Neurogenic shock in a patient with cervical myelopathy from severe cervical kyphoscoliosis

Excerpt

A 20-yr-old patient with neurofibromatosis (NF) type 1 presented to the emergency department in a wheelchair with isolated, painless, and progressive weakness in all four limbs approximately two months after an unwitnessed fall from standing height. Radiological imaging confirmed severe cervical stenosis from a kyphotic deformity (Figure, panel A) and spinal cord edema at C4 and C7 (Figure, panel B). Progressive myelopathy exacerbated by traumatic injury in the context of NF was diagnosed. After admission, cervical traction was applied with Gardner–Wells tongs using 15 lbs of weight. Two episodes of bradycardia and hypotension were resolved by standard treatment and by adjusting the traction. The patient was scheduled for single-stage anterior and posterior cervical decompression and fusion. A neurophysiologic monitoring baseline was established in the operating room with continuous spine traction in situ, and clinical examination confirmed no deterioration of spinal cord function. With the patient still in the traction bed, anesthesia was induced intravenously with neuromuscular blockade to facilitate tracheal intubation using a hyperangulated videolaryngoscope. Anesthesia was maintained intravenously and mean arterial pressure was maintained greater than 85 mm Hg. All monitored parameters, including neurophysiologic variables, remained stable throughout the 13-hr surgery. The estimated blood loss was 2.5 L and the patient remained intubated and ventilated overnight in the intensive care unit. Further recovery was uneventful. At eight weeks follow-up, the patient was able to stand and walk unassisted. This case represents an extremely compromised cervical spinal cord injury with preoperative neurogenic shock. Cervical spine injury can present with cardiovascular compromise at any time after injury and this can contribute significantly to morbidity and mortality. Maintaining cervical traction until definitive surgical decompression and stabilization may prevent further cervical cord compromise. Important perioperative goals include maintaining spinal cord perfusion and preventing secondary neurologic injury during transfers, positioning, and airway management. …