Effects of hypocapnia on canine spinal, subcortical, and cortical somatosensory-evoked potentials during isoflurane anesthesia

Hypocapnic hypothesis of Leigh disease

Leigh syndrome (LS) is a neurogenetic disorder of children caused by mutations in at least 75 genes which impair mitochondrial bioenergetics. The changes have typical localization in basal ganglia and brainstem, and typical histological picture of spongiform appearance, vascular proliferation and gliosis. ATP deprivation, free radicals and lactate accumulation are suspected to be the causes. Hypocapnic hypothesis proposed in the paper questions the energy deprivation as the mechanism of LS. We assume that the primary harmful factor is hypocapnia (decrease in pCO₂) and respiratory alkalosis (increase in pH) due to hyperventilation, permanent or in response to stress. Inside mitochondria, the pH signal of high pH/low bicarbonate ion (HCO^-₃) is transmitted by soluble adenyl cyclase (sAC) through cAMP dependent manner. The process can initiate brain lesions (necrosis, apoptosis, hypervascularity) in OXPHOS deficient cells residing at the LS area of the brain. The major message of the article is that it is not the ATP depletion but intracellular alkalization (and/or hyperoxia?) which seem to be the cause of LS. The paper includes suggestions concerning the methodology for further research on the LS mechanism and for therapeutic strategy.

Current approach on spinal cord monitoring: the point of view of the neurologist, the anesthesiologist and the spine surgeon

Optimal outcome in spine surgery is dependent of the coordination of efforts by the surgeon, anesthesiologist, and neurophysiologist. This is perhaps best illustrated by the rising use of intraoperative spinal cord monitoring for complex spine surgery. The challenges presented by neurophysiologic monitoring, in particular the use of somatosensory and motor evoked potentials, requires an understanding by each member for the team of the proposed operative procedure as well as an ability to help differentiate clinically important signal changes from false positive changes. Surgical, anesthetic, and monitoring issues need to be addressed when relying on this form of monitoring to reduce the potential of negative outcomes in spine surgery. This article provides a practical overview from the perspective of the neurophysiologist, the anesthesiologist, and the surgeon on the requirements which must be understood by these participants in order to successfully contribute to a positive outcome when a patient is undergoing complex spine surgery.

Mechanisms of signal change during intraoperative somatosensory evoked potential monitoring of the spinal cord

In scoliosis surgery, intraoperative somatosensory evoked potential (SSEP) monitoring has reduced the incidence of postoperative neurologic deficits. Many factors affect the amplitude and latency of SSEP waveforms during surgery. Somatosensory evoked potential amplitude decreases with ischemia and anoxia because of temporal dispersion of the afferent volley and conduction block in damaged axons. In conjunction with surgical manipulations, minor drops in blood pressure may result in substantial SSEP changes that reverse when perfusion pressure is increased. Irreversible anoxic injury to central nervous system white matter with loss of SSEP waveforms is dependent on calcium influx into the intracellular space. Somatosensory evoked potential monitoring may be less sensitive for detecting acute insults in the presence of preexisting white matter lesions. Increased extracellular potassium from acute baro-trauma can block axonal conduction transiently even when there is no axonal disruption. Marked temperature-related drops in SSEP amplitude may occur after exposure of the spine but before instrumentation and deformity correction. Hypothermia may increase false-negative outcomes. Short-interval double-pulse stimulation may improve the sensitivity of the SSEP in detecting early ischemic changes. For neurosurgical procedures on the spinal cord the use of SSEP monitoring in improving postoperative outcome is less well established.

Somatosensory evoked potentials during hypoxia and hypocapnia in conscious humans

PURPOSE

The objective of the study was to evaluate the effects of moderate hypoxia and hypocapnia on the latency and amplitude of cortical somatosensory evoked potentials (SSEPs) in conscious human subjects.

METHODS

In ten volunteers the amplitude and latency of the cortical somatosensory evoked potentials were recorded during stimulation of the left posterior tibial nerve. Measurements of SSEPs and respiratory variables were made breathing ambient air, air containing a reduced oxygen percentage (17% O2, 14% O2 (n = 6) or 11% O2 (n = 10)), and again during voluntary hyperventilation breathing ambient air (PETCO2 = 20 mmHg, n = 10).

RESULTS

Hypoxia (11% O2) caused mild stimulation of ventilation (P < 0.05) but had no effects on the latency or amplitude of the SSEP. Lesser degrees of hypoxia had no effects. Hyperventilation caused a small (2-4%) decrease) in the latency of the SSEP and an increase in the amplitude of the SSEP (P < 0.05).

CONCLUSIONS

These findings in conscious subjects were consistent with previous observations in anaesthetized humans and anaesthetized dogs and show that the decrease in latency of the SSEP associated with hypocapnia is not due to changes in the depth of anaesthesia. These effects of hypocapnia may contribute to small variations in the latency of the SSEP when monitoring is performed during surgery, but are unlikely to be large enough to be of clinical concern.