title: Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity.
abstract: OBJECTIVE
  Paraplegia after thoracoabdominal aneurysm (TAA) repair has been associated with poor survival. Little information exists concerning the spectrum of severity that characterizes spinal cord ischemic (SCI) complications. This study stratified SCI by deficit severity to determine its impact on late survival and functional outcomes.
  
  
  METHODS
  A review of our prospectively maintained thoracic aortic database was performed from May 1987 through December 2005 to identify patients who experienced SCI of any extent after TAA repair. During this period, 576 patients underwent descending thoracic aortic repair (93 open, 105 endovascular [TEVAR]) or open TAA repair (279 extent I to III; 99 extent IV). To stratify severity of SCI, we created a spinal cord ischemia deficit (SCID) scale, which is defined as: I, flaccid paralysis; II, average neurologic muscle grade indicating <50% function; and III, average neurologic muscle grade indicating >50% function. Long-term outcomes were evaluated in relation to these groups by actuarial methods.
  
  
  RESULTS
  During the study period, 64 (11.1%) patients developed SCI of any severity (7 of 105 [6.6%] TEVAR, 57 of 471 [12%] open). These were stratified by SCID level: I, 24 (37.5%); II, 31 (48.4%); and III, 9 (14.1%). SCI was immediate in 33 (54.1%) and delayed in 28 (45.9%). Most SCI (6 of 7) associated with TEVAR was delayed. The 30-day mortality was significantly higher in the SCI group than the overall patient cohort (15 of 64 [23.4%] vs 41 of 512 [8%], P < .001) and varied by SCID level: I, 11 of 24 (45.8%); II, 4 of 31 (12.9%); and III, 0 of 9 (0%; P = .001). The 5-year actuarial survival for all SCI was lower than for non-SCI patients (25% +/- 6% vs 51% +/- 3%, P < .001) and varied linearly with SCID level but was similar between SCID II/III and the non-SCI patients (41% +/- 10% vs 51% +/- 3%, P = .281). No SCID I patients were alive at 5 years. No patients with SCID I recovered the ability to walk, but eight of 11 (73%) with SCID II and the nine (100%) with SCID III could ambulate with or without assistance at last follow-up.
  
  
  CONCLUSIONS
  Survival and functional outcomes correlate with SCI severity. Patients with SCID I have a poor long-term outlook. Survival of SCID II/III patients is similar to non-SCI patients; most recover the ability to ambulate.
authors.affiliation: Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA. mconrad@partners.org
authors.forename: Mark F
authors.initials: MF
authors.lastname: Conrad
authors.forename: Jason Y
authors.initials: JY
authors.lastname: Ye
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Chung
authors.forename: J Kenneth
authors.initials: JK
authors.lastname: Davison
authors.forename: Richard P
authors.initials: RP
authors.lastname: Cambria
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology* / Q000401:mortality; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010264:Paraplegia / Q000209:etiology / Q000401:mortality; D011183:Postoperative Complications / Q000401:mortality; D018570:Risk Assessment; D013116:Spinal Cord / Q000098:blood supply*; D016019:Survival Analysis; D016896:Treatment Outcome