Critical Care Medicine-Neurologic Disorders>>>>>Spinal Cord Injury
Question 4#

A 88-year-old female presents to the ED after tripping over her cat and landing on her back. She sustains injury to her cervical spinal cord, which is immobilized with a cervical collar, and she is admitted to the ICU.

Which of the following interventions are more likely to improve her neurological outcome?

a. Maintaining systolic blood pressure (SBP) >120 mm Hg
b. Administering intravenous methylprednisolone
c. Maintaining mean arterial pressure (MAP) >85 mm Hg
d. Maintaining her central venous pressure (CVP) > 20 cm H2O
e. None of the above

Correct Answer is C

Comment:

Correct Answer: C

SCI results in significant morbidity and mortality. Improving neurological recovery by reducing secondary injury is a major principle in the management of SCI. To minimize secondary injury, maintaining adequate spinal cord perfusion using blood pressure (BP) augmentation has been advocated. Spinal cord perfusion pressure (SCPP) is the difference between the diastolic blood pressure (DBP) and Intraspinal pressure (ISP) or intracranial pressure (ICP). [SCPP = DBP−ISP/ICP]. Increasing the DBP, potentially increases the SCPP, thus improving perfusion to the injured spinal cord. Current recommendations according to the guidelines of the American Association of Neurological Surgeons/Congress of Neurological Surgeons (AANS/CNS) Joint Section on Spine and Peripheral Nerves advise correcting hypotension and maintaining a MAP goal of 85 to 90 mm Hg for 7 days postinjury.

The use of methylprednisolone after acute SCI is debatable, and there is unclear evidence about the efficacy and clinical impact of methylprednisolone in recovery from SCI. Consensus statements consider methylprednisolone as a treatment option for acute SCI, but not a standard of care based on available evidence. SBP or CVP has limited impact on improving spinal cord perfusion.

References:

  1. Breslin K, Agrawal D. The use of methylprednisolone in acute spinal cord injury: a review of the evidence, controversies, and recommendations. Pediatr Emerg Care. 2012;28(11):1238-1245.
  2. Walters BC, Hadley MN, Hurlbert RJ, et al. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013;60(suppl 1):82-91.
  3. Saadeh YS, Smith BW, Joseph JR, et al. The impact of blood pressure management after spinal cord injury: a systematic review of the literature. Neurosurg Focus. 2017;43(5):E20.