Case To Ponder

[Noyac]

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73y.o. Female with DM type II, cad, HTN and left foot drop secondary to HNP at T10/11. Strong family h/o CVA's and MI's. Spine guy wants to do T10 decomp. lami. and then a L2-5 PSF for spinal stenosis. Pt. cleared for surgery by Cards.😉 She has had a spinal fusion C3-5 and have moderate range of motion, MP2, full dentition.
We can get caught up in all kinds of things butwhat I am getting at is the intraop events. The pt was monitored with MEP's and SSEP's. 1 1/2 hrs into the decomp lami the neuro monitoring went flat. Bp has been rock stable the whole case and neither the surgeons nor I noticed any changes to this point. All conections to the pt were checked and double checked. MEP"S were performed with markedly decreased return. Plan was to do a wakeup test in the prone position and if she really couldn't move we would go to MRI. We went to MRI. the wakeup test revealed movement of bilat upper ext's and no movm't of bilat lower ext's. MRI was inconclusive. She was given20mg Decadron at the time of the event and started on steroid protocal. We went to ICU after the MRI and neuro exam was improving on the left. She could feel and move the left leg and was unable to move the riht leg and could only feel deep stimulus. At first he neuro monitoring person thought it was a TIA. I disagreed (of coarse) because she moved her upper and not her lower ext's, not one side or the other. Her exam has remained with total movement and sensation to the upper ext's and left leg but still with a foot drop on the left leg. Nothing on the right.
What are your thoughts?

 

[militarymd]

TIA...but not to the brain....probably to one of the feeders off the Aorta (Adamkiecz....or something like that)

 

[zippy2u]

A word to the wise,if people are going to monkey around on your back , make sure it's a neurosurgeon rather than an orthopod. --Zippy

 

[jwk]

A word to the wise,if people are going to monkey around on your back , make sure it's a neurosurgeon rather than an orthopod. --Zippy

Amen brother!

 

[Tenesma]

why would you get foot drop with T10 compression??? without any other focal findings??? that is kind of weird don't you think?

 

[bigdan]

I like the artery of Adamkiewicz route that military took, but that would suggest occulsion of that artery for some point in time. Sensory testing would likely give you some sort of dermatome level sense of what the deal is, if you're thinking spinal cord involvement...

The HNP at T10 is kinda high for a foot drop, unless it was a central/midline herniation with some sort of spinal cord compression...

I'm intrigued...let us know the story as it unfolds, please.

dc

 

[Noyac]

No answers as of yet but I get the unenviable task of taking her back to the OR tomorrow for a anterior approach via left thoracotomy. I asked why, and the responce was "we think there may be two areas of injury and that we can relieve the pressure on the cord above the operative site to lessen the deficit." 😕 Well I don't buy it but what you gonna do. On physical exam she seems to have some involuntary movmt to the RLE but no voluntary movmt. The neurologist came up with some weird reflex (I'll try to get the name of it tomorrow) that seems to make them think that it may be 2 areas. As of now, the leading causes are vascular infarct (nice Military) and reperfusion injury ( I doubt it).
No offense to you med studs and residents but isn't this better than board scores and interview questions? While they are fine, I needed to mix it up some.

 

[Noyac]

The HNP at T10 is kinda high for a foot drop, unless it was a central/midline herniation with some sort of spinal cord compression...

Your right Bigdan, It was central and with some cord edema.

 

[Noyac]

A little follow up. The pt had a rough night last night with some decr UOP, hypotension (SBP 80's), no response to fluids or albumin. Started on dopa. 2 mcg/kg/min. I talk to her and she looks like **** trying to talk with a nonrebreather on. CXR reveals atelectasis. Echo with increased PA pressure (65 or greater) right and left ventricles are OK. Creatinine elevated to 2.2. VQ scan indeterminant.
What are your thoughts?
I'll tell you that we don't have a definite reason for the change at this point. She has not been anticoagulated due to the spinal injury with possible hematoma worsening the process. Not sure that that was a good idea. We did not proceed with thoracotomy due to pulm process and will try again on Monday.

 

[militarymd]

A little follow up. The pt had a rough night last night with some decr UOP, hypotension (SBP 80's), no response to fluids or albumin. Started on dopa. 2 mcg/kg/min. I talk to her and she looks like **** trying to talk with a nonrebreather on. CXR reveals atelectasis. Echo with increased PA pressure (65 or greater) right and left ventricles are OK. Creatinine elevated to 2.2. VQ scan indeterminant.
What are your thoughts?
I'll tell you that we don't have a definite reason for the change at this point. She has not been anticoagulated due to the spinal injury with possible hematoma worsening the process. Not sure that that was a good idea. We did not proceed with thoracotomy due to pulm process and will try again on Monday.

Spinal cord injury at T10.......spinal shock??

PA pressures and pulmonary findings could be explained by the atelectasis if the atelectasis is bad enough.

And an indeterminant V/Q scan (that does not surprise me by the way with the atelectasis) still leaves you with a relatively high risk of PE in a high risk patients...look at the PIOPED data.

 

[Noyac]

Spinal cord injury at T10.......spinal shock??

PA pressures and pulmonary findings could be explained by the atelectasis if the atelectasis is bad enough.

And an indeterminant V/Q scan (that does not surprise me by the way with the atelectasis) still leaves you with a relatively high risk of PE in a high risk patients...look at the PIOPED data.

Agreed, I think PE is very likely in this obese, diabetic, immobile, vasculopath who is not anticoagulated.
Spinal shock is being thrown around along with SIRS.

We will use the next few days to try to "tune " her up assuming she doesn't get worse. Then try to proceed. The spine surgeon is really anxious to try to relieve the pressure. I gave him the risks of a long procedure with one-lung ventilation on an already straind right ventricle in a pt with moderate pulmonary function to this point at best. He agreed and decided to postpone.
With her neuro findings it does seem to be pressure on the anterior cord. Motor gone, some reflex, and now some heel pain with sensory being the posterior horn of the cord.

 

[militarymd]

SIRS is definitely up there in the differential diagnosis...depending on duration and severity of surgical trauma.