Spinal Cord Injury in Thoracoabdominal Aneurysm Surgery: Methods of Intra-operative Protection of the Spinal Cord

  • E. P. Van Dongen
  • M. A. Schepens
  • E. H. Boezeman
Conference paper


Aneurysms extending from the descending thoracic aorta into the abdominal aorta are classified as thoracoabdominal aneurysms. The first thoracoabdominal aortic aneurysm was replaced by a homograft in 1954 [1]. With the current anaesthetic practice and advances in operative techniques, respiratory management, intensive care and graft materials the 30 days in-hospital- mortality and morbidity have been improved, but are still high. A mortality range of 8–35%, an incidence of paraplegia/paraparesis of 16–38%, an incidence of renal failure of 18–27% and re-exploration for bleeding in 7% of the cases have been reported [2, 3, 4, 5, 6].


Spinal Cord Injury Somatosensory Evoke Potential Spinal Cord Ischemia Anterior Spinal Artery Transcranial Electrical Stimulation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Etheredge SN, Yee J, Smith JV et al (1955) Successful resection of a large aneurysm of the upper abdominal aorta and replacement with homograft. Surgery 38: 1071–1081PubMedGoogle Scholar
  2. 2.
    Cox GS, O’Hara PJ, Hertzer NR et al (1992) Thoracoabdominal aneurysm repair: a representative experience. J Vasc Surg 15: 780–788PubMedCrossRefGoogle Scholar
  3. 3.
    Golden MA, Donaldson MC, Whittemore MD et al (1993) Evolving experience with thoracoabdominal aortic aneurysm repair at a single institution. J Vasc Surg 13: 792–797CrossRefGoogle Scholar
  4. 4.
    Schepens M, Dekker E, Hamerlijnck R et al (1996) Survival and aortic events after graft replacement for thoracoabdominal aortic aneurysms in 172 patients. Cardiovasc Surg 4: 713–719PubMedCrossRefGoogle Scholar
  5. 5.
    Svensson LG, Crawford ES, Hess KR et al (1993) Experience with 1,509 patients undergoing thoraco-abdominal aortic operations. J Vasc Surg 17: 357–370PubMedCrossRefGoogle Scholar
  6. 6.
    Hollier LH, Money SR, Naslund TC et al (1992) Risk of spinal cord dysfunction in patients undergoing thoracoabdominal aortic replacement. Am J Surg 164: 210–214PubMedCrossRefGoogle Scholar
  7. 7.
    Allen BT, Davis CG, Osborne D et al (1994) Spinal cord ischemia and reperfusion metabolism: the effect of hypothermia. J Vasc Surg 19: 332–340PubMedCrossRefGoogle Scholar
  8. 8.
    Kwun BD, Vacanti FX (1995) Mild hypothermia protects against irreversible damage during prolonged spinal cord ischemia. J Surg Res 59: 780–782PubMedCrossRefGoogle Scholar
  9. 9.
    Marsala M, Vanick I, Yaksh TL (1994) Effect of graded hypothermia (27°C to 34°C) on behavorial function, histopathology, and spinal blood flow after spinal ischemia in rat. Stroke 25: 2038–2046PubMedCrossRefGoogle Scholar
  10. 10.
    Salazano RP, Ellison LH, Altonji PF et al (1994) Regional deep hypothermia of the spinal cord protects against ischemic injury during thoracic aortic cross-clamping. Ann Thor Surg 57: 65–70CrossRefGoogle Scholar
  11. 11.
    Cambria RP, Davison JK, Zanetti S et al (1997) Clinical experience with epidural cooling for spinal cord protection during thoracic and thoracoabdominal aneurysm repair. J Vasc Surg 25: 234–243PubMedCrossRefGoogle Scholar
  12. 12.
    Kouchoukos NT, Daily BB, Rokkas CK et al (1995) Hypothermie bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thor Surg 60: 67–77Google Scholar
  13. 13.
    Acher CW, Wynn MM, Hoch JR et al (1994) Combined use of cerebrospinal fluid drainage and naloxone reduces the risk of paraplegia in thoracoabdominal aneurysm repair. J Vasc Surg 19: 236–248PubMedCrossRefGoogle Scholar
  14. 14.
    Crawford ES, Svensson LG, Hess KR et al (1991) A prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg 13: 36–46PubMedCrossRefGoogle Scholar
  15. 15.
    Woloszyn TT, Marini CP, Coons MS et al (1990) Cerebrospinal fluid drainage and steroids provide better spinal cord protection during aortic cross-clamping than does either treatment alone. Ann Thor Surg 49: 78–82CrossRefGoogle Scholar
