今日の臨床サポート

脊髄梗塞

著者: 髙橋愼一 埼玉医科大学国際医療センター

監修: 内山真一郎 国際医療福祉大学臨床医学研究センター

著者校正/監修レビュー済:2021/04/21
患者向け説明資料

概要・推奨   

  1. 脊髄梗塞の診断にはMRIが推奨される(推奨度1)
  1. 脊髄梗塞に対する治療法は、脳梗塞と異なり、ヒトでの臨床試験で有効性が確立されたものはない。
  1. 脊髄梗塞の予後は、さまざまで脊髄の障害の程度と原因による。椎間板ヘルニアの脱出した核からの線維性軟骨による塞栓の場合が最も予後が悪い。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
髙橋愼一 : 未申告[2021年]
監修:内山真一郎 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、最新文献の追加を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 脊髄動脈は脳動脈に比べてアテローム性変化が少なく、また、側副血行路が発達しているため、脊髄梗塞は脳梗塞に比べきわめて頻度が少ない。脊髄梗塞の原因には多くの病態があるが、不明な場合も多い。臨床的に重要な原因は、胸腹部大動脈における解離性大動脈瘤、大動脈のアテローム硬化、大動脈の手術、大動脈からのアテローム塞栓などが挙げられる。
  1. 前脊髄動脈症候群は、前脊髄動脈の支配領域である脊髄腹側約2/3の領域に血流障害が生じ、急速に発現する対麻痺ないし四肢麻痺、病変レベル以下での解離性感覚障害(温痛覚のみが障害され、触覚、振動覚、位置覚は保たれる)、膀胱直腸障害などを特徴とする。発症年齢は若年者から高齢者まで幅広い、発症が急激で解離性感覚障害などを呈する典型例では、診断は容易である。MRIで急性期特有の脊髄腫大や脊髄前半部での高信号領域(拡散強調画像、T2強調画像)を認め、同部位がGd-DTPA造影で増強されれば確実な診断となる。病変部位は頚髄と胸髄、円錐部が多い。
  1. 後脊髄動脈症候群はまれな症候群であり、後脊髄動脈の支配領域である後索障害に由来する病変レベル以下の深部感覚障害、後角障害による病変髄節に一致した全感覚脱失、後側索にまで及んだ場合には運動麻痺、膀胱直腸障害などを呈する。
 
