Objectives To identify factors which predict intra-spinal pressure (ISP) and optimal spinal cord perfusion pressure (SCPPopt) in patients with acute, severe traumatic spinal cord injuries (TSCI) that could be used instead of invasive ISP monitoring.

Methods We monitored ISP, mean arterial pressure (MAP) and computed spinal cord perfusion pressure (SCPP), spinal pressure reactivity index (sPRx) and SCPPopt in 64 TSCI patients, AIS grades A–C who were part of the Injured Spinal Cord Pressure Evaluation (ISCoPE) study. We recorded baseline, injury/imaging and management variables which may influence ISP/SCPPopt. Statistical analysis was used to investigate differences in ISP/SCPPopt between the variables

Results 51% (34/64) had U-shaped sPRx vs. SCPP curve in the first 24 hours after surgery. Mean SCPPopt was 74 mmHg (range 48–103). Lower mean 24 hour ISP was found with: older age, alcohol excess, non-conus medullaris injury, duroplasty and less surgical bleeding. Mean ISP on day 1 after surgery correlates with mean ISP over the first week. Lower 24 hour SCPPopt was associated with: higher mean ISP and conus medullaris injury. No MRI factors predicted ISP or SCPPopt.

Conclusions Several factors predict ISP. Modifiable factors to reduce ISP are less surgical bleeding and expansion duroplasty. No variables predict SCPPopt. ISP monitoring remains the only way to estimate SCPPopt to help prevent secondary damage and we continue to support use of ISP monitoring to individualise management in acute, severe TSCI.