Hypotension-Induced Loss of Intraoperative Monitoring Data During Surgical Correction of Scheuermann Kyphosis: A Case Report

Othman, Zanariah; Lenke, Lawrence G.; Bolon, Shelly M.; Padberg, Anne M.

doi:10.1097/01.brs.0000127193.89438.b7

Cited by 31 publications

(14 citation statements)

References 48 publications

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“…6 We recommend careful neuromonitoring and avoidance of uncontrolled hypotensive anesthesia during and after kyphosis correction to decrease the risk of catastrophic stretch or ischemic spinal cord injury. 18 Although our SRS-30 scores were comparable, the scores in the anterior/posterior fusion group did not account for those patients with significant complications. Without these scores, clinical outcomes of P/TPS are comparable to the anterior/posterior fusion group.…”

Section: Discussionmentioning

confidence: 86%

Comparison of Scheuermann Kyphosis Correction by Posterior-Only Thoracic Pedicle Screw Fixation Versus Combined Anterior/Posterior Fusion

Lee

Lenke²,

Kuklo³

et al. 2006

Spine

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134

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Section: Discussionmentioning

confidence: 86%

Comparison of Scheuermann Kyphosis Correction by Posterior-Only Thoracic Pedicle Screw Fixation Versus Combined Anterior/Posterior Fusion

Lee

Lenke²,

Kuklo³

et al. 2006

Spine

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134

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“…Urinary and fecal incontinence, impotence, and spinal dysautonomia also may occur [12]. Specific risk factors, such as spinal stenosis, vascular disease, intraoperative hypotension, or the use of epinephrine in the local anesthetic solution may cause spinal cord ischemia [1,18]. In a case report of spinal cord ischemia after esophagectomy, the patient had a thoracic epidural catheter placed for postoperative pain control [21].…”

Section: Spinal Cord Ischemiamentioning

confidence: 99%

Spinal Cord Injury After Extremity Surgery in Children With Thoracic Kyphosis

Pruszczyński

Mackenzie

Rogers

et al. 2015

Clin Orthop Relat Res

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Background Spinal cord injury is a rare complication after lower extremity surgery in children with skeletal dysplasia and thoracic kyphosis. We encountered two patients who had this complication, from among 51 (39 from Nemours/Alfred I. duPont Hospital for Children and 12 from Seattle Children's Hospital) who underwent lower extremity surgery during an 8.5-year period (June 2004 to December 2012). Because spinal cord injury is a devastating complication likely not known to most physicians treating patients with skeletal dysplasias, we sought to examine factors that may contribute to this rare complication. Case Description We performed a retrospective review of two patients with skeletal dysplasia who had paraplegia develop after extremity surgery. Outcome measures included operative time, vital signs, and postsurgery recovery of neurologic deficit. MR images were reviewed. Two patients were found-an 8.5-year-old boy with spondyloepiphyseal dysplasia congenita with a 76°-thoracic kyphosis apex at T4 and a 6.5-year-old boy with mucopolysaccharidosis type 1-H with an 80°-thoracic kyphosis apex at T2. Bilateral proximal femoral osteotomies or bilateral innominate and proximal femoral osteotomies had been performed. The spinal cord injuries occurred at the apex of the kyphosis as determined by clinical examination and MRI assessment. In both patients, the mean arterial blood pressure decreased below 50 mm Hg and might be a factor in the etiology of the paralysis. The first patient recovered motor function in 5 months; the second had no recovery. Literature Review Paraplegia is extremely rare after nonspine operations. Many factors contribute to the risk for a spinal cord event: low mean arterial pressure, duration of the surgery, position on the operating table, the kyphotic spine deformity, or unappreciated vascular disease. Motorevoked potentials and somatosensory-evoked potentials together potentially provide high sensitivity and specificity for predicting a postoperative neurologic deficit. Clinical Relevance Based on our two patients with skeletal dysplasia and a literature review of patients with hyperkyphosis undergoing extremity surgery, the surgeon must be aware of the risk of spinal cord injury. Careful preoperative assessment possibly including MRI of the spine is recommended. Mean arterial pressure should be maintained at a safe level; neuromonitoring should be considered.

