What is the efficacy of high dose steroids for the initial treatment of spinal cord injury (SCI)?

Updated: Nov 01, 2018
  • Author: Lawrence S Chin, MD, FACS; Chief Editor: Brian H Kopell, MD  more...
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Answer

High doses of steroids or tirilazad are thought to minimize the secondary effects of acute SCI. The NASCIS II study evaluated a 30-mg/kg bolus of methylprednisolone administered within 8 hours of injury, whereas the NASCIS III study evaluated methylprednisolone 5.4 mg/kg/h for 24 or 48 hours versus tirilazad 2.5 mg/kg q6h for 48 hours. (Tirilazad is a potent lipid preoxidation inhibitor.)

Between the 2 studies, it was determined that: (1) in patients treated earlier than 3 hours after injury, the administration of methylprednisolone for 24 hours was best; (2) in patients treated 3-8 hours after injury, the use of methylprednisolone for 48 hours was best; (3) Tirilazad was equivalent to methylprednisolone for 24 hours. [43]

Both NASCIS studies evaluated the patients' neurologic status at baseline on enrollment into the study, at 6 weeks, and at 6 months and found absolutely no evidence suggests that giving the medication earlier (eg, in the first hour) provides more benefit than giving it later (eg, between hours 7 and 8). The authors concluded that there was only a benefit if methylprednisolone or tirilazad were given within 8 hours of injury. [43]

Controversy re results of NASCIS studies

Following the NASCIS trials, the use of high-dose methylprednisolone in nonpenetrating acute SCI had become the standard of care in North America. Nesathurai and Shanker revisited these studies and questioned the validity of the results. [45] These authors cited concerns about the statistical analysis, randomization, and clinical endpoints used in the study. In addition, the investigators noted that even if the benefits of steroid therapy were valid, the clinical gains were questionable. Other reports have also cited flaws in the study designs, trial conduct, and final presentation of the data.


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