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Zhang Z, Chang H, Liu K, Zhang D, Xue R, Li H, Wang Z, Liang G, Meng X. Is Intervertebral Disc Degeneration a Compensatory Mechanism in Adult Tethered Cord Syndrome? World Neurosurg 2023; 175:e511-e519. [PMID: 37028480 DOI: 10.1016/j.wneu.2023.03.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE The purpose of the present study was to evaluate the influence of high nerve tension on lumbar disc degeneration and sagittal morphologies. MATERIALS AND METHODS A total of 50 young and middle-aged patients (mean age 32.1 ± 7.4 years, 22 men and 28 women) who suffered from tethered cord syndrome (TCS) were retrospectively assessed by two observers. Demographic and radiological data were recorded, including lumbar disc degeneration, disc height index and lumbar spine angle, and were compared with 50 patients (mean age 29.7 ± 5.4 years, 22 men and 28 women) without spinal cord abnormalities. Statistical associations were assessed by student's t-test and chi-square test. RESULTS Our results showed patients with TCS had a significantly higher rate of lumbar disc degeneration in L1/2, L2/3, L4/5 and L5/S1 than in those without TCS (P < 0.05). Moreover, the rates of multilevel disc degeneration and severe disc degeneration in TCS group were significantly higher than those in control group (P < 0.01). The mean disc height index of L3/4 and L4/5 in TCS group was significantly lower than that in control group (P < 0.05). The mean lumbosacral angle of TCS patients was significantly higher than that of patients without TCS (38.4 ± 3.5°vs. 33.7 ± 5.9°, P < 0.01). CONCLUSIONS We found a certain correlation between TCS and lumbar disc degeneration and lumbosacral angle enlargement, suggesting that the spine reduces the high tension of the spinal cord through disc degeneration. Therefore, it is speculated that there is a "compromised regulation" mechanism in the body under the condition of neurological abnormalities.
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Affiliation(s)
- Zhuang Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China; Department of Graduate School, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Hengrui Chang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Kaiyu Liu
- Department of Orthopaedic Surgery, Chengde Medical College, Hebei, China
| | - Di Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Rui Xue
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Haoran Li
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China; Department of Graduate School, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhaoxuan Wang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China; Department of Graduate School, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Guzhen Liang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China; Department of Graduate School, Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xianzhong Meng
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
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Honkanen HP, Mustonen C, Herajärvi J, Tuominen H, Starck T, Kallio M, Kiviluoma K, Anttila V, Juvonen T. Priming protects the spinal cord in an experimental aortic occlusion model. J Thorac Cardiovasc Surg 2022; 164:801-809.e2. [PMID: 33220965 DOI: 10.1016/j.jtcvs.2020.09.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Paraplegia is a devastating complication in aortic aneurysm surgery. Modifying the spinal cord vasculature is a promising method in spinal cord protection. The aim of this study was to assess whether the spinal cord can be primed by occluding thoracic segmental arteries before simulated aneurysm repair in a porcine model. METHODS Twelve piglets were randomly assigned to the priming group (6) and the control group (6). Eight uppermost thoracic segmental arteries were occluded at 5-minute intervals in the priming group before a 25-minute aortic crossclamp. In the control group, the aorta was crossclamped for 25 minutes. During the first 5 minutes, 8 segmental arteries were occluded. After the aortic crossclamping, piglets were observed under anesthesia for 5 hours and followed up 5 days postoperatively. Near-infrared spectroscopy, motor-evoked potentials, blood samples, neurology with the modified Tarlov score, and histopathology of the spinal cord were assessed. RESULTS The median Tarlov score during the first postoperative day was higher in the priming group than in the control group (P = .001). At the end, 50% of the control animals had paraplegia compared with 0% of paraplegia in the priming group. The mean regional histopathologic score differed between the priming group and the control group (P = .02). The priming group had higher motor-evoked potentials during the operation at separate time points. The lactate levels were lower in the priming group compared with the control group (Pg = .001, Pg×t = .18). CONCLUSIONS Acute priming protects the spinal cord from ischemic injury in an experimental aortic crossclamp model.