  1. 脊髄虚血の原因はさまざまであり、昔は梅毒によるものが最も多く、次いで、大動脈の動脈硬化であった。現在では大動脈瘤などの手術が増加し、心血管系の手術が原因となる場合が増加しているが、原因が特定されない場合も多い。(参考文献:[1][2][3][4]
  1. 脊髄虚血の原因には、血管炎(結節性多発動脈炎、ベーチェット病、巨細胞性動脈炎)、塞栓性(心房粘液腫、僧帽弁疾患、細菌性心内膜炎、卵円孔開存、突出した椎間板ヘルニアからの線維軟骨性塞栓)、全身性血圧低下(心臓呼吸停止)、外傷性動脈破裂、動脈瘤解離、大動脈狭窄、医原性(胸腰部交感神経切除術、側弯症外科的手術、大動脈撮影、腎動脈塞栓症、臍帯動脈カテーテル術、椎骨動脈撮影、大動脈手術など)、感染症(梅毒、真菌症、細菌性髄膜炎)、その他(鎌形赤血球症、コカイン乱用、抗リン脂質抗体症候群、クローン病、頚椎脱臼、大動脈硬化など)がある。
問診、診察のポイント  
  1. 発症の仕方(突然発症か徐々に進行したか)、下肢のみの麻痺なのか、上肢の麻痺もあるのかどうか、感覚障害はどのレベルからか、感覚障害は解離性感覚障害かどうか、膀胱直腸障害を伴っているかどうか、大動脈瘤などの手術を受けたかどうか、高血圧、糖尿病、脂質異常症などの動脈硬化のリスク因子があるかどうか、などが問診、診察の重要なポイントとなる。画像診断では脊椎MRI検査で、脊髄を圧迫するような病変の有無、脊髄の髄内病変を明らかにする必要がある。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Nicholas L Zalewski, Alejandro A Rabinstein, Karl N Krecke, Robert D Brown, Eelco F M Wijdicks, Brian G Weinshenker, Timothy J Kaufmann, Jonathan M Morris, Allen J Aksamit, J D Bartleson, Giuseppe Lanzino, Melissa M Blessing, Eoin P Flanagan
雑誌名: JAMA Neurol. 2019 Jan 1;76(1):56-63. doi: 10.1001/jamaneurol.2018.2734.
Abstract/Text Importance: Spinal cord infarction (SCI) is often disabling, and the diagnosis can be challenging without an inciting event (eg, aortic surgery). Patients with a spontaneous SCI are often misdiagnosed as having transverse myelitis. Diagnostic criteria for SCI are lacking, hindering clinical care and research.
Objective: To describe the characteristics of spontaneous SCI and propose diagnostic criteria.
Design, Setting, and Participants: An institution-based search tool was used to identify patients evaluated at Mayo Clinic, Rochester, Minnesota, from January 1997 to December 2017 with a spontaneous SCI. Patients provided written consent to use their records for research. Participants were 18 years and older with a diagnosis of spontaneous SCI (n = 133), and controls were selected from a database of alternative myelopathy etiologies for validation of the proposed diagnostic criteria (n = 280).
Main Outcomes and Measures: A descriptive analysis of SCI was performed and used to propose diagnostic criteria, and the criteria were validated.
Results: Of 133 included patients with a spontaneous SCI, the median (interquartile range) age at presentation was 60 (52-69) years, and 101 (76%) had vascular risk factors. Rapid onset of severe deficits reaching nadir within 12 hours was typical (102 [77%]); some had a stuttering decline (31 [23%]). Sensory loss occurred in 126 patients (95%), selectively affecting pain/temperature in 49 (39%). Initial magnetic resonance imaging (MRI) spine results were normal in 30 patients (24%). Characteristic MRI T2-hyperintense patterns included owl eyes (82 [65%]) and pencil-like hyperintensity (50 [40%]); gadolinium enhancement (37 of 96 [39%]) was often linear and located in the anterior gray matter. Confirmatory MRI findings included diffusion-weighted imaging/apparent diffusion coefficient restriction (19 of 29 [67%]), adjacent dissection/occlusion (16 of 82 [20%]), and vertebral body infarction (11 [9%]). Cerebrospinal fluid showed mild inflammation in 7 of 89 patients (8%). Diagnostic criteria was proposed for definite, probable, and possible SCI of periprocedural and spontaneous onset. In the validation cohort (n = 280), 9 patients (3%) met criteria for possible SCI, and none met criteria for probable SCI.
Conclusions and Relevance: This large series of spontaneous SCIs provides clinical, laboratory, and MRI clues to SCI diagnosis. The diagnostic criteria proposed here will aid clinicians in making the correct diagnosis and ideally improve future care for patients with SCI. The validation of these criteria supports their utility in the evaluation of acute myelopathy.

PMID 30264146  JAMA Neurol. 2019 Jan 1;76(1):56-63. doi: 10.1001/jaman・・・
著者: T A Sandson, J H Friedman
雑誌名: Medicine (Baltimore). 1989 Sep;68(5):282-92.
Abstract/Text While the incidence of spinal cord ischemia is not known, it is generally considered to be rare. Diagnosis of presumed spinal cord ischemia requires the appropriate clinical picture and exclusion of other possible etiologies. Definitive diagnosis usually requires postmortem examination. During a 52-month period, 8 patients with presumed spinal cord infarction were evaluated at a 238-bed community hospital. These cases accounted for 1.2% of all admissions for stroke. Infarction of the spinal cord was confirmed on postmortem examination in 2 cases. All 6 surviving patients regained substantial motor function. Bowel and/or bladder dysfunction returned to normal in 3 patients. The literature is reviewed, and the cases are discussed in relation to the pertinent anatomic, pathogenic, and clinical aspects of spinal cord infarction.

