An 81 -year-old female with critical aortic stenosis has a valve replacement procedure. Post-operatively
she is diagnosed with an anterior spinal artery syndrome at the T6-T7 level on an MRI.
a) Describe the signs you would expect on sensory examination of her lower limbs. (20% marks)
b) What are the deep tendon reflexes likely to show? (20% marks)
c) What perioperative factors may contribute to this syndrome? (30% marks)
d) What therapies have been advocated to optimise spinal cord perfusion? (30% marks)
If a lumbar drain is in place, it should be opened and set to drain at 8 to 12mm Hg. If not in place, a lumbar drain should be placed if there is no response to blood pressure augmentation within 10 to 20 minutes.
The sensory signs of an anterior spinal artery syndrome are:
There would also be bilaterally absent motor control, and probably incontinence. The affected tracts are:
Tendon reflex examination would reveal a flaccid loss of reflexes. "Flaccid motor paralysis and absent deep tendon reflexes may later progress to spasticity and hyperactive tendon reflexes", say Santamato et al (2013), but they do not say how long it will take. Spinal reflex arcs below the level of the injury will be intact, but they are facilitated by input from upper motor neurons and when this is interrupted the deep tendon reflexes are transiently lost.
Perioperative factors in cardiothoracic or abdominal aortic surgery which promotes anterior spinal artery syndrome are
Management of an infarcted anterior cord involves maximising the perfusion of the cord via collaterals. The best information about this about this seems to come from Hnath et al (2007), who published a fairly successful protocol. This consisted of:
Hnath et al reported a 60% improvement, but their series had only 5 patients in the treatment arm, which somewhat dampens the enthusiasm of anybody following their footsteps. Chiesa et al (2005) list several other possible strategies:
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