Background: To avoid spinal cord ischemia following endovascular/open thoracic-abdominal aortic aneurysm (T-AAA) repair, lumbar drains (LDs) are placed to reduce intraspinal pressure, and increase spinal perfusion pressure. Here, we present a medicolegal case in which a critical care (CC) physician knew that the LD was obstructed following a T-AAA repair, but did not replace it until the patient became paraplegic. The patient was left with permanent sphincter loss, and a severe paraparesis.
Methods: A geriatric patient with multiple medical/cardiovascular comorbidities first underwent an endovascular T-AAA (Crawford Type II T-AAA) repair several years ago. Due to continued expansion of the aneurysm, the patient now required an open T-AAA repair.
Results: Prior to the open T-AAA surgery, a prophylactic LD was placed. Postoperatively, the patient required a second emergency operation to repair a leaking intercostal artery anastomosis. The next morning, the CC physician clearly documented the drain was obstructed, but chose to follow the patient; 3.5 hours later, the patient became paraplegic. The LD was replaced after the patient was first sent to MRI to rule out a spinal cord hematoma, resulting in a total delay of more than 6.5 h from when the CC physician first became aware of the non-functioning LD. The patient later regained only partial function, remaining significantly paraparetic with total loss of bowel/bladder function.
Conclusion: LD for endovascular/open T-AAA repairs reduce spinal fluid pressure, increase spinal cord perfusion pressures, and limits the frequency (i.e. 2.3-2.6%) of resultant spinal cord ischemia/paralysis. Here, despite the CC physician's failure to replace an obstructed LD after an open T-AAA, repair, the jury rendered a defense verdict.
Keywords: Cerebrospinal fluid pressure; Crawford Type II; Defense verdict; Lumbar drain; Medicolegal corner; Paralysis; Repair; Thoracic-abdominal aortic aneurysm.
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