Spinal Cord Perfusion Pressure Monitoring after Traumatic Spinal Cord Injury: Indications, Techniques, and Future Horizons

Impaired spinal cord perfusion can negatively impact neurological outcome after acute traumatic spinal cord injury (SCI). Hemodynamic management emphasizes maintenance of mean arterial pressure (MAP), although clinical practice remains variable and may be driven by systemic perfusion goals. Growing evidence suggests that spinal cord perfusion pressure (SCPP)-defined as MAP minus intrathecal pressure (ITP) measured via lumbar cerebrospinal fluid (CSF) or intraspinal pressure (ISP) measured directly at the injury site-may be a more meaningful physiological target. This narrative review synthesizes current SCPP monitoring techniques, emphasizing technical considerations for device placement, safety profiles, practical clinical factors guiding patient selection, and key gaps in current guidelines. A targeted literature search was performed using PubMed and Ovid MEDLINE for studies examining SCPP, ITP, CSF drainage, and hemodynamic management in traumatic SCI. Additional sources were identified through reference screening of key articles and prior reviews. Intrathecal lumbar subarachnoid drains (LSADs) are widely accessible, allow estimation of ITP, and facilitate CSF drainage, but have uncertain accuracy in the setting of spinal cord swelling and restricted CSF flow. LSADs advanced toward the site of injury offer the potential for local ITP assessment, although data remain sparse. ISP monitors provide high-fidelity measurements at the lesion site but cannot drain CSF, require intraoperative placement, and lack regulatory approval. Across modalities, key unresolved questions include optimal timing of monitor insertion, target SCPP ranges, and appropriate duration of monitoring. SCPP monitoring holds promise for individualizing hemodynamic management in acute traumatic SCI. Although studies suggest feasibility and potential benefit, consensus multi-institutional standardized guidelines are lacking. Future multicenter trials are needed to define indications, refine perfusion targets, and integrate SCPP-directed therapy into routine SCI care.