PMID 2677596  Medicine (Baltimore). 1989 Sep;68(5):282-92.
著者: Jan Novy, Alain Carruzzo, Philippe Maeder, Julien Bogousslavsky
雑誌名: Arch Neurol. 2006 Aug;63(8):1113-20. doi: 10.1001/archneur.63.8.1113.
Abstract/Text BACKGROUND: The natural history and pathogenesis of ischemic spinal cord infarction remain largely unknown because most clinical studies have included mostly patients with ischemic lesions associated with aortic surgery or prolonged arterial hypotension.
OBJECTIVE: To assess the pathogenetic mechanisms and outcomes of these cord infarctions based on clinical findings and spinal vascular anatomy.
DESIGN: Retrospective review.
PATIENTS: We analyzed the clinical, laboratory, imaging, and outcome data for 27 patients with acute spinal cord infarction admitted between 1990 and 2003. There were 11 men and 16 women (age range, 19-80 years [mean age, 56 years]).
RESULTS: Ten patients had anterior spinal artery patterns, 4 each had anterior and posterior unilateral patterns, 3 had central patterns, and 2 each had posterior spinal artery patterns, transverse syndromes, and unclassifiable clinical pictures. Twenty patients had no identifiable etiology. Patients with a central or transverse infarct showed a high frequency of peripheral vascular disease, and all transverse infarcts occurred following prolonged arterial hypotension. The onset of all other infarcts was associated with mechanical triggering movements (P = .02), and these patients frequently had diseases of the spine (P = .003) at the level of the spinal lesion, with the clinical data suggesting root involvement at the level of the spinal cord lesion and pointing to mechanical injury of a radicular artery. The outcomes were favorable, with only 13 patients showing significant gait impairment on leaving the hospital.
CONCLUSIONS: There are 2 main types of spinal cord ischemia: (1) radicular artery territory infarct (bilateral anterior or posterior spinal artery infarcts and unilateral infarcts) and (2) extensive spinal cord hypoperfusion (central and transverse infarcts). Each type has characteristic clinical, imaging, pathogenetic, and prognostic features.

PMID 16908737  Arch Neurol. 2006 Aug;63(8):1113-20. doi: 10.1001/archn・・・
著者: W P Cheshire, C C Santos, E W Massey, J F Howard
雑誌名: Neurology. 1996 Aug;47(2):321-30.
Abstract/Text We reviewed 44 cases of ischemia and infarction of the spinal cord at two university hospitals. Three patients experienced transient ischemic attacks. Etiologies of completed strokes were diverse and included rupture and surgical repair of aortic aneurysms, aortic dissection, aortic rupture and thrombosis, global ischemia, anterior spinal artery embolism, repair and thrombosis of spinal arteriovenous malformations, hematomyelia, epidural hematoma, cervical osteophytosis, celiac plexus block, systemic lupus erythematosus, coagulopathy, and decompression sickness. Motor function improved in 12 patients, was substantial in only one, and occurred largely within the first 2 to 4 weeks. Favorable ambulatory outcome correlated with improving neurologic examinations and relatively preserved strength in hip abductors and knee extensors. More extensive deficits without initial improvement portended a more severe prognosis. Autonomic dysfunction, pain, paresthesia, and depression were common and impeded recovery in some patients. The mean level of deficit was at T-8 and in cases of global ischemia was at T-9, which leads us to dispute the classical view of a midthoracic watershed zone of ischemic vulnerability near T-4.

