Vancouver Spine Surgery Institute (VSSI), Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.
Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.
J Neurotrauma. 2020 May 1;37(9):1127-1139. doi: 10.1089/neu.2019.6844. Epub 2020 Mar 11.
Interventions to optimize spinal cord perfusion via support of mean arterial pressure (MAP) or spinal cord perfusion pressure (SCPP) are thought to play a critical role in the management of patients with acute traumatic spinal cord injuries, but there is ongoing controversy about efficacy and safety. We aimed to determine the effects of optimizing spinal cord perfusion on neurological recovery and risks for adverse events. We searched multiple databases for published and unpublished reports. Two reviewers independently screened articles, extracted data, and evaluated risk of bias. We synthesized data and evaluated confidence in anticipated treatment effects according to the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach. We identified 20 eligible observational studies and 1 eligible randomized controlled trial. According to low or very low quality evidence, the effect of MAP support on neurological recovery after acute traumatic spinal cord injury is uncertain, and the use of vasopressors to support MAP may be associated with increased rates of predominantly cardiac adverse events. Increased SCPP appears likely to be associated with improved neurological recovery, but SCPP monitoring via intradural catheters at the anatomical site of injury may involve increased risks of cerebrospinal fluid leakage requiring revision surgery or pseudomeningocele. No study directly compared the effects of specific MAP goal ranges, SCPP ranges, SCPP monitoring techniques, or durations of treatment. Very low quality evidence suggests that norepinephrine may have less risk of adverse events than dopamine. The current literature is insufficient to make strong recommendations about interventions to support spinal cord perfusion via MAP or SCPP goals in patients with acute traumatic spinal cord injuries. Data are compatible with a variety of treatment decisions, and individualized approaches may be optimal. Further investigation to clarify the risks, benefits, and alternatives to MAP or SCPP support in this population is warranted.
通过支持平均动脉压（MAP）或脊髓灌注压（SCPP）来优化脊髓灌注的干预措施被认为在急性创伤性脊髓损伤患者的治疗中起着关键作用，但在疗效和安全性方面仍存在争议。我们旨在确定优化脊髓灌注对神经恢复和不良事件风险的影响。我们搜索了多个数据库，以获取已发表和未发表的报告。两名审查员独立筛选文章、提取数据并评估偏倚风险。我们根据推荐、评估、制定和评估（GRADE）方法综合数据并评估预期治疗效果的置信度。我们确定了 20 项合格的观察性研究和 1 项合格的随机对照试验。根据低质量或极低质量的证据，MAP 支持对急性创伤性脊髓损伤后神经恢复的影响尚不确定，使用血管加压药来支持 MAP 可能与心脏不良事件发生率增加有关。增加 SCPP 似乎可能与改善神经恢复有关，但通过在损伤解剖部位的硬膜内导管监测 SCPP 可能会增加需要修正手术或假性脑膜膨出的脑脊液漏的风险。没有研究直接比较特定的 MAP 目标范围、SCPP 范围、SCPP 监测技术或治疗持续时间的效果。极低质量的证据表明，去甲肾上腺素的不良事件风险可能低于多巴胺。目前的文献不足以对急性创伤性脊髓损伤患者通过 MAP 或 SCPP 目标支持脊髓灌注的干预措施提出强烈建议。数据与各种治疗决策兼容，个体化方法可能是最佳的。需要进一步研究，以明确在该人群中 MAP 或 SCPP 支持的风险、益处和替代方案。
