Effects of decompressive operation on cardiac autonomic regulation in patients with cervical spondylotic myelopathy: analysis of blood pressure, heart rate, and heart rate variability

Rapidly Deteriorating Degenerative Cervical Myelopathy Following Ventricular Shunt Revision for Hydrocephalus: Case Report

A female patient in her early 40s presented with a several-month history of gait unsteadiness and dragging her left leg. She had a background of congenital hydrocephalus, treated with a ventriculoatrial shunt. On examination, she had increased tone and brisk reflexes in the lower limbs and a positive Hoffmann sign. A computed tomography (CT) scan and shunt series x-rays identified hydrocephalus secondary to a disconnected shunt. Magnetic resonance imaging (MRI) of her cervical spine was also performed as part of the workup for her presenting symptoms and demonstrated features compatible with degenerative cervical myelopathy (DCM). The patient subsequently underwent a shunt revision. Following the operation, her walking and hand function deteriorated over a period of several weeks. She consequently underwent an anterior cervical decompression and fusion for DCM, which partially improved her symptoms. The sequence of events suggests that the shunt surgery may have precipitated a worsening of the DCM. Possible explanations include spinal cord injury related to neck extension or hypoperfusion during intubation and general anesthesia or the loss of cerebrospinal fluid cushioning following the reinstitution of effective cerebrospinal fluid shunting. Surgeons should be alert to this possibility and offer prompt surgical intervention for DCM if required.

Latent Autonomic Dysfunction in a Chronic Cervical Spinal Injury

Latent autonomic dysfunction has been identified in recent years among patients with chronic cervical lesions. This paper further illustrates a precautionary case of symptomatic manifestation with an elusive trigger. A 64-year-old male, who had shown excellent neurological recovery after decompression surgery for a cervical spinal injury (modified Frankel classification from C1 to D3), complained of recurrent syncope in the chronic phase. The cause remained unidentified for two years, but it was finally discovered that the syncope was induced by a transient sympathetic overactivation that was concurrent with mental strain and alcohol intake. Abstinence completely suppressed the episodes thereafter. The case suggests the possibility that patients with a history of cervical spinal injury, no matter how normal they appear, may have asymptomatic autonomic dysfunction. Additionally, identification of the trigger can be challenging due to its dynamic and protean nature. More emphasis should be paid to autonomic evaluation for chronic cervical spinal injuries.

Intraoperative hypotension in non-emergency decompression surgery for cervical spondylosis: The role of chronic arterial hypertension

Background

Cervical spondylotic myelopathy and chronic hypertension show a cause-effect relationship. Hypertension increases cardiovascular risk and is associated with intraoperative hypotension. We aimed to evaluate intraoperative hypotension in patients undergoing non-emergency decompression surgery for cervical spondylosis and its association with clinical myelopathy and chronic arterial hypertension.

Methods

This retrospective cohort study used healthcare data of adult patients undergoing cervical spine surgeries at Taipei Veterans General Hospital from 2015 to 2019. The primary outcomes were the incidence of intraoperative hypotension and predictive factors, and the secondary outcomes were the association of intraoperative hypotension and postoperative adverse outcomes in the surgical population.

Results

Among the 1833 patients analyzed, 795 (43.4%) required vasopressor treatment and 342 (18.7%) showed persistent hypotension. Factors independent associated with hypotension after anesthetic induction were age [odds ratio (OR), 1.15; 95% confidence interval (CI), 1.07-1.23 per 5 years, P < 0.001], male sex (OR, 1.63; 95% CI, 1.21-2.19, P < 0.001), chronic hypertension (OR, 1.77; 95% CI, 1.32-2.38, P < 0.001), upper cervical spine level C0-2 treated (OR, 3.04; 95% CI, 1.92-4.84, P < 0.001 vs. C3-T1), and increased number of spine segments treated (OR, 1.43; 95% CI 1.26-1.63, P < 0.001). Patients who developed intraoperative hypotension experienced more acute postoperative kidney injury (OR, 7.90; 95% CI, 2.34–26.63, P < 0.001), greater need for intensive care (OR, 1.80; 95% CI, 1.24–2.60, P = 0.002), and longer admission after surgery (1.09 days longer, 95% CI 0.06-2.12, P = 0.038).

Conclusion

Intraoperative hypotension is common even in non-emergency cervical spine surgery. A history of hypertension independently predicted intraoperative hypotension. Prompt assessments for identifiable features can help ameliorate intraoperative hypotension.

Normalization of Elevated Blood Pressure After Anterior Cervical Discectomy and Fusion

Perioperative change to the autonomic nervous system (ANS) in spine surgery is an uncommon occurrence but has a wide range of possible presentations including blood pressure, heart rate, and heart rate variability changes collectively referred to as dysreflexia. Increased sympathetic tone and decreased vagal output are believed to be the underlying causes of these autonomic manifestations and pose an important question as to effective treatment of these dysfunctions. Spinal nerve root decompression has shown to be a valuable tool in normalizing autonomic tone by increasing parasympathetic output, most notably to the cardiovascular system, leading to the resolution of the aforementioned cardiovascular complications. Here we report a patient with elevated blood pressure with complaints of upper extremity paresthesias. MRI showed nerve root compression, and anterior cervical discectomy was performed. Post-operatively the patient had a decrease in both systolic and diastolic blood pressure which was maintained two months after surgery and allowed for discontinuation of one anti-hypertensive medication.

