Cerebral Infarction after Spine Surgery: Report of Two Cases

doi:10.4236/ojo.2013.34037

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Open Journal of Orthopedics, 2013, 3, 204-207

http://dx.doi.org/10.4236/ojo.2013.34037 Published Online August 2013 (http://www.scirp.org/journal/ojo)

Cerebral Infarction after Spine Surgery: Report of Two

Cases*

Katsunori Fukutake, Hiroshi Takahashi, Yuichiro Yokoyma, Yasuaki Iida, Ryo Takamatsu,

Kazumasa Na kamura, Akihito Wada

Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan.

Email: [email protected]

Received June 13th, 2013; revised July 13th, 2013; accepted July 20th, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

There has been an increase in spinal surgery for the elderly, with a corresponding potential increase in perioperative

complications. In our department, 1833 patients underwent spinal surgery under general anesthesia from April 2001 to

October 2012, and 2 of 260 patients aged ≥75 years old had postoperative cerebral infarction. An analysis of the patho-

genic mechanism and potential risk factors showed that a history of cerebral infarction was a significant risk factor.

Blood pressure rapidly increased on arousal from anesthesia, and particularly on extubation. The change in blood pres-

sure was examined as a potential risk factor for cerebral infarction, but no significant relationship was observed. This

result requires further examination in more patients with cerebral infarction after spinal surgery.

Keywords: Cerebral infarction; Spine surgery; Complication

1. Introduction

Surgeries in elderly patients have increased with aging of

the population. Many elderly patients have comorbidity

such as hypertension and diabetes. Here, we report two

cases of elderly patients who developed cerebral infarc-

tion after surgery, for which we examined the pathogenic

mechanism and risk factors.

2. Materials and Methods

Postoperative cerebral infarction occurred in 2 of 1833

patients who underwent spinal surgery under general

anesthesia in our department between April 2001 and

October 2012. The two patients were aged 76 and 83

years old. No perioperative cerebral infarction was found

in patients aged less than 75 years old. Therefore, the

pathogenic mechanism and risk factors for postoperative

cerebral infarction were examined in 260 patients aged

≥75 years old. The 260 patients had a mean age of 78.9

years old, BMI 23.9, mean surgical time 174.8 min, and

mean blood loss 316.1 g. There were histories of hyper-

tension in 108 patients, diabetes in 39, cerebrovascular

disorder in 21 and ischemic cardiac disease in 18 (Table

1).

Multivariate analysis was conducted using age at sur-

gery, sex, BMI, history of hypertension, diabetes, cere-

brovascular disease and ischemic cardiac disease, surgi-

cal time, bleeding volume, and ratio of the systolic blood

pressure preoperatively and at extubation. Preoperative

systolic blood pressure was defined as the maximum

blood pressure on rising after admission and systolic

blood pressure on extubation as the maximum of sequen-

tial measurements of blood pressure.

Table 1. Baseline characteristics of the patoents (n = 260).

Characteristic

 Age (years old) 78.9 ± 3.3

 BMI (kg/m2) 23.8 ± 4.0

 Surgical time (min) 147.8 ± 81.0

 Blood loss (g) 316.1 ± 704.7

(mean ± SD)

 Comorbidity

Hypertension 108

Diabetes 39

Cerebrovascular disorder 21

Ischemic cardiac disease 17

*Sources of support: None,

Conflict of interest: None.

Cerebral Infarction after Spine Surgery: Report of Two Cases

205

Multiple regression, multiple logistic regression and

discriminant analyses were performed. The multiple lo-

gistic regression analysis was performed with binary

variables established using a cut-off value (Table 2).

Analyses were conducted using EXCEL Statistics (Social

Survey Research Information Co., Ltd., Tokyo, Japan)

for multiple logistic and multiple regression analyses and

SPSS (IBM SPSS Statistics version 19, IBM Japan Ltd.,

Tokyo, Japan) for discriminant analysis.

3. Case Report

Case 1: The patient was a 83-year old man with cervical

spondylotic myelopathy and lumbar spinal stenosis who

underwent simultaneous cervical and lumbar laminoplasty.

The surgical time was 290 min and the bleeding volume

was 295 g. He had a history of prostatic hyperplasia and

gastric ulcer. Blood pressure on rising on the operative

day was 134/74 mmHg and that on extubation was 184/

104 mmHg, giving a systolic blood pressure ratio (pre-

operative/extubation) of 0.73. Dysarthria occurred on

extubation and arousal from anesthesia. Brain MRI was

performed immediately and showed brainstem infarction,

for which neuroprotective drugs were administered. Re-

habilitation for swallowing was also started because dys-

phagia occurred. The symptoms gradually improved and

the patient had no disturbance of activities of daily living

(ADL) at about 6 months after surgery.

Case 2: The patient was a 76-year old man with cer-

vical spondylotic amyotrophy who underwent forami-

notomy. The surgical time was 132 min and the bleeding

volume was 130 g. He had a history of diabetes and ce-

rebrovascular disorder, but had not taken drugs for cere-

brovascular disorder. Blood pressure on rising on the

operative day was 132/62 mmHg and that on extubation

was 177/100 mmHg. The systolic blood pressure ratio

(preoperative/extubation) was 0.75. Marked dysarthria

was found in arousal from anesthesia. Brain MRI was

performed immediately and minor infarction was found

in the midbrain, for which neuroprotective drugs were

administered. The symptoms gradually improved and the

patient had no disturbance of ADL at about 6 months

after surgery.

