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Excerpt
I agree with the authors that midline ligation and avoidance of coagulation at the foramina or ligation on the concavity is to be avoided. I would disagree that hypotensive anesthesia cannot be used because it has been used frequently without risk. In a similar number of adult cases, I have had two patients with vascular paraplegia. Both had had numerous posterior procedures. Both had midline ligation. As in the author's experience, one patient had a normal wake-up test at the conclusion of the anterior procedure and was paraplegic by the time of wound closure. There were no structural reasons for this. Paraplegia may occur many minutes after ligation, and the wake-up test may not be sufficient. The belief is that one of the authors' patients who had a normal wake-up test and subsequently became paraplegic may have been a vascular case.
Although it may be expensive, I believe that it is essential to consider monitoring, particularly in deformity surgery or for cases undergoing corpectomy. The patients at risk can be monitored carefully via clamping segmental vessels and following their motor- and somatosensory-evoked potentials for 20 minutes to see if there are any significant changes. In my opinion, the cord at risk is that of patients who had multiple surgeries, kyphotic patients, patients with evidence of neurologic problems before surgery, and patients whose cords are compressed with effacement of cerebral spinal fluid. Although I generally agree with the authors, I believe that segmental vessels should not be divided without appropriate assessment during surgery, particularly in patients whose cords are at risk. Angiography done before surgery is, in my opinion, of no value.
