Open Journal of Orthopedics, 2013, 3, 204-207
http://dx.doi.org/10.4236/ojo.2013.34037 Published Online August 2013 (http://www.scirp.org/journal/ojo)
Cerebral Infarction after Spine Surgery: Report of Two
Cases*
Katsunori Fukutake, Hiroshi Takahashi, Yuichiro Yokoyma, Yasuaki Iida, Ryo Takamatsu,
Kazumasa Na kamura, Akihito Wada
Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan.
Received June 13th, 2013; revised July 13th, 2013; accepted July 20th, 2013
Copyright © 2013 Katsunori Fukutake et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
There has been an increase in spinal surgery for the elderly, with a corresponding potential increase in perioperative
complications. In our department, 1833 patients underwent spinal surgery under general anesthesia from April 2001 to
October 2012, and 2 of 260 patients aged ≥75 years old had postoperative cerebral infarction. An analysis of the patho-
genic mechanism and potential risk factors showed that a history of cerebral infarction was a significant risk factor.
Blood pressure rapidly increased on arousal from anesthesia, and particularly on extubation. The change in blood pres-
sure was examined as a potential risk factor for cerebral infarction, but no significant relationship was observed. This
result requires further examination in more patients with cerebral infarction after spinal surgery.
Keywords: Cerebral infarction; Spine surgery; Complication
1. Introduction
Surgeries in elderly patients have increased with aging of
the population. Many elderly patients have comorbidity
such as hypertension and diabetes. Here, we report two
cases of elderly patients who developed cerebral infarc-
tion after surgery, for which we examined the pathogenic
mechanism and risk factors.
2. Materials and Methods
Postoperative cerebral infarction occurred in 2 of 1833
patients who underwent spinal surgery under general
anesthesia in our department between April 2001 and
October 2012. The two patients were aged 76 and 83
years old. No perioperative cerebral infarction was found
in patients aged less than 75 years old. Therefore, the
pathogenic mechanism and risk factors for postoperative
cerebral infarction were examined in 260 patients aged
≥75 years old. The 260 patients had a mean age of 78.9
years old, BMI 23.9, mean surgical time 174.8 min, and
mean blood loss 316.1 g. There were histories of hyper-
tension in 108 patients, diabetes in 39, cerebrovascular
disorder in 21 and ischemic cardiac disease in 18 (Table
1).
Multivariate analysis was conducted using age at sur-
gery, sex, BMI, history of hypertension, diabetes, cere-
brovascular disease and ischemic cardiac disease, surgi-
cal time, bleeding volume, and ratio of the systolic blood
pressure preoperatively and at extubation. Preoperative
systolic blood pressure was defined as the maximum
blood pressure on rising after admission and systolic
blood pressure on extubation as the maximum of sequen-
tial measurements of blood pressure.
Table 1. Baseline characteristics of the patoents (n = 260).
Characteristic
 Age (years old) 78.9 ± 3.3
 BMI (kg/m2) 23.8 ± 4.0
 Surgical time (min) 147.8 ± 81.0
 Blood loss (g) 316.1 ± 704.7
(mean ± SD)
 Comorbidity
Hypertension 108
Diabetes 39
Cerebrovascular disorder 21
Ischemic cardiac disease 17
*Sources of support: None,
Conflict of interest: None.

Cerebral Infarction after Spine Surgery: Report of Two Cases
205
Multiple regression, multiple logistic regression and
discriminant analyses were performed. The multiple lo-
gistic regression analysis was performed with binary
variables established using a cut-off value (Table 2).
Analyses were conducted using EXCEL Statistics (Social
Survey Research Information Co., Ltd., Tokyo, Japan)
for multiple logistic and multiple regression analyses and
SPSS (IBM SPSS Statistics version 19, IBM Japan Ltd.,
Tokyo, Japan) for discriminant analysis.
3. Case Report
Case 1: The patient was a 83-year old man with cervical
spondylotic myelopathy and lumbar spinal stenosis who
underwent simultaneous cervical and lumbar laminoplasty.
