From the Guidelines
Paraplegia following aortic dissection repair surgery is most likely caused by spinal cord ischemia resulting from interruption of blood flow to the spinal cord during surgery, with risk factors including emergency surgery, dissection, extensive disease, prolonged aortic cross-clamp time, aortic rupture, level of aortic cross-clamp, patient age, prior abdominal aortic surgery, and hypogastric artery exclusion 1. The causes of paraplegia following aortic dissection repair surgery can be multifactorial, but the underlying mechanism is often related to spinal cord ischemia. This can occur due to various factors, including:
- Interruption of blood flow to the spinal cord during surgery
- Prolonged aortic cross-clamp time, which can lead to ischemia of the spinal cord
- Emergency surgery, dissection, and extensive disease, which can increase the risk of spinal cord ischemia
- Aortic rupture, level of aortic cross-clamp, patient age, prior abdominal aortic surgery, and hypogastric artery exclusion, which are all risk factors for spinal cord injury Some key points to consider in the management of paraplegia following aortic dissection repair surgery include:
- Maintaining adequate blood pressure to optimize spinal cord perfusion, often using vasopressors like norepinephrine or phenylephrine
- Cerebrospinal fluid drainage to reduce pressure on the spinal cord, typically maintaining CSF pressure below 10-12 mmHg for 48-72 hours
- Methylprednisolone administration, if started within 8 hours of onset, to reduce inflammation and improve outcomes
- Physical therapy to prevent complications like pressure ulcers, deep vein thrombosis, and muscle atrophy It is essential to note that the prognosis varies depending on the severity and duration of spinal cord ischemia, with some patients experiencing partial or complete recovery while others have permanent deficits. Early intervention is crucial, as the window for effective treatment is narrow, typically within the first 24-48 hours after symptom onset 1.
From the Research
Causes of Paraplegia
The causes of paraplegia following aortic dissection repair surgery can be attributed to several factors, including:
- Spinal cord ischemia due to impaired blood flow to the spinal cord 2, 3, 4, 5, 6
- Delayed or immediate postoperative paraplegia complicating repair of type A dissection 3
- Extensive spinal cord ischemia 4
- Anterior spinal artery syndrome 5
- Impaired spinal cord perfusion pressure 3, 5
Treatment Options
Treatment options for paraplegia after aortic dissection repair surgery include:
- Cerebrospinal fluid drainage (CSFD) to lower spinal pressure and maximize spinal cord perfusion pressure 2, 3, 4, 5, 6
- Permissive hypertension to maintain mean arterial blood pressure at over 90 mmHg 2
- Insertion of a spinal catheter to drain spinal fluid 3
- Surgical or interventional approaches to improve spinal cord perfusion 6
- Non-operative therapy, such as lowering blood pressure to prevent further dissection 5