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Table of Contents
LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 236-238
Complete recovery from paraplegia following apparently failed cerebrospinal fluid drainage in a case of thoracoabdominal aortic aneurysm repair


Department of Anesthesia, Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, India

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Date of Web Publication20-Aug-2011
 

How to cite this article:
Suneel PR, Koshy T, Unnikrishnan M. Complete recovery from paraplegia following apparently failed cerebrospinal fluid drainage in a case of thoracoabdominal aortic aneurysm repair. Ann Card Anaesth 2011;14:236-8

How to cite this URL:
Suneel PR, Koshy T, Unnikrishnan M. Complete recovery from paraplegia following apparently failed cerebrospinal fluid drainage in a case of thoracoabdominal aortic aneurysm repair. Ann Card Anaesth [serial online] 2011 [cited 2020 Jan 17];14:236-8. Available from: http://www.annals.in/text.asp?2011/14/3/236/84036


The Editor,

A 32-year-old woman weighing 55 kg and body mass index of 25 was admitted to our hospital with pain in the mid-thoracic area and was diagnosed to have thoracoabdominal aneurysm of aorta (TAAA) with impending rupture. Her history was significant for aortoarteritis and renovascular hypertension. She had undergone right renal and a left subclavian artery angioplasty in 1990. She subsequently required a left common carotid to subclavian artery bypass with an 8-mm Dacron graft. Computed tomography (CT) scan revealed a Crawford type III aneurysm, extending from the inferior pulmonary ligament to just above the aortic bifurcation, with 8 cm maximal diameter.

The patient underwent repair of the aneurysm under general anesthesia. Distal perfusion was provided by means of a passive shunt between the aorta proximal to the clamp and the left femoral artery. The nasopharyngeal temperature was allowed to drift down to 32° C. Surgical procedure consisted of inclusion graft repair of the TAAA using 22 mm Albograft (polyester vascular graft, Edwards Lifesciences, Saint-Prex Switzerland). The proximal anastomosis was 5 cm above the aortic hiatus and the distal anastomosis above inferior mesenteric artery. Celiac axis and superior mesenteric artery were Carelled together on the right side and left renal artery button was anastomosed on the left side of the graft. No appropriate intercostal arteries were identified for reinsertion. Visceral perfusion was done with blood from the side-arm of the aortofemoral bypass using Inahara-Pruitt shunt. Continuous Autotransfusion System (C.A.T.S, Fresenius Kabi AG, D-61346, Bad Hamburg) was used for blood retrieval and autotransfusion after priming the system with Ringers lactate and 1 mg/kg heparin. The proximal mean arterial pressure (MAP) was titrated to maintain the pressure distal to clamp above 70 mm. The total aortic cross-clamp time was 50 minutes. Residual heparin was reversed with 100 mg protamine. Patient was awake at the end of 3 hours . She had no movement in her left lower limb and weak flexion of the right knee with gravity excluded. A neurological evaluation revealed absence of deep tendon reflexes and plantar reflexes. Postoperative spinal cord dysfunction was diagnosed. It was decided to drain cerebrospinal fluid (CSF) with the hope of improving the spinal cord perfusion. A 16 G Tuohy needle was inserted in the L3-4 space after local infiltration with 1% lignocaine. Blood-stained CSF was obtained in the initial two attempts. We estimated that between 30-40 ml of CSF was lost during these attempts. Since the drainage was markedly blood stained, the catheter was not inserted. Despite several attempts, CSF drainage catheter could not be inserted. Soon after, the patient was able to move her toes and freely flex her right knee. Over the next hour, she gained complete movement of her both lower limbs and four hours later, she was extubated. 12 hours after extubation, patient complained of post-dural puncture headache (PDPH). By the 10 th postoperative day, her headache was considerably less and she was discharged from the hospital without any neurological deficit. At one-year follow-up, the patient continued to be active and without neurological deficit.

Paraplegia following TAAA repair is a devastating complication with poor outcome. [1] Risk factors for spinal cord injury are longer extent of the aneurysm, emergency operation, aortic dissection, longer duration of aortic cross-clamp, failure to reimplant segmental arteries, prior distal aortic surgery, hypotension, and severe peripheral vascular disease. [2]

The perioperative care of the patient should be oriented toward decreasing the duration of spinal cord ischemia and augmenting spinal cord blood flow. Methods to increase the tolerance of the spinal cord to ischemia, such as deliberate hypertension, deep hypothermic circulatory arrest, and selective hypothermia by epidural cooling and pharmacologic neuroprotection, may have a role in preventing cord dysfunction. [2]

The perfusion pressure of the spinal cord is the difference between the MAP and the CSF pressure (CSFP). When the thoracic aorta is clamped, there is marked increase in the proximal aortic pressure, central venous pressure (CVP), and CSFP, along with decrease in the distal aortic pressure. The net effect is a decrease in the spinal cord perfusion pressure. [3] Intraoperatively, maintaining an adequate perfusion pressure both proximal and distal to the aortic clamp by means of assisted circulation is an important means to preserve the perfusion pressure to the spinal cord. [4] In patients with TAAA, up to 50% of the intercostal arteries are chronically occluded. [5] Hence, the maintenance of high MAP to optimize collateral flow and prevention of back bleeding from interrupted intercostal vessels to prevent "steal phenomenon" are important methods to maintain spinal cord perfusion. [5],[6]

