The effect of preexisting hypertension on early neurologic results of patients with an acute spinal cord injury

Abstract

Study design: Retrospective case-control. Objectives: To characterize changes in American Spinal Injury Association Motor Score (AMS) in patients treated with relative hypertension (HTN) (mean arterial pressure (MAP) 4 85 mm Hg for 5 days) with and without preexisting HTN. Setting: A regional spinal cord injury (SCI) center in Pennsylvania, United States. Methods: All patients with an acute SCI who were treated with induced HTN (MAP goal above 85) in the intensive care unit (ICU) for at least 5 days were identified. Patients were stratified based on the presence of preexisting HTN, and the change in the AMS between admission and day 5 was determined. Predictors of outcome were identified using correlation analysis and multiple linear regression. Results: Ninety-two patients met inclusion criteria of which 22 had a previous history of HTN. HTN was a predictor of poor early outcome. Patients with HTN had an average decline in their AMS of 7.6, compared with an average decrease of only 0.6 in the AMS of patients without HTN (P = 0.04). HTN had no effect (P40.05) on other in-hospital variables including length of stay, length of stay in the ICU, complications or mortality. Additionally, multiple linear regression analysis demonstrated that diabetes, coronary artery disease and pulmonary disease had no effect on the change in AMS. Conclusion: Chronic HTN is an independent risk factor for poor early neurologic recovery in patients treated with relative HTN for an acute SCI. This is independent of age and other comorbidities.

The impact of blood pressure management after spinal cord injury: a systematic review of the literature

“…20,31 Nine studies were retrospective reviews that collected information on MAP after SCI as well as neurological outcome measures throughout the postinjury period. 6,9,16,17,19,21,27,33 Levi et al 20 performed a prospective study in which the authors described the outcomes of a group of 50 patients who underwent spinal immobilization or fixation as indicated, with their postinjury care at a trauma center between 1990 and 1991. An MAP goal higher than 90 mm Hg was maintained with fluids and dopamine for the 1st week after injury, although some patients required the addition of dobutamine for additional support.…”

“…Kepler et al 19 retrospectively reviewed 92 patients who were admitted between 2006 and 2009 for an acute SCI, with an MAP goal of higher than 85 mm Hg for at least 5 days. Outcomes compared the ASIA motor scores on admission and on hospital Day 5, which showed an overall decrease in neurological function over that period of an average of 2.2 points on the ASIA motor impairment scale.…”

“…The authors did find that the proportion of MAP measurements below the BP goal correlated with outcome for the first 7 days after injury. Hawryluk, 16 Kepler, 19 Inoue, 17 Wolf, 33 and Dakson 11 and their colleagues described methods in which elevated MAP goals were pursued for 5 days postinjury, rather than 7 days, and they did not report the occurrence of an associated neurological decline with the shorter duration of elevated BP goals.…”

Exploration of surgical blood pressure management and expected motor recovery in individuals with traumatic spinal cord injury

“…Subsequent animal models of the risk of hypertension demonstrated that norepinephrine did not improve spinal cord perfusion but was associated with increased size of parenchymal hemorrhage [33]. Kepler et al and Inoue et al found either decreased motor function with MAP > 85 mmHg or no correlation between MAP > 85 mmHg and motor recovery [34,35]. Given the evidence that maintenance of hypertension may have deleterious effects, Kwon et al evaluated clinical equipoise for motor outcomes among patients randomized to spinal cord perfusion pressure (SCPP) ≥ 75 mmHg or avoidance of hypotension with MAP ≥ 65 mmHg [36].…”

The Impact of Mean Arterial Pressure on Functional Outcome Post Trauma-Related Acute Spinal Cord Injury: A Scoping Systematic Review of the Human Literature

“…Two patients (6%) died during the course of treatment. The improvement in neurological status was shown to be Kepler et al 17 performed a retrospective review of a prospectively entered trauma database from a single regional SCI center. All patients admitted with an acute SCI who were treated with MAPs >85 mm Hg in the ICU for at least 5 days were included.…”