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Monitoring of Spinal Cord Perfusion Pressure in Acute Spinal Cord Injury: Initial Findings of the Injured Spinal Cord Pressure Evaluation Study*

Werndle, Melissa C. MRCS1; Saadoun, Samira PhD1; Phang, Isaac MRCS1; Czosnyka, Marek PhD2; Varsos, Georgios V. MSc2; Czosnyka, Zofia H. PhD2; Smielewski, Peter PhD2; Jamous, Ali MD3; Bell, B. Anthony MD, FRCS1; Zoumprouli, Argyro MD4; Papadopoulos, Marios C. MD, FRCS(SN)1

doi: 10.1097/CCM.0000000000000028
Neurologic Critical Care

Objectives: To develop a technique for continuously monitoring intraspinal pressure at the injury site (intraspinal pressure) after traumatic spinal cord injury.

Design: A pressure probe was placed subdurally at the injury site in 18 patients who had isolated severe traumatic spinal cord injury (American Spinal Injuries Association grades A–C). Intraspinal pressure monitoring started within 72 hours of the injury and continued for up to a week. In four patients, additional probes were inserted to simultaneously monitor subdural pressure below the injury and extradural pressure. Blood pressure was recorded from a radial artery catheter kept at the same horizontal level as the injured segment of the spinal cord. We determined the effect of various maneuvers on spinal cord perfusion pressure and spinal cord function and assessed using a limb motor score and motor-evoked potentials.

Setting: Neurosurgery and neuro-ICU covering a 3 million population in London.

Subjects: Patients with severe traumatic spinal cord injury. Control subjects without spinal cord injury (to monitor spinal cerebrospinal fluid signal and motor evoked potentials).

Interventions: Insertion of subdural spinal pressure probe.

Measurements and Main Results: There were no procedure-related complications. Intraspinal pressure at the injury site was higher than subdural pressure below the injury or extradural pressure. Average intraspinal pressure from the 18 patients with traumatic spinal cord injury was significantly higher than average intraspinal pressure from 12 subjects without traumatic spinal cord injury. Change in arterial PCO2, change in sevoflurane dose, and mannitol administration had no significant effect on intraspinal pressure or spinal cord perfusion pressure. Increase in inotrope dose significantly increased spinal cord perfusion pressure. Bony realignment and laminectomy did not effectively lower intraspinal pressure. Laminectomy was potentially detrimental by exposing the swollen spinal cord to compression forces applied to the skin. By intervening to increase spinal cord perfusion pressure, we could increase the amplitude of motor-evoked potentials recorded from below or just above the injury level in nine of nine patients with traumatic spinal cord injury. In two of two patients with American Spinal Injuries Association grade C traumatic spinal cord injury, higher spinal cord perfusion pressure correlated with increased limb motor score.

Conclusions: Our findings provide proof-of-principle that subdural intraspinal pressure at the injury site can be measured safely after traumatic spinal cord injury.

1Academic Neurosurgery Unit, St. George’s, University of London, London, United Kingdom.

2Department of Neurosurgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom.

3National Spinal Injuries Centre, Stoke Mandeville Hospital, Stoke Mandeville, United Kingdom.

4Department of Anaesthesia, St. George’s Hospital, London, United Kingdom.

* See also p. 749.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Supported, in part, by the U.K. Spinal Cord Injury Research Network, Neurosciences Research Foundation, London Deanery, Royal College of Surgeons of England, and National Institute of Health Research (Neuroscience Theme) in Cambridge.

Ms. Werndle’s institution received grant support from the Royal College of Surgeons of England and the Neurosciences Research Foundation (Househam fellowship). Dr. Saadoun is funded by the Guthy Jackson Charitable Foundation. Mr. Phang received support for article research from the Spinal Cord Injury Research Network, Neurosciences Research Foundation, and London Deanery. ICM+ (http://www.neurosurg.cam.ac.uk/icmplus) is licensed by the University of Cambridge (Cambridge Enterprise). Prof. M. Czosnyka received royalties from ICM+ software (part of the licensing fee). Prof. M. Czosnyka’s institutions received grant support from NIHR (Neurosciences Theme) in Cambridge. Dr. Smielewski received royalties from ICM+ software (part of the licensing fee). His institutions received grant support from National Institute of Health Research (Neurosciences Theme) in Cambridge. Prof. Papadopoulos is funded by the Guthy Jackson Charitable Foundation. His institution received grant support from Neurosciences Research Foundation, U.K. Spinal Cord Injuries Research Network, London Deanery, and Royal College of Surgeons of England. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: mpapadop@sgul.ac.uk

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins