Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study

• Published in: World neurosurgery Vol. 133; pp. e391 - e396
• Main Authors: Yue, John K., Hemmerle, Debra D., Winkler, Ethan A., Thomas, Leigh H., Fernandez, Xuan Duong, Kyritsis, Nikolaos, Pan, Jonathan Z., Pascual, Lisa U., Singh, Vineeta, Weinstein, Philip R., Talbott, Jason F., Huie, J. Russell, Ferguson, Adam R., Whetstone, William D., Manley, Geoffrey T., Beattie, Michael S., Bresnahan, Jacqueline C., Mummaneni, Praveen V., Dhall, Sanjay S.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-01-2020
• Subjects: Aged; Cerebrospinal Fluid Pressure; Cervical Vertebrae - surgery; Clinical Protocols; Combined Modality Therapy; Decompression, Surgical; Drainage; Feasibility; Fluid Therapy; Humans; Infusions, Intravenous; Ischemia - prevention & control; Laminectomy; Lumbar drain; Middle Aged; Outcomes; Safety; Spinal Cord - blood supply; Spinal Cord Injuries - physiopathology; Spinal Cord Injuries - surgery; Spinal Cord Injuries - therapy; Spinal cord injury; Spinal cord perfusion pressure; Spine surgery; Standard of Care; Thoracic Vertebrae - surgery; Trauma Centers; Treatment Outcome; Vasoconstrictor Agents - therapeutic use; CAMPER; TRACK-SCI; Lumbar drain; Spine surgery; ISP; HLOS; LSAD; NICU; Spinal cord perfusion pressure; AIS; UTI; Spinal cord injury; Outcomes; SCPP; CSF; SCI; Feasibility; ICU; TBI; Safety; SPSS; MAP
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2019.09.044

We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center.
Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A−C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day 7.
Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A−C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care.
In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.