Cortisone is used in the treatment of acute MS relapses in Multiple Sclerosis. Usually, a high-dose cortisone preparation is administered intravenously over a period of 3 to 5 days. In addition, high-dose intravenous cortisone administration is also often used in patients with advanced disease independent of relapse at regular (often 3 monthly) intervals to improve spastic paralysis and exploit the drive-increasing effect of high-dose steroids. Besides these two classic therapies, cortisone is also administered intrathecally in selected cases. Intrathecal means that the drug is injected directly into the spinal canal. This administration is basically comparable to a diagnostic lumbar puncture (spinal fluid removal), only that the spinal fluid is not removed, but only a drug is inserted into the spinal canal through the hollow needle.
A depot cortisone preparation, usually Triamcinolone acetonide (TCA), a crystal suspension from which the active ingredient Triamcinolone is slowly released, is used for this administration. Different regimes exist for intrathecal cortisone therapy. A working group from Bochum published a therapy scheme with 6 TCA injections every 3 days as induction therapy in 2003, which is then refreshed every 6 – 12 weeks. Although the authors were able to demonstrate an effect in patients with progressive multiple sclerosis and spinal symptoms, I consider the procedure with frequently repeated lumbar punctures to be little pragmatic and very stressful. However, I do consider intrathecal steroid therapy for patients with spinal symptoms to be an interesting option and offer it in my consultation hour.
But I do without induction therapy and instead give a single injection, which I then repeat every 3 months – provided the patient feels an effect of the measure. The dose of the single injections varies between 40 and 80 mg Triamcinolone per administration depending on the center. I personally prefer to administer 80 mg per single injection.
As already mentioned above, the injection is not suitable for every patient in the same way. I recommend the measure primarily to MS patients who suffer from moderate to severe paraspasticity and whose mobility is significantly impaired by paraspasticity. In these patients, good results can be achieved with intrathecal cortisone administration, although many patients report after repeated injections that the effect is often only short-lived. In such cases, one must then weigh whether the effort of repeated lumbar punctures is justified.
The intrathecal administration of cortisone is described in the literature as risk-free. The complications of a lumbar puncture are mainly reported, but they occur relatively rarely. This can primarily involve post-puncture headaches or local pain at the puncture site. However, it is also known that repeated lumbar punctures can lead to the development of subdural fluid accumulations (so-called hygromas), which can have a significant disease value in unfavorable cases. This is also a reason why I am rather critical of too frequent intrathecal interventions. Furthermore, the frequent administrations of the steroid-containing crystal suspension carry the risk that, in contrast to the short-term pulse therapies, there may be a relevant suppression of the adrenal function. Therefore, in summary, it can be said that intrathecal steroid administrations, if used wisely and sensibly, are a useful addition to the symptomatic therapy of paraspasticity. However, I am critical of too frequent and uncritical administrations – especially with only moderately pronounced paraspatik. But it is always true for every administration that the procedure should only be performed by experienced neurologists.