A modern theory of paraplegia in the treatment of aneurysms of the thoracoabdominal aorta: An analysis of technique specific observed/expected ratios for paralysis

Abstract

Paraplegia causation is anatomic but paraplegia prevention is physiologic (non-anatomic). We demonstrate that by using hypothermia, SFD, and increasing MAP, clinicians had similar improvements in paraplegia, reducing O/E deficit ratios from 1.03 to as low as 0.16, with or without intercostal reimplantation, and whether or not assisted circulation was used. Understanding the fundamental principles of paraplegia prevention and how to apply protective strategies leads to a reduction in paralysis in clinical series with or without the use of assisted circulation. This modern theory of paraplegia has significant implications for the rapidly advancing field of TAAA repair with branched endografts where the same principles apply.

The Evolution of Chemokine Release Supports a Bimodal Mechanism of Spinal Cord Ischemia and Reperfusion Injury

“…1 Other techniques, such as intercostal artery reimplantation, evoked potential monitoring, epidural cooling, and hypothermic circulatory arrest also appear to modestly reduce risk of spinal cord injury. [2][3][4] Unfortunately, no pharmacological adjuncts have proven clinically efficacious in attenuating this injury. Moreover, once the injury has clinically manifested, no pharmacological or surgical intervention (other than attempts to modify parenchymal perfusion) is currently available.…”

Assessment of intraoperative motor evoked potentials for predicting postoperative paraplegia in thoracic and thoracoabdominal aortic aneurysm repair

“…In 2007, Griepp and Griepp [16] presented the collateral network concept: i.e., the major declines in paraplegia rates have not occurred from reattaching important radicular arteries but rather from the introduction of strategies that focus on maximizing effective collateral perfusion. Acher and Wynn [17] presented a theory of paraplegia prevention in DTAA and TAAA surgery: paraplegia causation is anatomic but paraplegia prevention is physiologic (non-anatomic). In the present study, we had a patient with paraparesis whose L1 lumbar artery branching AKA was preserved, and this may be a typical episode which points to the importance of the physiologic approach.…”

Fighting spinal cord complication during surgery for thoracoabdominal aortic disease

“…The early mortality rate was 9.7%, and the postoperative incidence of paraplegia was 3.4%. 85 Griepp et al proposed stepwise sacrifi ce of intersegmental arteries at the start of the procedure, before the aneurysm was opened. At the same time, somatosensory or motor evoked potentials were used to monitor spinal cord function with temporary occlusion before the segmental arteries were tied off permanently.…”