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Electrocardiographic changes after cervical laminectomy
International Journal of Cardiology, 1 (1981) 37-40 Elsevier/North-Holland Biomedical Press
37
Electrocardiographic changes after cervical laminectomy Hans R. Baur, Fredarick L. Gobel and Claus A. Pierach University of Minnesota
Medical Unit, Abbott-Northwestern Hospital, 2727 Chicago Avenue, Minneapolis, MN 55407, U.S.A.
Received
12 August
1980; accepted
after revision
17 March
Baur HB, Gobel FL, Pierach CA. Electrocardiographic laminectomy. Int J Cardiol 1981; 1: 37-40.
1981
changes
after
cervical
Striking T-wave inversions were observed in the postoperative electrocardiograms of a 64-yr-old woman following an extensive cervical laminectomy. Except for the presence of a trace amount of CK-MB in a single serum specimen all her enzyme and isoenzyme studies were negative, and her clinical course was not suggestive of myocardial ischemia. Coronary angiography, including an ergonovine study, done 6 mth following the laminectomy were normal. Because of the nature of this patient’s surgery and the paucity of evidence for the presence of organic heart disease a neurogenic origin of these T-wave changes is suspected. neurogenic T-wave changes
Introduction
Changes in cardiac repolarization have been reported in association with various central nervous system disorders [ 11,radical neck dissection [2], manipulation of the stellate ganglia [3], and carotid endarterectomy [4]. These changes are thought to be of neurogenic origin and are probably related to a change in the cardiovascular sympathetic activity leading to an altered temporal and spatial recovery process of the myocardium [ 11. The recent observation of similar electrocardiographic changes following cervical laminectomy serves as the subject of this report.
Reprint requests and correspondence
0167-5273/81/@400-0000/$02.50
to: Claus A. Pierach,
MD.
0 1981 Elsevier/North-Holland
Biomedical
Press
38
Case report A 64-yr-old
foramenotomy,
woman underwent an extensive decompressive laminectomy and involving the 3rd through 7th cervical vertebra, to alleviate severe
Fig. I. Electrocardiogram before (A), I day after(B), and 6 mth after (C) cervical laminectomy. (A) Heart rate 63/min; QT interval 44 msec. (B) Heart rate 80/min; QT interval 44 msec. (C) Heart rate 62/min; QT interval 42 msec.
39
neck and left arm pain associated with neurological changes felt to be due to cervical spondylosis. She had no history of heart disease, but risk factors for coronary artery disease included cigarette smoking, hypertension (well-controlled), and a serum cholesterol of 272 mg/lOO ml. Surgery and anesthesia were uneventful. Her postoperative course was unremarkable except for the presence of a sharp, continuous pain in the left axilla with radiation to the left arm and sternum beginning the day after surgery. This pain was accentuated with deep inspiration and was not relieved with nitroglycerin. Diffuse precordial tenderness was present. A short, grade 2/6 early systolic murmur was audible along the left sternal border, and this finding was unchanged from the preoperative examination. There were no extracardiac sounds. The electrocardiogram recorded during this episode of pain was markedly changed when compared to the preoperative tracing. These changes were consistent with the diagnosis of subendocardial ischemia and/or acute myocardial infarction (Fig. 1). There was no evidence for sympathetic disturbance, and, except for meperidine. no medications were given in the immediate postoperative period. The patient was transferred to the coronary care unit. The pain subsided after 25 mg of meperidine was given intravenously, but reappeared for short periods the next day. Serial determinations of serum enzyme activities are depicted in Table I. (Creatine kinase[CK]-MB was determined by the electrophoretic technique.) Serum electrolytes were normal. No further episodes of pain occurred, and the patient was discharged the 12th postoperative day. The repolarization changes in the electrocardiogram remained stable throughout the hospitalization, and gradually disappeared during the following months. However, mild non-specific T-wave changes persisted (Fig. 1). During the next half year, the pain recurred several times, occasionally lasting more than 30 min. It was not related to exercise, and no further electrocardiographic changes were noted during these episodes. The response to nitroglycerin was variable. Because of the recurrent symptoms, left ventriculography and coronary arteriography were performed before and following 0.3 mg of ergonovine maleate. This study demonstrated neither organic nor dynamic obstruction of the coronary arteries. The left ventriculogram revealed normal contractility, a trace of mitral regurgitation, but no mitral valve prolapse.
TABLE
I
Enzyme
data.
