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GOOD MORNING!!

• R1???/Dr.???

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1. Anterior Spinal Artery Syndrome After
Abdominal Stabbing and Resuscitative
Thoracotomy 2. Complications Induced by
Regional Anesthesia
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Anterior Spinal Artery Syndrome After Abdominal
Stabbing and Resuscitative Thoracotomy

• J Trauma, 2007 62 526-528

C. Aylwin et al, Royal London Hospital
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Introduction

• Ant. spinal artery syndrome (ASAS) interruption
  of blood flow in the ant. spinal a.
• Infarction of the ant. and lat. columns of the
  spinal cord

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Introduction

• Plaque rupture vessel thrombosis
• During low-flow state of profound shock
• After aortic cross-clamping (aortic aneurysm
  surgery)
• Not common in trauma patients w/o spinal cord
  injury

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Case Report
ASAS Resuscitative thoracotomy Aortic
cross-clamping Laparotomy Permanent paraplegia
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Incident

• 35 y/o male, previously fit
• Multiple stab wound to neck, chest, abdomen, back
• Shocked, tachycardia, hypotension GCS14

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ER

• Arrived at ER within 30 min of the initial
  emergency
• CXR pneumothorax (-), hemothorax
• Sono free fluid in abd. cavity no cardiac
  tamponade

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OR

• Transferred to OR 35 min after arrival
• PEA ? CPR, epinephrine 1 mg
• Emergent lt ant. thoracotomy

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OR

• 2 L of blood in the lt hemithorax
• Empty heart
• 2 lacerations over lt hemidiaphragm
• Aorta cross-clamped above the diaphragm ? SBP
  restored

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OR

• Laparotomy 1.5 L of blood in abd.
• Spleen/lt kidney/stomach/jejunum laceration
  repaired
• Total aorta clamp time62 min

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OR

• No injuries to the thoracic or lumbar spinal
  column!

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ICU

• Wound closure at POD2
• Sepsis
• Superficial wound dehiscence
• Tracheostomy

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Recovery

• Absence of lower limb movement noted 12 days
  after injury
• 12 more days passed before detailed NEURO exam

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Neurologic Exam

• Flaccid paralysis of both legs
• Preserved light touch and joint position sense
• Sphincter tone (-)
• Spinal level of deficit T12

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MRI
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Diagnosis

• Ant. spinal artery syndrome
• No evidence of functional recovery one year later

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Discussion
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Spinal Cords Blood Supply

• Ant. spinal artery 2/3 of spinal white matter
• Post. spinal artery dorsal column

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Spinal Cords Blood Supply
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Spinal Cords Blood Supply

• Thoracic cord segmental aortic branches
• Ant. radicular artery of Adamkiewicz (T12-L2)
• Lowest part and cauda equina branches from int.
  iliac a.

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Spinal Cords Blood Supply

• The boundaries between each blood supply are
  vulnerable to hypoperfusion

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Anterior Spinal Artery Syndrome

• First described by Spiller in 1909
• Motor and sensory loss
• Bowel and urinary disturbances
• Infarction of the ant. and lat. spinal cord

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Anterior Spinal Artery Syndrome

• Spino-thalamic tract involved pain, temperature
  affected
• Proprioception, light touch, vibration preserved

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Anterior Spinal Artery Syndrome

• Thoracic cord lower limbs flaccid paralysis,
  spasticity, hyper-reflexia
• Lumbo-thoracic cord lower limbs wasting and
  areflexia
• Descending autonomic fibers incontinence

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Anterior Spinal Artery Syndrome

• Vessel thrombosis
• Embolism from aorta or heart
• Aortic cross-clamping

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Anterior Spinal Artery Syndrome

• 0.25 of abd. aortic surgeries
• 21 in thoraco-abdominal aortic surgeries
• No reports of ASAS after resuscitative
  thoracotomy and aortic cross-clamp for
  penetrating abd. trauma

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Anterior Spinal Artery Syndrome

• Profound shock
• Off-set by immediate recognition and ACLS
• Prolonged aortic clamp was the prime cause of
  ASAS in this case

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Summary

• All trauma surgeons should be aware of the
  potential for spinal cord ischemia and ASAS and
  minimize clamping times

