Cardiovascular changes and lumbar spine surgery: A neglected entity

Mahajan, Shalvi; Swami, Aditi; Kumar, Amit

doi:10.4103/ajns.ajns_224_19

Cited by 4 publications

(13 citation statements)

References 8 publications

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“…14 The Breuer-Lockhart reflex produces a comparable response to this whereby there is the activation of the afferent parasympathetic fibers in response to anal/perianal stimulation. 14 While the specific nuance of this spinal-cardiac reflex is yet to be fully understood, we agree with previous cases that there must be some central brain stem connection for this apparent lumbar spine-brainstem-heart loop that results in the negative chronotropic changes. 9 10 11 12 13 14 15…”

Section: Discussionmentioning

confidence: 99%

“…There is a scarcity of cases demonstrating hemodynamic changes during spinal surgery, 9 10 11 12 13 14 but their existence suggests that there may be a reflex mechanism in the spine as there is in the autonomous cerebral system similar to the trigeminocardiac reflex (TCR). 15 The current understanding of such a phenomenon is based on the current case in the literature.…”

Section: Discussionmentioning

confidence: 99%

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Negative Chronotropic Cardiovascular Changes in Lumbar Spine Surgery: A Potential Spinal-Cardiac Reflex?

et al. 2023

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Cardiovascular changes following lumbar spine surgery in a prone position are exceedingly rare. Over the past 20 years, a total of six cases have been published where patients experienced varying degrees of bradycardia, hypotension, and asystole, which could be attributed to intraoperative dural manipulation. As such, there is emerging evidence for a potential neural-mediated spinal-cardiac reflex. The authors report their experience of negative chronotropy during an elective lumbar spine surgery that coincided with dural manipulation and review the available literature. A 34-year-old male presented with a long-standing history of lower back pain recently deteriorating to bilaterally radiating leg pain, with restricted left leg raise, and numbness at the left L5 dermatomal territory. The patient was an athletic police officer with no comorbidities or past medical history. Magnetic resonance imaging lumbosacral spine revealed spinal stenosis most pronounced at L4/L5 and disc bulges at L3/L4 and L5/S1. The patient opted for lumbar decompression surgery. After an unremarkable comprehensive preoperative workup, including cardiac evaluation (electrocardiogram, echocardiogram), the patient was induced general anesthesia in a prone position. A lumbar incision was made from L2 to S1. When the left L4 nerve root was retracted while removing the prolapsed disc at L4/L5, the anesthetist cautioned the surgeon of bradycardia (34 beats per minute [bpm]), and the surgery was immediately stopped. The heart rate improved to 60 bpm within 30 seconds. When the root was later retracted again, a second episode of bradycardia occurred for 4 minutes with heart rate declining to 48 bpm. The surgery was stopped, and after 4 minutes, the anesthetist administered 600 µg of atropine. The heart rate then rose to 73 bpm within 1 minute. Other potential causes for bradycardia were excluded. The total blood loss was estimated to be 100 mL. He remains well at his 6-month follow-up and has returned to work as normal. Akin to previously published cases, each episode of bradycardia coincided with dural manipulation, which may indicate a possible reflex between the spinal dura mater and the cardiovascular system. Such a rare adverse event may occur even in seemingly healthy, young individuals, and anesthetists should caution the operating surgeon of bradycardias to exclude operative manipulation of the dura as the cause. While this phenomenon is only reported in a handful of lumbar spine surgery cases, it provides evidence for a potential spinal-cardiac physiological reflex in the lumbar spine that may be neural mediated and should be investigated further.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Negative Chronotropic Cardiovascular Changes in Lumbar Spine Surgery: A Potential Spinal-Cardiac Reflex?

et al. 2023

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“…8 The protruded nuclear material distracts the intervertebral endplates and may distract the adjacent spinous process by a fraction that cannot be appreciated through X-ray and MRI. The rupture of the annulus fibrosis and irritation of the sinovetebral nerve 29,30 in addition to the pressure on the thecal sac, inhibits the contraction of the lumbar multifidus and thereby the patient feels relatively comfortable in a flexed posture.…”

