Nagy G, Dzsinich C, Sepa G, Selmeci L, Windisch M, Petrohai A, Gálfy I, Szabolcs Z
Altalános Orvostudományi Kar, Er- és Szívsebészeti Klinika, Semmelweis Egyetem, Budapest.
Orv Hetil. 2000 Jun 11;141(24):1343-7.
Paraplegia remains to be one of the most dangerous complications following thoracoabdominal aortic surgery with an incidence of 0.5 to 40%. Therefore, intraoperative monitoring of spinal cord function is very important when choosing the appropriate surgical technique. Early detection of spinal cord injury continues to be a crucial problem, moreover, the currently applied electrophysiological methods appear to be inaccurate. The aim of the study was to detect prospective spinal cord injury intraoperatively by monitoring the biochemical parameters of the cerebrospinal fluid (CSF). The authors studied the reversible aerobic/anaerobic metabolic changes by monitoring CSF lactate levels, moreover S-100 protein and neuron-specific enolase (NSE) concentrations--specific for neuroglia and neuronal injury, respectively. One of the important methods to prevent paraplegia is the intraoperative CSF drainage, which may improve spinal cord perfusion. Between 1996-1998 51 patients underwent reconstructive thoracic or thoracoabdominal aortic aneurysm operation. The continuously drained CSF was collected in 10 ml fractions during the preparation, whereas during aortic cross-clamping and de-clamping 10 minute fractions were used. All CSF samples were immediately analysed intraoperatively for pH, pCO2, HCO3, potassium and lactate levels, S-100 protein and NSE were analysed by immunoluminescence. CSF lactate levels increased slightly during aortic clamping and a moderate, but non-significant increase was found in the hyperemic phase (reperfusion) in patients without spinal cord ischemia. Spinal cord injury was detected in 7 cases. These patients exhibited a significant CSF-lactate increase (control vs aortic cross-clamping: 1.9 vs 5.3 mmol/l), moreover CSF-lactate remained elevated throughout the whole operation. Paraplegia did not occur, Tarlov 2 paraparesis developed in four cases and three patients displayed cerebral damage. Intraoperative CSF--especially CSF-lactate--monitoring may help the operating team to detect early anaerobic changes of the metabolism the spinal cord.
截瘫仍然是胸腹主动脉手术后最危险的并发症之一，发生率为0.5%至40%。因此，在选择合适的手术技术时，术中脊髓功能监测非常重要。脊髓损伤的早期检测仍然是一个关键问题，此外，目前应用的电生理方法似乎并不准确。本研究的目的是通过监测脑脊液（CSF）的生化参数来术中检测潜在的脊髓损伤。作者通过监测脑脊液乳酸水平研究可逆的有氧/无氧代谢变化，此外还研究了分别对神经胶质和神经元损伤具有特异性的S-100蛋白和神经元特异性烯醇化酶（NSE）浓度。预防截瘫的重要方法之一是术中脑脊液引流，这可能改善脊髓灌注。1996年至1998年期间，51例患者接受了胸段或胸腹段主动脉瘤重建手术。在准备过程中，以10毫升的量连续收集引流的脑脊液，而在主动脉阻断和松开期间，以10分钟的量收集。所有脑脊液样本在术中立即分析pH、pCO2、HCO3、钾和乳酸水平，并通过免疫发光法分析S-100蛋白和NSE。在无脊髓缺血的患者中，主动脉阻断期间脑脊液乳酸水平略有升高，在充血期（再灌注）发现有中度但无统计学意义的升高。7例患者检测到脊髓损伤。这些患者脑脊液乳酸显著升高（对照组与主动脉阻断时：1.9 vs 5.3 mmol/L），此外，整个手术过程中脑脊液乳酸一直升高。未发生截瘫，4例患者出现Tarlov 2级轻瘫，3例患者出现脑损伤。术中脑脊液监测——尤其是脑脊液乳酸监测——可能有助于手术团队早期检测脊髓代谢的无氧变化。