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Complications Induced by Regional Anesthesia
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• Most regional anesthetic techniques, even in
  expert hands, have a failure rate of 1-10
• The complications range from bothersome to
  crippling and life-threatening

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Complications of Neuraxial Blocks
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Physiological Responses
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High Neural Blockade

• Occur with spinal or epidural anesthesia
• Excessive dose
• Unusual sensitivity

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High Neural Blockade

• Dyspnea, upper limbs weakness/numbness
• Nausea/vomiting
• Hypotension, bradycardia

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High Neural Blockade

• ASAS have been reported, possibly due to
  prolonged severe hypotension with increased
  intraspinal pressure

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Cardiac Arrest During SA

• Large prospective studies report a high incidence
  of 11500
• Vagal response decreased preload

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Urinary Retention

• Local blockade of S2-S4 roots decreases bladder
  tone and inhibits the voiding reflex
• Epidural opioids
• Pronounced in males
• Persistent bladder dysfunction may be a
  manifestation of serious neural injury

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Needle/Catheter Insertion
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Inadequate Anesthesia

• Inversely proportional to the clinicians
  experience
• Movement of needle during injection
• Incomplete entry of the needle opening into the
  desired space
• Loss of potency of LA solution

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Intravascular Injection

• CNS seizure and loss of consciousness
• CV hypotension, arrhythmia, cardiovascular
  collapse
• More common with epidural and caudal block
  (higher dosage) than spinal blockade

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Intravascular Injection

• Carefully aspirate before injection
• Use a test dose
• Inject in increment doses
• Close observation (tinnitus, lingual sensations)

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Total Spinal Anesthesia

• Occur during epidural/caudal anesthesia
• Rapid onset
• Subarachnoid lavage should be considered repeatd
  withdrawal of 5 ml of CSF and replacement with NS

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Subdural Injection

• Clinical presentation similar to high spinal
  anesthesia, but with delayed onset (15-30 min),
  and lasts for hours
• Subdural space is a potential space that extends
  cranially

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Backache

• Cause by various degree of tissue trauma
• 25-30 of GA recipients also complain of back
  pain
• May be an important sign of more serious
  complications (epidural hematoma and abscess)

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Postdural Puncture Headache

• Any breach of dura may produce PDPH
• Bilateral, frontal or retroorbital, occipital,
  extends into neck associated with photophobia
  and nausea
• Aggravated by sitting or standing

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Postdural Puncture Headache

• Leakage of CSF from a dural defect decreased ICP
• Traction of dura and tentorium
• Young age, female, pregnancy, large needle
• Epidural blood patch 15-20 ml of autologous
  blood

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Neurological Injury

• Injury of nerve roots or spinal cord
• Direct injection into the spinal cord can cause
  paraplegia
• Damaged conus medullaris sacral dysfunction
• Some studies suggest catheters can cause
  inflammation or demyelination in nerve tissue

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Spinal or Epidural Hematoma

• Trauma of epidural veins
• Abnormal coagulation or bleeding disorder
• 1150,000 for epidural blocks 1220,000 for
  spinal blocks
• Some occur right after the removal of an epidural
  catheter

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Spinal or Epidural Hematoma

• Symptoms more sudden compared with epidural
  abscess
• Sharp back and leg pain
• Progress to numbness
• Motor weakness
• Sphincter dysfunction

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Epidural Abscess

• Incidence 1/6500 to 1/500,000
• Catheter related
• Presentation could be delayed for weeks

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Epidural Abscess

• Back or vertebral pain
• Nerve root or radicular pain
• Motor/sensory deficits sphincter dysfunction
• Paraplegia/paralysis

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Epidural Abscess

• Once suspected, the catheter should be removed
  and tip cultured
• Staphylococcus aureus and Staphylococcus
  epidermidis

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Drug Toxicity
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Transient Neurological Symptoms

• Back pain radiating to the legs, w/o motor or
  sensory deficits
• Occurs after the resolution of spinal block,
  resolves after several days
• Most common with hyperbaric lidocaine

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Cauda Equina Synrome

• Associated with continuous spinal catheters and
  5 lidocaine
• Bowel and bladder dysfunction with multiple nerve
  root injury
• Sensory deficits may be patchy
• Pooling or maldistribution of hyperbaric
  solutions of lidocaine

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Thank You For Your Time!?