Spinal cord protection and thoracic aortic surgery

Impact of Intercostal Artery Reinsertion on Neurological Outcome after Thoracoabdominal Aortic Replacement: A 25-Year Single-Center Experience

BACKGROUND

Intercostal artery reinsertion (ICAR) during thoracoabdominal aortic replacement remains controversial. While some groups recommend the reinsertion of as many arteries as possible, others consider the sacrifice of multiple intercostals practicable. This study investigates the impact of intercostal artery reinsertion or sacrifice on neurological outcomes and long-term survival after thoracoabdominal aortic repair.

METHODS

A total of 349 consecutive patients undergoing thoracoabdominal aortic replacement at our institution between 1996 and 2021 were analyzed in a retrospective single-center study. ICAR was performed in 213 patients, while all intercostal arteries were ligated and sacrificed in the remaining cases. The neurological outcome was analyzed regarding temporary and permanent paraplegia or paraparesis.

RESULTS

No statistically significant differences were observed between the ICAR and non ICAR groups regarding the cumulative endpoint of transient and permanent spinal cord-related complications (12.2% vs. 11.8%, p = 0.9). Operation, bypass, and cross-clamp times were significantly longer in the ICAR group. Likewise, prolonged mechanical ventilation was more often necessary in the ICAR group (26.4% vs. 16.9%, p = 0.03). Overall long-term survival was similar in both groups in the Kaplan-Meier analysis.

CONCLUSION

Omitting ICAR during thoracoabdominal aortic replacement may reduce operation and cross-clamp times and thus minimize the duration of intraoperative spinal cord hypoperfusion.

Ranking sets of morbidities using hypergraph centrality

Multi-morbidity, the health state of having two or more concurrent chronic conditions, is becoming more common as populations age, but is poorly understood. Identifying and understanding commonly occurring sets of diseases is important to inform clinical decisions to improve patient services and outcomes. Network analysis has been previously used to investigate multi-morbidity, but a classic application only allows for information on binary sets of diseases to contribute to the graph. We propose the use of hypergraphs, which allows for the incorporation of data on people with any number of conditions, and also allows us to obtain a quantitative understanding of the centrality, a measure of how well connected items in the network are to each other, of both single diseases and sets of conditions. Using this framework we illustrate its application with the set of conditions described in the Charlson morbidity index using data extracted from routinely collected population-scale, patient level electronic health records (EHR) for a cohort of adults in Wales, UK. Stroke and diabetes were found to be the most central single conditions. Sets of diseases featuring diabetes; diabetes with Chronic Pulmonary Disease, Renal Disease, Congestive Heart Failure and Cancer were the most central pairs of diseases. We investigated the differences between results obtained from the hypergraph and a classic binary graph and found that the centrality of diseases such as paraplegia, which are connected strongly to a single other disease is exaggerated in binary graphs compared to hypergraphs. The measure of centrality is derived from the weighting metrics calculated for disease sets and further investigation is needed to better understand the effect of the metric used in identifying the clinical significance and ranked centrality of grouped diseases. These initial results indicate that hypergraphs can be used as a valuable tool for analysing previously poorly understood relationships and information available in EHR data.

Xenon Exerts Neuroprotective Effects on Kainic Acid-Induced Acute Generalized Seizures in Rats via Increased Autophagy

Xenon has been shown to have neuroprotective effects and is clinically used as a favorable safe inhalation anesthetic. We previously confirmed the neuroprotective effects of xenon treatment in epileptic animals. However, the mechanism underlying these protective effects remains unclear. We aimed to assess the effects of xenon inhalation on autophagy in neuronal injury induced by acute generalized seizures. Kainic acid (KA) was injected into the lateral ventricle of male Sprague–Dawley rats to induce acute generalized seizures. Next, the rats were treated via inhalation of a 70% xenon/21% oxygen/9% nitrogen mixture for 60 min immediately after KA administration. The control group was treated via inhalation of a 79% nitrogen/21% oxygen mixture. Subsequently, two inhibitors (3-methyladenine or bafilomycin A₁) or an autophagy inducer (rapamycin) were administered, respectively, before KA and xenon administration to determine the role of autophagy in the protective effects of xenon. The levels of apoptosis, neuronal injury, and autophagy were determined in all the rats. Xenon inhalation significantly attenuated the severity of the seizure-induced neuronal injury. Increased autophagy accompanied this inhibitive effect. Autophagy inhibition eliminated these xenon neuroprotective effects. A simulation of autophagy using rapamycin recapitulated xenon’s protective effects on KA-induced acute generalized seizures in the rats. These findings confirmed that xenon exerts strong neuroprotective effects in KA-induced acute generalized seizures. Further, they indicate that increased autophagy may underlie the protective effects of xenon. Therefore, xenon and autophagy inducers may be useful clinical options for their neuroprotective effects in epileptic seizures.