PMID 8757000  Neurology. 1996 Aug;47(2):321-30.
著者: Wilhelm Küker, Michael Weller, Uwe Klose, Hilmar Krapf, Johannes Dichgans, Thomas Nägele
雑誌名: J Neurol. 2004 Jul;251(7):818-24. doi: 10.1007/s00415-004-0434-z.
Abstract/Text Infarction is a rare cause of spinal cord dysfunction. Whereas diffusion-weighted (DW) MRI has been established as a highly sensitive technique for assessing acute cerebral ischemia, its role in spinal cord infarction remains to be determined. The purpose of this study is to present the signal characteristics of acute spinal cord ischemia using DWMRI within the first two days and after one week. MRI including DW imaging (DWI) was performed in three patients with acute spinal cord dysfunction 8, 12 and 30 hours after the onset of symptoms and repeated after one week in two patients. Two initial scans included EPI DW sequences in transverse and sagittal orientation. The remaining examinations were performed with an optimised high-spatial resolution DWI sequence in the transverse plane. The diagnosis of spinal cord ischemia was established by imaging, clinical history and CSF analysis. T2 signal abnormality and restricted diffusion was demonstrated in all initial examinations. Transverse DW sequences had the highest sensitivity. The spinal infarctions were mainly located in the centre of the spinal cord and the grey matter. Contrast enhancement was absent. After one week, the restricted diffusion had normalised (pseudo normalisation) whereas the T2 signal changes had become more prominent. Restricted diffusion in the course of spinal cord ischemic infarction can be demonstrated using DW-MRI. Whereas a diffusion abnormality can be found after few hours, it does not last for longer than one week. At this time, the establishment of the diagnosis has to rely mainly on T2-weighted images with additional post contrast T1-weighted images being useful.

PMID 15258783  J Neurol. 2004 Jul;251(7):818-24. doi: 10.1007/s00415-0・・・
著者: Majda M Thurnher, Roland Bammer
雑誌名: Neuroradiology. 2006 Nov;48(11):795-801. doi: 10.1007/s00234-006-0130-z. Epub 2006 Sep 15.
Abstract/Text INTRODUCTION: Spinal cord infarction is a rare clinical diagnosis characterized by a sudden onset of paralysis, bowel and bladder dysfunction, and loss of pain and temperature perception, with preservation of proprioception and vibration sense. Magnetic resonance imaging (MRI) usually demonstrates intramedullary hyperintensity on T2-weighted MR images with cord enlargement. However, in approximately 45% of patients, MR shows no abnormality. Diffusion-weighted MR imaging (DWI) has been widely used for the evaluation of a variety of brain disorders, especially for acute stroke. Preliminary data suggest that DWI has the potential to be useful in the early detection of spinal infarction.
METHODS: We performed DWI, using navigated, interleaved, multishot echo planar imaging (IEPI), in a series of six patients with a clinical suspicion of acute spinal cord ischemia.
RESULTS: In all patients, high signal was observed on isotropic DWI images with low ADC values (0.23 and 0.86x10(-3) cm(2)/s), indicative of restricted diffusion.
CONCLUSION: We analyzed the imaging findings from conventional MR sequences and diffusion-weighted MR sequences in six patients with spinal cord infarction, compared the findings with those in published series, and discuss the value of DWI in spinal cord ischemia based on current experience. Although the number of patients with described DWI findings totals only 23, the results of previously published studies and those of our study suggest that DWI has the potential to be a useful and feasible technique for the detection of spinal infarction.