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“…The problem with this alarm point is that anesthetic fade is not considered. Other causes of false positives include intraoperative hypothermia and hypotension [4, 5]. In our study, there were no cases of persistent intraoperative hypothermia or hypotension, and the amplitude of the lower limb significantly decreased at 4 h and markedly decreased at 5 h after the initial infusion of propofol.…”

Section: Discussionmentioning

confidence: 47%

“…The MEP amplitude can decrease even in the absence of any nerve damage (false positive), and this may be caused by electrode failure, intraoperative hypotension, or hypothermia [4, 5]. In addition, most anesthetics, other than remifentanil and ketamine, can cause false positive results by inhibiting MEP in a dose-dependent fashion [6].…”

Section: Introductionmentioning

confidence: 99%

An evaluation of anesthetic fade in motor evoked potential monitoring in spinal deformity surgeries

et al. 2018

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BackgroundIntraoperative neuromonitoring using motor evoked potentials (MEP) satisfactorily detects motor tract integrity changes during spinal surgery. However, monitoring is affected by “anesthetic fade,” in which the stimulation threshold increases because the waveform amplitude decreases with the accumulation of propofol. Therefore, the purpose of this study was to clarify the effect of anesthetic fade on transcranial MEPs by investigating the time-dependent changes of amplitude during spinal deformity surgeries.MethodsWe retrospectively reviewed medical records of 142 spinal deformity patients (66 patients with idiopathic scoliosis, 28 with adult spinal deformities, 19 with neuromuscular scoliosis, 17 with syndromic scoliosis, and 12 with congenital scoliosis). The average age was 28 years (range, 5 to 81 years). MEPs were recorded bilaterally from the abductor digiti minimi (ADM) and abductor hallucis (AH) muscles during spinal deformity surgeries. The Wilcoxon signed-rank test was used to investigate the time-dependent changes of amplitude after propofol infusion to evaluate anesthetic fade effects.ResultsThe average time to baseline from initial propofol infusion was 113 min (range, 45 to 182 min). In the ADM, the amplitude was 52% at 1 h after initial propofol infusion, 102% at 2 h, 105% at 3 h, 101% at 4 h, 86% at 5 h, and 81% at 6 h. Compared to the 2-h time point, MEP decreased significantly by 16% at 5 h (P < 0.0005) and by 21% at 6 h (P < 0.05). In the AH, the amplitude was 49% at 1 h after initial infusion of propofol, 102% at 2 h, 102% at 3 h, 92% at 4 h, 71% at 5 h, and 63% at 6 h. Compared to the 2-h time point, MEP decreased significantly by 10% at 4 h (P < 0.005), by 31% at 5 h (P < 0.0000005), and by 39% at 6 h (P < 0.05).ConclusionsMEP amplitude significantly decreased in the upper limbs at 5 and 6 h and in the lower limbs at 4, 5, and 6 h after the initial infusion of propofol, respectively. The influence of anesthetic fade could influence false positive MEPs during long spinal surgeries.

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Hypotension-Induced Loss of Intraoperative Monitoring Data During Surgical Correction of Scheuermann Kyphosis: A Case Report

Cited by 31 publications

References 48 publications

Comparison of Scheuermann Kyphosis Correction by Posterior-Only Thoracic Pedicle Screw Fixation Versus Combined Anterior/Posterior Fusion

Comparison of Scheuermann Kyphosis Correction by Posterior-Only Thoracic Pedicle Screw Fixation Versus Combined Anterior/Posterior Fusion

Spinal Cord Injury After Extremity Surgery in Children With Thoracic Kyphosis

An evaluation of anesthetic fade in motor evoked potential monitoring in spinal deformity surgeries

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