Anaesthesia for chronic spinal cord lesions

Abstract

SummaryIncreasing numbers of patients with spinal cord injury present for surgery or obstetric care. Spinal cord injury causes unique pathophysiological changes. The most important peri-operative dangers are autonomic dysreflexia, bradycardia, hypotension, respiratory inadequacy and muscle spasms. Autonomic dysreflexia is suggested by headache, sweating, bradycardia and severe hypertension and may be precipitated by surgery, especially bladder distension. Patients with low, complete lesions, undergoing surgery below the level of injury, may safely do so without anaesthesia provided there is no history of autonomic dysreflexia or troublesome spasms. An anaesthetist should be present to monitor the patient in this situation. General anaesthesia of sufficient depth is effective at controlling spasms and autonomic dysreflexia but hypotension and respiratory dysfunction are risks. There is a growing consensus that spinal anaesthesia is safe, effective and technically simple to perform in this group of patients. We present a survey of 515 consecutive anaesthetics in cord-injured patients and a review of the current literature on anaesthesia for patients with chronic spinal cord lesions. Dramatic improvements in the care of spinal cord injury patients have been achieved over the last few decades [1]. The active management of urinary tract and respiratory complications has lead to a decrease in mortality from renal and respiratory failure. Overall mortality decreased from over 80% at the time of World War I to less than 2% by the early 1980s. The implications of increased survival are an increase in the prevalence of spinal cord injuries, an increase in the numbers of patients presenting for elective surgery and an ever increasing number of spinal cord injured patients who develop further medical conditions as the result of normal ageing.Although the majority of spinal cord injured patients currently undergo elective surgery in specialised spinal units, the appearance of such patients on operating lists of other hospitals is likely to increase. Anaesthesia in the cord-injured patient poses unique difficulties. An understanding of the relevant pathophysiology assists in the provision of safe peri-operative care.

Haemodynamic Effects during Induction in Cervical Spine Injuries Patients: Comparison of Three Drug Dose Combinations of Ketamine and Propofol

“…Usually these patients come to operation theatre with a mechanical traction in place or have already fixed cervical spine in previous surgeries. Instead of airway, the main problem which is faced by an anesthesiologist in routine practice is cardiovascular depression during induction of anaesthesia as these patients are already on lower side of haemodynamics and unable to cope with fall in blood pressure due to functional sympathectomy 1 .…”

“…The most important perioperative dangers are autonomic dysreflexia, bradycardia, hypotension, respiratory inadequacy. These problems are very peculiar to cervical spinal cord injury patients, especially in early stage (phase of spinal shock) of injury which may last from few days to 6-8 weeks 1 .…”

A systematic review of the evidence supporting a role for vasopressor support in acute SCI

“…25 At that time, reflex hyperactivity begins manifesting as muscle spasms and elevation of blood pressure. 14,26 Furthermore, Ko and coworkers 27,28 specified that the time of return of deep tendon reflexes after SCI is within the first couple of weeks after injury with the delayed plantar reflex being the first followed by the bulbocavernous and cremasteric reflex. However, no established connection between spinal shock and neurogenic shock does exist.…”

Dexmedetomidine for chronic spinal cord injured patient

“…AD can occur not only in patients with lesions above T6, but also in those with lower lesion levels [1]. Therefore, close monitoring and careful management is essential for SCI patients [2].…”

“…Patients with SCI are sensitive to circulating noradrenaline [2]. Dexmedetomidine, a highly selective a 2 -adrenergic agonist, reduces circulating catecholamines and results in sympatholysis, anxiolysis, and respiratory preservation [3].…”