Postoperative coma in a patient with complete basilar syndrome after anterior cervical discectomy

Ischemic brainstem stroke resulting from occlusion of the basilar artery during cervical spine surgery in a previously asymptomatic patient is a rare event. We report the development of a large ischemic brainstem stroke, resulting from occlusion of the basilar artery during anterior cervical discectomy, in a patient without previous neurological deficit, or signs of vertebrobasilar insufficiency.

A 55-yr-old, diabetic and hypertensive male who developed a cervical spine infection, underwent surgery for anterior discectomy at C5-C6. During the 2.5-hr long procedure the patient was lying supine with his neck hyperextended. Except for a temporary reduction in systolic blood pressure, the intraoperative course was uneventful. At the end of surgery the patient remained unconscious with flaccid paralysis in all extremities, fixed pinpoint pupils, low respiratory rate, and no response to painful stimuli. Naloxone administration did not improve the clinical picture, while brain computed tomography showed a large brainstem and cerebellar stroke, implicating basilar artery occlusion. The patient died five days later from stroke complications. Intraoperative surgical manipulation with a severely inflamed vertebral system, as well as prolonged neck hyperextension occluding the blood flow of vertebrobasilar arteries might have contributed to fatal brainstem stroke in this patient.

Neck surgery carries a potential risk for posterior circulation stroke, and this report heightens awareness of this rare, but serious complication.