The Relationship between Atypical Symptoms of Degenerative Cervical Myelopathy and the Segments of Spinal Cord Compression: A Retrospective Observational Study

BACKGROUND

Patients with degenerative cervical myelopathy(DCM) often present with atypical symptoms such as vertigo, headache, palpitations, tinnitus, blurred vision, memory loss and abdominal discomfort. This study aims to investigate the relationship between atypical symptoms of DCM and the segments of spinal cord compression.

METHODS

166 DCM patients with atypical symptoms admitted to our institution from 2019 to 2020 were divided into vertigo, headache, blurred vision, tinnitus and palpitations groups according to their atypical symptoms; while the typical group was 214 DCM patients with typical symptoms only. Differences in segments of compression were compared between each group. And the results of over one-year follow-up were further summarized for non-surgical and surgical treatment of DCM patients with atypical symptoms.

RESULT

The incidence of vertigo, headache, blurred vision, tinnitus and palpitations of all DCM patients was 37%, 18%, 15%, 11% and 11% respectively. Compared to the typical group, patients in the blurred vision and tinnitus group were older (P < 0.05) and the incidence of spinal cord compression at C3-5 in the vertigo group, C4-5 in the headache group and C6-7 in the palpitation group was higher (P < 0.05). The scores of vertigo, headache and palpitations decreased after surgical decompression (P < 0.05), whereas only vertigo and headache scores decreased after non-surgical treatment (P < 0.05).

CONCLUSION

Atypical symptoms were common in patients with DCM and the segments of spinal cord compression might be associated with specific atypical symptoms. Surgical treatment is effective in relieving some of the atypical symptoms.

Effect of Cervical Decompression on Atypical Symptoms Cervical Spondylosis-A Narrative Review and Meta-Analysis

BACKGROUND

Atypical symptoms of cervical spondylosis refer to symptoms other than the typical symptoms of cervical spondylosis and include headache, nausea, gastrointestinal discomfort, blurred vision, tinnitus, hypomnesia, and palpitations. The role of cervical decompression in mitigating atypical symptoms of cervical spondylosis is still unclear.

METHODS

A comprehensive search of different databases was performed to retrieve articles that studied the effect of cervical decompression on associated atypical symptoms. The data were analyzed to obtain pooled improvement in the various atypical symptoms after cervical decompression.

RESULTS

Twenty-seven studies were included in the meta-analysis. Our analysis showed that cervical decompression was associated with significant improvement in Neck Disability Index-Headache Component (standardized mean difference [SMD], -0.84; 95% confidence interval [CI], -0.94 to -0.74; P < 0.0001), visual analog scale (SMD, -1.47; 95% CI, -1.73 to -1.21; P = 0.0004) and cervicogenic headache (odds ratio [OR], 0.19; 95% CI, 0.06-0.63; P = 0.01). Significant improvement was also observed in vertigo (OR, 0.27; 95% CI, 0.10-0.77; P = 0.02), tinnitus (OR, 0.54; 95% CI, 0.35-0.83; P = 0.02), and nausea (OR, 0.25; 95% CI, 0.13-0.47; P = 0.006) after cervical decompression. Nonsignificant improvement was noticed in the rates of blurred vision, hypomnesia, giddiness, gastrointestinal discomfort, palpitations, and hypertension.

CONCLUSIONS

Our analysis showed that cervicogenic headache, tinnitus, and nausea were significantly relieved after cervical decompression. There was no significant effect of cervical decompression on blurred vision, hypomnesia, giddiness gastrointestinal discomfort, palpitations, and hypertension.

Surgical Decompression for Cervical Spondylotic Myelopathy in Patients with Associated Hypertension: A Single-Center Retrospective Cohort and Systematic Review of the Literature

OBJECTIVE

To explore the relationship between spinal cord compression and hypertension through analysis of blood pressure (BP) variations in a cervical spondylotic myelopathy (CSM) cohort after surgical decompression, along with a review of the literature.

METHODS

A single-institution retrospective review of patients with CSM who underwent cervical decompression between 2016 and 2017 was conducted. Baseline clinical and imaging characteristics, preoperative and postoperative BP readings, heart rate, functional status, and pain scores were collected. In addition, a PRISMA guidelines-based systematic review was performed.

RESULTS

We identified 264 patients with CSM treated surgically; 149 (56.4%) of these had hypertension. The degree of spinal canal compromise and spinal cord compression, preoperative neurologic examination, and the presence of T2-signal hyperintensity on magnetic resonance imaging were associated with hypertension. Overall mean arterial pressure (MAP) decreased significantly at 1 and 12 months after surgery. Patients without T2-signal hyperintensity on imaging showed a MAP reduction at 12 months postoperatively, whereas those with T2-signal hyperintensity showed a transient MAP reduction at 1 month postoperatively before returning to preoperative values. At 12 months after surgery, 24 of 97 patients (24.7%) with initially uncontrolled hypertension had controlled BP values with significant reduction of MAP, systolic BP, and diastolic BP. Including the present study, 5 articles were eligible for systematic review, with all reporting a BP decrease in patients with CSM after decompression.

CONCLUSIONS

Analysis of our retrospective cohort and a systematic review suggest that cervical surgical decompression reduces BP in some patients with CSM. However, this improvement is less apparent in patients with preoperative spinal cord T2-signal hyperintensity.