Spinal cord vascular autoregulation: key concepts and opportunities to improve management

Study Design: Narrative review. Objectives: Vascular autoregulation in the central nervous system (CNS) maintains appropriate perfusion in the context of changing blood pressure. Impaired autoregulation in various diseases often contributes to their pathophysiology. While this mechanism is well characterized in the brain, it remains understudied in the spinal cord, limiting evidence-based blood pressure management in spinal cord pathology. In this review, we summarize the current understanding of spinal cord autoregulation, highlight advancements in cerebral autoregulation, and offer a framework for its clinical application in spinal cord care. Methods: A literature search was conducted comparing preclinical evidence of spinal cord autoregulation with current clinical practices in the brain. Results: Although autoregulation has been recognized in the spinal cord, it has been mostly measured in animals, and its clinical impact has been limited. In contrast, cerebral autoregulation has influenced patient care through continuous monitoring of dynamic autoregulation and clinical trials using personalized blood pressure targets. These innovations require measurement of blood flow or a surrogate, which is performed infrequently in the cord. Furthermore, confounding variables, such as arterial CO₂ levels, temperature, and pharmacology, must be tightly controlled, as they can affect blood flow and thus interfere with autoregulation measurements. Conclusions: Spinal cord autoregulation is an essential variable in neurology and neurosurgery. A better understanding of this process could improve outcomes in various conditions, including traumatic injury, ischemic injury, and other spinal diseases. As spinal cord blood flow measurement technologies improve, there is a growing opportunity to apply autoregulation to direct patient care.