Spinal Cord Ischemia in Pancreas Transplantation: The UK Experience

BACKGROUND

Spinal cord ischemia (SCI) is a rare but devastating condition that can occur in the perioperative period resulting in paraplegia. Although diabetes mellitus is a risk factor for SCI in other types of major surgery, SCI is not widely recognized in transplantation. The aim of this study was to quantify the risk of SCI in pancreatic transplantation.

METHODS

All UK pancreas transplant units were surveyed between 2017 and 2018. The risk of SCI in pancreas transplantation was estimated using the number of radiologically confirmed cases relative to the number of pancreatic transplants from UK registry data during the same time period.

RESULTS

There have been 6 cases of SCI during pancreas transplantation since 2002. No aortic clamping occurred in any recipient. During or after surgery, all patients experienced episodes of hypotension (systolic blood pressure ≤ 90 mm Hg) before the onset of neurological symptoms. Epoprostenol, epidural anesthesia, and postoperative hemodialysis may have contributed to systemic hypotension. The mainstay of early treatment for SCI for all cases was blood pressure control.

CONCLUSIONS

Based on these findings, there is approximately a 1:440 risk of SCI in pancreas transplantation. Hypotension appears to be a prominent risk factor. Strategies for mitigating the risk of SCI are discussed, drawing on evidence from thoraco-abdominal aortic aneurysm surgery. The risk of long-term neurological deficit should be discussed with prospective pancreas recipients given the potential impact on posttransplant quality of life.

Cerebrospinal fluid drains reduce risk of spinal cord injury for thoracic/thoracoabdominal aneurysm surgery: A review

Background

The risk of spinal cord injury (SCI) due to decreased cord perfusion following thoracic/thoracoabdominal aneurysm surgery (T/TL-AAA) and thoracic endovascular aneurysm repair (TEVAR) ranges up to 20%. For decades, therefore, many vascular surgeons have utilized cerebrospinal fluid drainage (CSFD) to decrease intraspinal pressure and increase blood flow to the spinal cord, thus reducing the risk of SCI/ischemia.

Methods

Multiple studies previously recommend utilizing CSFD following T/TL-AAA/TEVAR surgery to treat SCI by increasing spinal cord blood flow. Now, however, CSFD (keeping lumbar pressures at 5-12 mmHg) is largely utilized prophylactically/preoperatively to avert SCI along with other modalities; avoiding hypotension (mean arterial pressures >80-90 mmHG), inducing hypothermia, utilizing left heart bypass, and employing intraoperative neural monitoring [somatosensory (SEP) or motor evoked (MEP) potentials]. In addition, preoperative magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) scans identify the artery of Adamkiewicz to determine its location, and when/whether reimplantation/reattachment of this critical artery and or other major segmental/lumbar arterial feeders are warranted.

Results

Utilizing CSFD for 15-72 postoperative hours in T/TL-AAA/TEVAR surgery has reduced the risks of SCI from a maximum of 20% to a minimum of 2.3%. The major complications of CSFD include; spinal and cranial epidural/subdural hematomas, VI nerve palsies, retained catheters, meningitis/infection, and spinal headaches.

Conclusions

By increasing blood flow to the spinal cord during/after T/TL-AAA/TEVAR surgery, CSFD reduces the incidence of permanent SCI from, up to 10-20% down to down to 2.3-10%. Nevertheless, major complications, including spinal/cranial subdural hematomas, still occur.

