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Ann Thorac Surg 1996;62:278-280
© 1996 The Society of Thoracic Surgeons
Departments of Neurosurgery and Thoracic Surgery, Hospital "12 de Octubre", Madrid, Spain
Accepted for publication January 20, 1996.
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Abstract |
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Introduction |
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Tracheal resection is a standard surgical procedure that is performed in patients with tumoral or inflammatory diseases. After resection of cartilagenous rings, the neck has to be kept in flexion to minimize the tension on suture line [1].
In large series of tracheal reconstruction no neurologic complications have been reported [1]. We are reporting the case of a young woman without previous cervical pathology in whom an irreversible tetraplegia developed after she was kept in extreme cervical flexion and a sitting position after uneventful tracheal resection and reconstruction for tracheal stenosis.
Two months before she was admitted to our unit, this 21-year-old woman suffered a thoracic injury in a traffic accident, presenting pneumothorax, fracture of multiple ribs, pneumomediastinum, and left pulmonary contusion. The patient, who had a negative past history for hypertension or diabetes, had orotracheal intubation during 18 days because of respiratory complications (pneumonia and respiratory distress). Five days after extubation she was discharged home.
One week later the patient complained of dyspnea and inspiratory stridor. A bronchoscopy showed a tracheal stenosis 2 cm in length, 2 mm in thickness, and malacic in appearance, and she was transferred to our hospital for surgical treatment (January 1992). Physical examination did not reveal abnormalities. Laboratory test results were normal except for the cholesterol level (306 mg/dL; normal range, less than 200 mg/dL). Chest roentgenography revealed consolidated rib fractures (second to fourth) on the left side.
The patient was operated on by a cervicotomy, and three (second to fifth) cartilagenous rings were resected. An end-to-end anastomosis was performed, and the neck was kept in flexion by suturing from the chin to the anterior chest wall. The operation was uneventful. The patient was extubated 1 hour after the operation, and full-range movement of the four limbs was recorded. The patient was then placed in a sitting position. Blood pressure was moderately low (systolic close to 80 to 90 mm Hg) during the next several hours.
Eight hours after extubation a complete motor deficit (C4-C5 level) developed with preservation of propioceptive sensibility suggestive of an ischemic injury in the territory of the anterior spinal artery. Cervical roentgenography in maximal flexion did not show abnormal displacement of the vertebral bodies or stenosis of the spinal canal (diameter, 18 mm in extreme flexion and neutral position) (Fig 1
). The chin-thoracic fixation sutures were immediately removed and high-dose methylprednisolone was given intravenously (30 mg/kg in the first 15 minutes and 5.4 mg/kg during the following 23 hours). Conventional roentgenographic and computed tomographic myelographic studies showed no evidence of spinal cord compression. The patient had to be reintubated because of ventilatory failure, and a cervical magnetic resonance study performed 19 days later showed signal abnormality in the spinal cord (C4 to C7) consistent with infarction (Fig 2).
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Several cases of midcervical quadriplegia after acoustic tumor resection in patients operated in the sitting position with variable degrees of neck flexion also have been reported [4]. Wilder [5] also recorded a loss of somatosensory evoked response in a patient placed in the sitting position for a posterior fossa operation, which normalized when the head was turned to the normal position by releasing neck flexion. Wilder suggested that extreme neck flexion could produce stretching of the spinal cord severe enough to alter spinal cord autorregulation by mechanically affecting spinal cord vessels.
Kobrine and associates [6] demonstrated in the rhesus monkey operated on in the prone position that the spinal cord blood flow remains within normal range when the mean arterial pressure is kept between 50 and 135 mm Hg, and it should be noted that the mean arterial pressure was always greater than 50 mm Hg in our patient. However, Michenfelder and colleagues [7] have found that in the sitting position the intraspinal arterial pressure, 15 to 25 cm above the heart level is 12 to 20 mm Hg lower than that at heart level. If we accept that extreme flexion of the neck may disturb cervical spinal cord blood flow, then the combination of both a sitting position and extreme neck flexion could result in ischemic spinal cord damage. It should be remarked in this respect that our patient awoke from anesthesia without showing neurologic deficits, which developed after she was placed in a sitting position.
It remains uncertain whether spinal cord damage would have developed in our patient if she had been kept in a supine position, thus avoiding the addition of a second risk factor for spinal cord ischemia. We believe that relative arterial hypotension induced by the sitting position was of particular relevance in our patient. However, a vascular anomaly, either congenital or secondary to thoracic injury, that could have contributed to the spinal cord ischemia cannot be excluded.
Although the influence of the positional factor remains hypothetical in our case, we would recommend avoidance of the sitting position after operation in patients undergoing repair of tracheal stenosis as well as minimization of postoperative cervical hyperflexion by using other methods to reduce tension on the tracheal suture line. Finally, it seems also advisable to keep arterial blood pressure at the high range of normality.
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