First 7 days of traumatic spinal cord injury care: beyond the knife

As spine surgeons, it is easy to view the operating room as the definitive battleground. However, secondary injury mechanisms—ischemia, edema, and biochemical cascades—continue to threaten neurological recovery long after decompression. The management of tSCI must extend far beyond the operating room. To refine this post-operative frontier, the AO Spine Knowledge Forum SCI recently critically appraised three landmark studies using the GRADE methodology to deliver concise, contemporary practice updates for adjunctive medical therapies. 

The data highlights a clear reality: some of our long-held management strategies are maturing into concrete thresholds, while others present fascinating, patient-specific horizons that are not quite ready for routine deployment. 

Hemodynamic management: shifting from population targets to safe boundaries

For over a decade, maintaining an augmented mean arterial pressure (MAP) has been a foundational pillar of non-operative care to preserve spinal cord perfusion. However, traditional guidelines left physicians with massive global heterogeneity regarding exact targets and treatment lengths. 
The latest AO Spine Clinical Practice Guideline updates offer a major refinement by defining explicit lower and upper boundaries. Based on a comprehensive review of the literature, we conditionally recommend augmenting MAP to at least 75–80 mmHg to combat hypotension, but critically, not actively augmenting beyond 90–95 mmHg. 

Why the upper limit? The review illuminated a crucial clinical trade-off: pushing MAP into extreme ranges yields no demonstrable neurological benefit, yet it aggressively drives up the risk of severe vasopressor- and inotrope-induced systemic complications, such as cardiac arrhythmias and peripheral ischemia. Furthermore, the panel refined the treatment window to a flexible duration of 3 to 7 days. This acknowledges that while the earliest days post-injury are the most critical for perfusion, keeping a patient in a highly resource-intensive ICU environment for a rigid 7 days is often practically unfeasible for many trauma networks globally. 

SCPP monitoring: moving toward patient-specific precision

While setting population-level MAP targets is our current standard, it remains an indirect surrogate for what actually matters: the perfusion pressure inside the injured cord tissue. This brings us to the compelling, analogous concept of Traumatic Brain Injury protocols—Spinal Cord Perfusion Pressure (SCPP)-guided therapy. 

Prospective cohort data shows that SCPP (calculated as MAP minus cerebrospinal fluid pressure via a lumbar intrathecal catheter) is a far more sensitive and reliable predictor of 6-month neurological recovery than MAP alone. Specifically, dropping below an SCPP threshold of 50 mmHg strongly correlates with a failure to achieve AIS grade conversion. 

Yet, despite the conceptual elegance of this patient-level strategy, the AO Spine Knowledge Forum concluded that no formal recommendation can be made for routine clinical adoption at this time. The current evidence relies on observational data, and technical caveats remain—such as whether a lumbar catheter truly reflects pressure at the cervical or thoracic injury site. While some pioneering trauma centers have already integrated lumbar drains into their acute protocols, wide implementation awaits definitive, high-quality controlled trials (such as the upcoming insights from the CASPER trial). 

Pharmacologic neuroprotection: the Riluzole conundrum

Beyond perfusion, the holy grail of acute tSCI management remains definitive pharmacologic neuroprotection. The sodium-glutamate antagonist Riluzole has generated immense interest, backed by robust preclinical success and promising early-phase trials. 

The highly anticipated RISCIS trial—a multi-center, randomized, double-blinded, phase III trial—was designed to settle the debate in acute cervical tSCI. Unfortunately, the trial suffered an all-too-familiar modern setback: it was terminated early due to the COVID-19 pandemic, leaving the study underpowered at 193 patients instead of the planned 351. 

At the primary 180-day endpoint, no statistically significant difference was found between Riluzole and placebo regarding Upper Extremity Motor scores or overall functional Independence. Consequently, we cannot recommend the routine administration of Riluzole outside of clinical trials at this stage. However, this is far from a dead end. A recent secondary analysis using advanced global statistical analytic techniques suggests that Riluzole may still confer a meaningful global outcome benefit at 6 months. It remains an incredibly attractive therapeutic target that demands further formal evaluation. 

Translating evidence to the bedside

As active spine surgeons, managing acute trauma requires us to simultaneously embrace established guidelines while critically analyzing emerging paradigms. 

Right now, our immediate marching orders are clear: protect the cord through timely surgical decompression, avoid systemic hypotension, and closely titrate vasopressors within the newly defined 75–95 mmHg MAP window for 3 to 7 days. Beyond that, SCPP monitoring and novel neuroprotectants represent the exciting horizon of personalized trauma care. By understanding the precise boundaries of our current literature, we ensure our bedside decision-making remains safe, efficacious, and completely optimized.