Enhanced serum creatine kinase after neurosurgery in lateral position and intraoperative neurophysiological monitoring

The Effects of Patient Positioning on the Outcome During Posterior Cranial Fossa and Pineal Region Surgery

Background: Surgery on posterior cranial fossa (PCF) and pineal region (PR) carries the risks of intraoperative trauma to the brainstem structures, blood loss, venous air embolism (VAE), cardiovascular instability, and other complications. Success in surgery, among other factors, depends on selecting the optimal patient position. Our objective was to find associations between patient positioning, incidence of intraoperative complications, neurological recovery, and the extent of surgery.

Methods: This observational study was conducted in two medical centers: The Ohio State University Wexner Medical Center (USA) and The Burdenko Neurosurgical Institute (Russian Federation). Patients were distributed in two groups based on the surgical position: sitting position (SP) or horizontal position (HP). The inclusion criteria were adult patients with space-occupying or vascular lesions requiring an open PCF or PR surgery. Perioperative variables were recorded and summarized using descriptive statistics. The post-treatment survival, functional outcome, and patient satisfaction were assessed at 3 months.

Results: A total of 109 patients were included in the study: 53 in SP and 56 in HP. A higher proportion of patients in the HP patients had >300 mL intraoperative blood loss compared to the SP group (32 vs. 13%; p = 0.0250). Intraoperative VAE was diagnosed in 40% of SP patients vs. 0% in the HP group (p < 0.0001). However, trans-esophageal echocardiographic (TEE) monitoring was more common in the SP group. Intraoperative hypotension was documented in 28% of SP patients compared to 9% in HP group (p = 0.0126). A higher proportion of SP patients experienced a new neurological symptom compared to the HP group (49 vs. 29%; p = 0.0281). The extent of tumor resection, postoperative 3-months survival, functional outcome, and patient satisfaction were not different in the groups.

Conclusions: The SP was associated with, less intraoperative bleeding, increased intraoperative hypotension, VAE, and postoperative neurological deficit. More HP patients experienced macroglossia and increased blood loss. At 3 months, there was no difference of parameters between the two groups.

Clinical Trial Registration:ClinicalTrials.gov: registration number NCT03364283.

Elevated serum creatine kinase after neurosurgeries in lateral position with intraoperative neurophysiological monitoring is associated with OP duration, BMI and age

OBJECTIVES

Elevated serum levels of creatine kinase (CK) reflect skeletal muscle injury, which may lead to renal dysfunction following surgery. High CK levels are known to occur after neurosurgical interventions, especially following lateral positioning, but a consensus on possible risk factors is still lacking. Here we investigate risk factors for postoperative CK excess in a patient population at high risk (lateral position) with a special focus on the influence of intraoperative neurophysiological monitoring (IONM), particularly Motor Evoked Potentials (MEPs).

METHODS

We analyzed patient charts from elective surgeries in lateral position between 2010 and 2012 and where IONM was performed and where postoperative CK-levels were available. In these patients, the anesthesia regimen excluded muscle relaxants. Patient charts were reviewed retrospectively for patient characteristics, CK levels and indicators of renal dysfunction. The MEP response intensity was measured. These patients were compared to a matched (age, BMI, surgery duration) control group of patients operated with IONM, but operated in prone or supine position.

RESULTS

We included 96 patients (55 female, mean age 50years). The maximal CK level (CKmax) occurred on postoperative days 2 or 3 (mean 1763U/L). In a multivariate linear regression model, log(CKmax) correlated positively with duration of surgery (p<0.001) and BMI (p=0.007), and negatively with age (p=0.007), but not with MEP response intensity (p=0.481). We did not observe impaired renal function.

CONCLUSIONS

CK excess following neurosurgical procedures in lateral position correlated positively with duration of surgery and BMI and negatively with age. MEP stimulations of the muscles at risk did not cause further CK elevation.

SIGNIFICANCE

In patients undergoing long neurosurgeries without muscle relaxants, we recommend special care regarding positioning and perioperative management.