What is the evidence for maintaining a mean arterial pressure (MAP) of >85 mmHg during cervical decompression surgery?

Mean Arterial Pressure Management During Cervical Decompression Surgery

Based on current guidelines, maintaining a mean arterial pressure (MAP) of >85 mmHg during cervical decompression surgery is recommended to improve neurological outcomes, although the evidence supporting this specific target is limited. 1, 2

Evidence for MAP Targets in Cervical Decompression Surgery

• The American Association of Neurological Surgeons/Congress of Neurological Surgeons recommends maintaining MAP >85 mmHg for 5-7 days following spinal cord injury, which would include the perioperative period for cervical decompression surgery 1, 2
• This recommendation is based primarily on limited evidence from prospective interventional studies without control groups 2
• French guidelines from 2020 suggest a more conservative approach, recommending MAP >70 mmHg during the first week after injury, noting insufficient evidence to recommend levels over 70 mmHg 2
• The correlation between MAP level and neurological improvement appears strongest in the first 2-3 days after admission 2

Clinical Outcomes and MAP Targets

• A recent prospective randomized pilot study (2025) specifically examining MAP targets in degenerative cervical myelopathy found that maintaining intraoperative MAP at 20 mmHg above the patient's preoperative average MAP resulted in better neurological outcomes at 1-year follow-up compared to normotensive management 3
• Neurological improvement was documented in 63.3% of patients in the hypertensive group compared to 53.3% in the normotensive group 3
• Improvements in modified Japanese Orthopaedic Association (mJOA) scores were better for the hypertensive group during the 1-year follow-up 3

Monitoring Recommendations

• Continuous arterial pressure monitoring via arterial catheter is recommended as studies show MAP is below target approximately 25% of the time without close monitoring 2, 1
• The reference point for measuring cerebral perfusion pressure should be placed at the external ear tragus 4

Potential Risks and Considerations

• While vasopressor use to maintain elevated MAP is common practice, there is evidence that it may exacerbate spinal hemorrhage and extravasation in acute spinal cord injury 5
• Spinal decompression surgery itself may help mitigate these vasopressor-induced complications 5
• Patients with chronic hypertension are at increased risk for intraoperative hypotension during cervical spine surgery, which is associated with acute kidney injury and increased need for intensive care 6
• "White cord syndrome" or reperfusion injury is a rare complication after cervical decompression that may benefit from MAP goal-directed therapy 7

Vasopressor Selection

• Norepinephrine is recommended for cervical and upper thoracic injuries 8
• Phenylephrine or norepinephrine can be considered for mid- to lower thoracic injuries 8
• Dopamine has been associated with more complications than other vasopressors 8

Duration of MAP Augmentation

• Most guidelines recommend maintaining elevated MAP for 5-7 days post-injury 1, 2
• The correlation between MAP level and neurological improvement appears strongest in the first 2-3 days after admission 2

Algorithm for MAP Management During Cervical Decompression Surgery

1. Establish continuous arterial pressure monitoring prior to induction 2, 1
2. Target MAP >85 mmHg during surgery and for 5-7 days postoperatively 2, 1
3. Use norepinephrine as the first-line vasopressor for MAP maintenance 8
4. Monitor for complications related to vasopressor use, including excessive bleeding 5
5. Continue MAP monitoring in the postoperative period, as MAP often falls below target without vigilant monitoring 2

Despite some conflicting evidence, the most recent and highest quality evidence supports maintaining MAP >85 mmHg during cervical decompression surgery to optimize neurological outcomes 1, 3.