Intraspinal pressure and spinal cord perfusion pressure after spinal cord injury: an observational study

Varsos, Georgios V.; Werndle, Melissa C.; Czosnyka, Zofia; Smielewski, Peter; Kolias, Angelos G.; Phang, Isaac; Saadoun, Samira; Bell, B. Anthony; Zoumprouli, Argyro; Papadopoulos, Marios C.; Czosnyka, Marek

doi:10.3171/2015.3.spine14870

Cited by 56 publications

(50 citation statements)

References 26 publications

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“…Therefore, not only hypoperfusion (SCPP below 90 mmHg), but also hyperperfusion (SCPP above 100 mmHg) may be detrimental for the injured spinal cord. This is consistent with our earlier report of a U-shaped relationship between the spinal pressure reactivity index and SCPP, which also indicated optimum SCPP around 90 mmHg 5,8,21 . After TSCI, ISP is 20 -30 mmHg and therefore SCPP 90 -100 mmHg corresponds to mean arterial pressure 110 -130 mmHg.…”

Section: Annals Of Neurologysupporting

confidence: 93%

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Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Phang

Zoumprouli

Papadopoulos

et al. 2016

Annals of Neurology

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OBJECTIVE:There is lack of monitoring from the injury site to guide management of patients with acute traumatic spinal cord injury. Here we describe a bedside microdialysis monitoring technique for optimizing spinal cord perfusion and drug delivery at the injury site.METHODS: 14 patients were recruited within 72 hours of severe spinal cord injury. We inserted intradurally at the injury site a pressure probe, to monitor continuously spinal cord perfusion pressure, and a microdialysis catheter, to monitor hourly glycerol, glutamate, glucose, lactate and pyruvate. The pressure probe and microdialysis catheter were placed on the surface of the injured cord. RESULTS:Microdialysis monitoring did not cause serious complications. Spinal cord perfusion pressure 90 -100 mmHg and tissue glucose >4.5 mM minimized metabolic derangement at the injury site. Increasing spinal cord perfusion pressure by ~10 mmHg, increased the entry of intravenously administered dexamethasone at the injury site three-fold. INTERPRETATION:This study determined the optimum spinal cord perfusion pressure and optimum tissue glucose concentration at the injury site. We also identified spinal cord perfusion pressure as a key determinant of drug entry into the injured spinal cord. Our findings challenge current guidelines, which recommend maintaining mean arterial pressure at 85 -90 mmHg for a week after spinal cord injury. We propose that future drug trials for spinal cord injury include pressure and microdialysis monitoring to optimize spinal cord perfusion and maximize drug delivery at the injury site.

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Section: Annals Of Neurologysupporting

confidence: 93%

“…We also showed that simultaneous monitoring of SCPP and microdialysis could be used to enhance drug entry at the injury site. Based on our current findings and earlier studies [4][5][6][7][8][9]20,21 , a large-scale study of outcome from TSCI in patients who have monitoring vs. those who do not is warranted.…”

Section: Annals Of Neurologymentioning

confidence: 59%

Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Phang

Zoumprouli

Papadopoulos

et al. 2016

Annals of Neurology

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“…20 Currently, ICP monitoring and CPP optimization are the standard of care when managing severe TBI patients in developed countries. Based on our earlier studies 19,20,24,26 and the safety profile of ISP monitoring shown here, we hope that our ISP monitoring technique is used by other centers. Ultimately, a randomized controlled trial is warranted to determine if ISP monitoring and SCPP optimization improve outcome after TSCI.…”

Section: Discussionmentioning

confidence: 92%

“…26 Our analysis shows that the ISP and SCPP waveforms after TSCI have similar characteristics as the ISP and CPP waveforms after TBI, respectively. 24 We, therefore, proposed that the concepts of pressure reactivity (quantified using PRx), optimum cerebral perfusion pressure (CPP opt ), and compensatory reserve (quantified using RAP), which had been developed for TBI, could also be applied to the damaged spinal cord to yield spinal pressure reactivity (sPRx), optimum spinal cord perfusion pressure (SCPP opt ), and spinal compensatory reserve (sRAP). After TSCI, bony decompression (i.e., realignment of the fracture and laminectomy) does not effectively reduce the elevated ISP at the injury site.…”