Table 2. Binary variables.

 Age (0: <79 years old; 1≧

: 79 years old)

 BMI (0: <25; 1: ≧25)

 Systolic blood pressure ratio (on rising/on extubation)

(0: blood pressure ratio < ≧

0.8; 1: blood pressure ratio 0.8)

 Diastolic blood pressure ratio (on rising/on extubation)

(0: blood pressure ratio < 0.8; 1≧

: blood pressure ratio 0.8)

 Surgical time (0≧

: <150 min; 1: 150 min)

 Bleeding volume (0: <300 mL; 1≧

: 300 mL)

4. Results

Multiple regression analysis was conducted using the

stepwise selection method. Forward selection identified

sex, low systolic blood pressure ratio (preoperative/ex-

tubation), and a history of cerebrovascular disorder as

potentially important variables, but only a history of ce-

rebrovascular disorder was significant (p = 0.025) (Table

3). Backward elimination identified these variables and

surgical time, bleeding volume and history of hyperten-

sion, but similarly the only significant variable was a

history of cerebrovascular disorder (p = 0.021) (Table

4).

In multiple logistic regression analysis, the only sig-

nificant risk factor was a history of cerebrovascular dis-

order alone. In discriminant analysis, the 3 and 6 vari-

ables extracted in the respective multiple regression ana-

lyses were used for prognosis prediction. The predictive

value, sensitivity and specificity of the 3 variables were

lower than those of the 6 variables, indicating that the

latter were effective for prediction of prognosis (Table 5).

The findings were not significant because data were

available for only 2 subjects with postoperative cerebral

infarction, but these results support the findings from

multiple regression analysis.

5. Discussion

The incidence of cerebral infarction after spinal surgery

ranges from 0.3% to 1% [1,2]. In our department, 2 of

1833 patients (approx. 0.1%) developed cerebral infarc-

tion and the outcomes were better than those in previous

case reports. The results of the study indicate that a his-

tory of cerebral infarction posed a risk for perioperative

cerebral infarction, as also found in other case reports. A

history of transient ischemic attack (TIA) is also a risk

for perioperative cerebral infarction, and surgery 1 to 3

months after cerebral infarction should be avoided [3].

Continuous administration of anticoagulant and anti-

platelet drugs causes no serious hemorrhagic complica-

tion and decreases the risk for perioperative cerebral in-

farction [4]. However, in our department, drug admini-

stration is usually discontinued 1 to 2 weeks before sur-

gery and postoperative administration is resumed after

extubation. The two patients with cerebral infarction were

not given anticoagulant or antiplatelet drugs before sur-

gery. Therefore, this issue was not examined in this study,

but should be investigated in the future.

The onset of cerebral infarction was thought to have

occurred during surgery in both cases. In our hospital,

systolic blood pressure is controlled at ≤100 mmHg dur-

ing surgery when possible to prevent intraoperative

bleeding; however, a rapid increase in systolic blood

pressure on extubation occurs in all patients. Reduction

in perioperative variation of blood pressure decreases the

Cerebral Infarction after Spine Surgery: Report of Two Cases

206

Table 3. Forward se lection method.

Partial regression

coefficient

Standardized partial

regression coefficient T value P value decision

 Sex 0.0166 0.0948 1.5441 0.1238 NS

 Pre/postoperative blood pressure ratio −0.0597 −0.0931 −1.5175 0.1304 NS

 Cerebrovascular discorder 0.0442 0.1378 2.2456

0.0256 *

 Constant term 0.0467 1.3674 0.1727

Table 4. Backward elimination method.

Partial regression

coefficient

Standardized partial

regression coefficient T value P value decision

 Sex 0.0184 0.1049 1.7096 0.0886 NS

 Pre/postoperative blood pressure ratio −0.0600 −0.0935 −1.5307 0.1271 NS

 Operating time 0.0001 0.1008 1.6228 0.1059 NS

 Hypertension −0.0175 −0.0990 −1.5926 0.1125 NS

 Diabetes 0.0220 0.0898 1.4586 0.1459 NS

 Cerebrovascular discorder 0.0458 0.1429 2.3299

0.0206 *

 Constant term 0.0338 0.9597 0.3381

Table 5. Discriminant analysis by major 6 variables in the

backward selection incl uding pre/post operative blood pres-

sure ratio, operation time, hypertension, diabetes, cere-

brovascular disorder and 3 variables in the forward selec-

tion including sex, pre/post operative blood pressure ratio,

cerebrovascular disorder.

(a)

Postoperative onset

of cerebral infarction Actual result

no yes

no 235 0

Prediction by

major 6 variables yes 23 2

Predictive value: 91.2%.

(b)

Postoperative onset

of cerebral infarction Actual result

no yes

no 236 1

Prediction by

major 3 variables yes 22 1

Predictive value: 89.6%.

risk for cerebral infarction [5]; therefore, increased blood

pressure on extubation may be associated with the onset

of cerebral infarction. A significant relationship was not

found due to the small number of subjects in the study,

but the results suggested that increased blood pressure on

extubation influenced postoperative cerebral infarction.

Further studies in more patients with cerebral infarction

are required to examine this finding.

6. Summary

1) We experienced two patients who developed cere-

bral infarction after surgery and examined the pathogenic

mechanism and risk factors in these cases.

2) A history of cerebrovascular disorder posed a risk

of onset of cerebral infarction.

3) A rapid increase in systolic blood pressure on ex-

tubation was a possible risk factor for onset of postopera-

tive cerebral infarction.

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