Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management

Abstract

<jats:p>The optimal management of acute spinal cord injuries remains to be defined. The authors prospectively applied resuscitation principles of volume expansion and blood pressure maintenance to 77 patients who presented with acute neurological deficits as a result of spinal cord injuries occurring from C-1 through T-12 in an effort to maintain spinal cord blood flow and prevent secondary injury. According to the Intensive Care Unit protocol, all patients were managed by Swan-Ganz and arterial blood pressure catheters and were treated with immobilization and fracture reduction as indicated. Intravenous fluids, colloid, and vasopressors were administered as necessary to maintain mean arterial blood pressure above 85 mm Hg. Surgery was performed for decompression and stabilization, and fusion in selected cases. Sixty-four patients have been followed at least 12 months postinjury by means of detailed neurological assessments and functional ability evaluations.</jats:p> <jats:p>Sixty percent of patients with complete cervical spinal cord injuries improved at least one Frankel or American Spinal Injury Association (ASIA) grade at the last follow-up review. Thirty percent regained the ability to walk and 20% had return of bladder function 1 year postinjury.</jats:p> <jats:p>Thirty-three percent of the patients with complete thoracic spinal cord injuries improved at least one Frankel or ASIA grade. Approximately 10% of the patients regained the ability to walk and had return of bladder function.</jats:p> <jats:p>As of the 12-month follow-up review, 92% of patients demonstrated clinical improvement after sustaining incomplete cervical spinal cord injuries compared to their initial neurological status. Ninety-two percent regained the ability to walk and 88% regained bladder function.</jats:p> <jats:p>Eighty-eight percent of patients with incomplete thoracic spinal cord injuries demonstrated significant improvements in neurological function 1 year postinjury. Eighty-eight percent were able to walk and 63% had return of bladder function.</jats:p> <jats:p>The authors conclude that the enhanced neurological outcome that was observed in patients after spinal cord injury in this study was in addition to, and/or distinct from, any potential benefit provided by surgery. Early and aggressive medical management (volume resuscitation and blood pressure augmentation) of patients with acute spinal cord injuries optimizes the potential for neurological recovery after sustaining trauma.</jats:p>

Acute Changes in Systemic Hemodynamics and Serum Vasopressin After Complete Cervical Spinal Cord Injury in Piglets

“…Our main findings were that complete cervical SCI caused an immediate tachycardia which lasted for approximately 1 h, immediate hypotension which was sustained for the 4-h duration of the study, decreases in both systemic and pulmonary vascular resistance, and a compensatory increase in cardiac output, which resulted initially from an increase in HR but was later sustained after resolution of tachycardia by an increase in cardiac stroke volume. These data are consistent with previously published findings in adult small and large animal models as well as in humans, which consistently demonstrate reductions in HR, MAP, and systemic vascular resistance over the first few hours and in clinical studies for up to 2 weeks after SCI [3][4][5][6][7][8][9][17][18][19][20][21][22][23]. Levi et al invasively measured hemodynamics beginning 11 ± 6 h after complete and incomplete cervical SCI in adults and found that 82% required vasopressors for an average of 5.7 days after injury to maintain MAP >90 mmHg [8].…”

“…These investigators showed that hypotension was associated with decreased systemic as well as pulmonary vascular resistance. Vale et al demonstrated in adults with SCI that the higher the level of injury and the greater its severity, the higher the percentage of patients needing vasopressor therapy to maintain MAP >85 mmHg: complete cervical SCI-90% (for an average of 13 days), incomplete cervical-52%, complete thoracic-33%, and incomplete thoracic-25% [9].…”

“…While there are no reports describing acute hemodynamic changes after SCI in children, adult human observational studies have shown that as many as 50-90% of patients with cervical SCI require early hemodynamic support with intravascular volume loading and vasopressor infusions for up to 2 weeks to maintain mean arterial pressure (MAP) above 85-90 mmHg [6][7][8][9]. In the absence of aggressive management, hemodynamic instability can lead to delays in operative intervention after SCI [10] and may worsen long-term outcome by reducing spinal cord blood flow, which is already compromised by several vascular mechanisms, including primary injury to microvessels, intraluminal thrombosis, vasospasm, compression, edema, and endothelial injury [11][12][13][14][15].…”

Emergency Neurological Life Support: Traumatic Spine Injury

“…These entities recommend maintenance of mean arterial blood pressure (MAP) at 85-90 mmHg for the first 7 days following acute SCI to improve spinal cord perfusion [60]. This is based on uncontrolled studies that demonstrated benefit in patients who were maintained with a MAP of 85 for 7 days following injury [38,39]. Providers should maintain caution when inducing blood pressure in patients with concomitant injuries, especially traumatic brain injuries.…”

The Incomplete Picture of Incomplete Spinal Cord Injury

“…Current management in today's medical centers typically consists of maintaining perfusion pressures of 85 mmHG for 72 h in order to minimize the ischemia that contributes to secondary injury. Unfortunately, this practice is only supported by class III evidence provided in a single prospective case series [8]. Outside of these practice parameters and the consensus opinion for early surgical decompression, very little medical care is directed to specifically address spinal cord injury.…”