Article Citation: Sajdeya R, Yanez ND, Kampp M, et al. Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. JAMA Netw Open. 2025;8(9):e2525364. Published 2025 Sep 2. doi:10.1001/jamanetworkopen.2025.25364

Background: There is consensus that appropriate spinal cord perfusion should be maintained in order to prevent secondary injury in the setting of acute spinal cord injury (SCI).^1,2 A number of studies have addressed blood pressure targets in this clinical context; however the literature is limited by the quality of evidence. The 2013 Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries from the Congress of Neurological Surgeons recommend maintaining a mean arterial pressure between 85-90 mm Hg for the first seven days following injury (Level III).^3,4 A 2024 practice guideline recommends (with weak strength of recommendation) a mean arterial pressure (MAP) target of 75-80 mmHg and an upper threshold of 90-95 mmHg for 3 to 7 days.² Given the need for a higher quality of evidence, this current trial randomized patients with acute SCI to augmented versus standard blood pressure management, assessing the benefit of increased MAP targets using 6-month outcome measures.

Methods: The trial was conducted at 13 trauma centers in the United States, and eligible patients had cervical or thoracic traumatic spinal cord injuries with new clinical deficits and radiographic evidence. The severity of injury was determined by the American Spinal Injury Association (ASIA) Impairment Scale (AIS) and included patients with grades A, B, or C. Key exclusion criteria were concurrent severe traumatic brain injury or other neurologic conditions interfering with the accuracy of the neurologic exam. Additionally, a history of chronic myelopathy resulting in motor impairment and recent myocardial infarction were exclusion criteria. Patients were randomized in a 1:1 design to receive augmented blood pressure (ABP) with a MAP goal of >85-90 mmHg, or conventional blood pressure (CBP) with a goal MAP of > 65-70 mmHg. MAP targets were augmented with vasopressors, if necessary (per institutional protocol), and the duration of MAP goals was seven days, or until the end of ICU stay. Baseline motor and sensory AIS scores were compared to 6-month follow-up AIS scores, and scoring was performed in a blinded fashion. The target enrollment was 126 patients based on power of 80% to detect group differences of 5 points on the AIS at 6 months.

Results: 387 patients were screened, and 92 patients were included. Baseline demographics, injury severity, and mean blood pressure measurements were similar between groups. The trial was stopped early due to limited enrollment, and 27 patients were lost to follow-up at the 6-month end point. Both treatment groups maintained mean MAP targets above the assigned lower threshold, and the daily mean MAP for the CBP group was >80 mmHg. There were no statistical differences in the number of patients requiring vasopressors or the number of vasopressors used between the groups. There was no statistically significant difference between the ABP and CBP groups at 6 months in the average upper extremity motor score (mean difference (MD) 2.48; p=0.55), lower extremity motor score (MD -4.56; p=0.43), or total sensory score (MD -32; p=0.06). The patients in the ABP group had significantly higher SOFA scores on days 3 and 6. The ABP group demonstrated increased rates of respiratory complications (78% vs. 39%; p<0.01), specifically pneumonia and pulmonary edema, as well as increased mean days on mechanical ventilation (9.44 [15.27] vs. 3.78 [8.42] days; p=0.03). However, the groups had comparable hospital and ICU length of stays. Six-month mortality was similar between groups.

Commentary: Augmentation of MAP greater than 85-90 mmHg in patients with acute spinal cord injury was not shown to improve 6-month outcome measures when compared to patients receiving a standard MAP goal of greater than 65-70 mmHg. The 6-month mortality was comparable between groups, although there were more respiratory complications, longer duration of ventilation, and higher organ dysfunction scores in the augmented blood pressure group. Overall, these findings need to be considered in the context that the study was underpowered due to lack of full enrollment and had a high percentage (29%) of patients lost to follow-up. It should also be noted that hypotension was appropriately avoided in each study arm, and in fact, CBP participants showed MAPs consistently well above the lower target. Mean daily MAPs were >80 mmHg in the conventional blood pressure group. The study did not require a precise MAP range for each group but rather defined a lower threshold. This is a pragmatic design considering a strict MAP range may have been more difficult to implement, but this protocol appears to have resulted in higher than anticipated mean MAPs in the CBP arm.

Impact on Clinical Practice: Although the trial is underpowered, it suggests that avoiding hypotension may be sufficient after acute spinal cord injury, and further augmentation may increase ICU complications without clear neurologic benefit.

References: 

1. Lee, Y. S., Kim, K. T., & Kwon, B. K. (2021). Hemodynamic management of acute spinal cord injury: A literature review. Neurospine, 18(1), 7–14. https://doi.org/10.14245/ns.2040144.072
2. Kwon, B. K., Tetreault, L. A., Martin, A. R., et al. (2024). A clinical practice guideline for the management of patients with acute spinal cord injury: Recommendations on hemodynamic management. Global Spine Journal, 14(3 Suppl), 187S–211S. https://doi.org/10.1177/21925682231202348
3. Ryken, T. C., Hurlbert, R. J., Hadley, M. N., et al. (2013). The acute cardiopulmonary management of patients with cervical spinal cord injuries. Neurosurgery, 72(Suppl 2), 84–92. https://doi.org/10.1227/NEU.0b013e318276ee16
4. Walters, B. C., Hadley, M. N., Hurlbert, R. J., et al. (2013). Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery, 60(CN_suppl_1), 82–91. https://doi.org/10.1227/01.neu.0000430319.32247.7f