The surgical time was 290 min and the bleeding volume
was 295 g. He had a history of prostatic hyperplasia and
gastric ulcer. Blood pressure on rising on the operative
day was 134/74 mmHg and that on extubation was 184/
104 mmHg, giving a systolic blood pressure ratio (pre-
operative/extubation) of 0.73. Dysarthria occurred on
extubation and arousal from anesthesia. Brain MRI was
performed immediately and showed brainstem infarction,
for which neuroprotective drugs were administered. Re-
habilitation for swallowing was also started because dys-
phagia occurred. The symptoms gradually improved and
the patient had no disturbance of activities of daily living
(ADL) at about 6 months after surgery.
Case 2: The patient was a 76-year old man with cer-
vical spondylotic amyotrophy who underwent forami-
notomy. The surgical time was 132 min and the bleeding
volume was 130 g. He had a history of diabetes and ce-
rebrovascular disorder, but had not taken drugs for cere-
brovascular disorder. Blood pressure on rising on the
operative day was 132/62 mmHg and that on extubation
was 177/100 mmHg. The systolic blood pressure ratio
(preoperative/extubation) was 0.75. Marked dysarthria
was found in arousal from anesthesia. Brain MRI was
performed immediately and minor infarction was found
in the midbrain, for which neuroprotective drugs were
administered. The symptoms gradually improved and the
patient had no disturbance of ADL at about 6 months
after surgery.
Table 2. Binary variables.
 Age (0: <79 years old; 1≧ : 79 years old)
 BMI (0: <25; 1: ≧25)
 Systolic blood pressure ratio (on rising/on extubation)
(0: blood pressure ratio < ≧
0.8; 1: blood pressure ratio 0.8)
 Diastolic blood pressure ratio (on rising/on extubation)
(0: blood pressure ratio < 0.8; 1≧
: blood pressure ratio 0.8)
 Surgical time (0≧ : <150 min; 1: 150 min)
 Bleeding volume (0: <300 mL; 1≧
: 300 mL)
4. Results
Multiple regression analysis was conducted using the
stepwise selection method. Forward selection identified
sex, low systolic blood pressure ratio (preoperative/ex-
tubation), and a history of cerebrovascular disorder as
potentially important variables, but only a history of ce-
rebrovascular disorder was significant (p = 0.025) (Table
3). Backward elimination identified these variables and
surgical time, bleeding volume and history of hyperten-
sion, but similarly the only significant variable was a
history of cerebrovascular disorder (p = 0.021) (Table
4).
In multiple logistic regression analysis, the only sig-
nificant risk factor was a history of cerebrovascular dis-
order alone. In discriminant analysis, the 3 and 6 vari-
ables extracted in the respective multiple regression ana-
lyses were used for prognosis prediction. The predictive
value, sensitivity and specificity of the 3 variables were
lower than those of the 6 variables, indicating that the
latter were effective for prediction of prognosis (Table 5).
The findings were not significant because data were
available for only 2 subjects with postoperative cerebral
infarction, but these results support the findings from
multiple regression analysis.
5. Discussion
The incidence of cerebral infarction after spinal surgery
ranges from 0.3% to 1% [1,2]. In our department, 2 of
1833 patients (approx. 0.1%) developed cerebral infarc-
tion and the outcomes were better than those in previous
case reports. The results of the study indicate that a his-
tory of cerebral infarction posed a risk for perioperative
cerebral infarction, as also found in other case reports. A
history of transient ischemic attack (TIA) is also a risk
for perioperative cerebral infarction, and surgery 1 to 3
months after cerebral infarction should be avoided [3].
Continuous administration of anticoagulant and anti-
platelet drugs causes no serious hemorrhagic complica-
tion and decreases the risk for perioperative cerebral in-
farction [4]. However, in our department, drug admini-
stration is usually discontinued 1 to 2 weeks before sur-
gery and postoperative administration is resumed after
extubation. The two patients with cerebral infarction were
not given anticoagulant or antiplatelet drugs before sur-
gery. Therefore, this issue was not examined in this study,
but should be investigated in the future.
The onset of cerebral infarction was thought to have
occurred during surgery in both cases. In our hospital,
systolic blood pressure is controlled at ≤100 mmHg dur-
ing surgery when possible to prevent intraoperative
bleeding; however, a rapid increase in systolic blood
pressure on extubation occurs in all patients. Reduction
in perioperative variation of blood pressure decreases the

Cerebral Infarction after Spine Surgery: Report of Two Cases
206
Table 3. Forward se lection method.
