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Basu S, Gohil K. Subacute Posttraumatic Ascending Myelopathy After Thoracolumbar Spinal Cord Injury. JBJS Rev 2022; 10:01874474-202210000-00004. [PMID: 36206362 DOI: 10.2106/jbjs.rvw.22.00097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
➢ Subacute posttraumatic ascending myelopathy (SPAM) is defined as neurological deterioration ascending four or more levels above the initial injury level and occurring within the initial days to weeks after spinal cord injury (SCI). ➢ SPAM is a rare complication of spinal cord injury with an incidence of 0.42% to 1% affecting young to middle-aged male patients. ➢ Several hypotheses have been put forth to explain SPAM, but the exact pathomechanism remains elusive. ➢ Treatment guidelines for this rare entity are uncertain and still to be developed. ➢ The current prognosis of SPAM is poor, with a mortality rate of 10.34%.
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Affiliation(s)
- Saumyajit Basu
- Department of Spine Surgery, Kothari Medical Centre, Kolkata, India
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Behem CR, Haunschild J, Pinnschmidt HO, Gaeth C, Graessler MF, Trepte CJC, Etz CD, Debus ES, Wipper SH. Effects of fluids vs. vasopressors on spinal cord microperfusion in hemorrhagic shock induced ischemia/reperfusion. Microvasc Res 2022; 143:104383. [PMID: 35605693 DOI: 10.1016/j.mvr.2022.104383] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Spinal cord injury induced by ischemia/reperfusion is a devastating complication of aortic repair. Despite developments for prevention and treatment of spinal cord injury, incidence is still considerably high majorly impacting patient outcome. Microcirculation is paramount for tissue perfusion and oxygen supply and often dissociated from macrohemodynamic parameters used to guide resuscitation. Effects of fluids vs. vasopressors in the setting of hemodynamic resuscitation on spinal cord microperfusion are unknown. Aim of this study was to compare the effects of vasopressor and fluid resuscitation on spinal cord microperfusion in a translational acute pig model of hemorrhagic shock induced ischemia/reperfusion injury. METHODS We designed this study as prospective randomized explorative large animal study. We induced hemorrhagic shock in 20 pigs as a model of global ischemia/reperfusion injury. We randomized animals to receive either fluid or vasopressor resuscitation. We measured spinal cord microperfusion using fluorescent microspheres as well as laser-Doppler probes. We monitored and analyzed macrohemodynamic parameters and cerebrospinal fluid pressure. RESULTS Spinal cord microperfusion decreased following hemorrhagic shock induced ischemia/reperfusion injury. Both fluids and vasopressors sufficiently restored spinal cord microperfusion. There were no important changes between groups (percentage changes compared to baseline: fluids 14.0 (0.31-27.6) vs. vasopressors 24.3 (8.12-40.4), p = .340). However, cerebrospinal fluid pressure was higher in animals receiving fluid resuscitation (percentage changes compared to baseline: fluids 27.7 (12.6-42.8) vs. vasopressors -5.56 ((-19.8)-8.72), p = .003). Microcirculatory resuscitation was in line with improvements of macrohemodynamic parameters. CONCLUSIONS Both, fluids and vasopressors, equally restored spinal cord microperfusion in a porcine acute model of hemorrhagic shock induced ischemia/reperfusion injury. However, significant differences in cerebrospinal fluid pressure following resuscitation were present. Future studies should evaluate these effects in perfusion disruption induced ischemia/reperfusion conditions of microcirculatory deterioration.