PMID 16977443  Neuroradiology. 2006 Nov;48(11):795-801. doi: 10.1007/s・・・
著者: Mei-Yun Cheng, Rong-Kuo Lyu, Yeu-Jhy Chang, Chiung-Mei Chen, Sien-Tsong Chen, Yau-Yau Wai, Long-Sun Ro
雑誌名: J Neurol. 2009 Sep;256(9):1418-26. doi: 10.1007/s00415-009-5126-2. Epub 2009 Apr 28.
Abstract/Text The purpose of this article is to investigate the relationship between clinical features and imaging characteristics of spinal cord infarction (SCI). Twenty patients (11 women/9 men) were diagnosed at the Chang Gung Memorial Hospital between March 1993 and March 2007. Data of clinical features, possible causes and imaging findings were collected and analyzed retrospectively. Their average age was 56.6 +/- 15.5 years. Possible causes of SCI were found in 16 patients (80%), including 8 (40%) who had a high risk of atherosclerosis, 5 (25%) who had aortic diseases, and 3 (15%) who had adjacent spinal diseases; the other 4 (20%) were cryptogenic. Seven patients had concomitant SCI and vertebral body infarctions, and four of them had aortic diseases. Most of the vertebral body infarctions were seen in the thoracolumbar regions (p = 0.008, chi(2) test) and were adjacent to their cord lesions. Twelve patients (60%) had poor outcomes (mortality, unable to walk, or able to walk with two aids). Younger patients (
PMID 19399383  J Neurol. 2009 Sep;256(9):1418-26. doi: 10.1007/s00415-・・・
著者: L Tosi, G Rigoli, A Beltramello
雑誌名: J Neurol Neurosurg Psychiatry. 1996 Jan;60(1):55-60.
Abstract/Text A 16 year old girl did a handstand for fun, returned to her feet, experienced a sudden pain in her back, and became progressively paraplegic within 30 hours. MRI showed lumbar cord swelling, multiple Schmorl's nodes, a collapsed T11-T12 disc space, and intraspongious disc prolapse into the T12 vertebral body. These findings, related to the initial manoeuvre, suggested that an acute vertical disc herniation could have occurred as the first step in a process leading to spinal cord infarction due to fibrocartilaginous emboli from the nucleus pulposus of the intervertebral disc. The medical literature so far reports 32 cases of fibrocartilaginous embolism (FCE) of the spinal cord, all at necropsy, with the exception of one histologically demonstrated in a living patient. A clinical diagnosis of FCE would be desirable for many important reasons, but was never made. This causes severe limitations in the knowledge of the disease and precludes any therapeutic possibility. On the basis of the clinical features and findings in the present case, compared with data from the reported cases, a first attempt is made to identify the clinical context within which new information obtainable through MRI examination can lead to a reliable clinical diagnosis of FCE. The vexed question of the pathogenesis has been reviewed. An increased intraosseous pressure within the vertebral body, due to acute vertical disc herniation, seems to offer a consistent pathogenetic explanation and some therapeutic prospects.

PMID 8558152  J Neurol Neurosurg Psychiatry. 1996 Jan;60(1):55-60.
著者: Krassen Nedeltchev, Thomas J Loher, Frank Stepper, Marcel Arnold, Gerhard Schroth, Heinrich P Mattle, Matthias Sturzenegger
雑誌名: Stroke. 2004 Feb;35(2):560-5. doi: 10.1161/01.STR.0000111598.78198.EC. Epub 2004 Jan 15.
Abstract/Text BACKGROUND AND PURPOSE: Current knowledge of long-term outcome in patients with acute spinal cord ischemia syndrome (ASCIS) is based on few studies with small sample sizes and <2 years' follow-up. Therefore, we analyzed clinical features and outcome of all types of ASCIS to define predictors of recovery.
METHODS: From January 1990 through October 2002, 57 patients with ASCIS were admitted to our center. Follow-up data were available for 54. Neurological syndrome and initial degree of impairment were defined according to American Spinal Injury Association (ASIA)/International Medical Society of Paraplegia criteria. Functional outcome was assessed by walking ability and bladder control.
RESULTS: Mean age was 59.4 years; 29 were women; and mean follow-up was 4.5 years. The origin was atherosclerosis in 33.3%, aortic pathology in 15.8%, degenerative spine disease in 15.8%, cardiac embolism in 3.5%, systemic hypotension in 1.8%, epidural anesthesia in 1.8%, and cryptogenic in 28%. The initial motor deficit was severe in 30% (ASIA grades A and B), moderate in 28% (ASIA C), and mild in 42% (ASIA D). At follow-up, 41% had regained full walking ability, 30% were able to walk with aids, 20% were wheelchair bound, and 9% had died. Severe initial impairment (ASIA A and B) and female sex were independent predictors of unfavorable outcome (P=0.012 and P=0.043).
CONCLUSIONS: Considering a broad spectrum of clinical presentations and origins, the outcome in our study was more favorable than in previous studies reporting on ASCIS subgroups with more severe initial deficits.