S-100β and Antioxidant Capacity in Cerebrospinal Fluid during and after Thoracic Endovascular Aortic Repair

Background

Thoracic Endovascular Aortic Repair (TEVAR) has substantially decreased the mortality and major complications from aortic surgery. However, neurological complications such as spinal cord ischemia may still occur after TEVAR. S-100β is a biomarker of central nervous system injury, and oxidant injury plays an important role in neurological injury. In this pilot study, we examined the trends of S-100β and antioxidant capacity in the CSF during and after TEVAR.

Methods

We recruited 10 patients who underwent elective TEVAR. CSF samples were collected through a lumbar catheter at the following time points: before the start of surgery (T0) and immediately (T1) and 24 (T2) and 48 hours (T3) after the deployment of the aortic stent. S-100β and CSF antioxidant capacity were analyzed with the use of commercially available kits.

Results

We observed that the level of S-100β in all of the subjects at 24 hours after the deployment of the aortic stent (T2) increased. However, the levels of S-100β at T1 and T3 were comparable to the baseline value. The antioxidant capacity remained unchanged. No patient had a clinical neurologic complication.

Conclusions

Our observations may indicate biochemical/subclinical central nervous system injury attributable to the deployment of the aortic stent.

Electroacupuncture pretreatment attenuates spinal cord ischemia-reperfusion injury via inhibition of high-mobility group box 1 production in a LXA4 receptor-dependent manner

Paraplegia caused by spinal cord ischemia is a severe complication following surgeries in the thoracic aneurysm. HMGB1 has been recognized as a key mediator in spinal inflammatory response after spinal cord injury. Electroacupuncture (EA) pretreatment could provide neuroprotection against cerebral ischemic injury through inhibition of HMGB1 release. Therefore, the present study aims to test the hypothesis that EA pretreatment protects against spinal cord ischemia-reperfusion (I/R) injury via inhibition of HMGB1 release. Animals were pre-treated with EA stimulations 30min daily for 4 successive days, followed by 20-min spinal cord ischemia induced by using a balloon catheter placed into the aorta. We found that spinal I/R significantly increased mRNA and cytosolic protein levels of HMGB1 after reperfusion in the spinal cord. The EA-pretreated animals displayed better motor performance after reperfusion along with the decrease of apoptosis, HMGB1, TNF-α and IL-1β expressions in the spinal cord, whereas these effects by EA pretreatment was reversed by rHMGB1 administration. Furthermore, EA pretreatment attenuated the down-regulation of LXA₄ receptor (ALX) expression induced by I/R injury, while the decrease of HMGB1 release in EA-pretreated rats was reversed by the combined BOC-2 (an inhibitor of LXA₄ receptor) treatment. In conclusion, EA pretreatment may promote spinal I/R injury through the inhibition of HMGB1 release in a LXA₄ receptor-dependent manner. Our data may represent a new therapeutic technique for treating spinal cord ischemia-reperfusion injury.

Review of the History of Non-traumatic Spinal Cord Dysfunction

Background: The incidence of non-traumatic spinal cord dysfunction (SCDys) is reported to be higher than traumatic spinal cord injury (SCI) in many countries. No formal review of the history of SCDys has been published. Objective: This article aims to identify key highlights in the history of SCDys. Method: An electronic literature search was conducted (January 2017) using MEDLINE (1946-2016) and Embase (1974-2016) databases for publications regarding the history of SCDys. Publications on the history of SCI and a selection of neurology textbooks and books on the history of neurology were reviewed for potentially relevant references. The focus of the literature search was on identifying publications that detail key highlights regarding the history of the diagnosis and management of the most common SCDys conditions, as well as those of historical significance. Results: The electronic search of MEDLINE and Embase identified 11 relevant publications. The majority of publications included were identified from the authors' libraries and a selection of books on neurology and the history of neurology. Conclusions: This review outlines the history of SCDys, taking a broader historical perspective and covering the increasing awareness of the role of the spinal cord and knowledge of neuroanatomy. Key milestones in the history of the diagnosis and management of the most common SCDys conditions are presented. An appreciation of the history of SCDys increases our understanding of the large number of people who contributed to our current knowledge of these conditions and in some situations helps guide efforts regarding prevention of SCDys.