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Affiliation(s)
- Hannu-Pekka Honkanen
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland.
| | - Caius Mustonen
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Johanna Herajärvi
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland; University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Hannu Tuominen
- Department of Pathology, Oulu University Hospital, Oulu, Finland
| | - Tuomo Starck
- Research Unit of Medical Imaging, Physics and Technology, Medical Research Center Oulu University of Oulu, Oulu, Finland; Department of Clinical Neurophysiology, Oulu University Hospital, Oulu, Finland
| | - Mika Kallio
- Research Unit of Medical Imaging, Physics and Technology, Medical Research Center Oulu University of Oulu, Oulu, Finland; Department of Clinical Neurophysiology, Oulu University Hospital, Oulu, Finland
| | - Kai Kiviluoma
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Vesa Anttila
- Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Tatu Juvonen
- Research Unit of Surgery, Anesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland; Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
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Kriegel J, Patel V, Takayama H. Commentary: Prime and prevent paraplegia. J Thorac Cardiovasc Surg 2022; 164:810-811. [PMID: 33220961 DOI: 10.1016/j.jtcvs.2020.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Jacob Kriegel
- Aortic Center, Columbia University Medical Center, New York, NY
| | - Virendra Patel
- Aortic Center, Columbia University Medical Center, New York, NY
| | - Hiroo Takayama
- Aortic Center, Columbia University Medical Center, New York, NY.
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Simon MV, Dong CC, Jacobs MJ, Mess WH. Neuromonitoring during descending aorta procedures. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:407-431. [PMID: 35772899 DOI: 10.1016/b978-0-12-819826-1.00010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thoraco-abdominal aneurysm (TAA) repair carries a significant risk of spinal cord infarction. The latter results from irreversible changes in the spinal cord arterial network, e.g., sacrifice of the segmental arteries. Intra-operative neurophysiology with somatosensory and especially motor evoked potential (SEP and MEP respectively) monitoring, has emerged as an effective tool to assess the efficiency of the collateral blood flow, detect reversible spinal cord ischemia and guide the peri-operative multidisciplinary management to prevent postoperative paraplegia. The main roles of such monitoring include diagnosis of spinal cord vs peripheral limb ischemia, titration of mean arterial pressure during aortic clamping, the guidance of selective re-implantation of critical segmental arteries, and management of hemodynamics in the immediate postoperative period. In addition, manipulation of the aortic arch and proximal descending aorta, adds the risk of cerebral infarction from both low flow state and/or thromboembolic events. As such, EEG monitoring may be a useful add-on for either assessment of the efficiency of cerebral cooling as a neuroprotective method and/or for detection and treatment of reversible cerebral ischemia. This chapter presents the multimodality approach to open TAA monitoring as a versatile tool for the prevention of devastating postoperative neurologic deficits.
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Affiliation(s)
- Mirela V Simon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States.
