From the International Collaboration on Repair Discoveries (J.W.S., C.R.W., B.K.K.); MD/PhD Training Program (J.W.S.), School of Kinesiology (C.R.W.), and Department of Orthopaedics (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D.), University of British Columbia; Vancouver Spine Program (L.M.B., A.T., L.R.), Vancouver General Hospital, British Columbia; Department of Surgery (J.-M.M.-T., S. Parent), Hôpital du Sacré-Coeur de Montréal, and Chu Sainte-Justine (S.C.), Department of Surgery, Université de Montréal, Quebec; Division of Orthopaedic Surgery (C.B.), London Health Sciences Centre, University of Western Ontario, Canada; Department of Neurological Surgery (S.D.), University of California, San Francisco; Vancouver Spine Surgery Institute (R.C.-M., J.S., T.A., S. Paquette, N.D., C.G.F., M.F.D., B.K.K.); and Division of Neurosurgery (B.K.K.), University of British Columbia, Blusson Spinal Cord Centre, Vancouver, Canada.
Neurology. 2019 Sep 17;93(12):e1205-e1211. doi: 10.1212/WNL.0000000000008125. Epub 2019 Aug 13.
To determine the hemodynamic conditions associated with optimal neurologic improvement in individuals with acute traumatic spinal cord injury (SCI) who had lumbar intrathecal catheters placed to measure CSF pressure (CSFP).
Ninety-two individuals with acute SCI were enrolled in this multicenter prospective observational clinical trial. We monitored mean arterial pressure (MAP) and CSFP during the first week after injury and assessed neurologic function at baseline and 6 months after injury. We used relative risk iterations to determine transition points at which the likelihood of either improving neurologically or remaining unchanged neurologically was equivalent. These transition points guided our analyses in which we examined the linear relationships between time spent within target hemodynamic ranges (i.e., clinical adherence) and neurologic recovery.
Relative risk transition points for CSFP, MAP, and spinal cord perfusion pressure (SCPP) were linearly associated with neurologic improvement and directed the identification of key hemodynamic target ranges. Clinical adherence to the target ranges was positively and linearly related to improved neurologic outcomes. Adherence to SCPP targets, not MAP targets, was the best indicator of improved neurologic recovery, which occurred with SCPP targets of 60 to 65 mm Hg. Failing to maintain the SCPP within the target ranges was an important detrimental factor in neurologic recovery, particularly if the target range is set lower.
We provide an empirical, data-driven approach to aid institutions in setting hemodynamic management targets that accept the real-life challenges of adherence to specific targets. Our results provide a framework to guide the development of widespread institutional management guidelines for acute traumatic SCI.
确定与放置腰穿脑脊液压力（CSFP）测量导管的急性创伤性脊髓损伤（SCI）患者最佳神经改善相关的血流动力学条件。
本多中心前瞻性观察性临床试验共纳入 92 例急性 SCI 患者。我们在损伤后第一周监测平均动脉压（MAP）和 CSFP，并在基线和损伤后 6 个月评估神经功能。我们使用相对风险迭代来确定神经改善或神经状态不变的可能性相等的转变点。这些转变点指导了我们的分析，我们检查了目标血流动力学范围内（即临床依从性）时间与神经恢复之间的线性关系。
CSFP、MAP 和脊髓灌注压（SCPP）的相对风险转变点与神经改善线性相关，并指导确定关键血流动力学目标范围。对目标范围的临床依从性与神经功能改善呈正相关且呈线性关系。对 SCPP 目标的依从性而不是 MAP 目标的依从性是神经恢复改善的最佳指标，SCPP 目标为 60 至 65mmHg 时即可实现。未能将 SCPP 维持在目标范围内是神经恢复的重要不利因素，特别是如果目标范围设定较低。
我们提供了一种经验性的、数据驱动的方法，以帮助机构设定血流动力学管理目标，同时考虑到对特定目标的实际依从性挑战。我们的结果为急性创伤性 SCI 的广泛机构管理指南的制定提供了框架。
