Original Articles from the Society for Vascular SurgeryA prospective randomized study of cerebrospinal fluid drainage to prevent paraplegia after high-risk surgery on the thoracoabdominal aorta*
Section snippets
Methods
A review of historical data up to Sept. 12, 1988, in 1062 patients treated for thoracoabdominal aortic aneurysm revealed the expected incidence of lower limb neurologic events that vary according to extent and cause of aneurysm (Table I, Fig. 1).Patients with involvement of most or all of the descending thoracic and abdominal aorta down to renal arteries were classified as group I; most or all of the
Clinical material
Graft replacement was used in treatment of 210 patients with aneurysms of varying extent during the study period (Table II). Of these, 148 (70%) were patients with aneurysms of group I and II extent and were potential candidates for CSFD study. Forty-eight patients were excluded because of rupture, emergency operation for symptoms, previous brain or cord disease, bleeding dyscrasias (including chronic warfarin [Coumadin] therapy), previous low back operation or lumbosacral disk disease, fever,
Cerebrospinal fluid drainage
A catheter was introduced by lumbar puncture by use of local anesthesia at L4-5 or L3-4. It was advanced 5 to 10 cm within the intrathecal space by means of a guidewire as previously described.13 The cerebrospinal fluid pressure (CSFP) was continuously monitored throughout the operation, but only initial levels and those observed every 15 minutes were recorded in the protocol to be transferred to computer. After complete anesthesia and when the left lung was collapsed, 20 ml of CSF was
Statistical analysis
The data entered on the computer were analyzed by use of the BMDP statistical package. Preoperative, etiologic, technical, and postoperative variables were compared by Pearson's univariate chi-square test for balance between the control and treatment groups (Table VII), and for their effect on the occurrence of neuromuscular deficits occurring within 30 days after surgery (Table VIII).Multiple logistic regression was used to determine the independent determinants of neuromuscular deficits
Results of spinal fluid drainage
No difference was found in the incidence or degree of neurologic deficits that occurred in these patients irrespective of whether data were analyzed according to treatment assigned or treatment received (Table IV, Table VI) and regardless of CSFP levels maintained during operation. Neurologic deficits occurred in the patient with the highest CSFP as well as in one of the patients who had the lowest CSFP from whom the largest volume (120 ml) of CSF was removed. Of the six patients whose spinal
Cumulative results
The 30-day survival of all 210 patients treated by operation during the study period was (204/210) 97%, and the Kaplan-Meier survival was 93% at 3 months, 90% at 6 months, and 86% at 1 year. The incidence of immediate neurologic deficits in the 210 patients is shown in Table II. The survival rates in the randomized patients at 30 days (95/99), 60 days (93/99), and 90 days (91/99) in percentage were 96%, 94%, and 92%, respectively. Most of the deaths occurring 0 to 152 days after operation in
Neurologic events in randomized patients
Neurologic deficits in the lower extremities of varying intensity and duration occurred in 31 (32%) of the 98 patients in the randomized series. The deficit was observed immediately (within 24 hours) of the operation in 21 (68%) and from 3 to 22 days (delayed) in 10 (32%) of those affected. The deficit was severe (paraplegia) at onset in 21 and milder (paraparesis) in 10. By the time of death or hospital discharge, 9 patients had fully recovered; however, 22 (22%) patients continued to have
Discussion
Although numerous factors may be involved in the development of paraplegia during or after graft replacement of aortic segments, interruption of circulation to the spinal cord is the principal one. The interruption may be temporary or permanent, the latter caused by ligation of one or more aortic branches that supply blood to the spinal cord. Toleration of aortic clamping (cord ischemia) is variable. Simple aortic clamping without sacrifice of intercostal arteries in the repair of patent ductus
Acknowledgements
Grateful acknowledgement to Barbara Brooks and Yvette Crear for computer entry and patient follow-up; Chip Brown for manuscript preparation; and Mrs. Carol Pienta-Larson for illustration.
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Reprint requests: E. Stanley Crawford, MD, Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.