Paraparesis Management and Aetiologies

Common Aetiologies of Paraparesis

The American Heart Association recommends that spinal cord ischemia following thoracic aortic surgery is a significant cause of paraparesis, with a 2-6% incidence, and is the most feared complication of descending thoracic aortic repairs 1, 2
Risk factors for spinal cord ischemia include emergency surgery, dissection, extensive disease, prolonged aortic cross-clamp time, aortic rupture, level of aortic cross-clamp, patient age, prior abdominal aortic surgery, hypogastric artery exclusion, and renal dysfunction, as stated by the American College of Cardiology 2, 3
Cerebral venous thrombosis involving the sagittal sinus can cause bilateral motor signs including paraparesis, according to the American Heart Association 4

The American Stroke Association recommends complete blood count, chemistry panel, prothrombin time, and activated partial thromboplastin time for suspected vascular causes, and screening for prothrombotic conditions in suspected cerebral venous thrombosis 4
The American Academy of Neurology recommends CSF examination when inflammatory or infectious causes are suspected, particularly for Guillain-Barré syndrome variants 5

The American College of Cardiology recommends cerebrospinal fluid drainage as a primary spinal cord protective strategy in patients at high risk of spinal cord ischemic injury during thoracic aortic repair (Class I recommendation) 2
The American Heart Association recommends spinal cord perfusion pressure optimization using proximal aortic pressure maintenance and distal aortic perfusion (Class IIa recommendation) 2
The American College of Cardiology recommends moderate systemic hypothermia for protection during open repairs (Class IIa recommendation) 2
The American Heart Association recommends prevention of postoperative hypotension and continued CSF drainage for >40 hours to reduce paraparesis incidence 6
The American Academy of Neurology recommends neurophysiological monitoring (somatosensory or motor evoked potentials) to detect spinal cord ischemia and guide treatment (Class IIb recommendation) 2, 3
The American Cancer Society recommends surgical decompression for spinal cord compression from tumors or other mass lesions, and combined surgery and radiotherapy for malignant spinal cord compression has shown better outcomes than radiotherapy alone 7

The American Heart Association states that two-thirds of patients with paraparesis following thoracic aortic surgery will recover, and about half of patients with complete paraplegia will recover to the point of walking again 6

The American Heart Association recommends avoiding postoperative hypotension in patients with spinal cord ischemia, and early mobilization and rehabilitation to prevent deconditioning 6, 8
The American Urological Association recommends management of neurogenic bladder and bowel dysfunction to prevent secondary complications 6
The American Academy of Neurology recommends pain management, as pain is frequently reported in patients with paraparesis 5

The rate of symptom onset should be documented, as acute onset suggests vascular or inflammatory causes, while gradual progression suggests neoplastic or metabolic etiologies, according to the American Academy of Otolaryngology-Head and Neck Surgery 9