  16. 16.
    Safi HJ, Bartoli S, Hess KR et al (1994) Neurologic deficit in patients at high risk with thoracoabdominal aortic aneurysms: the role of cerebrospinal fluid drainage and distal aortic perfusion. J Vasc Surg 20: 434–443PubMedCrossRefGoogle Scholar
  17. 17.
    Schepens MA, Defauw JJ, Hamerlijnck RP et al (1995) The use of a left heart bypass in the surgical repair of thoracoabdominal aortic aneurysms. Ann Vasc Surg 9: 327–338PubMedCrossRefGoogle Scholar
  18. 18.
    Svensson LG, Hess KR, Coselli JS et al (1994) Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations. J Vasc Surg 20: 255–262PubMedCrossRefGoogle Scholar
  19. 19.
    Safi HJ, Miller CC, Carr C et al (1998) Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair. J Vasc Surg 27: 58–68PubMedCrossRefGoogle Scholar
  20. 20.
    Gharagozloo F, Larson J, Dausman MJ et al (1996) Spinal cord protection during surgical procedures on the descending thoracic and thoracoabdominal aorta. Chest 109: 799–809PubMedCrossRefGoogle Scholar
  21. 21.
    Simpson JI, Eide TR, Schiff GA et al (1994) Intrathecal magnesium sulfaye protects the spinal cord from ischemic injury during thoracic aortic cross-clamping. Anesthesiology 81: 1493–1499PubMedCrossRefGoogle Scholar
  22. 22.
    Wisselink W, Money SR, Crockett DE et al (1994) Ischemia-reperfusion injury of the spinal cord; protective effect of the hydroxyl radical scavenger dimethylthiourea. J Vasc Surg 20: 444–449PubMedCrossRefGoogle Scholar
  23. 23.
    Elmore JR, Gloviczky P, Harper CM et al (1992) Spinal cord injury in experimental thoracic aortic occlusion: investigation of combined methods of protection. J Vasc Surg 15: 789–799PubMedCrossRefGoogle Scholar
  24. 24.
    Svensson LG (1997) New and future approaches for spinal cord protection. Semin Thor Cardiovasc Surg 9: 206–221Google Scholar
  25. 25.
    Mauney MC, Blackbourne LH, Langenburg SE et al (1995) Prevention of spinal cord injury after repair of the thoracic or thoracoabdominal aorta. Thorac Surg 59: 245–252CrossRefGoogle Scholar
  26. 26.
    Rokkas C, Helfrich LR, Lobner D et al (1994) Dextrorphan inhibits the release of excitatory amino acids during spinal cord ischemia. Ann Thorac Surg 58: 312–320PubMedCrossRefGoogle Scholar
  27. 27.
    Domisse GF (1974) The blood supply of the spinal cord. J Bone and Joint Surg 56B(2): 225–235Google Scholar
  28. 28.
    Svensson LG (1996) Intraoperative identification of spinal cord blood supply during repairs of the descending aorta and thoracoabdominal aorta. J Thorac Cardiovasc Surg 112: 1455–1460PubMedCrossRefGoogle Scholar
  29. 29.
    Williams GM, Perler BA, Burdick JF, et al (1991) Angiographie localization of spinal cord blood supply and its relationship to postoperative paraplegia. J Vasc Surg 13: 23–33PubMedCrossRefGoogle Scholar
  30. 30.
    Cambria RP, Davison JK, Zanetti S, L’Italien G, Atamian S. (1997) Thoracoabdominal aortic aneurysm repair: Perspectives over a decade with the clamp-and-sew technique. Ann Surg 226(3): 294–303PubMedCrossRefGoogle Scholar
  31. 31.
    Jacobs MJHM, Myhre HO, Norgern L. (1999) Thoracoabdominal aortic surgery with special reference to spinal cord protection and perfusion techniques. Eur J Vasc Endovasc Surg 17: 253–256PubMedCrossRefGoogle Scholar
  32. 32.
    Kaplan DK Atsumi N D’Ambria MN Vlahakes GJ 1995 Distal circulatory support for thoracic aortic operations effects on intracranial pressure. Ann Thorac Surg 592 448–452Google Scholar
  33. 33.
    Brown RH Nash CL Jr Berilla JA et al 1984 Cortical evoked potential monitoring. A system for intraoperative monitoring of spinal cord function Spine. 9 3 256–261Google Scholar
  34. 34.
    Drummond JC, Todd MM, U HS (1985) The effects of high dose sodium thiopental on brain stem auditory and median nerve somatosensory evoked responses in humans. Anesthesiology 63: 249–254PubMedCrossRefGoogle Scholar
  35. 35.
    Sloan TB, Fugina ML, Toleikis JR (1990) Effects of midazolam on median nerve somatosensoryevoked potentials. Br J Anaesth 64: 590–593PubMedCrossRefGoogle Scholar
