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Three Part Question

In [patients with acute traumatic spinal cord injury] does [high-dose steroid] improve [neurological outcome]?

Clinical Scenario

A 40 year old man is involved in a road traffic accident. He has bony disruption at C7 / T1 with acute spinal cord injury. He has no associated head injury and no other life-threatening injuries. You wonder whether he should be given high-dose steroids for his cord injury.

Search Strategy

Cochrane Database of Systematic Reviews, Issue 3, 2004. Medline 1966-10/04 using the OVID interface.
[({exp spinal injuries OR spinal injury.mp OR spinal injuries.mp} AND {exp acute disease OR acute.mp}) OR exp. spinal cord injuries/ OR acute spinal injury.mp OR acute spinal injuries.mp] AND maximally sensitive RCT filter LIMIT to human AND english.

Search Outcome

255 papers found of which 251 were irrelevant or of insufficient quality. The remaining 4 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bracken MB et al 1984 (1) and 1985 (2) USA	330 patients with acute spinal injury Methylprednisolone 100mg vs methylprednisolone 1000mg	PRCT	Adverse effects	Wound infection rate increased in steroid group (RR 3.6)	No placebo. "High" dose is in fact quite low
			Neurological outcome	No difference at 6 weeks, 6 months and 1 year.
Bracken MB et al 1990 (3) and 1992 (4) USA	487 patients with acute spinal injury Methylprednisolone 30mg/kg vs naloxone 5.4mg/kg initial doses	PRCT	Neurological outcome	No difference overall.	Much stratification of data with significant risk of type 1 error
			Adverse effects	Stratification revealed significant neurological improvements if the steroid eas given within 8h

Comment(s)

No study has shown a benefit of steroids in all patients. While stratification of data in NASCIS 2 has shown a subgroup of patients in whom high dose methylprednisolone appears to be of benefit, the method of analysis has been criticized.

Clinical Bottom Line

Patients presenting within 8 hours of an acute spinal cord injury should be given methylprednisolone 30mg/kg as soon as possible. Further steroid therapy should be discussed with the admitting spinal unit.

References

1. Bracken MB, Collins WF, Freeman DF et al. Efficacy of methylprednisolone in acute spinal cord injury. JAMA 1984;251(1):45-52.
2. Bracken MB, Shepard MJ, Hellenbrand KG et al. Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg 1985;63(5):704-13.
3. Bracken MB, Shepard MJ, Collins WF et al. A randomized controlled trial of methylprednisolone or naxolone in the treatment of acute spinal cord injury. Results of the second National Acute Spinal Cord Injury Study. New England J Med. 1990;322(20):1405-11
4. Bracken MB, Collins WF jr, Freeman DF et al. Methylprednisolone or naxolone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study. J Neurosurg 1992;76(1):23-31.