Ann Thorac Surg 2001;71:1063-1064
© 2001 The Society of Thoracic Surgeons
Update
Update: Protection from postischemic spinal cord injury by perfusion cooling of the epidural space
Koichi Tabayashi, MDa,
Naotaka Motoyoshi, MDa
a Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, Sendai, Japan
Address reprint requests to Dr Tabayashi, Department of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryou-machi Aoba-ku, Sendai 980-8574, Japan
As Originally Published in 1993:
During thoracoabdominal aortic surgery, various additional protective methods for spinal cord ischemia have been proposed and performed clinically. However, paraplegia is still an unpredictable complication, which occurs by the clamping of the thoracoabdominal aorta, resulting in exclusion of blood flow in critical and essential intercostal arteries. It is reported that hypothermia has some protective effect against ischemia of the brain and other organs. We have investigated the epidural cooling method as a regional hypothermia, and reported an experimental model of epidural cooling and the effect in reducing the incidence of spinal cord injury after temporal occlusion of the descending thoracic aorta in this journal in 1993 [1]. Recently, we have performed the epidural cooling, modifying the above experimental method in 24 patients. All cases (17 aortic dissection and seven true aneurysm) were operated electively. Nine among them were reoperation cases. On the day before the operation, we inserted two catheters. One was inserted into the epidural space to infuse the chilled saline and the other was inserted into the subarachnoidal space to measure pressure and temperature, and to drain the spinal fluid. Epidural cooling was started 30 minutes before the aortic clamp, maintaining 25°C by infusion of chilled saline, and ended with the completion of intercostal vessel reattachment. Cerebrospinal fluid (CSF) pressure was maintained at less than 40 mm Hg by changing the infusion rate and drainage of spinal fluid. All patients received graft replacement of the thoracoabdominal aorta. Two or three pairs of intercostal and lumber arteries in the level of Th8 to L2 were reconstructed by way of island-shaped anastomosing, beveling, or interposition. Epidural cooling was finished after the reattachment of intercostal vessels. CSF drainage was maintained for 3 postoperative days. All patients survived but one suffered paraplegia. Magnetic resonance imaging of this case showed the low signal area in the thoracic spinal cord. One patient was complicated with subarachnoidal hemorrhage postoperatively, although the cause was not clear. Epidural cooling was successful. Chilled saline was infused from 260 to 2,260 mL, with a mean volume of 1,268 mL. CSF temperature was from 22.2°C to 26.3°C with a mean of 24.3°C during aortic cross-clamping with maintenance of a core temperature of 29.0°C ± 3.9°C. CSF temperatures returned to within 1°C of body temperature by the end of operation. Maximum CSF pressure ranged from 20 to 45 mm Hg. CSF pressure during epidural infusion was independent from all hemodynamic data. We conclude that epidural space perfusion cooling is an effective method in reducing postoperative spinal cord injury and a safe method in a clinical situation.
References
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Tabayashi K., Niibori K., Konno H., Mohri H. Protection from postischemic spinal cord injury by perfusion cooling of the epidural space. Ann Thorac Surg 1993;56:494-498.[Abstract/Free Full Text]
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Invited commentary
- Lars G. Svensson
Ann. Thorac. Surg. 2001 71: 1064.
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L. G. Svensson
Invited commentary
Ann. Thorac. Surg.,
March 1, 2001;
71(3):
1064.
[Full Text]
[PDF]
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