Gaps in the evidence-based knowledge
The use of steroids continues to be controversial despite 3 randomized, double-blind, multicenter trials (National Acute Spinal Cord Injury Study [NASCIS] I, II, and III). The NASCIS trials showed no statistical difference between steroids and placebo in terms of neurologic recovery (their primary endpoint) at 1 year, except in post hoc analyses of subgroups, and there has been considerable evidence of side effects in high-dose steriod therapy.
There are no precise guidelines regarding the timing of surgical decompression following acute SCI except for cervical SCI. There is growing evidence that spinal decompression following cervical injury should be performed within 24 hours of injury.10
Timing, dosage, and frequency of electric stimulation is controversial, because increasing activity at the site of injury acutely may lead to a larger penumbra. In the subacute period, there is insufficient evidence to quantify the amount of therapy required to obtain optimum results.
There is controversy regarding outcomes in body-weight-supported treadmill systems versus overground ambulation training.