Acute spinal cord injury (SCI) often results in severe neurologic deficits, with hemodynamic instability contributing to secondary ischemic damage. Beyond surgical decompression, maintaining adequate mean arterial pressure (MAP) is key to enhancing spinal cord perfusion and oxygenation. Vasopressor therapy is frequently used to achieve hemodynamic stability, but optimal MAP targets and vasopressor selection remain controversial. This review explores updated guidelines and current evidence regarding MAP management and the use of vasopressors in SCI, focusing on their impact on spinal cord perfusion and neurologic outcomes. Recent studies highlight the role of durotomy in directly improving spinal cord perfusion pressure (SCPP) by reducing intraspinal pressure (ISP), offering a complementary mechanical intervention as part of pharmacologic therapies. Recent guidelines suggest an MAP range of 75–80 mmHg as a lower limit and 90–95 mmHg as an upper limit for 3–7 days post-injury, highlighting the need for personalized hemodynamic management. Norepinephrine is commonly preferred due to its balanced effects on peripheral vascular resistance and spinal cord perfusion pressure (SCPP), though dopamine, phenylephrine, and dobutamine each offer unique hemodynamic profiles suited to specific clinical scenarios. Despite their benefits, vasopressors carry significant risks, including arrhythmias and potential myocardial strain, necessitating careful selection based on individual patient factors. Further research is needed to refine vasopressor use and establish evidence-based protocols that optimize neurologic recovery, alongside continued exploration of SCPP as a potential therapeutic target.

The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.

OBJECTIVE: Earlier research has demonstrated that social determinants of health (SDoH) impact neurosurgical access and outcomes, but these trends are less characterized for spine tumors relative to intracranial tumors. The authors aimed to elucidate the association between SDoH and outcomes for a nationwide cohort of spine tumor surgery admissions. METHODS: The authors identified all admissions with a spine tumor diagnosis in the National Inpatient Sample (NIS) from 2002 to 2019. Four SDoH were analyzed: race and ethnicity, insurance, household income, and safety-net hospital (SNH) treatment. Hospitals in the top quartile of safety-net burden (in terms of percentage of patients receiving Medicaid or uninsured) were categorized as SNHs. Multivariable regression queried the association between 22 variables and 5 perioperative outcomes: mortality, discharge disposition, complications, length of stay (LOS), and hospitalization costs. Interaction term analysis with hospitalization year was used to assess longitudinal changes in outcome disparities. Finally, the authors constructed random forest machine learning models to assess the impact of SDoH variables on prognostic accuracy and to quantify the relative importance of predictors for disposition. RESULTS: Of 6,593,392 total admissions with spine tumors, 219,380 (3.3%) underwent surgery. Non-White race (OR 0.80–0.91, p < 0.001) and nonprivate insurance (OR 0.76–0.83, p < 0.001) were associated with lower odds of receiving surgery. Among surgical admissions, presenting severity, including of myelopathy and plegia, was elevated among non-White, nonprivate insurance, and low-income admissions (all p < 0.001). Black race (OR 0.70, p < 0.001), Medicare (OR 0.70, p < 0.001), Medicaid (OR 0.90, p < 0.001), and lower income (OR 0.88–0.93, all p < 0.001) were associated with decreased odds of favorable discharge disposition. Increased LOS and costs were observed among non-White (+6%–10% in LOS and +5%–9% in costs, both p < 0.001) and Medicaid (+16% in LOS and +6% in costs, both p < 0.001) admissions. SNH treatment was also associated with higher mortality (OR 1.49, p < 0.001) and complication (OR 1.20, p < 0.001) rates. From 2002 to 2019, disposition improved annually for Medicaid patients (OR 1.03 per year, p = 0.022) but worsened for Black patients (OR 0.98 per year, p = 0.046). Random forest models identified household income as the most important predictor of discharge disposition. CONCLUSIONS: For spine tumor admissions, SDoH predicted surgical intervention, presenting severity, and perioperative outcomes. Over 2 decades, disparities improved for Medicaid patients but worsened for Black patients. Finally, SDoH significantly improve prognostic accuracy for outcomes after spine tumor surgery. Further study toward ameliorating patient disparities for this population is warranted.