| | - Charles C Dong
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Michael J Jacobs
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Werner H Mess
- Department of Clinical Neurophysiology, Maastricht University Medical Center, Maastricht, The Netherlands
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Zhang L, Yu C, Yang X, Sun X, Qiu J, Jiang W, Wang D. Normothermic iliac perfusion improves early outcomes after thoraco-abdominal aortic aneurysm repair. Eur J Cardiothorac Surg 2020; 55:1054-1060. [PMID: 30590503 DOI: 10.1093/ejcts/ezy440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/15/2018] [Accepted: 11/17/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study is to evaluate the safety and efficacy of thoraco-abdominal aortic aneurysm repair with normothermic iliac perfusion. METHODS One hundred and ninety patients who underwent aortic replacement for the Crawford type II thoraco-abdominal aortic aneurysm between January 2005 and June 2017 were assigned to 2 groups: normothermic iliac perfusion (group A, n = 75) and deep hypothermic circulatory arrest (group B, n = 115). We selected 58 pairs of patients for propensity score matching. We analysed early operative death, a composite of complications and mid-term survival. RESULTS After propensity score matching, no early operative death occurred in group A (0.0%), and group B had 4 cases of early operative death (6.9%), with a statistically significant difference (P = 0.047). The composite of complications was reported in 11 patients in group A (21.0%) and in 21 patients in group B (36.2%) (P = 0.038). Age >50 years [odds ratio (OR) 6.50, 95% confidence interval (CI) 2.32-16.36; P = 0.020], deep hypothermia (OR 12.13, 95% CI 1.64-23.13; P = 0.003) and chronic renal insufficiency (OR 8.21, 95% CI 2.34-43.33; P < 0.001) were independent risk factors for early operative death. The 3-year, 5-year and 7-year survival rates were 98.3%, 98.3% and 86.9% in group A and 86.9%, 86.9% and 86.9% in group B, respectively (P = 0.471). The 7-year cumulative incidence function rates for reintervention were 0.026% in group A and 0.048% in group B (P = 0.625). CONCLUSIONS Normothermic iliac perfusion provides a viable alternative for thoraco-abdominal aortic aneurysm repair, which reduced early operative death and composited complications.
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Affiliation(s)
- Liang Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Cuntao Yu
- Department of Aortic Surgery, The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xiubin Yang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiaogang Sun
- Department of Aortic Surgery, The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Juntao Qiu
- Department of Aortic Surgery, The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wenxiang Jiang
- Department of Aortic Surgery, The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - De Wang
- Department of Aortic Surgery, The State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Mazensky D, Flesarova S, Sulla I. Arterial Blood Supply to the Spinal Cord in Animal Models of Spinal Cord Injury. A Review. Anat Rec (Hoboken) 2017; 300:2091-2106. [PMID: 28972696 DOI: 10.1002/ar.23694] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/06/2017] [Accepted: 07/18/2017] [Indexed: 02/02/2023]
Abstract
Animal models are used to examine the results of experimental spinal cord injury. Alterations in spinal cord blood supply caused by complex spinal cord injuries contribute significantly to the diversity and severity of the spinal cord damage, particularly ischemic changes. However, the literature has not completely clarified our knowledge of anatomy of the complex three-dimensional arterial system of the spinal cord in experimental animals, which can impede the translation of experimental results to human clinical applications. As the literary sources dealing with the spinal cord arterial blood supply in experimental animals are limited and scattered, the authors performed a review of the anatomy of the arterial blood supply to the spinal cord in several experimental animals, including pigs, dogs, cats, rabbits, guinea pigs, rats, and mice and created a coherent format discussing the interspecies differences. This provides researchers with a valuable tool for the selection of the most suitable animal model for their experiments in the study of spinal cord ischemia and provides clinicians with a basis for the appropriate translation of research work to their clinical applications. Anat Rec, 300:2091-2106, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- David Mazensky
- Department of Anatomy, Histology and Physiology, University of Veterinary Medicine and Pharmacy, Kosice, Slovakia
| | - Slavka Flesarova
- Department of Anatomy, Histology and Physiology, University of Veterinary Medicine and Pharmacy, Kosice, Slovakia
| | - Igor Sulla
- Department of Anatomy, Histology and Physiology, University of Veterinary Medicine and Pharmacy, Kosice, Slovakia
