Neurocirugía

Neurocirugía

Volume 30, Issue 1, January–February 2019, Pages 50-52
Neurocirugía

Case Report
Severe hypertension and tachycardia during transforaminal endoscopic discectomy – Is indigocarmine to blame?Hipertensión severa y taquicardia durante la discectomía endoscópica transforaminal: ¿se puede culpar a la indigocarmina?

https://doi.org/10.1016/j.neucir.2018.08.004Get rights and content

Abstract

Endoscopic transforaminal discectomy is a minimally invasive technique used for the surgical treatment of herniated discs. Indigocarmine is a dye which is widely used to identify the ureteral orifice in urologic procedures. Hemodynamic effects such as hypotension and anaphylaxis in addition to hypertension, bradycardia and atrioventricular block have been reported in intravenous application of indigocarmine. The aim of this case report is to prepare anesthesiologists for such cases and make them consider invasive blood pressure monitorization. Both patients had radicular pain radiating to the leg and scheduled to undergo transforaminal endoscopic discectomy. Intraoperative vital signs were within normal limits, however severe hypertension and tachyarrhythmia developed following the injection. Hemodynamics in both patients returned to normal following lidocaine and nitroglycerine injection.

Resumen

La discectomía endoscópica transforaminal es una técnica mínimamente invasiva utilizada para el tratamiento quirúrgico de discos herniados. Indigocarmine es un tinte que se usa ampliamente para identificar el orificio ureteral en procedimientos urológicos. Se han informado efectos hemodinámicos como hipotensión y anafilaxia además de hipertensión, bradicardia y bloqueo auriculoventricular en la aplicación intravenosa de indigocarmina. El objetivo de este informe de caso es preparar a los anestesiólogos para tales casos y hacer que consideren la monitorización invasiva de la presión sanguínea. Ambos pacientes tenían dolor radicular que irradiaba a la pierna y se programaron para recibir una discectomía endoscópica transforaminal. Los signos vitales intraoperatorios se encontraron dentro de los límites normales, sin embargo, la hipertensión severa y la taquiarritmia se desarrollaron después de la inyección. La hemodinámica en ambos pacientes volvió a la normalidad después de la inyección de lidocaína y nitroglicerina.

Section snippets

Case 1

The patient was referred to the neurosurgery clinic with back pain radiating to right leg and MRI findings of radiculopathy and elective endoscopic disc surgery was planned. The patient was a hypertensive 59 years old female and had no known allergies and was using ACE inhibitor. Induction was carried out with 3 mg/kg propofol, 1 mcg/kg fentanyl and 0.6 mg/kg rocuronium and the patient was turned prone following intubation. Maintenance was carried out with total intravenous anesthesia (5 mg/kg/h

Case 2

Endoscopic disc surgery was planned for the patient who was referred to the neurosurgery clinic with back pain radiating to right foot and MRI findings of radiculopathy. The patient was a 54 years old female who had allergic asthma but was not using any medications. Anesthesia induction was carried out with 3 mg/kg propofol, 1 mcg/kg fentanyl and 0.6 mg/kg rocuronium and the patient was turned prone following intubation. Maintenance was carried out using total intravenous anesthesia (5 mg/kg/h

Discussion

Although its indications are more limited compared to open microdiscectomy, endoscopic spinal surgery has become a technique that is more often chosen by neurosurgeons. Sparing of the multifidus muscle during foraminal surgery maintains motion and negates or delays the need for fusion. In this context, it can be considered as completely minimally invasive.5

There are case reports in the literature concerning anaphylactic reactions resulting in deep hypotension which state that the exact

Conclusions

Considering that transforaminal discectomy operations are going to become more frequent, we believe that anesthesiologists should keep in mind that indigocarmine can cause serious hemodynamic disturbances not only in intravenous but also in transforaminal injection and invasive blood pressure monitorization should be considered and necessary precautions taken for emergency interventions prior to indigocarmine usage.

Funding

The authors declare that they have not received funding of any kind for this manuscript.

Conflict of interest

The authors declare no conflict of interests.

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© 2018 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.