Skip to main content

Advertisement

SpringerLink
Log in

Electrophysiologic deterioration in surgery for thoracic disc herniation: impact of mean arterial pressures on surgical outcome

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Objective

Severe thoracic disc herniation leads to increased pressure in adjacent neural structures, which in turn can require an increase in mean arterial pressure (MAP) to maintain adequate spinal cord perfusion. We report a case series of three patients with severe thoracic disc herniation that experienced deteriorations in motor-evoked potentials (MEPs) and somatosensory evoked potentials (SSEPs) following induction of general anesthesia, but prior to decompression of the neural elements.

Methods

In-depth chart reviews were completed for each patient from their initial presentation to long-term post-operative course. Careful attention was taken with regards to MAP at induction of each operative case.

Results

The origin of the decreased signals in all patients was thought to relate to inadequate cord perfusion pressures. Two of the patients recovered pre-operative neurologic function while the third was left with mild post-operative paraparesis. Mean arterial pressures at time of deterioration were noted to be 58, 80, and 60 mmHg. These measurements represented MAPs approximately 65, 92, and 60 % those of baseline values, respectively.

Conclusion

Based on these experiences, the authors’ institution has adopted new guidelines in the setting of thoracic disc herniations that includes pre-operative optimization of volume status, placement of an awake arterial line prior to induction of anesthesia, use of MEP and SSEP electrophysiologic monitoring, careful selection of anesthetic, and aggressive maintenance of MAPs >110 % of preoperative values at all times prior to decompression of the spinal cord.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

Abbreviations

MEPs:

Motor-evoked potentials

SSEPs:

Somatosensory evoked potentials

MAPs:

Mean arterial pressure

IRB:

Institutional review board

ED:

Emergency department

IV:

Intravenous

POD:

Post-operative day

SCBF:

Spinal cord blood flow

SCPP:

Spinal cord perfusion pressure

SCVR:

Spinal cord vascular resistance

References

  1. Arnold PM, Johnson PL, Anderson KK (2011) Surgical management of multiple thoracic disc herniations via a transfacet approach: a report of 15 cases. J Neurosurg Spine 15:76–81. doi:10.3171/2011.3.SPINE10642

    Article  PubMed  Google Scholar 

  2. Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH (1998) Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 88:623–633. doi:10.3171/jns.1998.88.4.0623

    Article  PubMed  CAS  Google Scholar 

  3. Quraishi NA, Khurana A, Tsegaye MM, Boszczyk BM, Mehdian SM (2014) Calcified giant thoracic disc herniations: considerations and treatment strategies. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cervl Spine Res Soc 23(Suppl 1):S76–S83. doi:10.1007/s00586-014-3210-5

    Article  Google Scholar 

  4. Martirosyan NL, Feuerstein JS, Theodore N, Cavalcanti DD, Spetzler RF, Preul MC (2011) Blood supply and vascular reactivity of the spinal cord under normal and pathological conditions. J Neurosurg Spine 15:238–251. doi:10.3171/2011.4.SPINE10543

    Article  PubMed  Google Scholar 

  5. Walker MT DS, Harbison DL, Partovi S (2001) CT perfusion imaging. Barrow Q 17

  6. Royse CF, Liew DF, Wright CE, Royse AG, Angus JA (2008) Persistent depression of contractility and vasodilation with propofol but not with sevoflurane or desflurane in rabbits. Anesthesiology 108:87–93. doi:10.1097/01.anes.0000296077.32685.26

    Article  PubMed  CAS  Google Scholar 

  7. Skues MA, Richards MJ, Jarvis AP, Prys-Roberts C (1989) Preinduction atropine or glycopyrrolate and hemodynamic changes associated with induction and maintenance of anesthesia with propofol and alfentanil. Anesth Analg 69:386–390

    Article  PubMed  CAS  Google Scholar 

  8. Vasileiou I, Xanthos T, Koudouna E, Perrea D, Klonaris C, Katsargyris A, Papadimitriou L (2009) Propofol: a review of its non-anaesthetic effects. Eur J Pharmacol 605:1–8. doi:10.1016/j.ejphar.2009.01.007

    Article  PubMed  CAS  Google Scholar 

  9. Ebert TJ (2005) Sympathetic and hemodynamic effects of moderate and deep sedation with propofol in humans. Anesthesiology 103:20–24

    Article  PubMed  CAS  Google Scholar 

  10. Smischney NJ, Beach ML, Loftus RW, Dodds TM, Koff MD (2012) Ketamine/propofol admixture (ketofol) is associated with improved hemodynamics as an induction agent: a randomized, controlled trial. J Trauma Acute Care Surg 73:94–101. doi:10.1097/TA.0b013e318250cdb8

    Article  PubMed  CAS  Google Scholar 

  11. Yaksh TL, Harty GJ, Onofrio BM (1986) High dose of spinal morphine produce a nonopiate receptor-mediated hyperesthesia: clinical and theoretic implications. Anesthesiology 64:590–597