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Streijger F, So K, Manouchehri N, Tigchelaar S, Lee JHT, Okon EB, Shortt K, Kim SE, McInnes K, Cripton P, Kwon BK. Changes in Pressure, Hemodynamics, and Metabolism within the Spinal Cord during the First 7 Days after Injury Using a Porcine Model. J Neurotrauma 2017; 34:3336-3350. [PMID: 28844181 DOI: 10.1089/neu.2017.5034] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Traumatic spinal cord injury (SCI) triggers many perturbations within the injured cord, such as decreased perfusion, reduced tissue oxygenation, increased hydrostatic pressure, and disrupted bioenergetics. While much attention is directed to neuroprotective interventions that might alleviate these early pathophysiologic responses to traumatic injury, the temporo-spatial characteristics of these responses within the injured cord are not well documented. In this study, we utilized our Yucatan mini-pig model of traumatic SCI to characterize intraparenchymal hemodynamic and metabolic changes within the spinal cord for 1 week post-injury. Animals were subjected to a contusion/compression SCI at T10. Prior to injury, probes for microdialysis and the measurement of spinal cord blood flow (SCBF), oxygenation (in partial pressure of oxygen; PaPO2), and hydrostatic pressure were inserted into the spinal cord 0.2 and 2.2 cm from the injury site. Measurements occurred under anesthesia for 4 h post-injury, after which the animals were recovered and measurements continued for 7 days. Close to the lesion (0.2 cm), SCBF levels decreased immediately after SCI, followed by an increase in the subsequent days. Similarly, PaPO2 plummeted, where levels remained diminished for up to 7 days post-injury. Lactate/pyruvate (L/P) ratio increased within minutes. Further away from the injury site (2.2 cm), L/P ratio also gradually increased. Hydrostatic pressure remained consistently elevated for days and negatively correlated with changes in SCBF. An imbalance between SCBF and tissue metabolism also was observed, resulting in metabolic stress and insufficient oxygen levels. Taken together, traumatic SCI resulted in an expanding area of ischemia/hypoxia, with ongoing physiological perturbations sustained out to 7 days post-injury. This suggests that our clinical practice of hemodynamically supporting patients out to 7 days post-injury may fail to address persistent ischemia within the injured cord. A detailed understanding of these pathophysiological mechanisms after SCI is essential to promote best practices for acute SCI patients.
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Affiliation(s)
- Femke Streijger
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Kitty So
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Neda Manouchehri
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Seth Tigchelaar
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Jae H T Lee
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Elena B Okon
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Katelyn Shortt
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - So-Eun Kim
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada
| | - Kurt McInnes
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada .,2 Departments of Mechanical Engineering and Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada
| | - Peter Cripton
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada .,2 Departments of Mechanical Engineering and Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada
| | - Brian K Kwon
- 1 International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, British Columbia, Canada .,3 Vancouver Spine Surgery Institute, Department of Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada
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O'Callaghan A, Mastracci TM, Eagleton MJ. Staged endovascular repair of thoracoabdominal aortic aneurysms limits incidence and severity of spinal cord ischemia. J Vasc Surg 2015; 61:347-354.e1. [DOI: 10.1016/j.jvs.2014.09.011] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 09/16/2014] [Indexed: 11/29/2022]
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Krishna V, Andrews H, Varma A, Mintzer J, Kindy MS, Guest J. Spinal cord injury: how can we improve the classification and quantification of its severity and prognosis? J Neurotrauma 2014; 31:215-27. [PMID: 23895105 DOI: 10.1089/neu.2013.2982] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The preservation of functional neural tissue after spinal cord injury (SCI) is the basis for spontaneous neurological recovery. Some injured patients in the acute phase have more potential for recovery than others. This fact is problematic for the construction of clinical trials because enrollment of subjects with variable recovery potential makes it difficult to detect effects, requires large sample sizes, and risks Type II errors. In addition, the current methods to assess injury and recovery are non-quantitative and not sensitive. It is likely that therapeutic combinations will be necessary to cause substantially improved function after SCI, thus we need highly sensitive techniques to evaluate changes in motor, sensory, autonomic and other functions. We review several emerging neurophysiological techniques with high sensitivity. Quantitative methods to evaluate residual tissue sparing after severe acute SCI have not entered widespread clinical use. This reduces the ability to correlate structural preservation with clinical outcome following SCI resulting in enrollment of subjects with varying patterns of tissue preservation and injury into clinical trials. We propose that the inclusion of additional measures of injury severity, pattern, and individual genetic characteristics may enable stratification in clinical trials to make the testing of therapeutic interventions more effective and efficient. New imaging techniques to assess tract injury and demyelination and methods to quantify tissue injury, inflammatory markers, and neuroglial biochemical changes may improve the evaluation of injury severity, and the correlation with neurological outcome, and measure the effects of treatment more robustly than is currently possible. The ability to test such a multimodality approach will require a high degree of collaboration between clinical and research centers and government research support. When the most informative of these assessments is determined, it may be possible to identify patients with substantial recovery potential, improve selection criteria and conduct more efficient clinical trials.
