Iatrogenic spinal cord injury with tetraplegia after an elective non-spine surgery with underlying undiagnosed cervical spondylotic myelopathy: Literature review and case report

Mathkour, Mansour; McCormack, Erin; Hanna, Joshua; Werner, Cassidy; Skinner, Kristen; Borchardt, Jeffrey; Dumont, Aaron S.; Maulucci, Christopher M.

doi:10.1016/j.clineuro.2019.105549

Cited by 9 publications

(6 citation statements)

References 24 publications

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“…SCI has been reported to occur in adult patients under anesthesia for nonspine procedures with no known spinal pathology. For example, a 2019 review article found 18 case reports in the extant literature of patients who sustained SCI during anesthesia for nonspine procedures who were ultimately found to have previously undiagnosed spinal spondylotic myelopathy 15 . This raises the question of better screening overall prior to anesthesia for all patients.…”

Section: Discussionmentioning

confidence: 99%

Intraoperative Neuromonitoring for Spines at Risk During Nonspine Surgery: A 9-Year Review

Jackson,

Galambas,

Bauer

2023

Journal of Pediatric Orthopaedics

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Background: Patients with certain spinal anomalies are at risk for rare but devastating spinal cord injuries under anesthesia. We created a Spine at Risk (SAR) program to evaluate and recommend precautions for such patients, including intraoperative neuromonitoring (IONM) use for the highest-risk patients. We aimed to review all monitored nonspine procedures to determine rate of potential spinal cord injuries avoided in those who would otherwise have been unmonitored. Methods: We performed a retrospective review of our institutional SAR program from 2011 to 2019 to analyze the number of nonspine anesthetized procedures that were done under IONM, the characteristics of those that had an IONM alert; and the clinical outcomes. Results: Of the 3,453 patients flagged for SAR review, 1121 (33%) received a precaution recommendation, and 359 (10% of all flagged) were given IONM recommendations. Of those, 57 patients (16% of recommendations, 2% of all flagged) had a total of 102 nonspine anesthetized procedures done under IONM. Seven patients had a total of 10 cases with IONM alerts. Two cases were aborted when improved signals could not be obtained after working through a checklist; one of these patients woke with transient neurological deficits. Signals improved to baseline in 7 cases by working through a signal loss checklist. One case was aborted preoperatively when monitorable baseline signals could not be obtained. Conclusions: In the highest-risk spinal anomaly patients, we monitored an average of 11.7 nonspine cases per year, with a 10% rate of IONM alerts, and no permanent neurological deficits. Although the majority of patients remain safe during procedures, in the most critical patients IONM allowed the team to identify and react to alerts that may have otherwise led to permanent neurological injury. This is the largest series of spinal cord-monitored nonspine pediatric cases. It is important for pediatric orthopedic surgeons to evaluate at-risk patients and recommend IONM where appropriate, to protect both patients and our procedural colleagues. Level of Evidence: Case series, level IV.

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Section: Discussionmentioning

confidence: 99%

Intraoperative Neuromonitoring for Spines at Risk During Nonspine Surgery: A 9-Year Review

Jackson,

Galambas,

Bauer

2023

Journal of Pediatric Orthopaedics

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“…Postoperative quadriparesis is a very rare complication of surgery that does not involve the cervical spine. Mathkour et al 7) reported a possible underlying mechanism, and most of their cases were associated with pre-existing cervical spondylosis in which the cervical cord was vulnerable to external compression. They found that the SCI was precipitated by inadequate neck extension during intubation, surgical positioning with overextension of the neck, and hypoperfusion related to relative hypotension.…”

Section: Discussionmentioning

confidence: 99%

Neurological Deterioration Immediately After Lumbar Surgery: Anesthetic Consideration for Co-existing Cervical Lesion: A Case Report

Kim

2022

Korean J Neurotrauma

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Most spine surgeons and anesthesiologists believe that the risk of spinal cord injury (SCI) during intubation is mainly due to mechanical compression of the spinal cord due to cervical spine movement in cases of undiagnosed but severe cervical lesions. With this reasoning, difficult intubation, which is more frequently encountered in patients with preexisting cervical diseases, is likely to result in SCI. Several reports have described SCI after non-cervical surgery in patients previously diagnosed with cervical myelopathy and a chronically compressed cervical cord; however, to date, there is less acknowledgement of SCI in patients with undiagnosed cervical myelopathy. Here, we report a painful experience of neurological deterioration that developed immediately after elective lumbar decompressive surgery in a 76-year-old man. The possible mechanism behind these unexpected complications is discussed in a review of the literature.

