Highlight
- Augmented mean arterial pressure (>85-90 mm Hg) did not improve 6-month motor or sensory neurologic recovery after acute spinal cord injury compared to conventional targets (>65-70 mm Hg).
- Higher blood pressure targets were associated with increased organ dysfunction, prolonged mechanical ventilation, and more respiratory complications.
- The study raises critical questions about the routine practice of aggressive blood pressure augmentation in spinal cord injury care.
- Further research is needed to identify subpopulations who might benefit and to elucidate mechanisms behind adverse effects.
Study Background and Disease Burden
Acute spinal cord injury (SCI) remains a devastating condition resulting in substantial morbidity, long-term disability, and significant healthcare burdens worldwide. Neurologic resuscitation strategies aiming to optimize spinal cord perfusion are pivotal early interventions that may influence functional recovery. Traditionally, maintaining an augmented mean arterial pressure (MAP) above conventional levels has been advocated to minimize secondary ischemic injury to the spinal cord. Clinical guidelines often recommend targeting higher MAP (>85-90 mm Hg), but this approach is based on limited controlled trial evidence and often extrapolated from observational data.
Despite its clinical importance, the definitive role and safety profile of augmented blood pressure management in SCI remain uncertain. Excessive vasopressor use and elevated blood pressure might predispose patients to complications such as organ dysfunction and respiratory issues, raising concerns about risk-benefit balance. Addressing this knowledge gap is critical to optimize care protocols and resource allocation in trauma centers treating SCI patients.
Study Design
This was a prospective, multicenter randomized clinical trial conducted from October 3, 2017, through July 26, 2023, across 13 major US trauma centers. The study enrolled adult patients aged 18 years and older with acute spinal cord injury. Participants were randomized in a 1:1 ratio to receive either an augmented MAP target (>85-90 mm Hg) or a conventional MAP target (>65-70 mm Hg) for 7 days post-injury or until discharge from the intensive care unit (ICU).
The primary efficacy outcomes were the changes from baseline to 6 months in motor and sensory scores of the American Spinal Injury Association (ASIA) Impairment Scale, which assess upper extremity motor, lower extremity motor, and total sensory function. Safety endpoints included assessments of organ dysfunction measured by a modified Sequential Organ Failure Assessment (SOFA) score (excluding cardiovascular components), duration of mechanical ventilatory support, respiratory complications, and mortality.
Key Findings
Ninety-two patients were randomized, with a mean age of 53.78 years (SD 18.74) and predominantly male (83%). At 6-month follow-up, 38 survivors completed assessments while 15 patients had died.
Comparison between the augmented and conventional blood pressure groups revealed no statistically significant differences in neurologic recovery. Specifically, changes in upper extremity motor scores were 34.95 (SD 3.25) vs 32.95 (SD 3.65) with a mean difference of 2.48 (95% CI: -5.93 to 10.90; P=0.55), lower extremity motor scores 18.53 (SD 4.62) vs 19.95 (SD 4.59) with a mean difference of -4.56 (95% CI: -16.11 to 7.03; P=0.43), and total sensory scores 108.47 (SD 12.49) vs 130.89 (SD 14.87) with a difference of -32.00 (95% CI: -65.40 to 1.40; P=0.06) in augmented versus conventional MAP arms, respectively.
Importantly, the augmented group demonstrated significantly higher mean modified SOFA scores at days 3 (1.65 vs 0.80; difference 0.85; 95% CI 0.23-1.47; P=0.008) and 6 (1.55 vs 0.80; difference 0.74; 95% CI 0.05-1.44; P=0.04), indicative of worse organ dysfunction excluding cardiovascular factors. They also required longer mechanical ventilatory support (9.44 vs 3.78 days; difference 5.67 days; 95% CI 0.48-10.85; P=0.03) and experienced more respiratory complications (78% vs 39%; risk difference 40%; 95% CI 22%-58%; P<0.001).
No statistically significant differences were found in overall mortality or other secondary outcomes.
Expert Commentary
This rigorously designed trial provides critical evidence questioning the routine use of elevated blood pressure targets in the early management of acute SCI. Its results contrast prior assumptions favoring aggressive MAP augmentation to enhance spinal cord perfusion and neurologic recovery. The lack of observed benefit coupled with a higher incidence of organ dysfunction and respiratory complications underscores the potential harms of vasopressor-driven blood pressure elevation.
Study limitations include a relatively small sample size and partial follow-up completion, potentially underpowering the ability to detect modest neurologic improvements. Nevertheless, it challenges widely held clinical practices and underscores the urgent need to refine blood pressure management strategies. This trial invites a more individualized approach potentially guided by injury severity, patient comorbidities, and risk profiling.
Further mechanistic studies are vital to elucidate how elevated MAP contributes to secondary organ injury and to identify biomarkers predictive of response to blood pressure intervention. Updated clinical guidelines will likely await confirmatory evidence and investigations into optimal hemodynamic targets for distinct SCI phenotypes.
Conclusion
The latest multicenter randomized clinical trial demonstrates that targeting an augmented mean arterial pressure in acute spinal cord injury patients does not improve neurologic outcomes at 6 months compared to conventional blood pressure management. Augmented MAP was associated with increased organ dysfunction, longer ventilation, and respiratory complications, raising concerns about its safety.
These findings question the current clinical practice of aggressively raising blood pressure post-SCI and call for careful reevaluation. Clinical decision-making should cautiously weigh potential risks against unproven neurologic benefits. Future research should focus on identifying subgroups who may derive advantage from tailored blood pressure augmentation and on unraveling the pathophysiological mechanisms driving adverse effects.
This trial marks a pivotal step toward evidence-based hemodynamic management in spinal cord injury, ultimately aiming to improve functional recovery and reduce complications in this vulnerable patient population.
References
1. Sajdeya R, Yanez ND, Kampp M, Goodman MD, Zonies D, Togioka B, et al. Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. JAMA Netw Open. 2025 Sep 2;8(9):e2525364. doi: 10.1001/jamanetworkopen.2025.25364. PMID: 40965887.
2. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: A clinical practice guideline for health-care professionals. J Spinal Cord Med. 2008;31(4):403-479.
3. Hawryluk GWJ, Snyder K, Narayan RK. Update on the Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injury. Neurosurgery. 2022;90(1):101-110.
4. Fehlings MG, Rabchevsky AG, Aarabi B, et al. Translational research in spinal cord injury: a review of current evidence and treatment strategies. Neuroscience. 2013;29(5):44-56.
