Interactive Cardiovascular and Thoracic Surgery 3:606-607(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Spinal infarction following coronary artery bypass grafting
Patrick M. Spielmann* and
Ciro Campanella
Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK
* Corresponding author. Address: 2F3 27 Meadowbank Crescent, Edinburgh EH8 7AJ, UK. Tel.: +44-7974-082-921. (E-mail: patrick_spielmann{at}hotmail.com).
Received February 27, 2004;
received in revised form June 30, 2004;
accepted July 12, 2004
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Abstract
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Spinal infarction is an extremely rare complication of coronary artery bypass grafting (CABG), almost invariably associated with use of the intra-aortic balloon pump (IABP). We present the case of a 63-year-old lady who developed paraplegia, secondary to spinal infarction, following CABG in whom the IABP was not used and no other predisposing factors were present.
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1. Case report
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Mrs JC, a 63-year-old lady underwent coronary artery bypass grafting (CABG) for stable angina. Her past medical history included two previous myocardial infarctions in 1987 and 1988, hypertension, hyperlipidaemia and type II diabetes mellitus requiring exogenous insulin. Her chest radiograph revealed changes consistent with chronic obstructive pulmonary disease; she had stopped smoking 18 months prior to surgery.
The operation was undertaken on cardiopulmonary bypass with general anaesthesia and no additional epidural analgesia. Cardiopulmonary bypass was established with cannulation of the ascending aorta for arterial return and two-stage right atrial cannulation for venous drainage. The aorta was cross-clamped and cold-blood cardioplegia delivered into the aortic root. The uncomplicated procedure was performed with a left internal mammary artery graft to the left anterior descending and right internal mammary artery graft to the distal right coronary artery. Following reperfusion the heart initially went into ventricular fibrillation, requiring a single 10J DC shock to restore sinus rhythm. Cardiopulmonary bypass was then slowly discontinued, no hypotensive episodes were encountered and no inotropic support required. She was extubated 10h after arriving in the intensive care unit. No focal neurological deficit was noted in the first 24h but a full assessment was not possible as the patient was too drowsy. Neurological examination the following morning revealed no motor power in all muscle groups of the lower limbs, a sensory level at L2 on the right, L3 on the left without sacral sparing and absent anal tone.
A magnetic resonance imaging scan was performed which showed an intramedullary lesion in conus extending from T11/12 to L1/2 (see Figs. 1 and 2). It appeared bright on the T2 weighted images and was initially reported as intra-medullary haemorrhage but was subsequently felt to represent an infarct. Dexamethasone was administered to minimize oedema. The patient fell ill with Staphylococcus aureus bronchopneumonia; she was re-intubated and subsequently required a tracheostomy to aid weaning from ventilation. She was transferred for rehabilitation further after 3 weeks and remains under follow-up. There has been no improvement in motor power.
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2. Discussion
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Paraplegia following any surgery is a rare, yet devastating complication which is poorly understood. CABG complicated by spinal infarction has been reported previously, but is almost always associated with the use of the intra-aortic balloon pump (IABP) [1,2]. There are few reported cases of patients suffering spinal infarctions without predisposing factors. Thomas and Harvey [2] report one patient with severe proximal vascular disease undergoing emergency CABG who developed paraplegia post-operatively. Geyer et al. [3] report a case when routine CABG was complicated by spinal infarction and no IABP was used. All other cases in the literature are associated with the insertion of the IABP.
The pathogenesis of spinal infarction following CABG is unclear. The most likely mechanism would appear to be micro-embolisation of atherosclerotic plaques or cholesterol emboli; especially when spinal infarction is associated with the use of the IABP [2]. The mid-thoracic spinal cord has historically been considered the watershed area, based on anatomical studies. Duggal and Lach [4] studied autopsy reports to identify ischaemic encephalopathy or myelopathy following cardiac arrest or prolonged hypotension. They found the lumbo-sacral spinal cord, which derives its blood supply from the artery of Adamkiewicz, to be particularly sensitive to hypoperfusion. They postulate that the selective vulnerability of lumbo-sacral neurons to ischaemic insults is due to the greater metabolic demands of grey matter at this level of the cord. A number of therapies are available to optimise spinal cord perfusion and minimise oedema including systemic corticosteroids, permissive hypertension and diuresis. Drainage of cerebro-spinal fluid has been shown to be effective in reversing neurologic dysfunction [5]. Such treatments have not been studied in spinal infarcts after CABG. We believe this to be an extremely rare case as a balloon pump was not used and the patient had no peripheral vascular disease or thrombophilia. The optimal management of such a complication is yet to be determined.
doi:10.1016/j.icvts.2004.07.007
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References
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- Gottesman MH, Saraya I, Tenti F. Modified Brown–Sequard syndrome following coronary artery bypass graft: case report Paraplegia 1992;30:178-180.[Medline]
- Thomas NJ, Harvey AT. Paraplegia after coronary artery bypass operations: relationship to severe hypertension and vascular disease J Thorac Cardiovasc Surg 1999;117:834-886.[Free Full Text]
- Geyer TE, Naik MJ, Pillai R. Anterior spinal artery syndrome after elective coronary artery bypass grafting Ann Thorac Surg 2002;73(6):1971-1973.[Abstract/Free Full Text]
- Duggal N, Lach B. Selective vulnerability of the lumbosacral spinal cord after cardiac arrest and hypotension Stroke 2000;33:116-121.
- Coselli JS, LeMaire SA, Schmittling ZC, Koksoy C. Cerebrospinal fluid drainage in thoracoabdominal aortic surgery Semin Vasc Surg 2000;13:308-314.[Medline]
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Abstract
1. Case report
