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Rhabdomyolysis after neurosurgery: a review and a framework for prevention

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Abstract

Rhabdomyolysis (RM) is a potentially fatal or disabling clinical syndrome resulting in muscle necrosis and leakage of muscle constituents into the blood. Lactic acidosis and more serious complications such as acute renal failure may occur in up to half of recognized cases, so accurate diagnosis is required. We present three cases in which RM occurred in patients undergoing neurosurgical procedures performed in the lateral position. A review of the literature is provided together with a framework for the prevention of this surgical complication. Three patients underwent neurosurgical procedures in the lateral position for left facial/glossopharyngeal neuralgia, for jugular foramen tumor, and for a petroclival meningioma, respectively. All patients were obese and all three showed massive postoperative elevation in creatine kinase (CK) levels characteristic of RM. Myoglobinuria was identified in two patients and all three showed hyperintensity of the hip gird muscles in the short tau inversion recovery sequence magnetic resonance imaging. All recovered spontaneously and none went on to develop renal failure. A literature review showed that RM has been rarely reported after neurosurgery. However, the duration of procedures of the cases of reported RM indicates that the prevalence of the condition is likely highly under-recognized in neurosurgery. This is particularly important given the rising obesity rates seen in many countries. Obese patients undergoing long neurosurgical procedures, particularly in the lateral position, should be suspected of RM and should be closely monitored for CK levels, myoglobinuria, and acidosis. We outline a framework of strategies for the prevention of the condition.

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Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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Authors and Affiliations

  1. Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, ON, Canada, M5B 1W8

    Claudio De Tommasi & Michael D. Cusimano

Authors
  1. Claudio De Tommasi
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  2. Michael D. Cusimano
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Correspondence to Claudio De Tommasi.

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Comments

Andreas M. Stark, Kiel, Germany

Rhabdomyolysis is a rare but serious complication of trauma, surgery, intoxication, hyperthermia, extreme exercise, and other conditions. The authors report three interesting cases of RM following neurosurgical procedures in three obese patients operated in the lateral position. They point well to this problem and discuss strategies to prevent RM. We personally have good experience in using the supine position with the patient’s head turned in obese individuals, also to prevent RM.

Ignacio J. Previgliano, Buenos Aires, Argentina

Dr. De Tomasi and Cusimano’s review address an important and almost forgotten cause of acute kidney failure in the intensive care unit: rhabdomyolysis (RM).

In their comprehensive research, they identify obesity as the main factor to develop RM, added to lateral decubitus and more than 6 h of surgery duration. Szeeczyk1 et al. promoted reperfusion of damaged tissue after prolonged ischemia, probably due to changes in muscular pressure that overlap mean arterial pressure during anesthesia, and the secondary release of necrotic products and mediators to the bloodstream after these excess of pressure is alleviated. The most common positions related with RM were lateral decubitus, lithotomy, sitting, knee-to-chest and prone position, added to increased body mass index, duration of surgery, hypovolemia, uremia, diabetes and arterial hypertension.2

Although there is a long list of genetic disorders and drugs that can cause RM, I will like to remain some of them that are related to the perioperative period.

One group of drugs is statins. They are commonly used not only for their cholesterol-lowering properties but for it pleiotropic effect. Developing RM seems to be a drug class effect because it was described with most of statins.3,4,5,6

Cocaine abuse either chronic or recreational is associated with RM.7 As its use is extended worldwide (according to Argentine Drug Abuse Office, 2.6 % of Argentinean adults consume cocaine8), this act should be attend during anamnesis.

One should never forget anesthetics drugs as a source for RM. Neuroleptic malignant syndrome, propofol infusion syndrome, opioids, and some inhalatory agents derived from halothane (malignant hyperthermia). The caffeine/halothane test is very useful to identify patients at risk for malignant hyperthermia.9

Although it extended use, there is little evidence to recommend urine alkalinization or mannitol for RM treatment.10 So the most reliable treatment lays on volume expansion according central venous pressure in order to maintain urine output near 100–150 ml/h.11

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De Tommasi, C., Cusimano, M.D. Rhabdomyolysis after neurosurgery: a review and a framework for prevention. Neurosurg Rev 36, 195–203 (2013). https://doi.org/10.1007/s10143-012-0423-0

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