The incidence of traumatic spinal cord injury is 11,000 per year, with 55% of the injuries occurring between the age of 16 and 33, 18% of these in women of reproductive age. Diagnostic and early spinal decompression along with maintaining the mean arterial pressure to improve spinal cord perfusion and a high progesterone level in pregnancy for its neuroprotective and anti-inflammatory effect have the leading role in neurological recovery and clinical outcome.
We present a case of a patient in the 17th week of pregnancy who sustained luxation fracture of the C5 and C6 vertebrae and tetraplegia as passenger in a road accident. The early operative treatment and appropriate anesthetic procedure resulted in good clinical outcome with complete neurological recovery.Učestalost traumatskih ozljeda kralježnice je 11.000 na godinu, a 55% ozljeda nastaje u dobi od 16 do 33 godine, od toga 18% u žena reproduktivne dobi. Radiološka dijagnostika, uz ranu kiruršku dekompresiju kralježnice s održavanjem srednjeg arterijskog tlaka za očuvanje perfuzije leđne moždine, uz progesteron kao neuroprotektivni i protuupalni faktor u akutnoj traumi leđne moždine, ima vodeće mjesto u neurološkom oporavku i dobrom kliničkom ishodu. Donosimo prikaz slučaja trudnice u 17. tjednu trudnoće koja je zadobila luksacijsku frakturu petog i šestog vratnog kralješka s razvojem tetraplegije, kod koje su rano operacijsko liječenje i odgovarajući anesteziološki postupak doveli do dobrog kliničkog ishoda

