Blood pressure targets in spinal cord injury (Treat patients not numbers)

Although guidelines have long suggested higher blood pressure targets in spinal cord injury, that recommendation has never been based on high quality evidence. (Walters 2013; Sanchez 2020) (This is the first ever RCT.) We have a bad habit of treating numbers in medicine, and often making things worse. (Remember the recent paper discussing worse outcomes when we lower blood pressure in ICH, for example.) So, what is the ideal blood pressure target in acute spinal cord injury? More importantly, will this trial answer the question?

The question

Do patients with acute spinal cord injury benefit from an augmented blood pressure (MAP greater than 85) as compared to a standard blood pressure target (MAP 65-70)?

The paper

Sajdeya R, Yanez ND, Kampp M, Goodman MD, Zonies D, Togioka B, Nunn A, Winfield RD, Martin ND, Kohli A, Huynh TT, Okonkwo DO, Poblete RA, Gilmore EJ, Chesnut RM, Bunnell AE, Ohnuma T, Hashemaghaie M, Treggiari MM. Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. JAMA Netw Open. 2025 Sep 2;8(9):e2525364. doi: 10.1001/jamanetworkopen.2025.25364. PMID: 40965887 NCT02878850

The methods

This is a partially blinded, multicenter RCT from 13 US trauma centers. 

Patients

Adult patients with acute spinal cord injuries of the cervical or thoracic spine, resulting in new neurologic deficits with AIS grade of A, B, or C.

Exclusions: Penetrating injury, injuries below T9, severe traumatic brain injury, preexisting motor deficits from chronic myelopathy, any condition preventing neurologic exam, decompensated CHF, MI with 6 months, terminal diagnosis, pregnancy. 

Intervention

Augmented blood pressure (ABP) – target MAP >85-90 mmHg – for 7 days, or until ICU discharge. 

Comparison

Conventional blood pressure (CBP) – target MAP >65-70 mmHG – for 7 days, or until ICU discharge. 

Outcome

The primary end point was the change from baseline in AIS motor and sensory scores 6 months after injury.

The results

They enrolled a total of 92 patients, with a mean age of 54, and 83% being male. The trial was stopped early because of slow enrollment. Their power calculation, based on a clinically meaningful 5 point difference in AIS scores, said that they needed 126 patients. 

Blood pressures are never exactly at target in trials like this, but they clearly separated and remain different throughout the vast majority of the 7 day trial period:

Unfortunately, the way they present their data is a bit of a mess. This is partial because they are actually using 3 co-primary outcomes, which is not ideal.

There were no statistical differences in:

• Upper extremity motor scores (34.95 for ABP vs 32.95 for CBP)
• Lower extremity motor scores (18.53 for ABP vs 19.95 for CBP)
• Total sensory scores (108.47 for ABP vs. 130.89 for CBP)

Figure 3 is really the clinical information that we want, but they don’t actually give us these numbers or any statistics around this figure, and so I find this next to impossible to interpret:

There were other secondary outcomes that sound important, or at least would help clarify Figure 3, such as quality of life scales and spinal cord independence measures. These are not included in the manuscript. They are supposed to be listed in tables e5 and e6 in the supplement, but there do not seem to be tables e5 and e6 in the supplement. (In the modern era, where literally everyone is reading these papers in electronic form, it makes no sense at all to hide data in a supplement. It costs nothing at all to put the supplemental information at the end of the primary PDF. This practice drives me crazy, because it makes it so much harder to access important information, and makes published research far less transparent.)

I can’t really figure out why, but the safety outcomes were a lot worse in the augmented blood pressure group. There was a significantly higher rate of respiratory complications (78% vs 39%), driven primarily by pneumonia (45% vs 25%) and pulmonary edema (22% vs 7%). The augmented blood pressure group spent about 1 day longer on mechanical ventilation.

Mortality was basically the same (17% with ABP vs 15% in CBP).

My thoughts

This is the first RCT we have on the topic, and therefore should clearly influence care decisions, but there are some very significant limitations.

The first is simply the size of the trial. It was designed as a small trial, and COVID made it even smaller, and so there are large confidence intervals around everything. These results could be consistent with significant benefit (or harm) from either strategy. 

The biggest problem with this study is follow-up. Only 41% of their patients had an ASIA assessment done at 6 months. Some of this was unavoidable – 16% of the patients had died – but a full 29% were simply lost to follow up. That is a very big number in a small trial, and it adds tremendous uncertainty to these numbers. 

Because of the small numbers, baseline neurologic status was quite different between the groups. Because their primary outcome was change in AIS scores, rather than simply final scores, the impact of that difference should be somewhat mitigated. However, the bias won’t be completely eliminated, because where you start will influence where you end up. 

Adding to the uncertainty caused by the small size and loss to follow up, this trial is only partially blinded. The people doing the neurologic assessments were blinded, but the clinicians and patients were not. A lack of blinding always increases the risk of bias, especially if clinicians have strong opinions about therapy, and I have never met an intensivist or spine surgeon who didn’t have strong opinions about blood pressure goals. 

I don’t really understand the safety numbers. Pulmonary edema makes sense when you are targetting higher blood pressures, but why would a higher blood pressure target cause a significant increase in pneumonia? I take these numbers with a massive grain of salt, but I think the safety concerns are enough, when combined with the lack of proven benefit, to say that standard blood pressure targets should be used until we see more research on the topic. 

Bottom line

This is the first RCT to ever look at blood pressure targets in acute spinal cord injury. There was no difference in neurologic outcomes with higher BP targets, but there were more adverse events. There are significant limitations, and more research is definitely needed, but for now conventional BP targets (MAP 65-70) should be the standard for patients with acute spinal cord injuries. 

Other FOAMed

Early Blood Pressure Targets in Acute Spinal Cord Injury

Evidence based medicine is easy

The EBM bibliography

Evidence based medicine resources

EBM deep dives

References

Sajdeya R, Yanez ND, Kampp M, Goodman MD, Zonies D, Togioka B, Nunn A, Winfield RD, Martin ND, Kohli A, Huynh TT, Okonkwo DO, Poblete RA, Gilmore EJ, Chesnut RM, Bunnell AE, Ohnuma T, Hashemaghaie M, Treggiari MM. Early Blood Pressure Targets in Acute Spinal Cord Injury: A Randomized Clinical Trial. JAMA Netw Open. 2025 Sep 2;8(9):e2525364. doi: 10.1001/jamanetworkopen.2025.25364. PMID: 40965887

Sánchez JAS, Sharif S, Costa F, Rangel JAIR, Anania CD, Zileli M. Early Management of Spinal Cord Injury: WFNS Spine Committee Recommendations. Neurospine. 2020 Dec;17(4):759-784. doi: 10.14245/ns.2040366.183. Epub 2020 Dec 31. PMID: 33401855

Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE, Harrigan MR, Rozelle CJ, Ryken TC, Theodore N; American Association of Neurological Surgeons; Congress of Neurological Surgeons. Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update. Neurosurgery. 2013 Aug;60(CN_suppl_1):82-91. doi: 10.1227/01.neu.0000430319.32247.7f. PMID: 23839357