Spinal Infarction Research Articles

A common surgical emergency complicated by anterior spinal cord infarction

This case explores how the presentation of a perforated duodenal ulcer is masked by a preceding anterior spinal artery infarction.

Nilotinib treatment‐associated peripheral artery disease and sudden death: Yet another reason to stick to imatinib as front‐line therapy for chronic myelogenous leukemia

Aichberger and colleagues recently described an association between nilotinib therapy for chronic myelogenous leukemia (CML) and adverse vascular events, which occurred in eight (~33%) of their 24 CML patients treated with nilotinib: severe peripheral artery disease (PAD; n = 3), less severe PAD (n = 1), sudden death (n = 1), myocardial infarction (n = 1), spinal infarction (n = 1), and subdural hematoma (n = 1) [1]. We were intrigued by these observations because of similar events that occurred in two of our patients receiving nilotinib therapy. A female patient developed severe and unrelenting PAD and coronary artery disease (CAD) after ~3 years of treatment with nilotinib and the second patient died suddenly after receiving nilotinib therapy for 3 weeks. None of the two patients had history of cardiovascular disease, tobacco use, or diabetes mellitus. These observations are troubling and question the prudence of rushing to replace imatinib with nilotinib, for front-line therapy in CML.

Progressive peripheral arterial occlusive disease and other vascular events during nilotinib therapy in CML

The second generation BCR/ABL kinase inhibitor nilotinib is increasingly used for the treatment of imatinib-resistant chronic myeloid leukemia (CML). So far, nilotinib is considered a well-tolerated drug with little if any side effects, although an increase in the fasting glucose level has been reported. We examined a series of 24 consecutive CML patients treated with nilotinib in our center for the development of non-hematologic adverse events. Three of these 24 CML patients developed a rapidly progressive peripheral arterial occlusive disease (PAOD) during treatment with nilotinib. In all three cases, PAOD required repeated angioplasty and/or multiple surgeries within a few months. No PAOD was known before nilotinib-therapy in these patients, although all three had received imatinib. In two patients, pre-existing risk factors predisposing for PAOD were known, and one of them had developed diabetes mellitus during nilotinib. In the other 21 patients treated with nilotinib in our center, one less severe PAOD, one myocardial infarction, one spinal infarction, one subdural hematoma, and one sudden death of unknown etiology were recorded. In summary, treatment with nilotinib may be associated with an increased risk of vascular adverse events, including PAOD development. In a subgroup of patients, these events are severe or even life-threatening. Although the exact mechanisms remain unknown, we recommend screening for pre-existing PAOD and for vascular risk factors such as diabetes mellitus in all patients before starting nilotinib and in the follow up during nilotinib-therapy.

Outcomes of endovascular treatment of chronic total occlusion of the infrarenal aorta

Few reports have been published on the outcomes of endovascular therapy in chronic total occlusion of the aorta. Endovascular treatment was attempted in 49 patients (40 men and nine women; aged 64.1 ± 10.9 years) with infrarenal aortic occlusion between January 1995 and December 2009. The first attempt at wire passage and balloon angioplasty was usually performed by an antegrade approach through the brachial artery. Stents were implanted with or without intra-arterial administration of thrombolytic agents. We investigated the immediate and midterm outcomes of endovascular therapy for chronic infrarenal aortic occlusions. Technical success was achieved in 40 patients (81.6%). Procedural failures were due to wire passage failure in eight patients and to embolization and spinal cord infarction in one. Stents were implanted in 97.5% of patients. Major complications occurred in eight patients (16.3%): two neurologic events (spinal and cerebral infarction), two cases of jailed renal artery after stenting, and one case each of periprocedural death from pneumonia, distal embolization requiring embolectomy, iliac artery rupture requiring implantation of covered stents, and access site pseudoaneurysm treated with surgery. In patients treated successfully, the primary patency rate was 88.4% at 1 year and 80.1% at 3 years. The major amputation rate was 0%. Seven patients (17.5%) required repeat intervention (n = 5) or bypass surgery (n = 2) during the follow-up period. Endovascular therapy of infrarenal aortic occlusion was feasible in most cases, and midterm patency was favorable. However, because of relatively high procedurally related complication rates, cautious selection of patients and appropriate preventive measures are necessary to improve immediate outcomes.

Lumbar Artery Injury Following Posterior Spinal Instrumentation for Scoliosis

Vascular injuries are uncommon but potentially serious complications of spinal surgery. Lumbar artery lesion complicating posterior spinal instrumentation for scoliosis has been occasionally described. A 39-year-old woman with adult scoliosis was treated with correction and stabilization from T8 to L5 via a midline posterior approach. Transpedicular screws were inserted from levels L1 to L5 on the convex left side and at T11, T12, L4, and L5 on the concavity right side. Pedicle screws were not inserted from L2 to L4 on the right side due to difficulty identifying the pedicle channel with the probe. The instrumentation was completed with 2 hooks at T8 and T5 on the left side and 1 at T7. Five hours postoperatively, the patient suffered a hypotensive attack and her abdomen was distended. Her hemoglobin level was 4.5 g/dL. Hemodynamic stabilization was achieved with emergent therapy, including fluid resuscitation, blood, and plasma transfusion. An urgent contrast-enhanced abdominal computed tomography scan showed a large hematoma at the right retroperitoneum with active extravasation of contrast medium, but the source of bleeding was not detectable because of metallic artifacts. Immediate angiography demonstrated rupture of the third right lumbar artery. Selective microcoil embolization was performed with occlusion of the corresponding branch. The bleeding stopped and hemodynamic parameters were stable. No spinal cord impairment or muscle infarction occurred, and 1-year follow-up was uneventful. Lumbar artery injury should be considered as a complication after posterior spinal surgery for scoliosis and prompt diagnosis and intervention are required. Selective lumbar artery embolization is a safe and effective procedure to stop bleeding in hemodynamically stable patients after fluid resuscitation and blood transfusion.

