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Correspondence |
Plano Presbyterian and Baylor Garland Hospital, Plano, USA, E-mail: drrdd{at}yahoo.com
To the Editor:
Tsai et al. present an interesting case of massive cerebral infarction and subsequent death after anterior cervical discectomy and fusion.1 The authors state that the cervical hyperextension may have led to cerebral ischemia and subsequent cerebral infarction.1 We offer several comments relevant to their case. First, it appears the patient had two primary risk factors, diabetes and hypertension, for vascular disease. We published a very similar case on a 56-yr-old male with hypertension and diabetes who underwent a C6 anterior cervical corpectomy for myelopathy.2 Our patient tolerated the procedure well, with minimal blood loss, normal intraoperative neurophysiological monitoring, and a normal intraoperative ‘wakeup’ test. Postoperatively, the patient was neurologically ‘sluggish’. An emergent computerized tomography (CT) scan of the brain and spine demonstrated posterior circulation infarcts and a normal spine. A vertebral artery dissection was demonstrated on angiography. The patient continued to have embolic infarcts requiring a suboccipital craniectomy for evacuation of edematous and infarcted cerebellum with subsequent sacrifice of the vertebral artery via aneurysm clipping. The patient died two weeks post-operatively.2 We investigated at length the possible etiologies for the vertebral dissection and concluded it was likely cervical traction. We also routinely utilize cervical hyperextension in our anterior cervical spine cases, but believe that traction on an atherosclerotic vessel led to the dissection. Vertebral artery dissection has been reported to occur spontaneously, with spinal trauma, after chiropractic treatment, and associated with suicide via hanging, all of which could result in either direct or indirect arterial injury.3–5 There are numerous reports of cerebrovascular insults secondary to vertebral artery dissection, which are most often due to thromboemboli in the posterior circulation.5 Tsai et al. denied any direct trauma, however, a CT scan of the cervical spine might have demonstrated a breach of the transverse foramen leading to a vertebral dissection. Another potential mechanism of vertebral artery injury that was not discussed, was the possibility of vibrations from a high-speed drill, if utilized in the surgery, leading to a vertebral dissection.
To support Tsai et al. on the hypothesis of a hyper-extension injury, there are reports of chiropractic manipulation causing vertebral injury due to extension of the neck with rotation causing intraforaminal contortion of the vessel leading to dissection.6 In addition, are the cases of "salon syndrome" where the neck is hyperextended for hairwashing and the person subsequently suffers neurological sequelae.7 Lastly, magnetic resonance angiography has demonstrated that certain patients have significantly decreased vertebro-basilar flow with cervical hyperextension, and are thus at an increased risk for ischemia with hyper-extension.8
In closing, we support Tsai et al. on their recommendations for limiting cervical hyperextension in patients at risk for vascular disease, i.e., diabetes and hypertension. We also suggest no cervical traction, and maintaining the head and neck in a neutral position throughout the case to ensure adequate circulation; this includes both anterior and posterior cervical spine surgery. Furthermore, cerebral vascular insult should be mentioned preoperatively as a risk of surgery, for all patients with vascular disease or comorbidities at risk for vascular disease.
Footnotes
Accepted for publication March 20, 2006.
References
1 Tsai YF, Doufas AG, Huang CS, Liou FC, Lin CM. Postoperative coma in a patient with complete basilar syndrome after anterior cervical discectomy. Can J Anesth 2006, 53: 202–7.
2 Dickerman RD, Zigler JE. Atraumatic vertebral artery dissection and death after cervical corpectomy: a traction injury? Spine 2005, 30: E658–61.[Medline]
3 Daentzer D, Deinsberger W, Boker DK. Vertebral artery complications in anterior approaches to the cervical spine: report of two cases and review of the literature. Surg Neurol 2003; 59: 300–9.[Medline]
4 Iwase H, Kobayashi M, Kurata A, Inoue S. Clinically unidentified dissection of vertebral artery as a cause of cerebellar infarction. Stroke 2001; 32: 1422–44.
5 Sagoh M, Hirose Y, Murakami M, Akaji K, Mayanagi K. Cerebellar infarction with hydrocephalus caused by spontaneous extracranial vertebral artery dissection–case report. Neurol Med Chir (Tokyo) 1997; 37: 538–41.[Medline]
6 Parenti G, Orlandi G, Bianchi M, Renna M, Martini A, Murri L. Vertebral and carotid artery dissection following chiropractic cervical manipulation. Neurosurg Rev 1999, 22: 127–9.[Medline]
7 Endo K, Ichimaru K, Shimura H, Imakiire A. Cervical vertigo after hair shampoo treatment at a hairdressing salon: a case report. Spine 2000, 25: 632–4.[Medline]
8 Weintraub MI, Khoury A. Critical neck position as an independent risk factor for posterior circulation stroke. A magnetic resonance angiographic analysis. J Neuroimaging 1995, 5: 16–22.[Medline]
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