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Intra-operative diabetes insipidus associated with cervical spine traction during staged scoliosis surgery
1Department of Anaesthesiology Children's Health Ireland at Crumlin Dublin Ireland.
Insights
Cervical traction during spinal surgery can cause temporary diabetes insipidus, a condition affecting water balance. Prompt removal of traction and vasopressin treatment resolved the issue in a teenage patient.
Area of Science:
- Anesthesiology
- Neurosurgery
- Pediatric Surgery
Background:
- Posterior spinal fusion for thoracolumbar scoliosis in a 15-year-old with cerebral palsy and epilepsy.
- Total intravenous anesthesia with propofol, remifentanil, and ketamine.
- Intraoperative prone positioning and cervical traction application.
Observation:
- Development of profound polyuria (4-18 mL/kg/h) and hypernatremia (132-145 mmol/L).
- Hemodynamic stability maintained with fluids and noradrenaline infusion.
- Cervical traction removal led to transient polyuria reduction.
Findings:
- Cervical traction suspected as the cause of intraoperative diabetes insipidus.
- Vasopressin infusion normalized diuresis and plasma sodium levels.
- This is the second reported case of diabetes insipidus during staged scoliosis surgery.
Implications:
- Cervical traction is a potential, albeit rare, cause of perioperative diabetes insipidus.
- Highlights the importance of monitoring fluid balance and electrolytes during complex spinal surgeries.
- Suggests considering vasopressin for managing intraoperative diabetes insipidus in this context.
Abstract:
A 15-year-old boy with cerebral palsy and epilepsy presented for a posterior spinal fusion as part of staged repair of thoracolumbar scoliosis. Total intravenous anaesthesia was induced and maintained with propofol, remifentanil and ketamine. Following prone positioning, cervical traction was applied. Polyuria developed intra-operatively, from 4 to 18 ml.kg-1.h-1. There was a corresponding rise in plasma sodium concentration from 132 to 145 mmol.l-1. Haemodynamic stability was maintained with boluses of Hartmann's solution and a noradrenaline infusion. Given the possibility of diabetes insipidus due to reduced cerebral perfusion pressure, the cervical traction was removed. This initially showed a good response with a transient reduction in polyuria to 3 ml.kg-1.h-1 before rising to 8 ml.kg-1.h-1. Subsequently, a vasopressin infusion was started with normalisation of diuresis and plasma sodium concentration by the end of surgery. Diabetes insipidus is an endocrine disorder related to lack of production or insensitivity to vasopressin. In the peri-operative period, it is mainly associated with pituitary surgery and rarely with spinal surgery. To the authors' knowledge, this is only the second report of diabetes insipidus associated with staged scoliosis surgery. Cervical traction should be considered as a potential cause of intra-operative diabetes insipidus.
