Review ArticleA Modern Theory of Spinal Cord Ischemia/Injury in Thoracoabdominal Aortic Surgery and Its Implications for Prevention of Paralysis
Section snippets
Mathematical Modeling Of Paralysis Risk: O/E Ratios Of Paralysis
Stanley Crawford, who performed more than 1,500 thoracic and thoracoabdominal aortic aneurysm repairs during his career, classified these aneurysms according to extent of aortic involvement.1 The most extensive aneurysms, Crawford type I (CI) and type II (CII) thoracoabdominal aneurysms, have the highest paralysis risk because repair interrupts the most segmental arteries.2 Without protective therapies, paralysis after elective repair of degenerative aneurysms is 10% in CI and more than 20% in
Pathophysiology Of Spinal Cord Ischemia And Infarction
The results of experimental studies of spinal cord ischemia in animal models suggest that spinal cord injury after thoracic aortic occlusion can be explained by an ischemia-reperfusion injury that progresses to infarction. In the last 20 years experimental findings have been adopted clinically by centers performing TAAA surgery in an effort to reduce the ischemia produced during aortic clamping, unclamping, and replacement that leads to infarction and paralysis in TAAA surgery. Examination of
Spinal Cord Blood Supply And Oxygen Delivery
Blood supply is the dominant determinant of spinal cord oxygen delivery. Clinical understanding of the blood supply to the spinal cord has evolved over the past 30 years. The vertebral arteries originate from the subclavian arteries and join to form the anterior spinal artery (ASA) that supplies the motor areas of the cord. Two posterior spinal arteries that also originate from the subclavian arteries supply the proprioceptive and sensory areas of the cord. The motor areas of the spinal cord
Spinal Cord Perfusion Pressure And Spinal FLUID Drainage
Animal experiments have demonstrated that when central venous pressure (CVP) increases, spinal fluid pressure (SFP) also increases.33 Occluding the descending thoracic aorta in a dog model doubled blood flow to the upper body and increased CVP, but when the thoracic aorta and inferior vena cava were occluded simultaneously, this redistribution of blood could not occur and CVP was unchanged.34 Animal experiments also confirmed that occluding the thoracic aorta increases spinal fluid pressure
Hypothermia
Hypothermia has long been known to reduce metabolic rate and oxygen demand in nervous tissue,47 which prolongs ischemic tolerance. Animal studies have shown that hypothermia also stabilizes cell membranes,48, 49 reduces excitatory neurotransmitter release from ischemic neurons,48 and blunts hyperemic reperfusion injury.21, 49 In animal studies, hypothermic circulatory arrest,48 spinal cord cooling,50 and moderate systemic hypothermia reduce paralysis after aortic occlusion.51
In clinical
Mean Arterial Pressure And Collateral Network Pressure
Mean arterial pressure is a primary determinant of spinal cord perfusion in TAAA surgery. Animal studies have shown that when the thoracic aorta is occluded, hypotension results in loss of motor evoked potentials (MEPs), reflecting cord ischemia, and that MEP changes can be reversed by increasing MAP.62 The same response is seen in patients when MEPs are monitored during TAAA repair. If MEPs are lost after intercostal artery occlusion, they can be restored by increasing MAP.12 Clinical
Intercostal Artery Reimplantation
The role of intercostal artery reimplantation (ICAR) in preventing paralysis is less well understood. For a long time the dominant paradigm was that reimplanting the artery of Adamkiewicz, source of the greater radicular artery, would prevent paralysis. But this has not been the case. However, a similar anatomic paradigm continues to drive selective intercostal artery reimplantation. (Selective ICAR here means that ICAs to be reimplanted were identified by MEP changes when an ICA was
Pharmacologic Adjuncts
Animal experiments have shown that intrathecal papaverine improves spinal cord perfusion during thoracic aortic occlusion by dilating spinal arteries and increasing spinal cord blood flow.68, 69 Based on these studies, intrathecal papaverine, combined with other protective adjuncts, has been used during TAAA repair with the goal of increasing spinal cord perfusion when the thoracic aorta is occluded.56
Other drugs are used during TAAA surgery based on experimental evidence that they reduce
Surgical Technique: Distal Perfusion
There are no randomized controlled trials of distal perfusion that show its effectiveness in reducing paralysis in TAAA repair.82 In spite of suggestions by some authors that distal perfusion/assisted circulation protects against paralysis,82, 83 this strategy is not supported by experimental observation in primate,68, 84 pig,85 or dog86 models of spinal cord ischemia. Currently, distal perfusion is combined with other strategies, such as hypothermia, SFD, optimizing hemodynamics and increasing
Surgical Technique And O/E Ratios For Paralysis
Table 2 shows paralysis and mortality results by series and surgical technique from retrospective reports of TAAAs treated from 1990 to 2013. These results are summarized in Figure 6, which plots the regression analysis for observed versus expected paralysis by surgical technique for more than 20,000 patients from more than 90 surgical series. Assisted circulation and cross-clamp alone each have an O/E ratio of 1—both have the expected number of deficits. However, SFD with cross-clamp, SFD with
Conclusions
Although the cause of paralysis in the repair of thoracoabdominal aortic aneurysms is primarily anatomic, prevention of paralysis is largely physiologic.
Reducing SFP by draining spinal fluid; increasing MAP, CNP, and cardiac index to maximize collateral circulation; and reimplanting ICA in the highest risk patients all increase spinal cord perfusion and oxygen delivery during and after surgery.
Hypothermia decreases oxygen demand, prolongs ischemic tolerance, and reduces direct neuronal and
Acknowledgments
Many thanks to Dr. Glen Leverson for biostatistical analysis and to Dr. Douglas Coursin for advice and support in preparing this manuscript.
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