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“…2 Most of these 11 patients had preoperatively unrecognized severe cervical spondylosis. Fourth, there are more than 20 case reports describing patients with severe cervical spondylosis and who, in the absence of a difficult intubation, suffered intraoperative cervical cord injury during noncervical spine surgery 33–35 (for additional references and discussion, see Supplemental Digital Content 3 [Case Reports of Perioperative Cervical Spinal Cord Injury in Patients with Cervical Spondylosis; http://links.lww.com/ALN/C742]). Accordingly, we hypothesize that patients who have severe cervical spondylosis have less tolerance to acute cord strain and consequently have greater potential to experience potentially injurious cord strain during an otherwise routine (normal force) intubation.…”

Section: Discussionmentioning

confidence: 99%

“…2 Most of these 11 patients had preoperatively unrecognized severe cervical spondylosis. Fourth, there are more than 20 case reports describing patients with severe cervical spondylosis and who, in the absence of a difficult intubation, suffered intraoperative cervical cord injury during noncervical spine surgery [33][34][35] the regional distribution of maximum principal strain (stretch) in sagittal and transverse sections of the cervical spinal cord at four force application locations are shown in (A) through (D). In the sagittal views, the white arrows show the locations and directions of the applied forces, and the red arrows show the locations of peak cord strain.…”

Section: Discussion Clinical Implications and Applicationsmentioning

confidence: 99%

Intubation Biomechanics: Clinical Implications of Computational Modeling of Intervertebral Motion and Spinal Cord Strain during Tracheal Intubation in an Intact Cervical Spine

et al. 2021

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Background In a closed claims study, most patients experiencing cervical spinal cord injury had stable cervical spines. This raises two questions. First, in the presence of an intact (stable) cervical spine, are there tracheal intubation conditions in which cervical intervertebral motions exceed physiologically normal maximum values? Second, with an intact spine, are there tracheal intubation conditions in which potentially injurious cervical cord strains can occur? Methods This study utilized a computational model of the cervical spine and cord to predict intervertebral motions (rotation, translation) and cord strains (stretch, compression). Routine (Macintosh) intubation force conditions were defined by a specific application location (mid-C3 vertebral body), magnitude (48.8 N), and direction (70 degrees). A total of 48 intubation conditions were modeled: all combinations of 4 force locations (cephalad and caudad of routine), 4 magnitudes (50 to 200% of routine), and 3 directions (50, 70, and 90 degrees). Modeled maximum intervertebral motions were compared to motions reported in previous clinical studies of the range of voluntary cervical motion. Modeled peak cord strains were compared to potential strain injury thresholds. Results Modeled maximum intervertebral motions occurred with maximum force magnitude (97.6 N) and did not differ from physiologically normal maximum motion values. Peak tensile cord strains (stretch) did not exceed the potential injury threshold (0.14) in any of the 48 force conditions. Peak compressive strains exceeded the potential injury threshold (–0.20) in 3 of 48 conditions, all with maximum force magnitude applied in a nonroutine location. Conclusions With an intact cervical spine, even with application of twice the routine value of force magnitude, intervertebral motions during intubation did not exceed physiologically normal maximum values. However, under nonroutine high-force conditions, compressive strains exceeded potentially injurious values. In patients whose cords have less than normal tolerance to acute strain, compressive strains occurring with routine intubation forces may reach potentially injurious values. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Iatrogenic spinal cord injury with tetraplegia after an elective non-spine surgery with underlying undiagnosed cervical spondylotic myelopathy: Literature review and case report

Cited by 9 publications

References 24 publications

Intraoperative Neuromonitoring for Spines at Risk During Nonspine Surgery: A 9-Year Review

Intraoperative Neuromonitoring for Spines at Risk During Nonspine Surgery: A 9-Year Review

Neurological Deterioration Immediately After Lumbar Surgery: Anesthetic Consideration for Co-existing Cervical Lesion: A Case Report

Intubation Biomechanics: Clinical Implications of Computational Modeling of Intervertebral Motion and Spinal Cord Strain during Tracheal Intubation in an Intact Cervical Spine

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