  36. 36.
    Shahin GM, Hamerlijnck RP, Schepens MA et al (1996) Upper and lower extremity somatosensory evoked potential recording during surgery for aneurysms of the descending thoracic aorta. Eur J Cardio-thorac Surg 10: 299–304CrossRefGoogle Scholar
  37. 37.
    Takaki O, Okumura F (1985) Application and limitation of somatosensory evoked potential monitoring during thoracic aortic aneurysm surgery: a case report. Anesthesiology 63: 700–703PubMedCrossRefGoogle Scholar
  38. 38.
    Ginsburg HH, Shetter AG, Raudszens PA (1985) Postoperative paraplegia with preserved intraoperative somatosensory evoked potentials. J Neurosurg 63: 296–300PubMedCrossRefGoogle Scholar
  39. 39.
    Brockstein B (1994) Bloodsupply to the spinal cord: anatomic and physiologic correlations. Ann Vasc Surg 8: 394–399PubMedCrossRefGoogle Scholar
  40. 40.
    Rothwell J, Burke D, Hicks R et al (1994) Transcranial electrical stimulation of the motor cortex in man: further evidence for the site of activation. J Physiol 481: 243–250PubMedGoogle Scholar
  41. 41.
    de Haan, Kalkman CJ, Ubags LH et al (1996) A comparison of the sensitivity of epidural and myogenic transcranial motor-evoked responses in the detection of acute spinal cord ischemia in the rabbit. Anesth Analg 83: 1022–1027Google Scholar
  42. 42.
    van Dongen EP, ter Beek HT, Schepens MA et al (1999) Effect of nitrous oxide on myogenic motor potentials evoked by a six pulse train of transcranial electrical stimuli: a possible monitor for aortic surgery. 82: 323–328Google Scholar
  43. 43.
    Kalkman CJ, Drummond JC, Ribberink AA et al (1992) Effects of propofol, etomidate, midazolam and fentanyl on motor evoked responses to transcranial electrical or magnetic stimulation in humans. Anesthesiology 76: 502–509PubMedCrossRefGoogle Scholar
  44. 44.
    Bernard JM, Pereon Y, Fayet G et al (1996) Effects of isoflurane and desflurane on neurogenic motor-and somatosensory-evoked potential monitoring for scoliosis surgery. Anesthesiology 85: 1013–1019.PubMedCrossRefGoogle Scholar
  45. 45.
    Kalkman CJ, Drummond JC, Kenelly NA et al(1992) Intraoperative monitoring of tibialis anterior muscle motor evoked responses to transcranial electrical stimulation during partial neuromuscular blockade. Anesth Analg 75: 584–89.PubMedCrossRefGoogle Scholar
  46. 46.
    Dongen van EP, ter Beek HT, Schepens MA et al (1999) Within patiënt variability of myogenic motor evoked potentials to multi-pulse transcranial electrical stimulation during two levels of partial neuromuscular blockade in aortic surgery. 88: 22–27Google Scholar
  47. 47.
    Kalkman CJ, Ubags LH, Been HD et al (1995) Improved amplitude of myogenic motor evoked responses after paired transcranial electrical stimulation during sufentani/nitrous oxide anesthesia. Anesthesiology 83: 270–276PubMedCrossRefGoogle Scholar
  48. 48.
    de Haan P, Kalkman CJ, de Mol BA et al (1997) Efficacy of transcranial motor-evoked myogenic potentials to detect spinal cord ischemia during operations for thoracoabdominal aneurysms. J Thorac Cardiovasc Surg 113: 87–100PubMedCrossRefGoogle Scholar
  49. 49.
    de Haan P, (1999) Spinal cord ischemia in thoracoabdominal aneurysm surgery: monitoring and conditioning the spinal cord. Tela Thesis: 43–71Google Scholar
  50. 50.
    van Dongen EP, ter Beek HT, Schepens MA et al (2000) The relationship between evoked potentials and measurements of S-100 protein in cerebrospinal fluid during and after thoracoab-dominal aortic aneurysm surgery J Vasc Surg 30(2): 293–300CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2002

Authors and Affiliations

  • E. P. Van Dongen
    • 1
  • M. A. Schepens
    • 2
  • E. H. Boezeman
    • 3
  1. 1.Department of Anaesthesiology and Intensive CareSt. Antonius HospitalNieuwegeinThe Netherlands
  2. 2.Department of Cardiothoracic SurgerySt. Antonius HospitalNieuwegeinThe Netherlands
  3. 3.Department of Clinical NeurophysiologySt. Antonius HospitalNieuwegeinThe Netherlands

Personalised recommendations