How should I manage an acute spinal cord infarction, including spinal stabilization, perfusion optimization, antithrombotic therapy, and rehabilitation?

Management of Spinal Cord Infarction

Maintain mean arterial pressure between 75-80 mmHg (lower limit) and 90-95 mmHg (upper limit) for 3-7 days post-infarction to optimize spinal cord perfusion, while implementing immediate spinal stabilization, comprehensive supportive care, and early rehabilitation. 1, 2

Immediate Hemodynamic Optimization

Blood pressure management is the cornerstone of acute spinal cord infarction treatment, as it represents the only available intervention that likely improves neurological outcomes. 2

Pre-Assessment Phase

• Maintain systolic blood pressure >110 mmHg immediately upon recognition and during initial assessment to reduce mortality 3, 1, 4
• This threshold is critical as hypotension at admission (SBP <110 mmHg) is an independent mortality predictor 3

Sustained Perfusion Support (Days 1-7)

• Target mean arterial pressure between 75-80 mmHg as the lower limit to prevent secondary ischemic injury 1, 2, 5
• Avoid actively augmenting MAP beyond 90-95 mmHg as the upper limit to prevent complications from excessive vasopressor use 2, 5
• Continue this MAP range for 3-7 days post-infarction, as correlation between MAP and neurological improvement exists primarily during the first 2-3 days but benefits may extend through the first week 3, 2, 5
• Use continuous arterial catheter monitoring, as achieving target MAP is challenging (patients spend approximately 25% of time below target despite aggressive management) 3

Important caveat: While the 2013 AANS/CNS guidelines recommended MAP 85-90 mmHg, the most recent 2024 Global Spine Journal guidelines acknowledge this was based on very low-quality evidence and now suggest a broader, more conservative range of 75-95 mmHg. 2, 6 This reflects recognition that the relationship between MAP and neurologic recovery remains uncertain, and excessive vasopressor use carries its own complications. 6

Spinal Stabilization and Immobilization

• Apply manual in-line stabilization immediately if any concern for concurrent vertebral injury exists 1, 4, 7
• Use rigid cervical collar combined with head fixation during transport 1, 7
• Transport on rigid backboard with vacuum mattress 1, 7

Antithrombotic Therapy Considerations

Current consensus for non-traumatic spinal cord infarction supports antiplatelet therapy as the primary antithrombotic approach. 8

• Initiate antiplatelet agents (aspirin or other antiplatelet therapy) for secondary stroke prevention 8
• Critical distinction: Unlike traumatic spinal cord injury where prophylactic anticoagulation with low-molecular-weight heparin is standard for DVT prophylaxis 9, the evidence for spinal cord infarction specifically supports antiplatelet rather than anticoagulation therapy 8
• Implement mechanical DVT prophylaxis (sequential compression devices) immediately given the high thromboembolic risk from paraplegia 8, 9

Respiratory Management

• Assess respiratory function immediately, as high cervical infarctions (C4 or above) may require immediate intubation 1, 7, 9
• For lower cervical/thoracic infarctions, evaluate respiratory mechanics on a case-by-case basis, recognizing that any lesion above T11 will disrupt respiratory function acutely 9
• Consider early tracheostomy (within 7 days) if prolonged ventilatory support is anticipated, particularly for high cervical lesions (C2-C5), as this accelerates weaning and reduces ICU length of stay 1, 7

Prevention of Secondary Complications

Pressure Ulcer Prevention (Prevalence reaches 26% without intervention)

• Begin early mobilization immediately once hemodynamic stability is achieved 3, 1, 7
• Perform visual and tactile checks of all at-risk areas (sacrum, heels, ischium, occiput) at least once daily 3, 7
• Reposition every 2-4 hours with pressure zone checks 3, 7
• Use high-level prevention supports (air-loss mattress, dynamic mattress) 3
• Apply discharge tools (cushions, foam, pillows) to avoid interosseous contact at knees 3

Urological Management

• Remove indwelling urinary catheter as soon as patient is medically stable 3, 1
• Transition to intermittent urinary catheterization once daily diuresis volume is adequate to reduce urological complications (urinary tract infections, urolithiasis) 3, 1, 7
• Self-intermittent urethral catheterization is the gold standard approach 3, 7

Pain Management

Implement multimodal analgesia from the acute phase to prevent development of chronic pain syndromes. 1, 4, 7

• Combine non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids during acute management 1, 4, 7
• For neuropathic pain that develops: initiate oral gabapentinoid treatment for >6 months 4, 7

Early Rehabilitation

Begin rehabilitation immediately after hemodynamic stabilization to maximize neurological recovery, as physical exercise enhances CNS regeneration through neurotrophic factor elaboration. 1, 7

• Start joint range-of-motion exercises and positioning upon achieving stability 4, 7
• Perform stretching for at least 20 minutes per zone 4, 7
• Apply simple posture orthoses to prevent contractures and deformities 4
• Recognize that neurologic recovery is a multi-year process with most improvement occurring in the first year, justifying aggressive rehabilitation 9

Transfer to Specialized Centers

• Transfer patients directly to Level 1 trauma centers or specialized spinal cord injury units within the first hours, as this reduces morbidity and mortality, enables earlier interventions, reduces ICU length of stay, and improves neurological outcomes 1, 4
• Direct admission is particularly important for spinal cord infarction given the time-sensitive nature of perfusion optimization 1

Critical Pitfalls to Avoid

• Never allow systolic blood pressure to drop below 110 mmHg during the acute phase, as this significantly increases mortality risk 3, 4
• Do not delay implementation of MAP augmentation, as the window for preventing secondary ischemic injury is narrow 3, 2
• Avoid inadequate blood pressure monitoring—use continuous arterial catheter monitoring rather than intermittent cuff measurements 3
• Do not neglect early mobilization and rehabilitation, as preventable complications (pressure ulcers, contractures, DVT) rapidly develop and worsen functional outcomes 3, 1, 7
• Do not use corticosteroids, as professional neurosurgical societies have issued level 1 statements against their use in spinal cord injury due to lack of benefit and potential harm 9