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Affiliation(s)
- Vibhor Krishna
- 1 Department of Neurosciences, Medical University of South Carolina , Charleston, South Carolina
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Hershberger R, Cho JS. Neurologic complications of aortic diseases and aortic surgery. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:223-238. [PMID: 24365299 DOI: 10.1016/b978-0-7020-4086-3.00016-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Aortic disease processes have a wide range of clinical manifestations. The inflammatory disease process of Takayasu's arteritis differs dramatically from the visceral ischemia of aortic dissection. The catastrophic event of aortic rupture tends to overshadow life-altering events such as stroke and paraplegia. However, these neurologic manifestations of aortic diseases have dramatic effects that extend beyond the individual patient to include both social and financial ramifications. This chapter focuses on the major aortic disease processes and how they can initiate, both directly and indirectly, adverse neurologic events. The chapter concludes with a brief discussion of aortic surgery, how interventions on the aorta can cause neurologic complications, and techniques to avoid these feared adverse neurologic outcomes.
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Affiliation(s)
- Richard Hershberger
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA.
| | - Jae S Cho
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, USA
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Ilić N, Končar I, Dragaš M, Pejkic S, Maksimovic Z, Davidovic L. A proposal for a predictive model of paraplegia prevention during thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2013; 146:726. [PMID: 23953301 DOI: 10.1016/j.jtcvs.2013.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 04/18/2013] [Indexed: 11/16/2022]
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12
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Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols. J Vasc Surg 2013; 57:1537-42. [DOI: 10.1016/j.jvs.2012.12.032] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 12/05/2012] [Accepted: 12/06/2012] [Indexed: 11/17/2022]
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Park SM, Cho SJ, Ryu SM, Lee KH, Kang G. The effect of distal aortic pressure on spinal cord perfusion in rats. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:73-9. [PMID: 22500275 PMCID: PMC3322188 DOI: 10.5090/kjtcs.2012.45.2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Revised: 11/11/2011] [Accepted: 11/11/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic cross clamping is associated with spinal cord ischemia. This study used a rat spinal cord ischemia model to investigate the effect of distal aortic pressure on spinal cord perfusion. MATERIALS AND METHODS Male Sprague-Dawley rats (n=12) were divided into three groups. In group A (n=4), the aorta was not occluded. In groups B (n=4) and C (n=4), the aorta was occluded. In group B the distal aortic pressures dropped to around 20 mmHg. In group C, the distal aortic pressure was decreased to near zero. The carotid artery and tail artery were cannulated to monitor the proximal aortic pressure and the distal aortic pressure. Fluorescent microspheres were used to measure the regional blood flow in the spinal cord. RESULTS After aortic occlusion, blood flow to the cervical spinal cord showed no significant difference among the three groups. In groups B and C, the thoracic and lumbar spinal cord and renal blood flow decreased. No microspheres were detected in the thoracic and lumbar spinal cord of group C. CONCLUSION The spinal cord blood flow is dependent on the distal aortic pressure after thoracic aortic occlusion.
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Affiliation(s)
- Sung-Min Park
- Department of Thoracic and Cardiovascular Surgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Korea
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14
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Current strategies for spinal cord protection during thoracic and thoracoabdominal aortic aneurysm repair. Gen Thorac Cardiovasc Surg 2011; 59:155-63. [DOI: 10.1007/s11748-010-0705-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 08/30/2010] [Indexed: 11/26/2022]
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Carmona P, Mateo E, Otero M, Marqués JI, Peña JJ, Llagunes J, Aguar F, De Andrés J. [Spinal cord protection during open and endovascular surgery in thoracic and thoracoabdominal aorta diseases]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:110-118. [PMID: 21427827 DOI: 10.1016/s0034-9356(11)70009-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.