Section: Discussionmentioning

confidence: 99%

A survey based study of quality of life in stroke patients ambulating with walker

Keramat¹,

Bhutta²,

Ahmad³

et al. 2022

JRCRS

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“…Although it is desired, analgesia, autonomic stability, and muscle relaxation are not always the complete components of anesthesia [43]. Negative cardiovascular changes have been recently also reported following lumbosacral spine surgery [44,45]. Application of a local esthetic agent to neural tissue, maintaining hemodynamic, and avoiding the stimulus was the corrective measures taken by few recent reports [44,45].…”

Section: Discussionmentioning

confidence: 99%

“…Negative cardiovascular changes have been recently also reported following lumbosacral spine surgery [44,45]. Application of a local esthetic agent to neural tissue, maintaining hemodynamic, and avoiding the stimulus was the corrective measures taken by few recent reports [44,45]. A temporal relationship of bradyarrhythmia and cardiac arrest after stimulation in neuromonitoring and polypharmacy has also been reported.…”

Section: Discussionmentioning

confidence: 99%

Hemodynamic Neuromonitoring, a Proposed Spino-Cardiac Protective Reflex: Prospective Study in 200 Patients of Lumbar Surgery

Krishnan¹,

Degulmadi²,

Ranjan³

et al. 2021

bbj

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Background: Parasympathomimetic reflexes are reported in literature in spine surgery. Our primary hypothesis is proposed that nociceptive stimuli can be elicited by various maneuvers of lumbar spinal surgery and the physiological manifestation depends on many patient variables and anesthesia. However, a sympathomimetic pathological response is indicative of potential neural damages, which may or may not be reversible. A spino-cardiac protective reflex (SPR), as a new entity for lumbar spinal surgery, is proposed. Study Design: This was a prospective single institution. Materials and Methods: All the patients who were undergoing single motion segment transforaminal lumbar interbody fusion (TLIF) in our institute for lumbar disc herniation or non-discogenic lumbar stenosis lumbar spinal stenosis were included who fitted into inclusion criteria till 200 subjects were recruited. Patients’ pertinent vital data were collected at clinical first pre-operative visit and preoperatively on admission. The intraoperative parameters were recorded: Pre-induction, post-induction, post-positioning, before skin incision, after skin/subcutaneous exposure, pre-screw insertion, after screw insertion, after rod connection and distraction, during central decompression-laminotomy/laminectomy, during lateral recess decompression, discectomy, and segmental compression. Significant pulse rate (PR) and mean arterial pressure (MAP) changes were monitored and correlated. Results: In the enrolled 200 patients, the change in mean MAP and PR changes in varying steps of TLIF was not significant. The positivity of a significant change in MAP and PR correlating with an evident manipulative/pathological-demographic cause was noted (plausibility), which could revert back to baseline (reversibility) after addressing the culprit in 22 cases. Non-correlating raise was also noted in 35 cases. Conclusion: Spino-protective reflex exists like any reflex in body. Prospective study on huge database needs to be done to validate these observations. However, this study does make the surgeon think for finding clues to neurological damage or left out residual compressions which can be identified and rectified in real time in many cases. INOM is the standard of care and SPR should be compared with intraoperative neuromonitoring to identify sensitivity and threshold of pathological response in future studies. Keywords: Lumbar, Protective, Reflex, Spine, Sympathomimetic, Transforaminal lumbar interbody fusion

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Cardiovascular changes and lumbar spine surgery: A neglected entity

Cited by 4 publications

References 8 publications

Negative Chronotropic Cardiovascular Changes in Lumbar Spine Surgery: A Potential Spinal-Cardiac Reflex?

Negative Chronotropic Cardiovascular Changes in Lumbar Spine Surgery: A Potential Spinal-Cardiac Reflex?

A survey based study of quality of life in stroke patients ambulating with walker

Hemodynamic Neuromonitoring, a Proposed Spino-Cardiac Protective Reflex: Prospective Study in 200 Patients of Lumbar Surgery

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