[Management of anesthesia in endovascular interventions]

Cardiovascular diseases are one of the leading causes of morbidity and mortality in Germany. In these patients, the high-risk profile necessitates an interdisciplinary and multimodal approach to treatment. Endovascular interventions and vascular surgery have become established as an important element of this strategy in the past; however, the different anatomical localizations of pathological vascular alterations make it necessary to use a wide spectrum of procedural options and methods; therefore, the requirements for management of anesthesia are variable and necessitate a differentiated approach. Endovascular procedures can be carried out with the patient under general or regional anesthesia (RA); however, in the currently available literature there is no evidence for an advantage of RA over general anesthesia regarding morbidity and mortality, although a reduction in pulmonary complications could be found for some endovascular interventions. Epidural and spinal RA procedures should be carefully considered with respect to the risk-benefit ratio and consideration of the recent guidelines on anesthesia against the background of the current study situation and the regular use of therapy with anticoagulants. The following article elucidates the specific characteristics of anesthesia management as exemplified by some selected endovascular interventions.

Protocol for prevention of spinal cord ischemia after thoracoabdominal aortic surgery

Objective

This manuscript was written to present a systemic protocol for the prevention, early detection, and treatment of spinal cord ischemia following open and endovascular thoracoabdominal aortic operations.

Methods

This protocol was a collaborative effort between surgeons, anesthesiologists and intensivists. It was implemented at our institution in November 2007. Nurses are trained to prevent, rapidly detect and ultimately aid in the treatment of spinal cord ischemia.

Results

Implementation of this protocol has aided in prevention, detection and treatment of spinal cord ischemia in patients after open and endovascular thoracoabdominal aortic operations.

Conclusion

Standardized care and reliance on trained nursing staff to monitor for symptoms following thoracoabdominal aortic operations are safe and aid in the rapid detection, treatment and reversal of spinal cord ischemia.

Hypoxic preconditioning increases the protective effect of bone marrow mesenchymal stem cells on spinal cord ischemia/reperfusion injury

Transplantation of bone marrow mesenchymal stem cells (BMSCs) protect against spinal cord ischemia/reperfusion injury (SCIRI). However, a large number of transplanted BMSCs often undergo apoptosis, which severely affects the treatment outcome. Previous studies have demonstrated that hypoxic preconditioning effectively increases the survival rate of BMSCs following transplantation, and increases their protective effect on injured tissues. However, there have been few reports regarding roles of hypoxic preconditioning in SCIRI. The present study isolated rat BMSCs and separately transplanted hypoxia‑ and non‑hypoxia‑preconditioned BMSCs into the spinal cord tissues of rats with SCIRI. The role of hypoxic preconditioning in the promotion of the protective effect of BMSCs on SCIRI was investigated using neurological function scores, Evans blue staining, hematoxylin and eosin staining and terminal deoxynucleotidyl transferase dUTP nick end labeling. In addition, reverse transcription‑quantitative polymerase chain reaction and western blotting were used to detect the expression levels of hypoxia‑inducible factor 1α (HIF‑1α), and to investigate its possible underlying mechanism of action. The results indicated that hypoxic preconditioning effectively increased the protective effects of BMSCs on neurological function, blood spinal cord barrier and tissue damage following SCIRI, and inhibited apoptosis. Furthermore, hypoxic preconditioned BMSCs upregulated the expression of HIF‑1α in spinal cord tissues. Therefore, hypoxic preconditioning effectively increased the protective effect of BMSCs on SCIRI and may be associated with upregulation of the expression of HIF‑1α. Hypoxic preconditioning may serve as an effective means of increasing the protective effect of BMSCs on SCIRI.

The Effect of Perioperative Ischemia and Reperfusion on Multiorgan Dysfunction following Abdominal Aortic Aneurysm Repair

Abdominal aortic aneurysms (AAAs) are relatively common and are potentially life-threatening medical problems. The aim of this review is to provide an overview of the effect of I/R injury on multiorgan failure following AAA repair. The PubMed, CINAHL, EMBASE, Medline, Cochrane Review, and Scopus databases were comprehensively searched for articles concerning the pathophysiology of I/R and its systemic effects. Cross-referencing was performed using the bibliographies from the articles obtained. Articles retrieved were restricted to those published in English. One of the most prominent characteristics of AAA open repair is the double physiological phenomenon of ischemia-reperfusion (I/R) that happens either at the time of clamping or following the aortic clamp removal. Ischemia-reperfusion injury causes significant pathophysiological disturbances to distant organs, increasing the possibility for postoperative multiorgan failure. Although tissue injury is mediated by diverse mechanisms, microvascular dysfunction seems to be the final outcome of I/R.

