Introduction show reduced spinal cord perfusion following crossclamping of the descending thoracic aorta or the Despite many protective measures during and after azygos vein. Drainage of spinal fluid during crosssurgery, the morbidity and mortality of thoraclamping increases microcirculatory perfusion of the coabdominal aortic aneurysm (TAAA) repair remains spinal cord. These experimental results were clinically a major concern. Spinal cord ischaemia and renal confirmed by combining cerebrospinal fluid drainage failure are the main complications besides myocardial and distal aortic perfusion, significantly reducing infarction, multiple organ failure, visceral ischaemia neurologic complications after repair of TAAA types and pulmonary problems. The first Nordic workshop I and II. Thus, CSF drainage is now regarded as an of TAAAs was organised in 1992 and it was then important adjunct. There was no dissent from the generally agreed that the surgical method of choice was requirement for continuous CSF drainage to maintain the Crawford technique with direct cross-clamping. a pressure of less than 10 mmHg. There was agreement During the last 5 years, however, different techniques that a CSF pressure exceeding 30 mmHg was ashave been developed and the aim of the second worksociated with paraplegia. Nevertheless, it was reshop was to evaluate progress in experimental and cognised that CSF drainage alone does not prevent all clinical research and to discuss the potential benefits ischaemic events of the spinal cord. for the patient. Although a short clamp time is of importance the majority of participants were against the rapid no heparin “clamp and go” method, in favour of distal aortic perfusion, low dose heparin (1 mg/kg) and careSpinal Cord Ischaemia and Protection ful intercostal artery incorporation. Local cooling of the spinal cord or systemically by extracorporeal cirIn the workshop it was confirmed that the most exculation was seen to increase the ischaemic tolerance. tensive aneurysm (type II) carries the highest risk of Participants felt that detection of spinal cord ischparaplegia and mortality. Spinal cord injury is largely aemia during surgery would be a great advantage so due to the duration of ischaemia and failure to rethat measures to re-establish blood supply to the spinal establish blood flow after aortic repair. The mechanism cord could be improved. It was generally agreed that of delayed paraplegia is not completely understood somatosensory evoked potentials (SSEP) are inaccurate but is associated with raised cerebrospinal fluid (CSF) because they do not reflect motor function. Several pressure, intraand postoperative hypotensive periods techniques for monitoring motor neuron pathways or occluded reattached intercostal arteries. exist, but only myogenic responses are entirely specific To combat spinal cord ischaemia, the importance of for the status of the motor neurons in the anterior the intercostal blood supply from T6 to L1 was stressed. horn. Transcranial motor-evoked potentials (MEP) Animal models and the use of laser Doppler fluxmetry were used in one centre and were demonstrated to be important in monitoring spinal cord function. Spinal ∗ Please address all correspondence to: M. J. H. M. Jacobs, Academic cord ischaemia could be detected within minutes and Medical Center, Department of Vascular Surgery, P/O box 22700, 1100 De Amsterdam, The Netherlands. the technique helped to identify segmental arteries