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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 3  |  Page : 889-890

Reflex bradycardia due to traction on filum terminale during detethering of spinal cord


Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication23-Jul-2019

Correspondence Address:
Dr. Girija P Rath
Department of Neuroanaesthesiology and Critical Care, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.263184

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How to cite this article:
Chavali S, Das K, Sokhal S, Rath GP. Reflex bradycardia due to traction on filum terminale during detethering of spinal cord. Neurol India 2019;67:889-90

How to cite this URL:
Chavali S, Das K, Sokhal S, Rath GP. Reflex bradycardia due to traction on filum terminale during detethering of spinal cord. Neurol India [serial online] 2019 [cited 2019 Dec 15];67:889-90. Available from: http://www.neurologyindia.com/text.asp?2019/67/3/889/263184




Sir,

An 18-year old female, weighing 53 kg underwent release of low-lying tethered cord associated with a type 2 split cord malformation at our institute. She did not any history of heart disease, arrhythmias, or episodes of syncope; baseline electrocardiogram (ECG) was found to be within normal limits. She received 0.2 mg glycopyrrolate intramuscularly as premedication, and anesthesia was induced with 100 mg propofol and 100 μg fentanyl. Tracheal intubation was facilitated with 50 mg rocuronium and anesthesia was maintained with a mixture of desflurane/oxygen/nitrous oxide, and infusions of rocuronium and fentanyl. The patient was then placed in the prone position and surgery was carried out. The procedure was uneventful until the neurosurgeon applied traction to the filum terminale during the procedure. At that point of time, there was a sudden increase in heart rate from 70 to 110 beats per minute (bpm), followed immediately by bradycardia (from 110 to 52 bpm). There was no use of electrocautery during this episode, and hence, interference with the ECG was ruled out. Since this episode of bradycardia resolved spontaneously after traction was removed, and was not associated with any hypotension, anticholinergic therapy was not administered. Cotton soaked with local anesthetic agent was placed over the filum terminale with the aim to prevent any further reflex episode before proceeding with the surgery. The remainder of the surgery was uneventful, and the patient recovered normally, without any neurologic deficit in the postoperative period.

Acute hemodynamic disturbances during lumbar spine surgery are very uncommon, with only few cases reported exhibiting this phenomenon. A review of literature did not reveal similar occurrences during surgery for release of tethered spinal cord.[1],[2],[3],[4] Chowdhury et al., hypothesized a phenomenon termed as spinal-cardiac reflex (SCR).[5] The afferent part of this reflex arc originates from direct branches of the sympathetic chain and the sinu-vertebral nerves that innervate the spinal dura mater, and the efferent part originates from the medulla oblongata, similar to the trigeminocardiac reflex arc. It may manifest as a vasovagal reaction, leading to bradycardia and/or hypotension. Mechanical or thermal stimulation of the spinal dura, with its intrinsic as well as extrinsic innervation, may be the triggering factor for the reflex in our case, which is considered to be similar to the trigeminocardiac reflex seen during various neurosurgical procedures. Majority of such cases are of a younger age. Thus, a younger age and female gender might be the risk factors for occurrence of this phenomenon. Maintenance of an adequate depth of anesthesia is essential, and application of a local anesthetic agent to the exposed neural structures may help to reduce the incidence of this reflex. We emphasize vigilance during an otherwise simple surgical procedure such as detethering of cord, especially during traction of the dura as well as the filum terminale. Vagolytic and sympathomimetic drugs should be kept ready to treat a possible episode of acute hemodynamic disturbance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chowdhury T, Sapra H, Dubey S. Severe hypotension in transforaminal lumbar interbody fusion surgery: Is it vasovagal or? Asian J Neurosurg 2017;12:149.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Chowdhury T, Narayanasamy S, Dube SK, Rath GP. Acute hemodynamic disturbances during lumbar spine surgery. J Neurosurg Anesthesiol 2012;24:80-1.  Back to cited text no. 2
    
3.
Dooney N. Prone CPR for transient asystole during lumbosacral spinal surgery. Anaesth Intensive Care 2010;38:212-3.  Back to cited text no. 3
    
4.
Deschamps A, Carvalho G. Lumbo-sacral spine surgery and severe bradycardia. Can J Anaesth J Can Anesth 2004;51:277.  Back to cited text no. 4
    
5.
Chowdhury T, Schaller B. The negative chronotropic effect during lumbar spine surgery: A systemic review and aggregation of an emerging model of spinal cardiac reflex. Medicine (Baltimore) 2017;96:e5436.  Back to cited text no. 5
    




 

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