Karl E. Misulis, MD, PhD
COMMON EVENTS
Neurologic complications in surgical patients can be directly related to surgery, indirectly related to hospitalization, or related to exacerbation of underlying medical conditions. In addition, trauma patients requiring surgery may have had neural trauma as a component of their injury that may not be recognized at intake.
Some of the neurologic scenarios unrelated to surgical specialty are:
Encephalopathy and delirium develop commonly especially in elderly patients and patients with pre-existing medical conditions who are hospitalized. This is commonly exacerbated by effects of sedative/hypnotics, sleep deprivation, protein-calorie deficit, and any of a host of other medications including antibiotics. Hospital delirium is further discussed in Chapter 18.
Stroke in the peri-operative period is most commonly ischemic but can be hemorrhagic.
•Ischemic stroke can be related to being off antithrombotics for surgery, right-to-left shunt, hypercoagulable state related to a medical condition, or systemic hypotension producing watershed infarction.
•Hemorrhagic stroke is more likely in patients who had transient or sustained hypertension and in patients who are or had recently been anticoagulated or had been on antiplatelet agents.
Seizure is a common cause for hospital neurology consultation. In the peri-operative state, conditions predisposing to seizure include metabolic disturbance with electrolyte, renal, or hepatic dysfunction; medications, including select antibiotics; withdrawal state; stroke (ischemic or hemorrhagic); and in patients with known seizure disorder missing meds.
Withdrawal state with encephalopathy or seizures can develop when a patient admitted for surgery is abruptly withdrawn from agents such as ethanol or opiates. If regular use is known, precautions can be taken, but often the history of use or abuse is not revealed. Less common withdrawal events can be from dopaminergic agents such as those used for Parkinson disease.
SURGERY
Nerve Injuries
Direct surgical injuries to peripheral nerves are uncommon but do occur. Decreased sensation after abdominal or chest or breast surgeries is expected. Neuropathic pain can be an associated problem, although the duration is usually limited. Prognosis depends on the type of injury, whether stretch, crush, or cut. Crush injuries can be from hemostats or retractors intraoperatively or from positioning of the limb (e.g., ulnar or peroneal compression).
PRESENTATION can be with any combination of pain, motor, and sensory deficit in the distribution of the affected nerve.
DIAGNOSIS is usually evident immediately with acute intraoperative trauma. Crush injuries may not be appreciated immediately and, because of symptoms related to the postoperative course, might not be noticed for a few days following surgery.
MANAGEMENT depends on the type of injury. Transection of the nerve warrants consideration of epineurial repair. Partial transections might be amenable to fascicular anastomosis depending on size and anatomy. Stretch and crush injuries leave the epineurium intact.
Orthopedic Surgery
Shoulder surgery has been described as producing damage to the suprascapular, axillary, or musculocutaneous nerves. Incidence is usually far less than 5%.1
Spine surgery of a variety of types has been associated with a variety of deficits, some due to mechanical damage to the spinal cord. Scoliosis surgery has a small risk of nerve damage.
Hip surgery can be associated with neural injury that is usually transient, just as dislocation can produce neural manifestations. The peroneal division of the sciatic nerve is most commonly affected.2
Long bone fracture and surgery may result in fat embolism, which can present neurologically as delirium progressing to coma. Seizures can occur. Associated symptoms are dyspnea and often petechiae.
Cardiovascular Surgery
Cardiovascular surgery has the principal complications of stroke and hypoxic encephalopathy.
Stroke can be ischemic or hemorrhagic. Ischemic stroke is likely from proximal emboli or from hypotension producing watershed infarction. Hemorrhage is usually related to present or recent anticoagulation or an epoch of hypertension.
Hypoxic encephalopathy can occur after an episode of cardiac arrest prior or subsequent to cardiac surgery. A nontrivial episode of hypotension can produce hypoxic encephalopathy or cause watershed infarction.
Seizure in the peri-operative period raises concern over cerebral infarct or hemorrhage. Acquired CNS infection during hospitalization is rare. However, if the patient has cardiac infection, cerebral abscess can develop.
Trauma
Trauma patients have numerous potential reasons for neurologic consultation. Among the most common are:
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