Date
CK-MB
14 July 1978 18 July 1978
Cervical
19 July 1978 20 July 1978 21 July 1978
552 362 24
SGOT
LDH
LDHI
LDH2
w/u
W/l)
wJ/l)
@J/I)
41
187
43 38 26
189
50
65
227
58
77
laminectomy trace neg neg
Discussion
To our knowledge, an association between cervical laminectomy and repolarization changes in the electrocardiogram has not been reported. Because of the paucity of evidence for the existence of organic heart disease in this patient, we feel that the electrocardiographic changes are of neurogenic origin. It is unlikely that coronary spasm with subsequent myocardial ischemia was responsible for the T-wave changes in view of the negative ergonovine study, although this possibility cannot be excluded completely. Elevation of the total creatine kinase (CK) in the postoperative period was likely from skeletal muscle secondary to the laminectomy. The presence of a trace amount of CK-MB, as measured by the electrophoretic technique, has been noted in association with large amounts of CK-MM, and it does not necessarily indicate that myocardial necrosis had occurred. Small amounts of the MB fraction of creature kinase have been found in skeletal muscle by the electrophoretic technique, in contrast to results obtained by column chromatography where no CK-MB activity of skeletal muscle can be demonstrated [5]. On the other hand, the occurrence of myocardial necrosis cannot be entirely excluded as neurogenic electrocardiographic changes have been occasionally associated with scattered areas of hemorrhage in the myocardium [6]. High and extensive cervical dissection associated with the laminectomy may have irritated the glossopharyn@‘and vagal nerve in this patient and initiated changes in the carotid sinus reflex. I$ is conceivable that those reflex changes influenced the outflow balance of the autonomic nervous system activity and thus the same mechanism producing ECG changes after bilateral carotid endarterectomy [4] and carotid sinus denervation [7] may have been responsible for the cardiac repolarization changes observed in this patient.
References 1 Abildskov JA, Millar K, Burgess MJ, Vincent W. The electrocardiogram and the central nervous system. Progr Cardiovas Dis 1970; 13: 210. 2 Hugenholtz PG. Electrocardiographic changes typical for central nervous system disease after right radical neck dissection. Am Heart J 1967; 74: 438. 3 Yanowitz F, Preston JB, Abildskov JA. Functional distribution of right and left stellate innervation to the ventricles: production of neurogenic electrocardiographic changes by unilateral alteration of sympathetic tone. Circ Res 1966; 18: 416. 4 Baur HR, Pierach CA. Electrocardiographic changes after bilateral carotid endarterectomy. New Engl J Med 1974; 291: 1121. 5 Roberts R, Sobel BE. Fundamentals of clinical cardiology: creatine kinase isoenzymes in the assessment of heart disease. Am Heart J 1978; 95: 521. 6 Greenhoot JH, Reichenbach DD. Cardiac injury and subarachnoid hemorrhage: a clinical, pathological, and physiological correlation. J Neurosurg 1969; 30: 521. 7 Baur HR, Pierach CA. Electrocardiographic changes after bilateral carotid sinus denervation in the rat. Am J Physiol 1979; 237: H 475.
37
Electrocardiographic changes after cervical laminectomy Hans R. Baur, Fredarick L. Gobel and Claus A. Pierach University of Minnesota
Medical Unit, Abbott-Northwestern Hospital, 2727 Chicago Avenue, Minneapolis, MN 55407, U.S.A.
Received
12 August
1980; accepted
after revision
17 March
Baur HB, Gobel FL, Pierach CA. Electrocardiographic laminectomy. Int J Cardiol 1981; 1: 37-40.
1981
changes
after
cervical
Striking T-wave inversions were observed in the postoperative electrocardiograms of a 64-yr-old woman following an extensive cervical laminectomy. Except for the presence of a trace amount of CK-MB in a single serum specimen all her enzyme and isoenzyme studies were negative, and her clinical course was not suggestive of myocardial ischemia. Coronary angiography, including an ergonovine study, done 6 mth following the laminectomy were normal. Because of the nature of this patient’s surgery and the paucity of evidence for the presence of organic heart disease a neurogenic origin of these T-wave changes is suspected. neurogenic T-wave changes
Introduction
Changes in cardiac repolarization have been reported in association with various central nervous system disorders [ 11,radical neck dissection [2], manipulation of the stellate ganglia [3], and carotid endarterectomy [4]. These changes are thought to be of neurogenic origin and are probably related to a change in the cardiovascular sympathetic activity leading to an altered temporal and spatial recovery process of the myocardium [ 11. The recent observation of similar electrocardiographic changes following cervical laminectomy serves as the subject of this report.
Reprint requests and correspondence
0167-5273/81/@400-0000/$02.50
to: Claus A. Pierach,
MD.
0 1981 Elsevier/North-Holland
Biomedical
Press
38
Case report A 64-yr-old
foramenotomy,
woman underwent an extensive decompressive laminectomy and involving the 3rd through 7th cervical vertebra, to alleviate severe
Fig. I. Electrocardiogram before (A), I day after(B), and 6 mth after (C) cervical laminectomy. (A) Heart rate 63/min; QT interval 44 msec. (B) Heart rate 80/min; QT interval 44 msec. (C) Heart rate 62/min; QT interval 42 msec.
