Department of Orthopaedic Surgery and Musculoskeletal Medicine, Canterbury School of Medicine, Canterbury District Health Board, Univeristy of Otago, 2 Riccarton Avenue, Christchurch, 8011, New Zealand.
L'Institut de la Colonne Vertébrale, CHU Pellegrin, 33076, Bordeaux, France.
Eur Spine J. 2019 Mar;28(3):463-469. doi: 10.1007/s00586-017-5364-4. Epub 2017 Oct 26.
Firstly, to describe two cases of cerebral ischaemia complicating anterior upper thoracic spinal surgery and define the likely cause of this complication. Secondly, to describe preventative measures and the effect these have had in reducing this complication within our institution.
Firstly, a review of two cases of cerebral ischaemia complicating anterior upper thoracic spinal surgery utilizing a partial manubrial resection. Secondly, cadaveric dissections of the carotid arteries to determine the effect of neck positioning and aortic arch retraction during a simulated procedure. Thirdly, a retrospective review of 65 consecutive cases undergoing this procedure and assessment of the rate of this complication before and after the adoption of preventative measures.
Two cases of carotid artery territory cerebral ischaemia, without radiographic evidence of carotid or cardiac pathology were identified in 50 consecutive cases prior to the implementation of preventative measures. These patients revealed fluctuating hemodynamic instability after placement of the inferior retractor. Cadaveric dissection reveals significant carotid artery traction particularly with neck extension. Since the adoption of preventative measures, no cases of cerebral ischaemia have been encountered.
Cerebral ischaemia is a potential complication of anterior upper thoracic spinal surgery requiring retraction of the aortic arch. This most likely occurs from carotid stenosis due to aortic retraction and therefore, may be reduced by positioning the patient with neck flexion. Continuous non-invasive monitoring of cerebral saturation, as well as actively monitoring for hemodynamic instability and reduced carotid pulsation after retractor placement, allows for early detection of this complication. If detected, perfusion can be easily restored by reducing the retraction of aortic arch.
首先，描述两例并发于上前胸脊柱手术的脑缺血病例，并确定该并发症的可能原因。其次，描述预防措施及其在我们机构中减少该并发症的效果。
首先，回顾两例使用部分胸骨柄切除术并发上前胸脊柱手术的脑缺血病例。其次，对颈动脉进行尸体解剖，以确定在模拟手术中颈部位置和主动脉弓牵引对其的影响。第三，回顾 65 例连续进行该手术的病例，并评估在采取预防措施前后该并发症的发生率。
在实施预防措施之前的 50 例连续病例中，发现了两例颈动脉供血区脑缺血病例，且无颈动脉或心脏病理的影像学证据。这些患者在放置下牵开器后出现波动的血流动力学不稳定。尸体解剖显示，尤其是在颈部伸展时，颈动脉会受到明显的牵拉。自采取预防措施以来，未再发生脑缺血病例。
脑缺血是上前胸脊柱手术中需要牵引主动脉弓的潜在并发症。这最有可能是由于主动脉弓牵引引起的颈动脉狭窄所致，因此，通过使患者颈部弯曲可以减少这种并发症的发生。持续进行脑饱和度的非侵入性监测，以及在放置牵开器后积极监测血流动力学不稳定和颈动脉搏动减弱，可早期发现该并发症。如果发现，通过减少主动脉弓的牵引，可以轻松恢复灌注。
