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Ischemic injury to the spinal cord or lumbosacral plexus after aorto-iliac reconstruction
P Gloviczki1, S A Cross, A W Stanson
1Department of Neurology, Mayo Clinic, Rochester, Minnesota 55905.
Insights
Spinal cord or lumbosacral plexus ischemic injury occurred in 0.3% of abdominal aortic surgeries. Injury to the lumbosacral plexus offers a better prognosis for recovery.
Area of Science:
- Vascular Surgery
- Neurology
- Surgical Complications
Background:
- Ischemic injury to the spinal cord or lumbosacral plexus is a rare but serious complication following abdominal aortic surgery.
- The incidence varies depending on the type of surgery, with higher rates observed in emergency aneurysm repair.
Purpose of the Study:
- To analyze the incidence, characteristics, and outcomes of ischemic spinal cord or lumbosacral plexus injury after abdominal aortic operations.
- To identify risk factors and potential preventive strategies for this complication.
Main Methods:
- Retrospective review of 3,320 abdominal aortic operations performed between January 1, 1980, and June 30, 1989.
- Analysis of patient demographics, surgical procedures, perioperative complications, and neurological outcomes.
Main Results:
- Nine patients (0.3%) developed ischemic injury. Incidence was higher after emergency aneurysm repair (1.4%) than elective (0.1%) or occlusive disease repair (0.3%).
- Risk factors included hypotension, supraceliac aortic cross-clamping, and exclusion of internal iliac arteries. Early mortality was 22%.
- Neurologic injury extent correlated with outcome; lumbosacral root/plexus injuries had better recovery.
Conclusions:
- Preventive measures like gentle surgical technique, avoiding hypotension and prolonged supraceliac clamping, revascularizing internal iliac arteries, and using heparin may reduce, but not eliminate, risk.
- Careful neurologic evaluation is crucial for prognosis once this complication occurs.
Abstract:
Between January 1, 1980, and June 30, 1989, 9 patients (6 males and 3 females) developed ischemic injury to the spinal cord or lumbosacral plexus following 3,320 operations on the abdominal aorta (0.3%). The incidence of this complication was 0.1% (2 of 1,901) after elective and 1.4% (3 of 210) after emergency abdominal aortic aneurysm repair, and 0.3% (4 of 1,209) after repair for occlusive disease. Three of the latter had prior clinical evidence of distal embolization. Eight grafts were bifurcated (aorto-iliac:four, aorto-femoral: three, aorto-ilio-femoral:one). One patient underwent extra-anatomic revascularization. Only two patients had supraceliac aortic cross-clamping and one patient underwent exclusion of both internal iliac arteries. Four patients had hypotension. Early mortality was 22% (two of nine). Severe perioperative complications, mostly due to associated visceral and somatic ischemia and sepsis, were present in seven of the nine patients. The extent and type of the neurologic injury correlated with long-term outcome. Patients with ischemic injury of the lumbosacral roots or plexus had better recovery. Attention to the pelvic circulation and the collateral blood supply is important. Use of gentle technique to prevent embolization, avoidance of hypotension and prolonged supraceliac cross-clamping, revascularization of at least one internal iliac artery, and the use of heparin may decrease but not eliminate paraplegia. Once this unexpected complication occurs, careful neurologic evaluation should be done to localize the lesion and aid prognosis.