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Paraplegia after Extensive Thoracic and Thoracoabdominal Aortic Aneurysm Repair: Does Critical Spinal Cord Ischemia Occur Postoperatively?
C. D. Etz, M. Luehr, E. Griepp, K. A. Plestis, D. Weisz, R. B. Griepp*. Mount Sinai School of Medicine, New York, NY,
BACKGROUND: Paraplegia remains the most devastating complication after extensive thoracic and thoracoabdominal aortic aneurysm (TAA/A) repair. Recent experimental studies suggest that ischemic spinal cord injury is independent of segmental artery (SA) preservation, and may occur not intraoperatively, but during the first few hours postoperatively.
METHODS: A series of more than 800 TAA/A repairs (06/90-06/06), with an overall paraplegia rate < 5%, was analyzed retrospectively. Somatosensory evoked potentials (SSEP) to monitor spinal cord integrity and cerebrospinal (CSF) drainage to promote spinal cord perfusion were routinely used.
In 10 cases (paraplegia group), spinal cord injury occurred within 48h after TAA/A repair despite intact SSEPs at the end of the procedure, indicating normal spinal cord function intraoperatively, after SA sacrifice. Ten matched controls with equivalent aortic disease and TAA/A repair using the same surgical technique and who recovered without spinal cord injury, whose operation was closest in time to the paraplegia cases were selected (recovery group).
RESULTS: In the paraplegia group (N=10; intact SSEPs after SA sacrifice), there were 9 males; median age was 63 (40-79) yrs; 7/10 pts had CSF drainage, and a median of 9 (5-12) SAs were sacrificed. In the recovery group, the same number of SAs were sacrificed (9 [2-12]); there were 4 males, median age was 66 [40-78] yrs, and 8/10 pts had CSF drainage. During the first 48h postoperatively, there were no significant differences in mean aortic pressure, oxygen saturation, partial pressures of O2 and CO2, temperature, pH, glucose levels or hematocrit between the groups.
The mean central venous pressures (mCVP) were significantly higher in the paraplegia group at 1 thru 5 hours, postoperatively (overall p=.03); the strongest differences occurred at 2-3- and 4 hours (p=.02; p<.005; p=.03).
CONCLUSIONS: This study suggests that a significant proportion of cases of paraplegia are associated with a relatively high CVP during the first 5h postoperatively. With better hemodynamic and fluid management, these spinal cord injuries may be avoidable. 
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