Abstract:

Spinal cord injury (SCI) is a devastating in pathology, with significant physical, psychosocial, and financial burdens. Despite the severity of this disease, and our deepening understanding of the pathophysiology, we remain limited in our treatment options. Recent well-publicized studies have focused on the benefit of early surgical decompression in this patient population, but fewer studies have focused on the medical management of these patients. In light of the recent controversy surrounding methylprednisolone administration, many believe that supraphysiologic mean arterial pressure (MAP) maintenance offers the best hope for improving outcomes through medical management. The 2013 guidelines recommend the maintenance of MAP between 85 and 90 mm Hg for the first seven days following acute cervical SCI. Although limited by the paucity of current literature on the topic, this recommendation provides the foundation for medical management of SCI at many institutions. Given the devastating nature of this injury pattern, the long term sequelae of injury, and the limited number of interventions, we continue to search for alternative and improved therapies to reduce the burden of disease. While research in MAP therapy is promising, it must be viewed contextually. Throughout these studies, spinal cord injury is treated as a homogenous injury pattern, when SCIs can vary extensively in prognosis. Variables including level of injury, mechanism of injury, presence of hemorrhagic spinal cord trauma, and pattern of intraspinal injury can all impact long-term outcomes. Applying universal standards to what must be considered a heterogeneous patient population may not be the best approach. In a 2015 study, Readdy et al. show that patients with acute traumatic central cord injury (ATCCS) who received vasopressors for MAP goal maintenance suffered high rates of cardiogenic complications (76%). Results indicate that vasopressor administration was associated with significant and preventable adverse outcomes. It is our belief that these discrepancies highlight the continued importance of clinical decision-making. The implementation of the 2013 AANS Guidelines on the administration of vasopressors in acute SCI shows promise, but clinicians must continue to exercise situational judgment. Universal application of guidelines to the heterogeneous mixture of spinal cord injury patients may result in concerning risk-benefit ratios in certain patient populations. Additionally, a multicenter study is needed to elucidate the proper management of acute SCI. To date, a major limitation in the development of such a study has been the incongruence amongst SCI data recording methods across centers. We recommend that members of the clinical SCI research community begin to adapt a standardized data collection approach, such as the National Institute of Health/National Institute of Neurologic Disorders and Stroke (NIH/NINDS) Common Data Elements to facilitate multi-center studies. Expanding the current single-institutional studies to larger multi-institutional collaborations is essential, given the limited incidence of acute SCI. These subpopulation analyses will allow for clearer, personalized guidelines while also elucidating the true risk-benefit ratio of vasopressor administration in each group.