The perfusion pressures within the collateral arterial supply represent the inflow pressure of the spinal cord. Since the spinal canal is a closed space, the outflow pressures within the spinal cord are equally important. These outflow pressures are determined by the CSFP and the CVP. [7] When the outflow pressures are elevated, a compartment syndrome develops within the confines of the spinal canal which can be corrected only by improvement in the arterial pressures and decrease in the CSFP and CVP. Safi et al. attributes an element of spinal cord edema set in motion by the aortic cross-clamp in the pathogenesis of delayed spinal cord dysfunction. [8]

The methods to improve inflow pressure should focus on the elevating MAP, maintenance of cardiac output, correction of anemia, maintenance of low CVP by means of inotropes, and maintenance of acid-base balance. If spinal cord ischemia occurs, then the MAP should be raised in increments of 5 mm of Hg. [1],[2] The absolute MAP in the postoperative period should be compared against the patient's own preoperative blood pressure and maintained in the normal range for that patient. [7]

The physiological basis for inserting the CSF drain (CSFD) is to reduce the CSFP and improve the spinal cord perfusion pressure. CSFD should ideally be instituted before the start of the surgery and should be continuously monitored. [3] CSFP should be kept less than 10 mm Hg under anesthesia. Excessive drainage of CSF can lead to CSF hypotension with the risk of subsequent intracranial hemorrhage. [9] Once the patient is awake and without neurologic deficit, the CSF drainage should be limited to 15 ml/h. If there is delayed neurologic deficit, CSF should be drained so that the CSFP is brought to less than 5 mm Hg pressure. [10] The postoperative insertion of CSFD after the onset of paraplegia is supported by many case reports. [11],[12]

We failed to insert a CSFD in this patient despite multiple attempts. During each of these failed attempts to insert the drainage catheter, the epidural space was easily located with the Tuohy needle using the "loss of resistance technique" and the dural puncture "feel" was experienced. Such a perplexing situation has been noted once before, albeit, in a different setting. [13] In this patient, we believe, spinal cord perfusion was decreased on account of the increased CSFP secondary to cord edema and/or reperfusion injury. [8] Initial attempts at CSFD, though resulted in blood-stained drainage, might have effectively reduced the CSFP. The dural punctures achieved with the initial two attempts might have continued to drain CSF into the epidural space and the surrounding tissues. This produced effective decompression of the subarachnoid space, leading to failure in attaining a free flow of CSF on subsequent attempts at lumbar puncture.

Improving the systemic MAP and CSFD may provide an alternate means of improving spinal cord perfusion in the setting of postoperative paraplegia following thoracoabdominal aortic aneurysm repair.

 
   References Top

1.Conrad MF, Ye JY, Chung TK, Davison JK, Cambria RP. Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity. J Vasc Surg 2008;48:47-53.  Back to cited text no. 1
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2.Sinha AC, Cheung AT. Spinal cord protection and thoracic aortic surgery. Curr Opin Anaesthesiol 2010;23:95-102.   Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Fedorow CA, Moon MC, Mutch AC, Grocott HP. Lumbar cerebrospinal fluid drainage for thoracoabdominal aortic surgery:Rationale and practical considerations for management. Anesth Analg 2010;111:46-58  Back to cited text no. 3
    
4.Acher CW, Wynn M. A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: An analysis of technique specific observed/expected ratios for paralysis. J Vasc Surg 2009;49:1117-24.   Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Williams GM, Roseborough GS, Webb TH, Perler BA, Krosnick T. Preoperative selective intercostal angiography in patients undergoing thoracoabdominal aneurysm repair. J Vasc Surg 2004;39:314-21   Back to cited text no. 5
    
6.Maniar HS, Sundt TM 3rd, Prasad SM, Chu CM, Camillo CJ, Moon MR, et al. Delayed paraplegia after thoracic and thoracoabdominal aneurysm repair:a continuing risk. Ann Thorac Surg 2003;75:113-20.  Back to cited text no. 6
[PUBMED]    
7.Etz CD, Luehr M, Kari FA, Bodian CA, Smego D, Plestis KA, et al. Paraplegia after extensive thoracic and thoracoabdominal aneurysm repair: Does critical spinal cord ischemia occur postioertaitvely? J Thorac Cardiovasc Surg 2008;135:324-30   Back to cited text no. 7
    
8.Safi HJ, Miller CC 3 rd , Azizzadeh A, Iliopoulos DC. Observations on delayed neurologic deficit after thoracoabdominal aortic aneurysm repair. J Vasc Surg 1997;26:616-22.   Back to cited text no. 8
    
9.Dardik A, Perler BA, Roseborough GS, Williams GM. Subdural hematoma after thoracoabdominal aortic aneurysm repair: an underreported complication of spinal fluid drainage? J Vasc Surg 2002;36:47-50.   Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Estrera AL, Sheinbaum R, Miller CC, Azizzadeh A, Walkes JC, Lee TY, et al. Cerebrospinal fluid drainage during thoracic aortic repair: safety and current management. Ann Thorac Surg 2009;88:9-15   Back to cited text no. 10
    
11.Khong B, Yang H, Doobay B, Skala R. Reversal of paraparesis after thoracic aneurysm repair by cerebrospinal fluid drainage .Can J Anesth 2000;47:992-5   Back to cited text no. 11
    
12.Garutti I, Fernandez C, Bardina A, Martinez E, Ferrando A, Fernandez-Quero L. Reversal of paraplegia via cerebrospinal fluid drainage after abdominal aortic surgery. J Cardiothorac Vasc Anesth 2002;16:471-72.   Back to cited text no. 12
    
13.Dennison B. A failed spinal following an epidural block. Anaesthesia 1982;37:348-349  Back to cited text no. 13
    

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Correspondence Address:
Puthuvassery Raman Suneel
Department of Anesthesia, Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.84036

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