Lumbar Cerebrospinal Fluid Drainage for Thoracoabdominal Aortic Surgery

Abstract

Paraplegia remains one of the most devastating complications of thoracoabdominal aortic surgery and is associated with a significant increase in both morbidity and mortality. Modern aortic repair techniques use many modalities aimed at reducing the risk of spinal cord ischemia inherent with surgical management. One of these modalities that acts via optimizing spinal cord blood flow is lumbar cerebrospinal fluid (CSF) drainage. Either alone or in combination with other interventions, CSF drainage remains one of the most frequently used spinal cord protection techniques. Despite no definitive proof of efficacy for reducing spinal cord injury, there are compelling data supporting its use. However, the potential benefit of CSF drainage must be balanced against the risks associated with its use, including nerve injury during insertion, compressive neuraxial hematoma formation, intracranial hemorrhage due to excessive drainage, and infection. The optimal benefit to risk ratio can be achieved by understanding the rationale for its use and following practical management guidelines.

Rehabilitation for Spinal Cord Injury Caused by Thoracic Aortic Aneurysm

“…Intraoperative ischemia in the spinal cord is thought to be, at least in part, related to the interruption of blood flow through these intercostal arteries due to cross-clamping of the www.intechopen.com Diagnosis, Screening and Treatment of Abdominal, Thoracoabdominal and Thoracic Aortic Aneurysms 366 aorta and surgical ligation during aneurysmal resection. In patients with significant thoracic aortic aneurysms, spinal cord integrity may also be maintained by an extensive network of collateral arteries, including supplies from the lumbar and pelvic circulation (Fedorow et al, 2010). Spinal cord ischemia is caused by aortic cross-clamping and interruption of the blood supply to the spinal cord via critical intercostal arteries.…”

“…Embolic processes induced by reversed flow might be responsible for reduced flow to the anterior spinal artery. Fedorow et al summarized the risk factors for paraplegia after open TAAA repair; emergency presentation (aortic dissection or rupture), postoperative hypotension, more extensive aneurysms (Crawford Type I or II), ligation of spinal collateral vessels, prolonged aortic cross-clamp time, previous abdominal aortic aneurysm repair, diabetes, advanced age (Fedorow et al, 2010). Similar risk factors for spinal cord ischemia after TEVAR were also listed by Sinha & Cheung; longer extent of aneurysm, hypotension, emergency operation, open operative repair, acute aortic rupture, aortic dissection, longer duration of aortic cross-clamp, failure to re-implant segmental arteries, prior distal aortic surgery, severe peripheral vascular disease, anemia (Sinha & Cheung, 2010).…”

“…Various methods have been devised to protect against spinal cord ischemia during surgery for TAA (Bicknell et al, 2009;Tabayashi, 2005), such as cerebrospinal fluid drainage (Acher et al, 1994;Coselli, et al, 2002;Fedorow et al, 2010;Griepp et al, 1996;Griepp & Griepp, 2007), hypothermia (Griepp et al, 1996), epidural cooling (Cambria et al, 1997), monitoring of somatosensory (SSEP) (Crawford et al, 1988) and motor evoked potentials (MEP) (de Haan et al, 1997;Jacobs et al 2006), intercostal artery reattachment (Acher et al, 2008), distal aortic perfusion (Crawford et al, 1988;Safi et al, 2003), and direct spinal cord cooling (Davison et al, 1994). Spinal cord perfusion is regulated according to the following formula,…”

“…The effects of distal aortic perfusion (DAP) and cerebrospinal fluid drainage (CFD) (Safi et al, 2003) After the release of the cross-clamp, the spinal cord is at further risk of ischemia secondary to hypercapnia and hypotension, which can result in decreased tissue perfusion. Metabolic acidosis after the release of the cross-clamp causes an increase in cerebral blood flow, resulting in increases in intracranial pressure and cerebrospinal fluid pressure (Fedorow et al, 2010), which increase tissue back pressure, leading to decreased spinal cord perfusion due to ischemia. Epidural morphine for postoperative pain relief also carries a risk of paraplegia.…”

Migrating lumbar intrathecal catheter fragment associated with intracranial subarachnoid hemorrhage

“…These include delivery of intrathecal narcotic analgesics and muscle relaxants, perioperative drainage of CSF to facilitate brain relaxation during intracranial surgery, perioperative drainage of CSF to facilitate spinal cord perfusion during open or endovascular repair of thoracoabdominal aortic aneurysms, 4 intermittent drainage of CSF for diagnosis of normal-pressure hydrocephalus, and drainage of CSF to facilitate resolution of a CSF fistula.…”