Branka Maldini

Robert Kolundžić

Senka Baranović

Tomislav Čengić

English

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98 Acta Clin Croat,  Vol. 53,   No. 1,  2014Acta Clin Croat 2014; 53:98-101 Case ReportAnesthetiC MAnAgeMent of ACute CeRviCAl spinAl CoRd injuRy in pRegnAnCysenka Baranović1, Branka Maldini1, tomislav Čengić2 and Robert Kolundžić21department of Anesthesiology, Resuscitation and intensive Care unit; 2department of traumatology, sestre milosrdnice university hospital Center, Zagreb, CroatiasuMMARy – The incidence of traumatic spinal cord injury is 11,000 per year, with 55% of the injuries occurring between the age of 16 and 33, 18% of these in women of reproductive age. diagnostic and early spinal decompression along with maintaining the mean arterial pressure to improve spinal cord perfusion and a high progesterone level in pregnancy for its neuroprotective and anti-inflammatory effect have the leading role in neurological recovery and clinical outcome. We present a case of a patient in the 17th week of pregnancy who sustained luxation fracture of the C5 and C6 vertebrae and tetraplegia as passenger in a road accident. The early operative treatment and appropriate anesthetic procedure resulted in good clinical outcome with complete neurological recovery.Key words: Spinal cord injuries; Pregnancy; Acute disease; Arterial pressure; Decompression, surgicalCorrespondence to: Senka Baranović, MD, department of Ane-sthesiology, Resuscitation and intensive Care unit, sestre milo-srdnice university hospital Center, vinogradska c. 29, hR-10000 Zagreb, Croatiae-mail: senka.baranovic1@zg.t-com.hrReceived March 20, 2013, accepted october 30, 2013IntroductionThe incidence of traumatic spinal cord injury (sCi) is 11,000 per year; 55% of the injuries occur between the age of 16 and 33, with 18% of patients being wom-en of reproductive age1,2. Acute injuries sustained in pregnancy produce immediate changes in the mater-nal neurogenic and hemodynamic physiology, which may profoundly affect the fetus3. The rate of fetal mal-formations in acutely acquired sCi in pregnancy is as high as 11%3-5. The patient with traumatic sCi, there-fore, presents specific challenges requiring a multidis-ciplinary approach for maternal and fetal health2,6,10. evaluation of a pregnant patient with acute sCi does not greatly differ from the non pregnant patient with similar injury2,11. spinal shock may develop in approximately half of sCis occurring at any level. neurogenic shock, which causes hemodynamic per-turbations in addition to sensorimotor effects, gener-ally lasts from 1 to 3 weeks and results in peripheral vasodilation that leads to profound hypotension11,12.positive inotropic support with dopamine or dobu-tamine may also be necessary and is not contraindi-cated in pregnancy11,12, but the use of noradrenaline is still unclear. Methylprednisolone has been recom-mended after an acute injury by the American As-sociation of neurological surgeons and the Congress of neurologic surgeons11,14. As thought before, when administered within 6-8 hours of the initial insult, methylprednisolone may significantly improve mo-tor and sensory function 6 months postinjury11,12,14-16; however, this year some new and revised guidelines have arisen17-19. The new guidelines do not recom-mend administration of methylprednisolone for the treatment of acute sCi. in our case, we used meth-ylprednisolone despite more than 8 hours after injury, based on our good clinical experience with steroid therapy after acute spinal trauma. Acta Clin Croat,  Vol. 53,   No. 1,  2014 99senka Baranović et al. Anesthetic management of acute cervical spinal cord injury in pregnancyCase ReportWe present a case of a patient in her 17th week of pregnancy who sustained luxation fracture of the C5 and C6 vertebrae and tetraplegia as passenger in a road accident. The patient was primarily treated in a sec-ondary surgical facility, where radiology diagnostics of the spine was not performed due to pregnancy. At the first clinical evaluation in the emergency depart-ment, the patient complained of tingling sensation in her arms with movement preserved in all extremities. The patient was referred for emergency gynecologic assessment, where she developed tetraplegia during transportation (American spinal injury Association, AsiA B). she arrived at the sCi unit 16 hours after the accident.Magnetic resonance imaging (MRi) is recom-mended for identifying the level of injury. MRi of the spine showed luxation fracture C5 and C6 (fig. 1); upon MRi, she was submitted to an emergency surgical procedure of disk extirpation and anterior spondylodesis (fig. 2). The patient was assessed as the