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Affiliation(s)
- Christoph R Behem
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Josephina Haunschild
- University Department for Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Hans O Pinnschmidt
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Catharina Gaeth
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg (UHZ), Hamburg, Germany
| | - Michael F Graessler
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Constantin J C Trepte
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - E Sebastian Debus
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg (UHZ), Hamburg, Germany
| | - Sabine H Wipper
- Department of Vascular Medicine, University Heart and Vascular Center Hamburg (UHZ), Hamburg, Germany
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Haunschild J, Khachatryan Z, von Aspern K, Herajärvi J, Ossmann S, Naumann J, Borger MA, Etz CD. Effect of cerebrospinal fluid pressure elevation on spinal cord perfusion during aortic cross-clamping with distal aortic perfusion. Eur J Cardiothorac Surg 2021; 60:569-576. [PMID: 33839764 DOI: 10.1093/ejcts/ezab167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/29/2021] [Accepted: 02/28/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Distal aortic perfusion (DaP) is a widely accepted protective adjunct facilitating early reinstitution of visceral perfusion during extended thoracic and thoraco-abdominal aortic repair. DaP has also been suggested to secure distal inflow to the paraspinal collateral network via the hypogastric arteries and thereby reduce the risk of spinal cord ischaemia. However, an increase in cerebrospinal fluid (CSF) pressure is frequently observed during thoracoabdominal aortic aneurysm repair. The aim of this study was to evaluate the effects of DaP on regional spinal cord blood flow (SCBF) during descending aortic cross-clamping and iatrogenic elevation of cerebrospinal fluid pressure. METHODS Eight juvenile pigs underwent central cannulation for cardiopulmonary bypass according to our established experimental protocol followed by aortic cross-clamping of the descending thoracic and abdominal aorta-mimicking sequential aortic clamping-with the initiation of DaP. Thereafter, CSF pressure elevation was induced by the infusion of blood plasma until baseline CSF pressure was tripled. At each time-point, microspheres of different colours were injected allowing for regional SCBF analysis. RESULTS DaP led to a pronounced hyperperfusion of the distal spinal cord [SCBF up to 480%, standard deviation (SD): 313%, compared to baseline]. However, DaP provided no or only limited additional flow to the upper and middle segments of the spinal cord (C1-Th7: 5% of baseline, SD: 5%; Th8-L2: 24%, SD: 39%), which was compensated by proximal flow only at C1-Th7 level. Furthermore, DaP could not counteract an experimental CSF pressure elevation, which led to a further decrease in regional SCBF most pronounced in the mid-thoracic spinal cord segment. CONCLUSIONS Protective DaP during thoraco-abdominal aortic repair may be associated with inadequate spinal protection particularly at the mid-thoracic spinal cord level ('watershed area') and result in the adverse effect of a potentially dangerous hyperperfusion of the distal spinal cord segments.
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Affiliation(s)
- Josephina Haunschild
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Zara Khachatryan
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Konstantin von Aspern
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Johanna Herajärvi
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Susann Ossmann
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Jörg Naumann
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Michael A Borger
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- University Department for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Heisenberg Working Group for Aortic Surgery, Saxonian Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
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Haunschild J, VON Aspern K, Misfeld M, Davierwala P, Borger MA, Etz CD. Spinal cord protection in thoracoabdominal aortic aneurysm surgery: a multimodal approach. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:316-325. [PMID: 33496426 DOI: 10.23736/s0021-9509.21.11783-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spinal cord injury (SCI) is one major complication of open and endovascular thoracic and thoracoabdominal aortic aneurysm repair. Despite numerous neuroprotective adjuncts, the incidence of SCI remains high. This review article discusses established and novel adjuncts for spinal cord protection, including priming and preconditioning of the paraspinal collateral network, intraoperative systemic hypothermia, distal aortic perfusion, motor- and somatosensory evoked potentials and noninvasive cnNIRS monitoring as well as peri- and postoperative drainage of cerebrospinal fluid. Regardless of the positive influence of many of these strategies on neurologic outcome, to date no strategy assures definitive preservation of spinal cord integrity during and after aortic aneurysm repair.
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Affiliation(s)
| | | | - Martin Misfeld
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.,Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, University of Sydney, Sydney, Australia.,Institute of Academic Surgery, RPAH, Sydney, Australia.,The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia
| | - Piroze Davierwala
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Christian D Etz
- Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany -
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Commentary: Going transesophageal will make your monitoring simpler! JTCVS Tech 2020; 4:36-37. [PMID: 34317959 PMCID: PMC8306879 DOI: 10.1016/j.xjtc.2020.08.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 11/21/2022] Open
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