Severe spinal cord ischemic injury secondary to device embolization after transcatheter closure of a patent arterial duct

Percutaneous closure of patent arterial ducts with the Amplatzer Ductal Occluder has become an effective and widely accepted alternative to surgical management. Although rarely, the occluder can be dislodged after an initially successful deployment, and with catastrophic consequences. We describe such a case in a 12-month-old girl who underwent transcatheter closure of a patent arterial duct. After device deployment, the occluder embolized in the patient's descending thoracic aorta, and severe spinal cord ischemic injury resulted. To our knowledge, ours is the first report of this complication after the deployment of an Amplatzer Ductal Occluder. We discuss pathophysiologic mechanisms that could expose patients to the risk of device dislodgment, and we review the relevant medical literature.

Thoracic endovascular aortic repair: update on indications and guidelines

Thoracic endovascular aortic repair (TEVAR) has revolutionized thoracic aortic surgery and has increased the options available to the aortic specialist in treating thoracic aortic disease. TEVAR is less invasive, and is associated with a decrease in perioperative morbidity and mortality when compared with open surgical repair. The dramatic expansion of TEVAR activity has necessitated a better definition for the indications, contraindications, and limitations of this new technology. Ideally TEVAR should be performed in specialized aortic centers providing a full range of diagnostic and treatment options, using a multidisciplinary team approach.

Post-conditioning by xenon reduces ischaemia-reperfusion injury of the spinal cord in rats

BACKGROUND

The neuroprotective effects of xenon post-conditioning following spinal cord injury remain unknown. We monitored the effect of xenon post-conditioning on the spinal cord following ischaemia-reperfusion injury and determined its mechanism of action.

METHODS

Spinal cord ischaemia was induced following balloon occlusion of the thoracic aorta in male Sprague-Dawley rats. Rats were divided into three groups (n = 30 in each group). The control group underwent ischaemia-reperfusion injury and immediately inhaled 50% (v/v) nitrogen at the time of reperfusion for 60 min continuously. The xenon-post-conditioning group underwent the same surgical procedure and immediately inhaled 50% (v/v) xenon at the time of reperfusion for 60 min continuously. The sham operation group underwent the same surgical procedure without aortic catheter occlusion and inhaled the same gas as that in control rats. Neurologic function was assessed using the Basso, Beattie, and Bresnahan score at 4, 24, and 48 h after reperfusion. Histological changes were observed using Nissl staining, the ultrastructure of the spinal cord was examined using transmission electron microscopy, and apoptosis was monitored using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labelling.

RESULTS

Compared with the control group, the xenon-post-conditioning group showed improved neurologic outcomes (11.3 ± 1.6 vs. 15.7 ± 3.1, respectively) and had more morphologically normal neurons (6 ± 2 vs. 12 ± 3) at 48 h after reperfusion. Moreover, apoptotic cell death in xenon-treated rats was reduced when compared with control rats (18.29 ± 3.06 vs. 27.34 ± 3.63, P < 0.05, respectively).

CONCLUSIONS

Xenon post-conditioning exerts a neuroprotective effect on the spinal cord following ischaemia-reperfusion injury via its anti-apoptotic role.

[Transient delayed paraplegia after repair of thoracic and thoracoabdominal aneurysms]

Thoracoabdominal aneurysm requires multidisciplinary management due to its complexity both in surgical technique and anesthetic considerations. One of the most feared postoperative complication is spinal cord ischemia. It can be presented as different clinical patterns, and its recovery may be partial or complete. The postoperative management of spinal cord ischemia is mainly based on techniques to increase spinal cord perfusion, above all, hemodynamic stability and cerebrospinal fluid drainage. We present two cases of delayed paraplegia after an open repair of a thoracoabdominal aneurysm and a descending thoracic aortic aneurysm repair using an endovascular stent graft. They both had a complete neurological recovery after cerebrospinal fluid drainage.

