Abstract
We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. Key concepts are discussed such as intraspinal pressure and spinal cord perfusion pressure (SCPP) at the injury site, respectively, analogous to intracranial pressure and cerebral perfusion pressure for traumatic brain injury. The concept of spinal cord autoregulation is introduced and quantified using spinal pressure reactivity index (sPRx), which is analogous to pressure reactivity index for traumatic brain injury. The U-shaped relationship between sPRx and SCPP defines the optimum SCPP as the SCPP that minimizes sPRx (i.e., maximizes autoregulation), and suggests that not only ischemia but also hyperemia at the injury site may be detrimental. The observation that optimum SCPP varies between patients and temporally in each patient supports individualized management. We discuss multimodality monitoring, which revealed strong correlations between SCPP and injury site metabolism (tissue glucose, lactate, pyruvate, glutamate, glycerol), monitored by surface microdialysis. Evidence is presented that the dura is a major, but unappreciated, cause of spinal cord compression after TSCI; we thus propose expansion duroplasty as a novel treatment. Monitoring spinal cord blood flow at the injury site has revealed novel phenomena, e.g., 3 distinct blood flow patterns, local steal, and diastolic ischemia. We conclude that monitoring from the injured spinal cord in the intensive care unit is a safe technique that appears to enable optimized and individualized spinal cord perfusion.
Highlights
We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets
In 2014, we described a technique (Fig. 1a–d) for placing a probe intradurally at the injury site to monitor the pressure of the injured cord as it is compressed against surrounding structures, which we termed intraspinal pressure (ISP) [17, 18]
The nonlinear ISP dynamics can be quantified by computing hourly the detrended fluctuation exponent α [29, 30], the multiscale entropy (MSE) [31, 32], and the maximal Lyapunov exponent λmax [33]. Such analyses revealed that pathological processes at the injury site including cord swelling, hypoperfusion, or impaired pressure reactivity were associated with increased α and decreased MSE, which render the cord less adaptable to external changes [26]
Summary
We review state-of-the-art monitoring techniques for acute, severe traumatic spinal cord injury (TSCI) to facilitate targeted perfusion of the injured cord rather than applying universal mean arterial pressure targets. In 2014, we described a technique (Fig. 1a–d) for placing a probe intradurally at the injury site to monitor the pressure of the injured cord as it is compressed against surrounding structures, which we termed intraspinal pressure (ISP) [17, 18].
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