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Affiliation(s)
- P Carmona
- Consorcio Hospital General Universitario de Valencia.
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Juvonen T, Biancari F, Rimpiläinen J, Satta J, Rainio P, Kiviluoma K. Strategies for Spinal Cord Protection during Descending Thoracic and Thoracoabdominal Aortic Surgery: Up-to-date Experimental and Clinical Results - A review. SCAND CARDIOVASC J 2009. [DOI: 10.1080/cdv.36.3.136.160] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Ulus F, Hellberg A, Ulus AT, Karacagil S. Alterations in Cerebrospinal Fluid PO2, PCO2, and pH Measurements during and after Experimental Thoracic Aortic Cross-Clamping. Ann Vasc Surg 2009; 23:122-7. [DOI: 10.1016/j.avsg.2008.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2008] [Revised: 05/14/2008] [Accepted: 06/09/2008] [Indexed: 10/21/2022]
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A quantitative assessment of the impact of intercostal artery reimplantation on paralysis risk in thoracoabdominal aortic aneurysm repair. Ann Surg 2008; 248:529-40. [PMID: 18936565 DOI: 10.1097/sla.0b013e318187a792] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We previously demonstrated an 80% reduction in paraplegia risk using hypothermia, naloxone, steroids, spinal fluid drainage, intercostal ligation, and optimizing hemodynamic parameters. This report demonstrates that intercostal revascularization for the last 3 years further reduced our paraplegia risk index by 75%. METHODS We evaluated 655 patients who had thoracic or thoracoabdominal aneurysm repair for factors that affected paraplegia risk including aneurysm extent, acuity, cardiac function, blood pressure mean arterial pressure, and spinal fluid drainage with naloxone (SFDN). Eighteen patients died during or shortly after surgery leaving 637 patients for analysis of paralysis. We evaluated the effect of intercostal reimplantation (IRP) using a highly accurate (r(2) > 0.88) paraplegia risk index we developed and published previously. RESULTS Fifty-eight percent of patients were male with a mean age of 67. Thirty-three percent were acute with rupture, acute dissection, mycotic aortitis, and trauma. Eighty (12%) had dissections. Thirty-five patients had paraplegia or paraparesis (5.4%). Significant factors by univariate analysis (P < 0.05) were Crawford type 2, acuity, SFDN, cardiac index after unclamping, mean arterial pressure during crossclamping, and IRP. In multivariate modeling, aneurysm extent, SFDN, acuity, and IRP remained significant (P < 0.02). The paraplegia risk index declined from 0.20 to 0.05 (P < 0.03). CONCLUSIONS The incidence of paralysis after TAAA repair decreased from 4.83% to 0.88% and paralysis risk index decreased from 0.26 to 0.05 when intercostal artery reimplantation was added to neuroprotective strategies that had already substantially reduced paralysis risk. These findings suggest that factors that affect collateral blood flow and metabolism account for approximately 80% of paraplegia risk and intercostal blood flow accounts for 20% of risk. This suggests a limit to paraplegia risk reduction in thoracoabdominal endograft patients. Early results in this emerging field support this prediction of high paraplegia risk with thoracoabdominal branched endografts with extensive aortic coverage.
