1591. Iatrogenic Spinal Cord Injury with Tetraplegia After an Elective Non-Spine Surgery with Underlying Undiagnosed Cervical Spondylotic Myelopathy

Authors: Mansour Hassan Mathkour, MD; Mansour Mathkour, MD, MSc; Erin McCormack, MD; Aaron S. Dumont, MD; Christopher M. Maulucci, MD (Kenner, LA)

Introduction: Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in individuals older than 55 years. To our knowledge there are only 18-cases with cervical canal stenosis as a predisposing factor for postoperative quadriplegia and acute spinal cord injury following non-spine surgery. Method: A 68-year-old-male with known cervical stenosis and prior cervical fusion presented for an elective robotic inguinal hernia repair. Preoperative physical exam elicited slightly decreased cervical extension with positive Hoffman’s sign but otherwise no other pathologic reflexes, motor deficits, or sensory deficits. Baseline mean arterial pressure (MAP) was in 90-100mmHg. Anesthesia induction and intubation were uneventful. During surgery, the patient was positioned in steep (30 degrees) Trendelenburg for 135 minutes and MAPs were allowed to drift to the mid 70s mmHg for 60 minutes. The postoperative course was complicated by American Spinal Injury (ASIA) Impairment Scale type B spinal cord injury with new and acute onset tetraparesis with a T4 sensory level. Results: Cervical magnetic resonance imaging showed severe spinal stenosis at the C6-7 level with a significant compression of the spinal cord and T2-weighted cord signal changes. The patient immediately underwent urgent C6-7 anterior cervical discectomy and fusion with subsequent return of sensation and noted improvement in motor function to AIS type D. Conclusion: Maintenance of cervical cord neutrality is not sufficient to ensure that patients will not sustain cord injury intraoperatively; vigilance to factors affecting cord perfusion and vascular compromise, such as the MAP and positioning, is imperative. Further studies should evaluate the role of steep Trendelenburg that is commonly used in robotic surgeries and whether or not this contributes to spinal cord venous congestion and cord ischemia. Our review illustrates the importance of having a heightened awareness of this common degenerative condition in our aging patient population, often a forgotten underlying medical comorbidity.