PMID 14726546  Stroke. 2004 Feb;35(2):560-5. doi: 10.1161/01.STR.00001・・・
著者: K Tofuku, H Koga, T Yamamoto, K Yone, S Komiya
雑誌名: Spinal Cord. 2008 Mar;46(3):241-2. doi: 10.1038/sj.sc.3102092. Epub 2007 Jun 19.
Abstract/Text STUDY DESIGN: A case report of spinal cord infarction following endoscopic variceal ligation.
OBJECTIVES: To describe an exceedingly rare case of spinal cord infarction following endoscopic variceal ligation.
SETTING: Department of Orthopaedic Surgery, Kagoshima, Japan.
METHODS: A 75-year-old woman with cirrhosis caused by hepatitis C virus, who was admitted to our hospital for the treatment of esophageal varices, experienced numbness of the hands and lower extremities bilaterally following an endoscopic variceal ligation procedure. Sensory and motor dysfunction below C6 level progressed rapidly, resulting in inability to move the lower extremities the following day. Magnetic resonance imaging of the spine revealed abnormal spinal cord signal on T2-weighted images from approximately C6 through T5 levels, which was diagnosed as spinal cord infarction.
RESULTS: The patient underwent hyperbaric oxygen treatment. Her symptoms and signs related to spinal cord infarction gradually remitted, and nearly complete disappearance of neurological deficits was noted within 3 months after the start of treatment.
CONCLUSION: We speculate that the pathogenesis of the present case may have involved congestion of the abdominal-epidural-spinal cord venous network owing to ligation of esophageal varices and increased thoracoabdominal cavity pressure.

PMID 17579614  Spinal Cord. 2008 Mar;46(3):241-2. doi: 10.1038/sj.sc.3・・・
著者: M B Bracken, M J Shepard, T R Holford, L Leo-Summers, E F Aldrich, M Fazl, M Fehlings, D L Herr, P W Hitchon, L F Marshall, R P Nockels, V Pascale, P L Perot, J Piepmeier, V K Sonntag, F Wagner, J E Wilberger, H R Winn, W Young
雑誌名: JAMA. 1997 May 28;277(20):1597-604.
Abstract/Text OBJECTIVE: To compare the efficacy of methylprednisolone administered for 24 hours with methyprednisolone administered for 48 hours or tirilazad mesylate administered for 48 hours in patients with acute spinal cord injury.
DESIGN: Double-blind, randomized clinical trial.
SETTING: Sixteen acute spinal cord injury centers in North America.
PATIENTS: A total of 499 patients with acute spinal cord injury diagnosed in National Acute Spinal Cord Injury Study (NASCIS) centers within 8 hours of injury.
INTERVENTION: All patients received an intravenous bolus of methylprednisolone (30 mg/kg) before randomization. Patients in the 24-hour regimen group (n=166) received a methylprednisolone infusion of 5.4 mg/kg per hour for 24 hours, those in the 48-hour regimen group (n=167) received a methylprednisolone infusion of 5.4 mg/kg per hour for 48 hours, and those in the tirilazad group (n=166) received a 2.5 mg/kg bolus infusion of tirilazad mesylate every 6 hours for 48 hours.
MAIN OUTCOME MEASURES: Motor function change between initial presentation and at 6 weeks and 6 months after injury, and change in Functional Independence Measure (FIM) assessed at 6 weeks and 6 months.
RESULTS: Compared with patients treated with methylprednisolone for 24 hours, those treated with methylprednisolone for 48 hours showed improved motor recovery at 6 weeks (P=.09) and 6 months (P=.07) after injury. The effect of the 48-hour methylprednisolone regimen was significant at 6 weeks (P=.04) and 6 months (P=.01) among patients whose therapy was initiated 3 to 8 hours after injury. Patients who received the 48-hour regimen and who started treatment at 3 to 8 hours were more likely to improve 1 full neurologic grade (P=.03) at 6 months, to show more improvement in 6-month FIM (P=.08), and to have more severe sepsis and severe pneumonia than patients in the 24-hour methylprednisolone group and the tirilazad group, but other complications and mortality (P=.97) were similar. Patients treated with tirilazad for 48 hours showed motor recovery rates equivalent to patients who received methylprednisolone for 24 hours.
CONCLUSIONS: Patients with acute spinal cord injury who receive methylprednisolone within 3 hours of injury should be maintained on the treatment regimen for 24 hours. When methylprednisolone is initiated 3 to 8 hours after injury, patients should be maintained on steroid therapy for 48 hours.

PMID 9168289  JAMA. 1997 May 28;277(20):1597-604.

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