Mean Arterial Pressure Augmentation for Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-Analysis of Neurological Recovery and Mortality

Study Design Systematic review. Objectives Maintenance of mean arterial pressure (MAP) at 85-90 mmHg after traumatic spinal cord injury (SCI) is widely recommended, but supporting evidence is limited. We performed a systematic review and meta-analysis to evaluate whether MAP augmentation improves outcomes after SCI. Methods PubMed, Embase, and CENTRAL were searched through January 2026. Random-effects meta-analyses were performed. Prespecified cohort-level analyses compared standard (≥65 mmHg) with augmented MAP targets (≥85 mmHg). Weighted linear meta-regression explored dose-response relationships between achieved MAP and primary outcomes. Results Thirty-three studies comprising 3535 patients were included. Neurological improvement occurred in 31.4% and 37.6% of patients subjected to standard and augmented MAP, respectively ( P = 0.25; I 2 = 84.6). Mortality occurred in 38.8% and 10.3% of patients, respectively ( P = 0.08; I 2 = 83.9), though this was observed with markedly asymmetric denominators (103 vs 1162) and substantial inter-study heterogeneity, and is unlikely to reflect a true treatment effect. Respiratory complications were significantly lower in patients subjected to standard MAP ( P = 0.04; I 2 = 82.2%). Meta-regression did not identify a linear association between achieved MAP and either primary outcome. Certainty of evidence was low. Conclusions Across heterogeneous, predominantly observational cohorts, pooled analyses showed no statistically significant differences in neurological improvement or mortality between standard and augmented MAP targets after acute traumatic SCI. A higher incidence of respiratory complications in patients subjected to augmented MAP represented the only statistically significant signal. These findings support avoidance of hypotension but do not establish clear benefit of universal MAP escalation.