Posterior biportal endoscopic cervical foraminotomy requires para median muscle splitting due to the absence of the lumbar “Son’s fat space” in the cervical spine. We propose a modified juxta-midline approach to create a subperiosteal corridor using incisions placed next to the spinous process and subperiosteal muscle stripping to create a continuous working space while avoiding muscle splitting or cutting. This modification reduces docking hemorrhage, optimizes fluid flow space, and simplifies fluoroscopy.
ABSTRACT Vasoplegia is a form of vasodilatory shock characterized by low systemic vascular resistance and severe hypotension with normal or high cardiac output that is unresponsive to volume resuscitation and conventional vasopressors. Its occurrence after major complex spine surgery has rarely been reported. Hypotension during complex spine surgery is associated with increased perioperative morbidity. This case series describes the management of refractory distributive shock of unknown cause in patients who underwent complex spine surgery. Three American Society of Anesthesiologists (ASA-1) patients underwent complex spine surgery involving spinal cord manipulation/retraction/stretching. All three patients encountered severe refractory hypotension toward the end of the surgery without any obvious causes of hypotension (hypovolemia, anaphylaxis, spinal shock, cardiogenic, embolic, or pneumothorax). All patients were treated with high doses of noradrenaline and vasopressin for 12-36 h after surgery. All patients had good neurological outcomes despite transient severe hypotension. Awareness of this entity helps anesthesiologists manage hypotension by early institution of nonconventional vasopressors (e.g., vasopressin) after ruling out other causes.
