Hemodynamic Neuromonitoring, a Proposed Spino-Cardiac Protective Reflex: Prospective Study in 200 Patients of Lumbar Surgery

Volume 2 | Issue 2 | October 2021-March 2022 | page: 71-78 | Ajay Krishnan, Devanand Degulmadi, Ravi Ranjan, Shivanand Mayi, Namit Nitherwal, Lingraj Reddy, Ankur Patel, Iboyama Singh, Mirant Dave, Kashyap R Shah, Paresh A Mehta, Shaunak Dudhia, Bharat R Dave

DOI: 10.13107/bbj.2022.v02i02.024

Authors: Ajay Krishnan [1], Devanand Degulmadi [1], Ravi Ranjan [1], Shivanand Mayi [1], Namit Nitherwal [1], Lingraj Reddy [1], Ankur Patel [1], Iboyama Singh [1], Mirant Dave [1], Kashyap R Shah [2], Paresh A Mehta [3], Shaunak Dudhia [3], Bharat R Dave [1]

[1] Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Mithakali, Ahmedabad, Gujarat, India.
[2] Department of Medicine, Stavya Spine Hospital and Research Institute, Mithakali, Ahmedabad, Gujarat, India.
[3] Department of Anaesthesia, Stavya Spine Hospital and Research Institute, Mithakali, Ahmedabad, Gujarat, India.

Address of Correspondence
Dr. Ajay Krishnan,
Consultant spine surgeon, Stavya Spine Hospital and Research Institute, Mithakali, Ahmedabad , Gujarat, India.


Background: Parasympathomimetic reflexes are reported in literature in spine surgery. Our primary hypothesis is proposed that nociceptive stimuli can be elicited by various maneuvers of lumbar spinal surgery and the physiological manifestation depends on many patient variables and anesthesia. However, a sympathomimetic pathological response is indicative of potential neural damages, which may or may not be reversible. A spino-cardiac protective reflex (SPR), as a new entity for lumbar spinal surgery, is proposed.
Study Design: This was a prospective single institution.
Materials and Methods: All the patients who were undergoing single motion segment transforaminal lumbar interbody fusion (TLIF) in our institute for lumbar disc herniation or non-discogenic lumbar stenosis lumbar spinal stenosis were included who fitted into inclusion criteria till 200 subjects were recruited. Patients’ pertinent vital data were collected at clinical first pre-operative visit and preoperatively on admission. The intraoperative parameters were recorded: Pre-induction, post-induction, post-positioning, before skin incision, after skin/subcutaneous exposure, pre-screw insertion, after screw insertion, after rod connection and distraction, during central decompression-laminotomy/laminectomy, during lateral recess decompression, discectomy, and segmental compression. Significant pulse rate (PR) and mean arterial pressure (MAP) changes were monitored and correlated.
Results: In the enrolled 200 patients, the change in mean MAP and PR changes in varying steps of TLIF was not significant. The positivity of a significant change in MAP and PR correlating with an evident manipulative/pathological-demographic cause was noted (plausibility), which could revert back to baseline (reversibility) after addressing the culprit in 22 cases. Non-correlating raise was also noted in 35 cases.
Conclusion: Spino-protective reflex exists like any reflex in body. Prospective study on huge database needs to be done to validate these observations. However, this study does make the surgeon think for finding clues to neurological damage or left out residual compressions which can be identified and rectified in real time in many cases. INOM is the standard of care and SPR should be compared with intraoperative neuromonitoring to identify sensitivity and threshold of pathological response in future studies.
Keywords: Lumbar, Protective, Reflex, Spine, Sympathomimetic, Transforaminal lumbar interbody fusion