39
neck and left arm pain associated with neurological changes felt to be due to cervical spondylosis. She had no history of heart disease, but risk factors for coronary artery disease included cigarette smoking, hypertension (well-controlled), and a serum cholesterol of 272 mg/lOO ml. Surgery and anesthesia were uneventful. Her postoperative course was unremarkable except for the presence of a sharp, continuous pain in the left axilla with radiation to the left arm and sternum beginning the day after surgery. This pain was accentuated with deep inspiration and was not relieved with nitroglycerin. Diffuse precordial tenderness was present. A short, grade 2/6 early systolic murmur was audible along the left sternal border, and this finding was unchanged from the preoperative examination. There were no extracardiac sounds. The electrocardiogram recorded during this episode of pain was markedly changed when compared to the preoperative tracing. These changes were consistent with the diagnosis of subendocardial ischemia and/or acute myocardial infarction (Fig. 1). There was no evidence for sympathetic disturbance, and, except for meperidine. no medications were given in the immediate postoperative period. The patient was transferred to the coronary care unit. The pain subsided after 25 mg of meperidine was given intravenously, but reappeared for short periods the next day. Serial determinations of serum enzyme activities are depicted in Table I. (Creatine kinase[CK]-MB was determined by the electrophoretic technique.) Serum electrolytes were normal. No further episodes of pain occurred, and the patient was discharged the 12th postoperative day. The repolarization changes in the electrocardiogram remained stable throughout the hospitalization, and gradually disappeared during the following months. However, mild non-specific T-wave changes persisted (Fig. 1). During the next half year, the pain recurred several times, occasionally lasting more than 30 min. It was not related to exercise, and no further electrocardiographic changes were noted during these episodes. The response to nitroglycerin was variable. Because of the recurrent symptoms, left ventriculography and coronary arteriography were performed before and following 0.3 mg of ergonovine maleate. This study demonstrated neither organic nor dynamic obstruction of the coronary arteries. The left ventriculogram revealed normal contractility, a trace of mitral regurgitation, but no mitral valve prolapse.
TABLE
I
Enzyme
data.
Date
CK-MB
14 July 1978 18 July 1978
Cervical
19 July 1978 20 July 1978 21 July 1978
552 362 24
SGOT
LDH
LDHI
LDH2
w/u
W/l)
wJ/l)
@J/I)
41
187
43 38 26
189
50
65
227
58
77
laminectomy trace neg neg
Discussion
To our knowledge, an association between cervical laminectomy and repolarization changes in the electrocardiogram has not been reported. Because of the paucity of evidence for the existence of organic heart disease in this patient, we feel that the electrocardiographic changes are of neurogenic origin. It is unlikely that coronary spasm with subsequent myocardial ischemia was responsible for the T-wave changes in view of the negative ergonovine study, although this possibility cannot be excluded completely. Elevation of the total creatine kinase (CK) in the postoperative period was likely from skeletal muscle secondary to the laminectomy. The presence of a trace amount of CK-MB, as measured by the electrophoretic technique, has been noted in association with large amounts of CK-MM, and it does not necessarily indicate that myocardial necrosis had occurred. Small amounts of the MB fraction of creature kinase have been found in skeletal muscle by the electrophoretic technique, in contrast to results obtained by column chromatography where no CK-MB activity of skeletal muscle can be demonstrated [5]. On the other hand, the occurrence of myocardial necrosis cannot be entirely excluded as neurogenic electrocardiographic changes have been occasionally associated with scattered areas of hemorrhage in the myocardium [6]. High and extensive cervical dissection associated with the laminectomy may have irritated the glossopharyn@‘and vagal nerve in this patient and initiated changes in the carotid sinus reflex. I$ is conceivable that those reflex changes influenced the outflow balance of the autonomic nervous system activity and thus the same mechanism producing ECG changes after bilateral carotid endarterectomy [4] and carotid sinus denervation [7] may have been responsible for the cardiac repolarization changes observed in this patient.
References 1 Abildskov JA, Millar K, Burgess MJ, Vincent W. The electrocardiogram and the central nervous system. Progr Cardiovas Dis 1970; 13: 210. 2 Hugenholtz PG. Electrocardiographic changes typical for central nervous system disease after right radical neck dissection. Am Heart J 1967; 74: 438. 3 Yanowitz F, Preston JB, Abildskov JA. Functional distribution of right and left stellate innervation to the ventricles: production of neurogenic electrocardiographic changes by unilateral alteration of sympathetic tone. Circ Res 1966; 18: 416. 4 Baur HR, Pierach CA. Electrocardiographic changes after bilateral carotid endarterectomy. New Engl J Med 1974; 291: 1121. 5 Roberts R, Sobel BE. Fundamentals of clinical cardiology: creatine kinase isoenzymes in the assessment of heart disease. Am Heart J 1978; 95: 521. 6 Greenhoot JH, Reichenbach DD. Cardiac injury and subarachnoid hemorrhage: a clinical, pathological, and physiological correlation. J Neurosurg 1969; 30: 521. 7 Baur HR, Pierach CA. Electrocardiographic changes after bilateral carotid sinus denervation in the rat. Am J Physiol 1979; 237: H 475.