    Article  PubMed  CAS  Google Scholar 

  12. El-Tahan MR (2011) Preoperative ephedrine counters hypotension with propofol anesthesia during valve surgery: a dose dependent study. Ann Card Anaesth 14:30–40. doi:10.4103/0971-9784.74397

    PubMed  Google Scholar 

  13. Kawaguchi M, Furuya H, Patel PM (2005) Neuroprotective effects of anesthetic agents. J Anesthe 19:150–156. doi:10.1007/s00540-005-0305-5

    Article  Google Scholar 

  14. Moore SPT (2004) Definitive neurological surgery board review, 1st edn. Lippincott Williams and Wilkins, Philadelphia

    Google Scholar 

  15. Marcus ML, Heistad DD, Ehrhardt JC, Abboud FM (1977) Regulation of total and regional spinal cord blood flow. Circ Res 41:128–134

    Article  PubMed  CAS  Google Scholar 

  16. Bridwell KH, Lenke LG, Baldus C, Blanke K (1998) Major intraoperative neurologic deficits in pediatric and adult spinal deformity patients. Incidence and etiology at one institution. Spine 23:324–331

    Article  PubMed  CAS  Google Scholar 

  17. Othman Z, Lenke LG, Bolon SM, Padberg A (2004) Hypotension-induced loss of intraoperative monitoring data during surgical correction of scheuermann kyphosis: a case report. Spine 29:E258–E265

    Article  PubMed  Google Scholar 

  18. May DM, Jones SJ, Crockard HA (1996) Somatosensory evoked potential monitoring in cervical surgery: identification of pre- and intraoperative risk factors associated with neurological deterioration. J Neurosurg 85:566–573. doi:10.3171/jns.1996.85.4.0566

    Article  PubMed  CAS  Google Scholar 

  19. Cheh G, Lenke LG, Padberg AM, Kim YJ, Daubs MD, Kuhns C, Stobbs G, Hensley M (2008) Loss of spinal cord monitoring signals in children during thoracic kyphosis correction with spinal osteotomy: why does it occur and what should you do? Spine 33:1093–1099. doi:10.1097/BRS.0b013e31816f5f73

    Article  PubMed  Google Scholar 

  20. Noonan KJ, Walker T, Feinberg JR, Nagel M, Didelot W, Lindseth R (2002) Factors related to false- versus true-positive neuromonitoring changes in adolescent idiopathic scoliosis surgery. Spine 27:825–830

    Article  PubMed  Google Scholar 

  21. Chi JH, Dhall SS, Kanter AS, Mummaneni PV (2008) The Mini-Open transpedicular thoracic discectomy: surgical technique and assessment. Neurosurg Focus 25:E5. doi:10.3171/FOC/2008/25/8/E5

    Article  PubMed  Google Scholar 

  22. Cornips EM, Janssen ML, Beuls EA (2011) Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome. J Neurosurg Spine 14:520–528. doi:10.3171/2010.12.SPINE10273

    Article  PubMed  Google Scholar 

  23. Levi L, Wolf A, Belzberg H (1993) Hemodynamic parameters in patients with acute cervical cord trauma: description, intervention, and prediction of outcome. Neurosurgery 33:1007–1016

  24. Vale FL, Burns J, Jackson AB, Hadley MN (1997) Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management. J Neurosurg 87:239–246

Download references

Acknowledgments

The content of this manuscript, in part or in full, has not been published elsewhere in any form. I, Scott Zuckerman, certify that this manuscript is a unique submission and is not being considered for publication with any other source in any medium. All of the above-mentioned authors contributed to the preparation of this manuscript. There are no relevant financial disclosures from any of the authors. All authors adhered to ethical standards of research in the preparation of this manuscript.

Conflict of interest

The authors have no conflict of interest to report.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, Vanderbilt University Medical Center, T-4224 Medical Center North, Nashville, TN, 37232-9557, USA

    Scott L. Zuckerman, Akshitkumar M. Mistry & Joseph S. Cheng

  2. Department of Neurological Surgery, David Grant Medical Center, Travis AFB, Fairfield, CA, USA

    Jonathan A. Forbes

  3. Vanderbilt University School of Medicine, Nashville, TN, USA

    Harish Krishnamoorthi

  4. Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA

    Sheena Weaver & Letha Mathews

  5. Charlotte Neurosurgical Associates, Charlotte, NC, USA

    Matthew J. McGirt

Authors
  1. Scott L. Zuckerman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jonathan A. Forbes
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Akshitkumar M. Mistry
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Harish Krishnamoorthi
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sheena Weaver
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Letha Mathews
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Joseph S. Cheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Matthew J. McGirt
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Scott L. Zuckerman.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zuckerman, S.L., Forbes, J.A., Mistry, A.M. et al. Electrophysiologic deterioration in surgery for thoracic disc herniation: impact of mean arterial pressures on surgical outcome. Eur Spine J 23, 2279–2290 (2014). https://doi.org/10.1007/s00586-014-3390-z

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-014-3390-z

Keywords

Search

Navigation