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Strauch JT, Lauten A, Zhang N, Wahlers T, Griepp RB. Anatomy of Spinal Cord Blood Supply in the Pig. Ann Thorac Surg 2007; 83:2130-4. [PMID: 17532411 DOI: 10.1016/j.athoracsur.2007.01.060] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Revised: 01/24/2007] [Accepted: 01/29/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND In a species as popular in research as the pig, little information is available concerning the blood supply and vascular anatomy of the spinal cord and comparability to humans. METHODS To visualize vessels contributing to the blood supply of the spinal cord, x-ray digital subtraction angiography and vascular casting by injection of a polymerizing solution of methylmethacrylate were used. RESULTS The pig has larger internal thoracic arteries and subscapular arteries than the human, providing extensive collateral flow to the lower body, which offers blood supply to the spinal cord through the collaterals. The pig has a fine-caliber vessel plexus providing blood to the neck area, from which flow will reach both the spinal cord and the base of the brain. The segmental thoracic and lumbar arteries are relatively small in pigs, and they almost all originate as a single branch from the aorta and divide after 3 to 4 mm. The segmental vessels show a clear diminution after 2 to 3 cm at the level of the vertebral bodies. Pigs show major differences in the anatomy of the aortic bifurcation compared with humans. The median sacral artery in pigs is a large-caliber vessel, of a size almost comparable to the common iliac artery, with an isolated single dorsal branch leading to the spinal cord. CONCLUSIONS Documenting the anatomic differences in spinal cord blood supply between pigs and humans will aid in the planning of future experimental studies and in determining the clinical relevance of such studies.
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Affiliation(s)
- Justus T Strauch
- Department of Cardiothoracic Surgery, The Mount Sinai Medical Center/New York University, New York, New York, USA.
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Etz CD, Homann TM, Plestis KA, Zhang N, Luehr M, Weisz DJ, Kleinman G, Griepp RB. Spinal cord perfusion after extensive segmental artery sacrifice: can paraplegia be prevented? Eur J Cardiothorac Surg 2007; 31:643-8. [PMID: 17293121 DOI: 10.1016/j.ejcts.2007.01.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2006] [Revised: 12/28/2006] [Accepted: 01/05/2007] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Understanding the ability of the paraspinal anastomotic network to provide adequate spinal cord perfusion pressure (SCPP) critical for both surgical and endovascular repair of thoracoabdominal aortic aneurysms (TAAA). METHODS To monitor pressure in the collateral circulation, a catheter was inserted into the distal end of the divided first lumbar segmental artery (SA) of 10 juvenile Yorkshire pigs (28.9+/-3.8kg). SA pairs from T3 through L5 were serially sacrificed at 32 degrees C; SCPP and function - using motor-evoked potentials (MEPs) - were continuously monitored until 1h after clamping the last SA. Intermittent aortic and SCPP monitoring was continued for 5 days postoperatively, along with evaluation of motor function. RESULTS A mean of 14.4+/-0.7 SAs were sacrificed without loss of MEP. SCPP (mmHg) dropped from 68+/-7 before SA clamping (77% of aortic pressure) to 22+/-6 at end clamping, and 21+/-4 after 1h, reaching its lowest point - 19+/-4 - after 5h. Postoperatively, SCPP recovered to 33+/-6 at 24h; 42+/-10 at 48h; 56+/-14 at 72h; 62+/-15 at 96h, returning to baseline (63+/-20) at 120h. Despite comparable SCPP patterns, four pigs did not fully regain the ability to stand. Six animals recovered: two could stand and four could walk. CONCLUSIONS Interruption of all SAs at 32 degrees C in this pig model results in a spectrum of cord injury, with normal function in a majority of pigs postoperatively. The short duration of low SCPP suggests that hemodynamic manipulation lasting only 24-48h may allow routine complete preservation of normal cord function despite sacrifice of all SAs.