1. Chowdhury T, Petropolis A, Cappellani RB. Cardiac emergencies in neurosurgical patients. BioMed Res Int 2015;2015:751320.
2. Chowdhury T, Schaller B. The negative chronotropic effect during lumbar spine surgery. Medicine 2017;96:e5436.
3. Doyle DJ, Mark PW. Reflex bradycardia during surgery. Can J Anaesth 1990;37:219-22.
4. Hainsworth R. Reflexes from the heart. Physiol Rev 1991;71:617-58.
5. Matsumura K, Miura K, Takata Y, Kurokawa H, Kajiyama M, Abe I, et al. Changes in blood pressure and heart rate variability during dental surgery. Am J Hypertens 1998;11:1376-80.
6. Deschamps A, Carvalho G. Lumbo-sacral spine surgery and severe bradycardia (Letter). Can J Anesth 2004;51:277.
7. Mandal N. More on lumbo-sacral spine surgery and bradycardia (Letter). Can J Anaesth 2004;51:942.
8. Dooney N. Prone CPR for transient asystole during lumbosacral spinal surgery. Anaesth Intensive Care 2010;38:212-3.
9. Chowdhury T, Sapra H, Dubey S. Severe hypotension in transforaminal lumbar interbody fusion surgery: Is it vasovagal or? Asian J Neurosurg 2017;12:149-50.
10. Chowdhury T, Narayanasamy S, Dube SK, Rath GP. Acute hemodynamic disturbances during lumbar spine surgery. J Neurosurg Anesthesiol 2012;24:80-1.
11. Nash CL Jr., Lorig RA, Schatzinger LA, Brown RH. Spinal cord monitoring during operative treatment of the spine. Clin Orthop Relat Res 1977;126:100-5.
12. Devlin VJ, Schwartz DM. Intraoperative neurophysiologic monitoring during spinal surgery. J Am Acad Orthop Surg 2007;15:549-60.
13. Mysliwiec LW, Cholewicki J, Winkelpleck MD, Eis GP. MSU classification for herniated lumbar discs on MRI: Toward developing objective criteria for surgical selection. Eur Spine J 2010;19:1087-93.
14. Schizas C, Theumann N, Burn A, Tansey R, Wardlaw D, Smith FW, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine (Phila Pa 1976) 2010;35:1919-24.
15. UK National Institute for Health and Care Excellence. Low Back Pain and Sciatica in Over 16s: Assessment and Management; 2016. Available from: [Last accessed on 2017 Nov 07].
16. Swift A. Understanding pain and the human body’s response to it. Nurs Times 2018;114:22-6.
17. Ditunno JF, Little JW, Tessler A, Burns AS. Spinal shock revisited: A four-phase model. Spinal Cord 2004;42:383-95.
18. Krassioukov A. Autonomic function following cervical spinal cord injury. Respir Physiol Neurobiol 2009;169:157-64.
19. Wallin BG, Stjernberg L. Sympathetic activity in man after spinal cord injury. Brain 1984;107:183-98.
20. Krassioukov A, Warburton DE, Teasell R, Eng JJ. Spinal cord injury rehabilitation evidence research team. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil 2009;90:682-95.
21. Karlsson AK Autonomic dysreflexia. Spinal Cord 1999;37:383-91.
22. Groen GJ, Baljet B, Drukker J. The innervation of the spinal dura mater: Anatomy and clinical implications. Acta Neurochirur 1988;92:39-46.
23. Bogduk N. The innervation of the lumbar spine. Spine 1983;8:286-93.
24. Bridge CJ. Innervation of spinal meninges and epidural structures. Anat Gec 1959;133:553-61.
25. Pedersen HE, Blunck CF, Gardner E. The anatomy of lumbosacral posterior rami and meningeal branches of spinal nerves (sinu-vertebral nerves). J Bone Joint Surg 1956;38:377-91.
26. Stilwell DL. The nerve supply of the vertebral column and its associated structures in the monkey. Anat Rec 1956;125:139-169.
27. Meglio M, Cioni B, Dei Lago A, De Santis M, Pola P, Serrichio M. Pain control and improvement of peripheral blood flow following spinal cord stimulation. J Neurosurg 1981;54:821-3.