American society of Anesthesiologists classification (AsA) iiie. following the spinal injuries protocol, methylprednisolone (national Acute spinal Cord in-jury study nAsCis iii, 30 mg/kg loading dose fol-lowed by a maintenance infusion at 5.4 mg/kg for 23 hours) was administered and invasive hemodynamic monitoring was set (central venous catheter with ul-trasound control and invasive arterial pressure). dur-ing the surgical procedure and due to hemodynamic instability (spinal and neurogenic shock), low dosage of noradrenaline (0.05 μg/kg/min) was administered until the mean arterial pressure of 85-90 mm hg with volume replacement (central venous pressure was be-tween 6 and 11 mm hg). Blood loss during the proce-dure was insignificant. The patient was stable during the procedure and was extubated two hours postop-eratively. The patient achieved complete recovery of the neu-rological deficit within few days of the surgery. she was verticalized with the help of physiotherapist 48 hours after the procedure. she was kept in the inten-sive care unit until complete hemodynamic normaliza-tion 48 hours postoperatively. fetal and hemodynamic monitoring was sustained during intensive care with preservation of pregnancy without complications. she delivered a healthy baby at term.DiscussionAcute traumatic sCi is frequently associated with systemic hypotension1. hypotension may be attribut-able to associated traumatic injuries with hypovolemia, direct severe spinal cord trauma itself, or a combina-tion2. The occurrence of hypotension has been shown Fig. 2. Magnetic resonance imaging after operation.Fig. 1. Magnetic resonance imaging before operation.100 Acta Clin Croat,  Vol. 53,   No. 1,  2014senka Baranović et al. Anesthetic management of acute cervical spinal cord injury in pregnancyto be associated with worse outcomes after traumatic injury1,2,8,11,16. The principal anesthetic concern was to avoid secondary (irreversible) cord damage11 in the mother. ischemia of the spinal cord is thought to be one of the most important contributors to neuronal injury and neurological deficit after acute sCi11. Both local and systemic vascular alterations can contribute to ischemia after acute sCi by further reducing spinal cord blood flow that can exacerbate and extend the principal spinal cord insult1,6,8,16.several reports of case series suggest that treat-ment of hypotension and resuscitation to maintain the mean arterial pressure at high-normal levels, 85 to 90 mm hg, for the first 7 days following an sCi is recommended18,19, and may enhance neurological out-come after acute sCi1,2,5,7. A protocol of aggressive, early medical and surgical management of patients with acute sCi may improve neurological outcome af-ter injury15,16. treatment in the intensive care unit set-ting, hemodynamic monitoring with maintenance of the mean arterial pressure above 85 mm hg1, and ear-ly decompression of the spinal cord seemed to reduce secondary complications after acute sCi3,4,15. The use of vasoconstrictive drugs for raising and maintenance of the mean arterial pressure and perfusion pressure in the placenta is not yet fully understood, but there are no clear contraindications for the use of these drugs in pregnancy2,10,11.during pregnancy, progesterone secretion has a protective effect on myelin and also increases my-elination5,6,14. progesterone exerts strong stimulatory effects upon the oligodendrocyte progenitors and ma-ture oligodendrocytes, and inhibitory effects upon inflammatory mediators8,9,13,14. in this sense, proges-terone is a recognized promyelinating factor for trau-ma, degeneration and inflammation of the peripheral and central nervous system17. As mentioned earlier, methylprednisolone should not be routinely used in the treatment of patients with acute sCi, suggesting that high-dose methylprednisolone administration is associated with a variety of complications including infection, respiratory compromise, gastrointestinal hemorrhage, and death18,19.in conclusion, early spinal decompression6,10,20 (within 12-24 hours) and maintaining the mean arte-rial pressure at 85-90 mm hg to improve spinal cord perfusion1,11,15, as well as high progesterone level in pregnancy7,21 with its neuroprotective, promyelinating and anti-inflammatory effect14,17 play an important role in neurological recovery and clinical outcome in acute sCi. The care of a pregnant patient with acute sCi poses multiple challenges that require a multi-disciplinary team approach and individualization of therapy. References  1. McCoRMiCK p. Blood pressure management after acute spinal cord injury. neurosurgery 2002;50:58-62.  