- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, USA
- Department of Orthopedic Surgery, Oregon Health and Science University, Portland, OR, USA
D. Kojo Hamilton
Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
DOI:10.4103/2152-7806.180771Copyright: © 2016 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ozpinar A, Liu JJ, Tempel ZJ, Choi PA, Hart RA, Hamilton DK. Intracranial pressure monitoring during adult spinal deformity correction in a patient with critical venous occlusive disease and superior vena cava syndrome: A technical note. Surg Neurol Int 20-Apr-2016;7:47
How to cite this URL: Ozpinar A, Liu JJ, Tempel ZJ, Choi PA, Hart RA, Hamilton DK. Intracranial pressure monitoring during adult spinal deformity correction in a patient with critical venous occlusive disease and superior vena cava syndrome: A technical note. Surg Neurol Int 20-Apr-2016;7:47. Available from: http://surgicalneurologyint.com/surgicalint_articles/intracranial-pressure-monitoring-during-adult-spinal-deformity-correction-in-a-patient-with-critical-venous-occlusive-disease-and-superior-vena-cava-syndrome-a-technical-note/
Background:Intracranial pressure (ICP) monitoring is not routinely used during complex spinal deformity correction surgery. The authors report a 66-year-old male who during thoracolumbar deformity surgery required the placement of an ICP monitor due to the underlying history of a superior vena cava syndrome (e.g., s/p right jugular stent).
Case Description:A 66-year-old male with multiple prior lumbar spinal procedures presented with lower back and bilateral lower extremity pain, paresthesias, and weakness. He had a history of chronic left internal jugular and brachiocephalic venous occlusion (e.g., he had a right internal jugular stent). During deformity surgery, a frontal intraparenchymal ICP monitor was placed. During the early portion of the operation, bed adjustments (increasing reverse trendelenburg position) were required to compensate for ICP elevations as high as 30 mm Hg. A subsequent inadvertent durotomy during decompression lowered the ICP to
Conclusion:ICP monitoring may be a useful adjunct for patient safety in selected patients who are at risk for developing intracranial hypertension during extensive spinal deformity surgery.
Keywords: Deformity correction, intracranial pressure monitoring, superior vena cava syndrome
Intracranial pressure (ICP) monitoring is frequently used by neurosurgeons for the management of multiple pathologies including traumatic brain injury, hydrocephalus, and idiopathic intracranial hypertension.[
A 66-year-old male with multiple prior lumbar spine surgeries presented with intractable, disabling low back and radicular pain, and neurogenic claudication with severe sagittal imbalance refractory to conservative measures. He was unable to walk more than 20 yards at a time and experienced severe pain and cramping with any movement. His quality of life had been severely affected by his symptoms. He had a history of SVC syndrome (right internal jugular stent), managed with long-term warfarin anticoagulation; he also had chronic left internal jugular and brachiocephalic veins occlusions.
Physical examination demonstrated normal motor strength in the upper extremities. No pathologic reflexes were noted in any extremity. He had a slight weakness in the right gastrocnemius and extensor hallicus longus (EHL) graded at 4+/5 strength.
Computed tomography (CT) and plain radiographics indicated pseudarthrosis of his prior construct [
Description of intraoperative procedures
After induction of general endotracheal anesthesia, electrodes were placed for routine neuromonitoring including somatosensory and motor evoked potentials as well as electromyography. Subsequently, a right frontal ICP monitor was placed. The initial pressure reading from the ICP monitor was 6 mm Hg (normal ICP <20 mm Hg). Once all lines and monitors were in place, the patient was then carefully turned prone onto the Jackson frame. The prone-view facial padding device notably needed to be modified to accommodate the anchor of the pressure monitor. A semicircular cut was made, so the anchor would rest without strain on the device. The pressure reading after turning the patient prone was 30 mm Hg. The decision was made to only proceed with the case if the ICP could be maintained <15 mm Hg at rest since surgical manipulation would likely lead to elevation of the ICP. The Jackson frame was then elevated to 30° of reverse Trendelenburg position. The patient's ICP gradually decreased over the next 10 min and stabilized at 14–15 mm Hg [
After successful instrumentation, laminectomies and a discectomy were performed. Next, an interbody spacer was then placed at the L2–L3 level via a transforaminal approach. A PSO was then performed at L2. During the exposure and removal of scar in preparation for the PSO, a durotomy occurred on the right side (approximately 5 h into the procedure) [
Once the PSO was closed, intraoperative long-cassette radiographs were obtained demonstrating significant improvement in lordosis. Two-column Smith-Peterson type osteotomies were then carried out, long segment rods were contoured, cap screws were placed and tightened, and the wound was closed expeditiously.
The patient was then carefully turned back supine onto the bed and taken directly to the Intensive Care Unit still intubated and in stable condition. The head of the bed was maintained at 30° as a compromise between improving cerebral venous drainage and protecting the dural closure.
ICPs were monitored overnight to evaluate for intracranial hypertension; however, the pressures remained in the normal range. His postoperative examination was grossly stable compared with his preoperative examination. The ICP monitor was removed, and he was extubated shortly thereafter. On discharge, he had significant improvement in his preoperative pain, and he continued to have stable slight weakness of the right EHL and gastrocnemius.
Standing long-cassette radiographs were obtained at his 3-month postoperative visit and revealed slight proximal junctional kyphosis. His postoperative pelvic incidence was 58.5°, his pelvic tilt was 29°, and his sagittal vertical axis (SVA) was 13.7 cm [
Several traditional etiologies such as infections, tumors, and fibrosing mediastinitis can cause varying degrees of central venous system obstruction leading to the diagnosis of SVC syndrome. More recently, accurate diagnosis of hypercoagulable states, placement of indwelling central venous devices or pacemaker leads as a cause of SVC syndrome has drawn more attention to the diagnosis.[
During a prone procedure with limited ability for standard maneuvers to increase venous return (such as elevating the head), the ICP monitor, in this case, was a very useful monitoring adjunct to ensure safety.[
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