28. Musizza B, Ribaric S. Monitoring the depth of anaesthesia. Sensors 2010;10:10896-935.
29. Kaul H, Bharti N. Monitoring the depth of anaesthesia. Indian J Anaesth 2002;46:323-32.
30. Wiedemayer H, Sandalcioglu IE, Armbruster W, Regel J, Schaefer H, Stolke D. False negative findings in intraoperative SEP monitoring: Analysis of 658 consecutive neurosurgical cases and review of published reports. J Neurol Neurosurg Psychiatry 2004;75:280-6.
31. Cole T, Veeravagu A, Zhang M, Li A, Ratliff JK. Intraoperative neuromonitoring in single-level spinal procedures. Spine 2014;39:1950-9.
32. Prys-Roberts C. Anaesthesia: A practical or impossible construct (editorial). Br J Anaesth 1987;59:1341.
33. Poon KS, Wu KC, Chen CC, Fung ST, Lau AW, Huang CC, et al. Hemodynamic changes during spinal surgery in the prone position. Acta Anaesthesiol Taiwan 2008;46:57-60.
34. Savitha KS, Dhanpal R, Vikram MS. Hemodynamic responses at intubation, change of position, and skin incision: A comparison of multimodal analgesia with conventional analgesic regime. Anaesth Essays Res 2017;11:314-20.
35. Gruenewald M, Ilies C. Monitoring the nociception-anti-nociception balance. Best Pract Res Clin Anaesthesiol 2013;27:235-47.
36. Hu HT, Ren L, Sun XZ, Liu FY, Yu JH, Gu ZF. Contralateral radiculopathy after transforaminal lumbar interbody fusion in the treatment of lumbar degenerative diseases: A case series. Medicine (Baltimore) 2018;97:e0469.
37. Jang KM, Park SW, Kim YB, Park YS, Nam TK, Lee YS. Acute contralateral radiculopathy after unilateral transforaminal lumbar interbody fusion. J Korean Neurosurg Soc 2015;58:350-6.
38. Bärlocher CB, Krauss JK, Seiler RW. Central lumbar disc herniation. Acta Neurochir (Wien) 2000;142:1369-74.
39. Choi JW, Lee JK, Moon KS, Hur H, Kim YS, Kim SH. Transdural approach for calcified central disc herniations of the upper lumbar spine. J Neurosurg Spine 2007;7:370-4.
40. Kim DS, Lee JK, Jang JW, Ko BS, Lee JH, Kim SH. Clinical features and treatments of upper lumbar disc herniations. J Korean Neurosurg Soc 2010;48:119-24.
41. Podnar S. Cauda equina lesions as a complication of spinal surgery. Eur Spine J 2010;19:451-7.
42. Raw DA, Beattie JK, Hunter JM. Anaesthesia for spinal surgery in adults. Br J Anaesth 200391:886-904.
43. Schnider TW, Minto CF, Struys MM, Absalom AR. The safety of target-controlled infusions. Anesth Analg 2016;122:79-85.
44. Mahajan S, Swami AC, Kumar A. Cardiovascular changes and lumbar spine surgery: A neglected entity. Asian J Neurosurg 2019;14:1253-5.
45. Chavali S, Das K, Sokhal S, Rath GP. Reflex bradycardia due to traction on filum terminale during detethering of spinal cord. Neurol India 2019;67:889-90.
46. Marie JR, Jennifer S, Alexander PH, Andrew AS, Ronald GE, Carrie G, et al. Hemodynamically significant cardiac arrhythmias during general anesthesia for spine surgery: A case series and literature review. N Am Spine Soc J 2020;2:100010.
47. Morano JM, Tung A. Bradycardic arrest during somatosensory-evoked potential monitoring. A A Pract 2019;13:461-3.

How to Cite this Article: Krishnan A, Degulmadi D, Ranjan R, Mayi S, Nitherwal N, Reddy L, Patel A, Singh I, Dave M, Shah KR, Mehta PA, Dudhia S, Dave BR Hemodynamic | Neuromonitoring, a Proposed Spino- Cardiac Protective Reflex: Prospective Study in 200 Patients of Lumbar Surgery | Back Bone: The Spine Journal | October 2021-March 2022; 2(2): 71-78.

(Abstract Text HTML)      (Download PDF)