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Affiliation(s)
- Christian D Etz
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Griepp RB, Griepp EB. Spinal Cord Perfusion and Protection During Descending Thoracic and Thoracoabdominal Aortic Surgery: The Collateral Network Concept. Ann Thorac Surg 2007; 83:S865-9; discussion S890-2. [PMID: 17257943 DOI: 10.1016/j.athoracsur.2006.10.092] [Citation(s) in RCA: 224] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 10/17/2006] [Accepted: 10/23/2006] [Indexed: 11/29/2022]
Abstract
In the last two decades, as an increasing number of patients with descending thoracic and thoracoabdominal aneurysms are being diagnosed and treated, a more sophisticated understanding of spinal cord perfusion has become important in the attempt to minimize the frequency of spinal cord injury. The synthesis of information from laboratory studies and clinical experience has led to the collateral network concept, a framework for understanding spinal cord perfusion and thereby improving spinal cord protection during treatment of aneurysmal disease of the aorta distal to the left subclavian artery. Application of principles based on the collateral network concept has resulted in falling rates of spinal cord injury, which now approach 1% in descending thoracic aneurysm resection and less than 10% in extensive thoracoabdominal resections. These accomplishments suggest that, with further investigation, routine sacrifice of segmental aortic branches can be carried out in a way that will allow surgical and endovascular therapy of extensive distal aortic aneurysms without neurologic injury.
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Affiliation(s)
- Randall B Griepp
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York, USA
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Biglioli P, Roberto M, Cannata A, Parolari A, Fumero A, Grillo F, Maggioni M, Coggi G, Spirito R. Upper and lower spinal cord blood supply: the continuity of the anterior spinal artery and the relevance of the lumbar arteries. J Thorac Cardiovasc Surg 2004; 127:1188-92. [PMID: 15052221 DOI: 10.1016/j.jtcvs.2003.11.038] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Thoracic and thoracoabdominal aortic repair are still complicated by spinal cord ischemia and paraplegia. The aim of the present article is to present the results of an anatomical study conducted by means of both postmortem injection of the vertebral artery and perfusion of the abdominal aorta. METHODS The spinal cord blood supply was investigated in 51 Caucasian cadavers: in 40 cases a methylene blue solution was hand-injected into the vertebral artery, whereas in the remaining 11 cases the abdominal aorta was perfused with a methylene blue solution by means of a roller pump. The level and side of the arteria radicularis magna and the continuity of the anterior spinal artery were recorded. RESULTS The anterior spinal artery was a continuous vessel without interruptions along the spinal cord in all 51 cases. The arteria radicularis magna level was variable, ranging from T9 to L5. The arteria radicularis magna arose from a lumbar artery in 36 cases (70.5%) and it was left-sided in 32 cases (62.7%). CONCLUSIONS The anterior spinal artery constitutes an uninterrupted pathway between the vertebral arteries, the arteria radicularis magna, and the posterior intercostal and lumbar arteries. Moreover, the arteria radicularis magna arises from a lumbar artery in most of cases. Therefore, the sacrifice of the intercostal arteries during a thoracic aorta repair could be justified, at least from an anatomical standpoint. However, if an extended thoracoabdominal aortic repair is planned, it may be prudent to preserve the blood flow from the lumbar arteries.
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Affiliation(s)
- Paolo Biglioli
- Department of Cardiovascular Surgery, University of Milan, Centro Cardilogico Fondazione Monzino IRCCS, Italy
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Jacobs MJ, Mess WH. The role of evoked potential monitoring in operative management of type I and type II thoracoabdominal aortic aneurysms. Semin Thorac Cardiovasc Surg 2003; 15:353-64. [PMID: 14710377 DOI: 10.1053/s1043-0679(03)00084-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Spinal cord ischemia with subsequent paraplegia remains the most dreaded and impressive complication following thoracoabdominal aortic aneurysm repair. Protective measures, such as cerebrospinal fluid drainage, distal aortic perfusion, and epidural cooling, have significantly reduced paraplegia rate. A major impediment is the inability to assess the efficacy of reattaching intercostal arteries or the contributing value of the adjunctive procedures during the operation. Monitoring motor-evoked potentials is a reliable technique to assess spinal cord integrity, dictating surgical strategies to restore and maintain blood supply to the gray matter. Based on motor-evoked potentials, hemodynamic and operative maneuvers during thoracoabdominal aortic aneurysm repair resulted, in our experience, in prevention of neurologic deficit in 98% of patients.
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Affiliation(s)
- Michael J Jacobs
- Department of Surgery, University Hospital Maastricht, The Netherlands.
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