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Meta-Analysis
. 2025 Jul 16;29(1):308.
doi: 10.1186/s13054-025-05531-3.

Effect of blood pressure threshold on adverse outcomes in patients with acute spinal cord injury: a systematic review and meta-analysis

Azasma Tanvir  1 , Abramo Aziz Rizk  2 , Wendy Wang  3 , Hamed Alsagga  4 , Husain Shakil  5 , Ha Le  6 , Prosanta Mondal  6 , Frederick A Zeiler  7   8   9 , Tumul Chowdhury  10
Affiliations
Meta-Analysis

Effect of blood pressure threshold on adverse outcomes in patients with acute spinal cord injury: a systematic review and meta-analysis

Azasma Tanvir et al. Crit Care. .

Abstract

Background: Inadequate spinal perfusion in acute spinal cord injury (SCI) can exacerbate secondary injury. While current guidelines recommend maintaining mean arterial pressure (MAP) ≥ 75-80mmHg post-injury, no quantitative analysis on effects of blood pressure on neurological outcomes exists. We aim to address this gap and evaluate the impact of blood pressure thresholds on adverse outcomes in acute traumatic and non-traumatic SCI to inform current guidelines.

Methods: The project adhered to PRISMA and MOOSE guidelines and was registered in PROSPERO (CRD42024550044). We searched seven databases: MEDLINE, Embase, Cochrane Central, Cochrane Reviews, CINAHL, Scopus, and Web of Science. We included studies involving patients ≥ 16yrs with acute SCI, randomized control trials, prospective cohorts, and retrospective (case-control, cohort) studies. Excluded were chronic SCI and studies mentioning induced hypotension. The main outcome was the relationship between blood pressure thresholds and adverse functional outcome at up to one-year post-injury. Outcomes (unadjusted odds ratios (uOR) and adjusted odds ratios (aOR)) were calculated using a random-effect model with 95% confidence intervals (CI). Quality was assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool.

Results: Of 16,366 identified articles, 38 (n = 7,167, 73% male) were included in the qualitative and 14 (n = 2,553, 76% male) in the quantitative analysis. Pooled analysis found an increase in adverse functional outcomes in patients with below threshold blood pressures (uOR, 3.28; 95% CI, 2.39-4.50; aOR, 1.04; 95% CI, 1.03-1.05). Subgroup analyses consistently showed that lower blood pressure thresholds were associated with worse outcomes across all subgroups. Risk of bias was low to moderate in most studies. Heterogeneity was moderate to high (I2: 69.88%).

Conclusion: Lower blood pressure thresholds were consistently associated with worse functional outcomes in patients with acute SCI. While these findings support the rationale for MAP augmentation, they should be interpreted cautiously due to the observational nature of the data and high heterogeneity. High-quality prospective studies are needed to determine optimal blood pressure targets.

Keywords: Blood pressure; Functional recovery; Mean arterial pressure; Meta-analysis; Spinal cord injury; Vasopressors.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. FAZ currently has provisional patents (63/659, 989; provisional filed June 14, 2024 and 63/652,106; provisional filed May 27, 2024) and software copyrights (Canada IP Office Registration #: 1231355 and 1231080) held in relation to advanced brain monitoring devices and physiologic metric algorithms. All of this is unrelated to the content of this manuscript. FAZ is supported through the Endowed MPI Chair in Neuroscience, the Natural Sciences and Engineering Research Council of Canada (NSERC; DGECR-2022-00260, RGPIN-2022-03621, ALLRP-578524-22, ALLRP-576386-22, I2IPJ 586104–23, ALLRP 586244-23, ALLRP-590680-2023, ALLRP 597442-24, ALLRP-597708-24, I2IPJ 2024-598125), the Canadian Institutes of Health Research (CIHR; Grant #: 530549), the MPI Neuroscience Research Operating Fund, the Health Sciences Centre Foundation Winnipeg, the Canada Foundation for Innovation (CFI) (Project #: 38583), Research Manitoba (Grant #s: 3906, 5429, 5914, 6554), and the Pan Am Clinic Foundation of Winnipeg.

Figures

Fig. 1
Fig. 1
PRISMA flow diagram of study selection
Fig. 2
Fig. 2
Forest plot summarizing the unadjusted (left) and adjusted (right) odds ratios for adverse outcomes associated with blood pressure thresholds in acute SCI
See this image and copyright information in PMC

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