Partial regression
coefficient
Standardized partial
regression coefficient T value P value decision
 Sex 0.0166 0.0948 1.5441 0.1238 NS
 Pre/postoperative blood pressure ratio −0.0597 −0.0931 −1.5175 0.1304 NS
 Cerebrovascular discorder 0.0442 0.1378 2.2456
0.0256 *
 Constant term 0.0467 1.3674 0.1727
Table 4. Backward elimination method.
Partial regression
coefficient
Standardized partial
regression coefficient T value P value decision
 Sex 0.0184 0.1049 1.7096 0.0886 NS
 Pre/postoperative blood pressure ratio −0.0600 −0.0935 −1.5307 0.1271 NS
 Operating time 0.0001 0.1008 1.6228 0.1059 NS
 Hypertension −0.0175 −0.0990 −1.5926 0.1125 NS
 Diabetes 0.0220 0.0898 1.4586 0.1459 NS
 Cerebrovascular discorder 0.0458 0.1429 2.3299
0.0206 *
 Constant term 0.0338 0.9597 0.3381
Table 5. Discriminant analysis by major 6 variables in the
backward selection incl uding pre/post operative blood pres-
sure ratio, operation time, hypertension, diabetes, cere-
brovascular disorder and 3 variables in the forward selec-
tion including sex, pre/post operative blood pressure ratio,
cerebrovascular disorder.
(a)
Postoperative onset
of cerebral infarction Actual result
no yes
no 235 0
Prediction by
major 6 variables yes 23 2
Predictive value: 91.2%.
(b)
Postoperative onset
of cerebral infarction Actual result
no yes
no 236 1
Prediction by
major 3 variables yes 22 1
Predictive value: 89.6%.
risk for cerebral infarction [5]; therefore, increased blood
pressure on extubation may be associated with the onset
of cerebral infarction. A significant relationship was not
found due to the small number of subjects in the study,
but the results suggested that increased blood pressure on
extubation influenced postoperative cerebral infarction.
Further studies in more patients with cerebral infarction
are required to examine this finding.
6. Summary
1) We experienced two patients who developed cere-
bral infarction after surgery and examined the pathogenic
mechanism and risk factors in these cases.
2) A history of cerebrovascular disorder posed a risk
of onset of cerebral infarction.
3) A rapid increase in systolic blood pressure on ex-
tubation was a possible risk factor for onset of postopera-
tive cerebral infarction.
REFERENCES
[1] K. Hayashi, K. Yone, S. Matsunaga, T. Lzumi, H. Shi-
mada and S. Komiya, “Neurological Complications in Cer-
vical Laminoplasty-Open Door vs. French Door Lamino-
plasty,” Orthopedics & Traumatology, Vol. 53, No. 1,
2004, pp. 88-90. doi:10.5035/nishiseisai.53.88
[2] T. Chikawa, T. Nakagaawa, S. Endo, M. Nakamura, S.
Nakano and T. Shimakawa, “Spinal Surgery in Elderly
Patient More than Eighty Years Old-Complications and
Surgical Results,” Journal of Spine Research, Vol. 3,
2012, pp. 812-818.
[3] J. L. Ng, M. T. Chan and A. W. Gelb, “Perioperative Stroke
in Noncardiac, Nonneurosurgical Surgery,” Anesthesio-
logy, Vol. 115, No. 4, 2011, pp. 879-890.
doi:10.1097/ALN.0b013e31822e9499
[4] H. Ohmiya, K. Okajima, Y. Abe, M. Tanoue, N. Mura-

Cerebral Infarction after Spine Surgery: Report of Two Cases
207
kami and S. Mori, “Anticoagulant during Perioperaive
Stage of Spiral Surgery,” Orthopedics & Traumatology,
Vol. 56, No. 2, 2007, pp. 214-216.
doi:10.5035/nishiseisai.56.214
[5] M. Selim, “Perioperative Stroke,” The New England
Journal of Medicine, Vol. 356, 2007, pp. 706-713.
doi:10.1056/NEJMra062668