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confidence: 99%

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

Phang

Zoumprouli

Saadoun

et al. 2016

SPI

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OBJECTIVE A novel technique for monitoring intraspinal pressure and spinal cord perfusion pressure in patients with traumatic spinal cord injury was recently described. This is analogous to monitoring intracranial pressure and cerebral perfusion pressure in patients with traumatic brain injury. Because intraspinal pressure monitoring is a new technique, its safety profile and impact on early patient care and long-term outcome after traumatic spinal cord injury are unknown. The object of this study is to review all patients who had intraspinal pressure monitoring to date at the authors' institution in order to define the accuracy of intraspinal pressure probe placement and the safety of the technique. METHODS At the end of surgery to fix spinal fractures, a pressure probe was inserted intradurally to monitor intraspinal pressure at the injury site. Postoperatively, CT scanning was performed within 48 hours and MRI at 2 weeks and 6 months. Neurointensive care management and complications were reviewed. The American Spinal Injury Association Impairment Scale (AIS) grade was determined on admission and at 2 to 4 weeks and 12 to 18 months postoperation. RESULTS To date, 42 patients with severe traumatic spinal cord injuries (AIS Grades A–C) had undergone intraspinal pressure monitoring. Monitoring started within 72 hours of injury and continued for up to a week. Based on postoperative CT and MRI, the probe position was acceptable in all patients, i.e., the probe was located at the site of maximum spinal cord swelling. Complications were probe displacement in 1 of 42 patients (2.4%), CSF leakage that required wound resuturing in 3 of 42 patients (7.1%), and asymptomatic pseudomeningocele that was diagnosed in 8 of 42 patients (19.0%). Pseudomeningocele was diagnosed on MRI and resolved within 6 months in all patients. Based on the MRI and neurological examination results, there were no serious probe-related complications such as meningitis, wound infection, hematoma, wound breakdown, or neurological deterioration. Within 2 weeks postoperatively, 75% of patients were extubated and 25% underwent tracheostomy. Norepinephrine was used to support blood pressure without complications. Overall, the mean intraspinal pressure was around 20 mm Hg, and the mean spinal cord perfusion pressure was around 70 mm Hg. In laminectomized patients, the intraspinal pressure was significantly higher in the supine than lateral position by up to 18 mm Hg after thoracic laminectomy and 8 mm Hg after cervical laminectomy. At 12 to 18 months, 11.4% of patients had improved by 1 AIS grade and 14.3% by at least 2 AIS grades. CONCLUSIONS These data suggest that after traumatic spinal cord injury intradural placement of the pressure probe is accurate and intraspinal pressure monitoring is safe for up to a week. In patients with spinal cord injury who had laminectomy, the supine position should be avoided in order to prevent rises in intraspinal pressure.

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“…This treatment paradigm has resulted in a significant reduction of mortality and morbidity associated with TBI and is attributed to the significant improvements in clinical outcomes for these patients [Marshall et al, 1979;Miller et al, 1981]. A few recent studies have suggested that increases in tissue pressure after SCI are associated with negative functional outcomes Varsos et al, 2015] ( fig. 1 a), and surgical alleviation of this pressure improves functional outcomes in both experimental animals [Yang et al, 2013] as well as patients .…”

Section: Pressure-induced Damage To the Spinal Cord After The Primarymentioning

confidence: 99%

Injectable Hydrogels for Spinal Cord Repair: A Focus on Swelling and Intraspinal Pressure

Khaing

Ehsanipour

Hofstetter

et al. 2016

Cells Tissues Organs

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Spinal cord injury (SCI) is a devastating condition that leaves patients with limited motor and sensory function at and below the injury site, with little to no hope of a meaningful recovery. Because of their ability to mimic multiple features of central nervous system (CNS) tissues, injectable hydrogels are being developed that can participate as therapeutic agents in reducing secondary injury and in the regeneration of spinal cord tissue. Injectable biomaterials can provide a supportive substrate for tissue regeneration, deliver therapeutic factors, and regulate local tissue physiology. Recent reports of increasing intraspinal pressure after SCI suggest that this physiological change can contribute to injury expansion, also known as secondary injury. Hydrogels contain high water content similar to native tissue, and many hydrogels absorb water and swell after formation. In the case of injectable hydrogels for the spinal cord, this process often occurs in or around the spinal cord tissue, and thus may affect intraspinal pressure. In the future, predictable swelling properties of hydrogels may be leveraged to control intraspinal pressure after injury. Here, we review the physiology of SCI, with special attention to the current clinical and experimental literature, underscoring the importance of controlling intraspinal pressure after SCI. We then discuss how hydrogel fabrication, injection, and swelling can impact intraspinal pressure in the context of developing injectable biomaterials for SCI treatment.

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Intraspinal pressure and spinal cord perfusion pressure after spinal cord injury: an observational study

Cited by 56 publications

References 26 publications

Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Microdialysis to Optimize Cord Perfusion and Drug Delivery in Spinal Cord Injury

Safety profile and probe placement accuracy of intraspinal pressure monitoring for traumatic spinal cord injury: Injured Spinal Cord Pressure Evaluation study

Injectable Hydrogels for Spinal Cord Repair: A Focus on Swelling and Intraspinal Pressure

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