May near infra-red spectroscopy and rapid perfusion pressure recovering be enough to rule out post-operative spinal cord

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May near infra‑red spectroscopy and rapid perfusion pressure recovering be enough to rule out post‑operative spinal cord injury? Two compared case‑reports Enrico Giustiniano1,3   · Gian Michele Battistini1 · Fabio Piccirillo1 · Giorgio Luca Poletto2 · Athos Popovich2 · Efrem Civilini2 · Maurizio Cecconi1 Received: 26 September 2019 / Accepted: 23 October 2019 © Springer Nature B.V. 2019

Thoraco-abdominal aortic (TAA) repair exposes the patient to several potential peri-operative complications, among which spinal cord injury (SCI) is the most dreadful with post-operative paraplegia having still a significant incidence (5–11%) [1]. According the “Collateral Network” concept described by Etz et al. [2], we used paraspinous muscles oxygenation monitoring by near infra-red spectroscopy (NIRS) as adjunctive monitoring of blood supplying to spinal cord (SC) during TAA surgery. We report about two consecutive cases of TAA open surgery which showed a quite different intra-operative monitoring trends and a coherent opposite neurological post-operative outcome.

1 Management protocol of patient submitted to TAA repair Before the induction of general anesthesia a sub-arachnoid catheter (Hermetic™ Lumbar Catheter Open Tip, 80 cm, Integra NeuroSciences, Plainsboro, NJ, USA) was inserted at L3–4 level to manage and monitor both cerebro-spinal fluid pressure ­(PCSF) and cerebro-spinal fluid lactate concentration ­(LacCSF) measured by a point-of-care machine (GEM Premier 3500—Instrumentation Laboratory Company, Bedford, MA, USA). * Enrico Giustiniano [email protected] 1



Department of Anesthesia and Intensive Care, Humanitas Clinical and Research Hospital, Milan, Italy

2



Vascular Surgery Unit I, Humanitas Clinical and Research Hospital, Milan, Italy

3

Department of Anesthesia and Intensive Care, Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy



According previous publications 4–8, we used INVOS™ 5100 Somanetics (Medtronic, Minneapolis, MN, USA) to monitor SC oxygenation ­(SrO2), indirectly, at upper lumbar region over paraspinous muscles. Sensors were placed as showed in Fig. 1. Post-operative NIRS monitoring was not available. During the operation invasive mean blood pressure (mIBP) both right radial artery (­ mIBPrad), as a marker of the upper body perfusion pressure, and right femoral artery ­(mIBPfem) as a marker of the lower body perfusion pressure, were monitored. Before aortic clamping started a left pulmonary vein–left femoral artery (LPv–LFa) bypass (Bioconsole560—Medtronic, Minneapolis, MN, USA) was implanted. During extracorporeal circulation the pressure targets were m ­ IBPrad > 65  mmHg and ­mIBPfem 60–70 mmHg. SC perfusion pressure was computed as follows: SC-PP = mIBPrad − PCSF. We used radial artery blood pressure because we assumed it correspond to the mean blood pressure of the paraspinous muscles circulation. Intra-operative mild-hypothermia was tolerated (34.5–35.5 °C). After surgery patients were admitted to intensive care unit (ICU) sed