Steroids are not routine in acute spinal-cord injury — Rapid

Synopsis

Avoid ineffective and harmful high-dose steroid neuroprotection after traumatic cord injury, distinguish non-traumatic steroid indications, and prioritise oxygenation, perfusion, imaging, decompression and specialist spinal care.

NICE says not to use methylprednisolone, nimodipine or naloxone in the acute stage after traumatic spinal-cord injury for neuroprotection.
Do not start a historical high-dose methylprednisolone regimen because presentation is within an alleged treatment window; timing does not create a NICE indication.
Run ABCDE with spinal protection, support a weak high-cervical airway and ventilation early and prevent even brief hypoxaemia.
Exclude and control haemorrhage before diagnosing neurogenic shock, then use specialist perfusion support rather than steroid bolus.
Obtain CT for fracture and alignment and MRI after CT when neurological abnormality could be attributable to cord, disc, ligament or epidural injury.
Discuss decompression and stabilisation urgently with spinal surgery and contact a spinal-cord-injury centre early for respiratory, skin, bladder, bowel and rehabilitation care.
If steroids were already given, stop further non-indicated dosing, document product, dose and time and monitor glucose, infection, gastrointestinal and wound complications.
Separate traumatic cord injury from malignant compression, inflammatory myelitis and adrenal crisis, where steroids may be indicated through a different evidence-based pathway.

Key red flags

New weakness, sensory level, sacral change, respiratory muscle weakness or sphincter dysfunction after trauma requires emergency cord assessment and must not be delayed while debating steroid administration.

Hypotension, hypoxaemia, rising carbon dioxide, hypothermia and ongoing compression are modifiable causes of secondary injury that demand immediate treatment.

A proposed steroid indication may be non-traumatic—such as malignant cord compression, inflammatory myelitis or adrenal crisis—and requires its own diagnosis and regimen rather than transfer of trauma guidance.

Investigation priorities

First-line trauma and neurological assessmentFirst stepFirst line

Confirm mechanism, level, completeness and immediate physiological threats.

Preferred CT spinePreferred

Define bony injury, displacement and canal fragments.

Management branches

ImmediateUse effective neuroprotection

A patient has neurological signs after acute spinal trauma.

Run ABCDE with safe spinal alignment, support ventilation, control haemorrhage and prevent hypoxia, hypotension and hypothermia.
Document motor, sensory and sacral findings and arrange complete CT and MRI after CT for attributable cord abnormality.
Contact spinal surgery and a spinal-cord-injury centre early and plan decompression, stabilisation and transfer according to anatomy and physiology.
Record that methylprednisolone, nimodipine and naloxone are not indicated for traumatic cord neuroprotection under NICE guidance.

Key medicines

Methylprednisolone for traumatic cord neuroprotectionDo not administer a high-dose methylprednisolone bolus or infusion for neuroprotection in the acute stage of traumatic spinal-cord injury; NICE recommends against this treatment.High-dose exposure can cause severe infection, hyperglycaemia, gastrointestinal bleeding, delirium, myopathy and impaired wound healing; a distinct malignant, inflammatory or endocrine indication needs its own specialist regimen.

Open full textbook →Answer 2 questions