Reversal of Paraplegia Via Cerebrospinal Fluid Drainage After Abdominal Aortic Surgery I. Garutti, MD, C. Ferna ´ndez, MD, A. Bardina, MD, E. Martı ´nez, MD, A. Ferrando, MD, and L. Ferna ´ndez-Quero, MD P ARAPLEGIA IS ONE of the most severe complications after aortic surgery, with an incidence of 1 in 400 after abdominal aortic aneurysmectomy and 1 in 5,000 after recon- struction for aortoiliac occlusive disease. 1 Ischemia of the spi- nal cord after operative procedures on the infrarenal abdominal aorta and the iliac arteries has a bad prognosis. 2 The injury to the spinal cord in abdominal aortic surgery is likely secondary to operative interference with pelvic circulation. The distal spinal cord receives blood not only from the descending ante- rior spinal artery, but also from iliosacral arteries that are branches of the hypogastric arteries. Operative interference with pelvic circulation may result in colon or buttock necrosis and paraplegia or paraparesis. 3 CASE REPORT A 52-year-old man was diagnosed with bilateral iliac arterial aneurysms. He underwent surgery, and the aneurysms were repaired with a Y Dacron tube graft replacing the aneurysm. Before anesthetic induction, a lumbar epidural catheter was placed at L2-L3, and a single bolus dose of 14 mL of lignocaine 1.5% was administered, resulting in sensory block of der- matomes T8-L5. No further doses were administered. Anesthe- sia was induced with 3 mg of midazolam, 12 mg of etomidate, 250 g of fentanyl, and 50 mg of vecuronium. An endotracheal tube was inserted. Anesthesia was maintained with sevoflurane and boluses of intravenous fentanyl. Before aortic clamping, 5,000 U of heparin was adminis- tered. The clamping was done below the renal arteries and lasted for 115 minutes. Meanwhile, hypotension developed, and 500 mL of colloids and a continuous infusion of norepi- nephrine for 30 minutes were required to maintain a mean arterial pressure of around 70 mmHg. After the procedure, the patient was transferred to the sur- gical intensive care unit. Blood pressure was 120/80 mmHg. Two hours later, the patient was extubated, and a few minutes later, he complained of loss of mobility and sensation of the lower limbs. Neurologic examination showed complete bilat- eral lower extremity paralysis and L2 level anesthesia with a significant diminution of superficial sensation. The patellar, Achilles, and plantar reflexes were abolished. A computed tomography scan of the spine was performed because he had an epidural catheter placed previously and had been heparinized for the procedure. T9 to S1 images were obtained to rule out an epidural hematoma. The scan showed no clinical findings. A neurologist was consulted, who agreed with the authors’ diag- nosis of ischemic injury to the spinal cord. Subsequently, an intrathecal catheter (20G) was introduced at level L4-L5. Cerebrospinal fluid (CSF) pressure measured was 21 mmHg; 20 mL of CSF was withdrawn with a syringe. When the CSF was withdrawn, the patient immediately (1 minute) stated that sensitivity loss and motor block (on toes) partially reversed, although ankle and knee movements still remained blocked. At this time, CSF pressure was 9 mmHg. One hour later, CSF pressure was 16 mmHg. Another 15 mL of CSF was withdrawn, followed by a complete return of bilateral lower extremity sensation and motor function. A drain was connected to the intrathecal catheter, 60 mL of CSF was drained over the first 24 hours, and CSF pressure remained 8 mmHg. Blood pressure was stable during this episode (mean arterial pressure, 70 to 90 mmHg). After 48 hours, power and sensitivity were fully recovered. Sigmoidoscopy was done in the first 24 hours. It showed an ischemic-like lesion, measuring 6  2 cm at 20 cm from the anal margin. This lesion was followed up during the next 3 days, at 24-hour intervals, and left alone because it showed no increase in size. The patient was discharged from the hospital on day 21 with no sequelae. DISCUSSION Differential diagnosis of postoperative aortic surgery para- paresis includes (1) nerve injury from either surgical dissection or retraction, (2) prolonged effects of local anesthetic, (3) spinal cord ischemia, (4) epidural hematoma, and (5) spinal cord trauma during epidural catheter insertion. The distribution of the neurologic deficits in this case was atypical of nerve trunk injury. The negative computed tomography scan and clinical evolution ruled out epidural hematoma and spinal cord trauma. It was unlikely that the effects of 1 dose of epidural lignocaine worked for 12 hours. The nature of the neurologic signs suggested compromise of anterior spinal cord blood flow. In this case, the authors isolated 2 facts that could have con- tributed to the development of this complication. First, arterial hypotension occurred during aortic cross-clamping, and, sec- ond, the long cross-clamping time (120 minutes) accounted for it. Several authors have shown significant recovery of neuro- logic function of patients with delayed paraparesis and para- plegia, with postoperative spinal cord decompression using CSF catheter drainage 4-6 ; however, it has never been reported in abdominal aortic surgery. CSF drainage, whether intraopera- tively or postoperatively, is associated with an improvement in cord perfusion pressure, and swelling and neurologic compli- cations decrease. 7 Current recommendations are to carry out the drainage during or after surgery when CSF pressure increases 10 to 15 mmHg. 8,9 From the Department de Anestesiologı ´a, Reanimacio ´n y Terapia del dolor, Hospital General Universitario Gregorio Maran ˜o ´n, Madrid, Spain. Address reprint requests to I. Garutti, Servicio de Anestesiologı ´a, Reanimacio ´n y Terapia del dolor, Hospital General Universitario Gregorio Maran ˜o ´n, Doctor Esquerdo, 46, 28007 Madrid, Spain. E- mail: ngarutti@inicia.es Copyright 2002, Elsevier Science (USA). All rights reserved. 1053-0770/02/1604-0017$35.00/0 doi:10.1053/jcan.2002.125139 Key words: aortic aneurysms, aortic clamping, aortic surgery, ce- rebrospinal fluid (CSF) drainage, epidural catheter, intrathecal cath- eter, neurologic complications, paraplegia, spinal cord ischemia 471 Journal of Cardiothoracic and Vascular Anesthesia, Vol 16, No 4 (August), 2002: pp 471-472