Authors: Rob Hirst, Dave McCreary, Andy Neill, Chris Connolly, Becky Maxwell / Codes: GP1, SLO10, SLO4, TP2, TP3 / Published: 24/02/2026
Clinical question
Should we pursue higher BP targets in those with acute spinal cord injury?
Title
Early Blood Pressure Targets in Acute Spinal Cord Injury
A Randomized Clinical Trial
Authors
Sajdeya et al. JAMA Network open 2025
Background
Spinal cord injuries are an unfortunately common and life changing injury. Unlike the bony bits which we can fix fairly well we seem to be able to do very little to fix the spinal cord itself. We have tried a number of things over the years including the infamous story of steroids in spinal cord injury. For quite some time now we have tried treating injured cords like injured brains by pursuing a higher perfusing pressure. The idea being that in the injured cord there is disturbed autoregulation and pursuing a CPP type strategy might be helpful in getting perfusion to a vulnerable cord. Typically this has involved ursing a MAP target of 80 instead of the usual 65 for the first week post injury. This has been in guidelines for some time albeit with a low evidence quality. Now we have an actual RCT to help us answer the question
Methods
MCRCT 13 US centres over 6 years
ASIA A, B or C blunt without severe TBI. Remember the ASIA score is like the opposite of your A levels where the higher the grade the worse your spinal cord injury is with an A being a complete and terrible injury
Aimed 85-90 vs 65-70 for 7 days
Blinded assessors though the individual clinicians were aware of the what arm they were in
Multiple agents could be used to get to the BP but understandably noradrenaline very common
Outcome as a change from baseline ASIA at 6 months
Results
Stopped early poor recruitment (powered for only 126)
92 pts 80% male, age 54, 25% ventilated, most ASIA A, 80% cervical
Both groups met their targets in terms of BP and unsurprisingly the conventional group often had MAP above target (i.e. they had a higher MAP unsupported)
No difference in clinical outcomes
Slightly higher safety complications in the higher BP group (that seemed repsiratory so not sure they're real)
Thoughts
I have always been sceptical of this as the initial evidence base to get in the guidelines was always poor. This is probably the best evidence we have so far (though it is still small) which suggests it is not of benefit.