What are the ideal blood pressure goals for individuals with cervical spinal cord injury?

Blood Pressure Goals in Cervical Spinal Cord Injury

For patients with cervical spinal cord injury, a systolic blood pressure >110 mmHg initially and a mean arterial pressure (MAP) of at least 70 mmHg should be maintained during the first week after injury to optimize neurological outcomes and reduce mortality. 1

Initial Management (First 24 Hours)

• Initial target: Systolic blood pressure >110 mmHg before injury assessment 1
• Avoid hypotension: Systolic blood pressure <110 mmHg is an independent factor for increased mortality in spinal cord injury patients 1
• Continuous monitoring: Arterial line placement is recommended as MAP falls below target 25% of the time without continuous monitoring 1

Ongoing Management (First Week)

• Minimum MAP goal: Maintain MAP ≥70 mmHg during the first week post-injury 1
• Duration: Continue MAP goals for 5-7 days after injury 2
• Monitoring method: Use arterial catheter for continuous blood pressure monitoring 1

Evidence Analysis

The French recommendations (2020) provide the most recent and comprehensive guidelines, suggesting:

• MAP ≥70 mmHg during the first week to limit neurological deterioration 1
• A small retrospective study showed correlation between time spent with MAP <65-70 mmHg and poorer neurological improvement 1
• Recent evidence correlates spinal perfusion pressure >50 mmHg with better neurological status at 6 months 1

While the American Association of Neurological Surgeons/Congress of Neurological Surgeons has recommended higher MAP targets (>85 mmHg), these recommendations are based on two prospective studies without control groups, providing insufficient evidence for MAP levels over 70 mmHg 1.

A 2017 systematic review identified two prospective studies suggesting MAP goals of 85-90 mmHg for 5-7 days 2, but the French guidelines (2020) represent more recent expert consensus.

Vasopressor Selection

• Cervical and upper thoracic injuries: Norepinephrine preferred 2
• Mid to lower thoracic injuries: Phenylephrine or norepinephrine 2
• Avoid: Dopamine has been associated with more complications than other vasopressors 2

Important Considerations and Pitfalls

• Blood pressure variability: Recent research (2019) has shown that increasing MAP can paradoxically decrease blood flow in some regions of the injured cord, termed "blood pressure-induced local steal" 3
• Diastolic ischemia: In some patients, parts of the injury site are only perfused during systole despite maintaining MAP 85-90 mmHg 3
• Hemorrhagic contusion: Elevated MAP goals do not significantly increase the risk of hemorrhagic expansion in cervical SCI with hemorrhagic contusion 4
• Hypertension history: Patients with a history of hypertension and higher preoperative MAP have shown better neurological recovery at 1 year of follow-up 5

Transfer Recommendations

• Transfer patients with traumatic spinal cord injury (including those with transient neurological recovery) to a specialized care unit to decrease morbidity and long-term mortality 1
• Level 1 trauma centers with access to specialized spinal cord injury care are associated with earlier surgical procedures, reduced ICU stays, and improved neurological outcomes 1

The evidence supports maintaining adequate blood pressure in cervical spinal cord injury patients, with a minimum systolic BP >110 mmHg initially and MAP ≥70 mmHg for the first week to optimize neurological recovery and reduce mortality.