injury should not be extrapolated to patients with penetrating spinal cord injury (e.g., gunshot wounds, stabs). Studies have shown no improvement in neurological outcome in penetrating injury and should not be used in this patient population.