Prevention, Identification, and Treatment of Perioperative SCI
Prevention, Identification, and Treatment of Perioperative SCI
Object: In this report, the authors suggest evidence-based approaches to minimize the chance of perioperative spinal cord injury (POSCI) and optimize outcome in the event of a POSCI.
Methods: A systematic review of the basic science and clinical literature is presented.
Results: Authors of clinical studies have assessed intraoperative monitoring to minimize the chance of POSCI. Furthermore, preoperative factors and intraoperative issues that place patients at increased risk of POSCI have been identified, including developmental stenosis, ankylosing spondylitis, preexisting myelopathy, and severe deformity with spinal cord compromise. However, no studies have assessed methods to optimize outcomes specifically after POSCIs. There are a number of studies focussed on the pathophysiology of SCI and the minimization of secondary damage. These basic science and clinical studies are reviewed, and treatment options outlined in this article.
Conclusions: There are a number of treatment options, including maintenance of mean arterial blood pressure > 80 mm Hg, starting methylprednisolone treatment preoperatively, and multimodality monitoring to help prevent POSCI occurrence, minimize secondary damage, and potentially improve the clinical outcome of after a POSCI. Further prospective cohort studies are needed to delineate incidence rate, current practice patterns for preventing injury and minimizing the clinical consequences of POSCI, factors that may increase the risk of POSCI, and determinants of clinical outcome in the event of a POSCI.
Perioperative SCI is one of the most feared complications of spine surgery, potentially resulting in a devastating and debilitating outcome for the patient and tremendous stress for the surgeon. Fortunately, the incidence of POSCI is relatively uncommon with an estimated incidence varying from 0 to 3%, depending on the pathological entity treated, the spinal level, and surgical approach. Perioperative SCI involves a direct or indirect physiological insult to the spinal cord during immediate preparation for surgery, intraoperatively, or immediately postoperatively. This physiological insult leads to neuronal/axonal dysfunction or disruption, and consequently to motor, sensory, and/or autonomic impairment. Injury to the spinal cord may be complete or incomplete, and can result in temporary or permanent impairment. Numerous trials of pharmacological agents for traumatic SCI have been performed, with some trials showing a potential benefit; however, no reviews exist in the literature concerning the causes and management of POSCIs. The lack of a formal protocol for management of POSCI is the impetus for this paper, which will review the pathophysiology and causes of POSCI, and then propose evidence-based recommendations for the prevention of and treatment of POSCI based on a systematic review of basic science and clinical studies.
Abstract and Introduction
Abstract
Object: In this report, the authors suggest evidence-based approaches to minimize the chance of perioperative spinal cord injury (POSCI) and optimize outcome in the event of a POSCI.
Methods: A systematic review of the basic science and clinical literature is presented.
Results: Authors of clinical studies have assessed intraoperative monitoring to minimize the chance of POSCI. Furthermore, preoperative factors and intraoperative issues that place patients at increased risk of POSCI have been identified, including developmental stenosis, ankylosing spondylitis, preexisting myelopathy, and severe deformity with spinal cord compromise. However, no studies have assessed methods to optimize outcomes specifically after POSCIs. There are a number of studies focussed on the pathophysiology of SCI and the minimization of secondary damage. These basic science and clinical studies are reviewed, and treatment options outlined in this article.
Conclusions: There are a number of treatment options, including maintenance of mean arterial blood pressure > 80 mm Hg, starting methylprednisolone treatment preoperatively, and multimodality monitoring to help prevent POSCI occurrence, minimize secondary damage, and potentially improve the clinical outcome of after a POSCI. Further prospective cohort studies are needed to delineate incidence rate, current practice patterns for preventing injury and minimizing the clinical consequences of POSCI, factors that may increase the risk of POSCI, and determinants of clinical outcome in the event of a POSCI.
Introduction
Perioperative SCI is one of the most feared complications of spine surgery, potentially resulting in a devastating and debilitating outcome for the patient and tremendous stress for the surgeon. Fortunately, the incidence of POSCI is relatively uncommon with an estimated incidence varying from 0 to 3%, depending on the pathological entity treated, the spinal level, and surgical approach. Perioperative SCI involves a direct or indirect physiological insult to the spinal cord during immediate preparation for surgery, intraoperatively, or immediately postoperatively. This physiological insult leads to neuronal/axonal dysfunction or disruption, and consequently to motor, sensory, and/or autonomic impairment. Injury to the spinal cord may be complete or incomplete, and can result in temporary or permanent impairment. Numerous trials of pharmacological agents for traumatic SCI have been performed, with some trials showing a potential benefit; however, no reviews exist in the literature concerning the causes and management of POSCIs. The lack of a formal protocol for management of POSCI is the impetus for this paper, which will review the pathophysiology and causes of POSCI, and then propose evidence-based recommendations for the prevention of and treatment of POSCI based on a systematic review of basic science and clinical studies.