[Intraoperative electrophysiological monitoring with evoked potentials]

During the last 30 years intraoperative electrophysiological monitoring (IOEM) has gained increasing importance in monitoring the function of neuronal structures and the intraoperative detection of impending new neurological deficits. The use of IOEM could reduce the incidence of postoperative neurological deficits after various surgical procedures. Motor evoked potentials (MEP) seem to be superior to other methods for many indications regarding monitoring of the central nervous system. During the application of IOEM general anesthesia should be provided by total intravenous anesthesia with propofol with an emphasis on a continuous high opioid dosage. When intraoperative MEP or electromyography guidance is planned, muscle relaxation must be either completely omitted or maintained in a titrated dose range in a steady state. The IOEM can be performed by surgeons, neurologists and neurophysiologists or increasingly more by anesthesiologists. However, to guarantee a safe application and interpretation, sufficient knowledge of the effects of the surgical procedure and pharmacological and physiological influences on the neurophysiological findings are indispensable.

Recovery of paraplegia after type B dissection due to spinal collateral recruitment

Acute paraplegia could be a symptom of aortic dissection due to sudden compromise of arterial spinal cord blood supply. Complete spontaneous neurologic recovery is possible and was observed in the present case 3 hours after symptom onset. Spontaneous spinal cord reperfusion after acute type B dissection was probably due to two main mechanisms. Reperfusion of false lumen and collateral vascular network recruitment, recently confirmed by anatomic animal studies, serve as potential explanations. Favorable evolution of acute paraplegia after aortic dissection exists, but prognosis is uncertain, probably due to individual variable anatomic distribution of spinal cord blood supply.

Neurological complications of thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.

Giant aneurysm after aortic coarctation: repair without circulatory arrest

We describe the case of a 23-year-old patient presenting for redo aortic arch surgery because of recoarctation and poststenotic aneurysm formation after patch aortoplasty in infancy. Using the hemi-clamshell approach, the entire aortic arch was replaced and the supraaortic branches were reimplanted. The applied surgical technique using hypothermic extracorporeal circulation without cardiac arrest allowed an uninterrupted cerebral and spinal cord perfusion due to stepwise clamping of the aortic arch during reconstruction and resulted in an excellent neurologic outcome at six-month follow-up. 

Avoiding the use of helmet continuous positive airway pressure after surgery on thoracic aorta

Spinal cord ischaemia remains a major problem after surgery of the thoracic aorta. Early detection and avoidance of systemic hypotension can prevent permanent neurological damage. We report a rare case that developed a temporary paraplegia postoperatively, associated with the use of helmet continuous positive airway pressure.

Intrathecal lactate concentration and spinal cord injury in thoracoabdominal aortic surgery

OBJECTIVE

The aim of this study was to evaluate the role of lactate as an early predictor of spinal cord injury during thoracoabdominal aortic aneurysm repair.

DESIGN

Observational study.

SETTING

University hospital.

PARTICIPANTS

Sixteen consecutive patients (10 men and 6 women) scheduled to undergo thoracoabdominal aortic aneurysm repair were enrolled in the study. All patients were affected by atherosclerotic aneurysmal pathology.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During surgery, the authors simultaneously withdrew samples of cerebrospinal fluid and arterial blood to evaluate pO(2), pCO(2), pH, and lactate concentration. Samples were collected at 5 fixed times during and after surgery: T1 (before aortic cross-clamping), T2 (15 minutes after clamping), T3 (just before unclamping), T4 (end of surgery), and T5 (4 hours after the end of surgery). Lactate levels in cerebrospinal fluid rose consistently during aortic cross-clamping (T1 = 1.89 mmol/L, T2 = 2.21 mmol/L, T3 = 2.88 mmol/L, T4 = 3.655 mmol/L, and T5 = 3.16 mmol/L). Lactate concentrations in the cerebrospinal fluid were significantly higher in the 4 patients who developed neurologic injury, even at T1 (before surgery), than in those who did not end in spinal cord injury with the 4 highest values belonging to the 4 patients who later developed spinal cord injury.

CONCLUSIONS

This study has the potential to elucidate the time course of early lactate level elevation during thoracoabdominal aortic aneurysm repair and its clinical use in predicting the development of postoperative spinal cord injury.