Use of steroids for acute spinal cord injury must be reassessed

EDITOR—Yates and Roberts's editorial on corticosteroids in head injury caused me considerable concern in so far as it portrayed the situation for treating acute spinal cord injury.1 Intravenous high dose methylprednisolone given within eight hours of injury has been promoted since the second American national acute spinal cord injury study. The positive benefit of this is based on conclusions derived from a selected post hoc subgroup analysis in one clinical trial. Current recommendations regarding evidence of clinical efficacy consistently advise caution in applying results from such non-randomised groups of patients.2

The evidence produced by a systematic review that colleagues and I recently carried out did not support the use of high dose methylprednisolone in acute spinal cord injury to improve neurological recovery.3 We also concluded that “a deleterious effect on early mortality and morbidity cannot be excluded by this evidence.” In terms of experimental acute spinal cord injury, the functional neurological results extracted from non-rodent animal studies using high doses of either methylprednisolone or dexamethasone “constituted a body of evidence which cannot endorse a beneficial effect.” A trend to increased mortality in cat models of high spinal cord lesions was of concern. On the basis of information available to them, clinicians in Canada4 and the United States5 also consider it inappropriate to advise treatment with methylprednisolone in this context.

An independent assessment of the evidence available, particularly information from the American national acute spinal cord injury studies, is long overdue.