2. King Bs, guptA R, nARAyAn RK. The early assess-ment and intensive care unit management of patients with se-vere traumatic brain and spinal cord injuries. surg Clin north Am 2000;80:855-70.  3. vACCARo AR, hulBeRt Rj, pAtel AA, fisheR C, dvoRAK M, lehMAn RA, et al. The subaxial cervical spine injury classification system: a novel approach to recog-nize the importance of morphology, neurology, and integrity of the disco-ligamentous complex. spine 2007;32:2365-74.  4. vACCARo AR, lehMAn RA jR, huRlBeRt Rj, AndeRson pA, hARRis M, hedlund R, et al. A new classification of thoracolumbar injuries: the importance of injury morphology, the integrity of the posterior ligamen-tous complex, and neurologic status. spine 2005;30:2325-33.  5. KWon BK, seKhon lh, fehlings Mg. emerging repair, regeneration, and translational research advances for spinal cord injury. spine 2010;35(suppl):263-70.  6. RoWlAnd jW, hAWRyluK gW, KWon B, et al. Current status of acute spinal cord injury pathophysiology and emerging therapies: promise on the horizon. neurosurg focus 2008;25:e2.  7. lABoMBARdA f, gonZAleZ-deniselle MC, deniColA Af, gonZAleZ sl. progesterone and the spinal cord: good friends in bad times. neuroimmunomodu-lation 2010;17:146-9.  8. lABoMBARdA f, gonZAleZ sl, gonZAleZ- deniselle MC, guennoun R, sChuMACheR M, deniColA Af. Cellular basis for progesterone neu-roprotection in the injured spinal cord. j neurotrauma 2002;19:343-55.  9. sChnell l, sChWAB Me. Axonal regeneration in the rat spinal cord produced by an antibody against myelin-asso-ciated neurite growth inhibitors. nature 1990;343:269-72.10. KAng Ah. traumatic spinal cord injury. Clin obstet gy-necol 2005;48:67-72.11. stevens Rd, BhARdWAj A, KiRsCh jR, et al. Criti-cal care and perioperative management in traumatic spinal cord injury. j neurosurg Anesthesiol 2003;15:215-29.12. van hooK jW. trauma in pregnancy. Clin obstet gynecol 2002;45:414-24.Acta Clin Croat,  Vol. 53,   No. 1,  2014 101senka Baranović et al. Anesthetic management of acute cervical spinal cord injury in pregnancy13. hu sl, luo hs, li jt, XiA yZ, li l, ZhAng lj, et al. functional recovery in acute traumatic spinal cord injury after transplantation of human umbilical cord mesenchymal stem cells. Crit Care Med 2010;38:2181-9.14. liM p, toW AM. Recovery and regeneration after spinal cord injury: a review and summary of recent literature. Ann Acad Med singapore 2007;36:49-57.15. national spinal Cord injury statistical Center. spinal cord injury, facts and figures at a glance. j spinal Cord Med 2008;31:357-8.16. huRlBeRt Rj, hAMilton Mg. Methylprednisolone for acute spinal cord injury: 5-year practice reversal. Can j neurol sci 2008;35:41-5.17. hAWRyluK gW, RoWlAnd j, KWon BK, et al. pro-tection and repair of the injured spinal cord: a review of com-pleted, ongoing, and planned clinical trials for acute spinal cord injury. neurosurg focus 2008;25:e14.18. RyKen tC, huRlBeRt Ro, hAdley Mn, AARA-Bi B, dhAll ss, gelB de, RoZZelle Cj, theo-doRe n, WAlteRs BC. The acute cardiopulmonary management of patient with cervical spinal cord injuries. neurosurgery 2013;72:84-92.19. huRlBeRt Rj, hAdley Mn, WAlteRs BC, AARABi B, dhAll ss, gelB de, RoZZelle Cj, RyKen tC, theodoRe n. pharmacological therapy for acute spinal cord injury. neurosurgery 2013;72:93-105.20. vuKAs d, lediĆ d, gRAhovAC g, KoliĆ Z, RotiM K, vilendeČiĆ M. Clinical outcome in patients after lumbar disk surgery with annular reinforcement device: two-year follow up. Acta Clin Croat 2013;52(1):87-91.21. ljuCA d, hudiĆ i, hAdŽiMehMedoviĆ A. het-erotopic pregnancy in natural conception – our initial experi-ence: case report. Acta Clin Croat 2011;50(2):249-52.sažetakAnesteZioloŠKi pRistup Kod AKutne oZljede vRAtne KRAljeŽniCe u tRudnoĆiS. Baranović, B. Maldini, T. Čengić i R. Kolundžićučestalost traumatskih ozljeda kralježnice je 11.000 na godinu, a 55% ozljeda nastaje u dobi od 16 do 33 godine, od toga 18% u žena reproduktivne dobi. Radiološka dijagnostika, uz ranu kiruršku dekompresiju kralježnice s održavanjem srednjeg arterijskog tlaka za očuvanje perfuzije leđne moždine, uz progesteron kao neuroprotektivni i protuupalni faktor u akutnoj traumi leđne moždine, ima vodeće mjesto u neurološkom oporavku i dobrom kliničkom ishodu. donosimo prikaz slučaja trudnice u 17. tjednu trudnoće koja je zadobila luksacijsku frakturu petog i šestog vratnog kralješka s razvo-jem tetraplegije, kod koje su rano operacijsko liječenje i odgovarajući anesteziološki postupak doveli do dobrog kliničkog ishoda.Ključne riječi: Kralježnična moždina, ozljede; Trudnoća; Akutna bolest; Arterijski tlak; Dekompresija, kirurška

Anesteziološki pristup kod akutne ozljede vratne kralježnice u trudnoći

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