“Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on
1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit;
2. The duration of such MAP augmentation; and
3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets.”

Kwon, Brian K et al. “A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management.” Global spine journal vol. 14,3_suppl (2024): 187S-211S.

“For recommendation #1, 89% of the GDG voted to accept and endorse this 2013 statement regarding the use of cardiac, hemodynamic and respiratory monitoring devices. The GDG
agreed that patients with SCI often require a higher level of care and close monitoring in an ICU setting given increased rates of respiratory insufficiency, cardiac dysfunction and
systemic hypotension. Patients with cervical SCI may require mechanical ventilation. Early detection of cardiopulmonary dysfunction and hemodynamic instability may allow for
timely implementation of effective and life-saving strategies. The GDG acknowledged that some patients with less severe SCI, such as those with a mild “central cord syndrome” pattern of incomplete tetraplegia, may be safely monitored and managed in a step down or acute care unit. Furthermore, it was recognized that providing ICU level care for every SCI patient might not be feasible in resource-limited clinical settings (eg low or middle-income countries).
For recommendation #2, 84% of the GDG voted to accept and endorse this 2013 statement regarding the correction of hypotension to a systolic blood pressure above 90 mmHg. As
stated previously, the injured spinal cord is particularly susceptible to decreases in systolic blood pressure given impaired vascular reactivity and loss of auto-regulation. Given that
small changes in the perfusion of the spinal cord can worsen ischemia and propagate secondary injury, the GDG agreed that systemic hypotension should be avoided or corrected as soon as possible. Furthermore, the GDG recognized that maintaining a systolic blood pressure over 90 mmHg represents standard of care for most patients admitted to the hospital to ensure adequate systemic perfusion and limit end-organ damage.
For recommendation #3 on the MAP target of 85-90 mmHg for 7 days, 84% of the GDG voted to revise this recommendation based on the reasons outlined in the introduction.
The GDG then aimed to establish a new recommendation by addressing 3 key components of hemodynamic management: (i) the upper and lower limits of a MAP target range; (ii) the
optimal duration of MAP augmentation; and (iii) the choice of vasopressor or inotrope for pharmacologic support of MAP.”

Kwon, Brian K et al. “A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management.” Global spine journal vol. 14,3_suppl (2024)

“Spinal cord injury (SCI) is a leading cause of long-term disability, accounting for 4.5 million years of life lived with disability worldwide in 2021. Although SCI may initially present with irreversible damage, adherence to treatment protocols to prevent secondary injury is associated with long-term improvement in neurologic and functional outcomes. Evidence supports preventing hypotension as a critical component of early SCI management to improve outcomes. The 2013 American Association of Neurological Surgeons and Congress of Neurological Surgeons SCI guideline recommends maintaining a mean arterial pressure (MAP) of 85 to 90 mm Hg for 7 days. However, this level III recommendation was based on low-quality evidence of neurologic improvement and has not been studied in randomized clinical trials. More recent guidelines recommended maintaining a MAP of 75 to 80 mm Hg for 3 to 7 days, but this was a similarly weak recommendation based on very low quality evidence.”

Sajdeya, Ruba et al. “Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial.” JAMA network open vol. 8,9 e2525364. 2 Sep. 2025

“Early blood pressure management, particularly the augmentation of mean arterial pressure (MAP), after acute spinal cord injury (SCI) remains a cornerstone of initial neurocritical care. However, the precise blood pressure targets necessary to optimize neurologic outcomes and mitigate risks are based on low quality evidence. Sajdeya et al conducted a multicenter randomized clinical trial evaluating early blood pressure augmentation strategies in patients with acute SCI aimed at addressing a substantial knowledge gap in current clinical practice. The authors compared 2 distinct MAP management strategies: a MAP target of greater than 85 to 90 mm Hg vs a conventional MAP target of greater than 65 to 70 mm Hg, maintained up to 7 days after injury. The primary end points assessed were motor and sensory outcomes at 6 months after injury using the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Secondary outcomes included pain, functional status, and quality of life, with additional assessment of safety outcomes, such as organ dysfunction and respiratory complications.”

Tigchelaar, Seth S, and Allan D Levi. “Blood Pressure Augmentation in Patients With Spinal Cord Injury.” JAMA network open vol. 8,9 e2525375. 2 Sep. 2025

Position Statement
“Complete and incomplete cervical spinal cord injuries that require surgical intervention deserve individualized treatment. Decisions regarding the timing of surgical management must take into account both the particular characteristics of the injury and additional patient-specific factors that may influence outcomes. Injury-specific factors include neurological status, the degree and type of bony and/or ligamentous disruption, and the degree and cause of spinal cord compression. Patient-specific factors may include age, medical comorbidities, and the use of certain high-risk medications such as antiplatelet/anticoagulant therapy or immune-modulating agents. The choice of timing also depends upon the ability to ensure that the right resources are in place to perform the procedure efficiently and safely. Only the surgeon — weighing these essential elements — will be able to determine the optimal timing of surgical intervention to maximize both safety and outcome.

Rationale

• The best current evidence regarding the timing of surgery is constrained by heterogenous patient populations, inconsistent treatment protocols, and variable outcome measures. These deficiencies limit the ability to draw conclusions regarding the timing of surgical intervention that will have a meaningful impact on the patient’s neurological outcome.
• There is no prospective class I evidence that supports a recommendation for the timing of surgical intervention”

American Association of Neurological Surgeons Congress of Neurological Surgeons
AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves AANS/CNS Joint Section on Neurotrauma and Critical Care Neurosurgery Position Statement on AO Spine/PRAXIS Acute Spinal Cord Injury Guidelines May 14, 2024. American Association of Neurological Surgeons