Acute onset intramedullary spinal cord abscess with spinal artery occlusion: a case report and review

Intramedullary spinal cord abscess (ISCA) without meningitis is an extremely rare entity in the central nervous system, and it is often difficult to diagnose immediately, and no definitive imaging findings have been established. We experienced the case of a 61-year-old male who presented with a sudden onset back pain without fever following rapidly worsening paraparesis for 3days, who subsequently become unable to walk. According to the initial MRI and 3D-CTA, the presumptive diagnosis was spinal infarction due to spinal artery embolism. However, his symptoms did not improve, despite the gradual changes in MRI following antiplatelet therapy. He underwent a biopsy in an attempt to prevent the lesion from progressing toward the upper spinal cord. The pathological examination revealed an intramedullary abscess, so we performed a midline myelotomy and drained the pus from the abscess. After surgery, MRI showed improvement, but the patient's paraplegia persisted. To the best of our knowledge, this is the first case report of spinal cord abscess with the confirmation of spinal artery occlusion on angiography, which could have been caused by a bacterial embolism. We herein discuss its possible etiology and also review recent reports on ISCA.

Spinal ischaemic stroke: clinical and radiological findings and short‐term outcome

The mechanism and pathogenesis of ischemic spinal stroke remain largely undetermined because most clinical studies have included mostly patients without a systematic study of associated vascular and concomitant disease of the vertebral body. Therefore, we assessed the pathogenetic mechanisms and short-term outcomes of the patients with spinal stroke based on clinical data and magnetic resonance imaging findings. We studied clinical, imaging, and outcome data for 36 patients with acute spinal stroke admitted between 1998 and 2008. There were 16 men and 20 women (mean age 73, range 56-85 years). Twelve patients (33%) had anterior spinal artery patterns, 8 (22%) had anterior and 6 (17%) had posterior unilateral infarct, 5 (14%) had posterior spinal artery infarct pattern, 3 (8%) had central involvement, and 2 (5%) had transverse syndrome. Twelve patients (33%) had no cause of stroke. Patients with central infarct and transverse infarct had a high frequency of peripheral vascular disease and prolonged hypotension, and one patient each had a chronic spinal disease. The onset of all other infarcts was associated with mechanical triggering movements in 12 patients (41%, P<0.05), and with diseases of the spine in 19 (66%; P<0.001), with the clinical picture suggesting root involvement at the level of the spinal cord ischemia. The short-term outcomes were favorable in two-thirds of patients, while 25% of them did not show any recovery on leaving the hospital. The most common type of spinal cord ischemia is bilateral or unilateral anterior spinal artery infarcts due to radicular artery disease with acute or chronic spinal disease and followed by central and transverse infarcts due to extensive spinal cord hypoperfusion and arteriopathy.

Editorial: Surgery for lumbar stenosis

Lumbar spinal stenosis is a major cause of morbidity in our aging population.4 With an increased premium placed on quality of life and changes in societal expectations, more spine surgeons and patients are opting for surgical intervention to treat this condition in the elderly. The goal of this type of surgery is to provide symptomatic relief from radicular pain, neurogenic claudication, and neurological dysfunction while at the same time minimizing the risk of segmental instability and complications. One can appreciate the greater challenge that this surgical intervention may pose in the elderly population with their associated comorbidities. The literature supports surgical intervention versus nonoperative treatment for long-term clinical relief of symptomatic lumbar spinal stenosis;12 however, controversy remains regarding the application of these interventions in the elderly population because of the potential for increased perioperative complications.2,3,5,6 Recently, investigators have been examining the differences in outcomes between traditional and less invasive surgery for lumbar spinal stenosis in all patient populations, including the elderly.1,8,9,10,11 Traditionally, surgeons have thought that a laminectomy is required to achieve an adequate decompression. Those favoring less invasive surgery believe that a sufficient decompression may be achieved with a unilateral partial hemilaminectomy. The rationale for considering less invasive surgery is the potential for decreased postoperative spinal stability, decreased postoperative pain, and a shorter hospital length of stay. The article by Morgalla et al.7 in this issue of Journal of Neurosurgery: Spine is a retrospective review evaluating the results of lumbar spinal decompression 1 year postoperatively in a group of 108 patients who were 60 years of age or older and had lumbar spinal stenosis at 1 or more levels and in whom conservative treatment lasting at least 3 months had failed. The 3 approaches evaluated in this study were unilateral partial hemilaminectomy, hemilaminectomy, and laminectomy. Patients with previous lumbar spinal surgery, developmental spinal deformities, vertebral fractures, inflammatory spondylopathies, spinal infarct or tumors, or severe comorbid conditions greater than American Society of Anesthesiologists Class 3 were excluded from this study. The outcome was assessed 12 months postoperatively using the Quebec Back Pain Disability Scale and the Hannover Functional Back Pain Questionnaire. There was a statistically significant clinical improvement in the preand postoperative states with all 3 techniques; however, there was no significant difference between the techniques. A unilateral partial hemilaminectomy potentially produces clinical results that are equivalent to those achieved by a more formal laminectomy. However, it is important to point out that only 10 patients in this series actually underwent a formal laminectomy. Considering the retrospective nature of this paper and the potential for selection bias, the authors must be commended for their attempt in assessing 3 cohorts that were well matched for the baseline demographic covariates of sex, age, marital status, number of children, educational level, and key social supports. However, given the nonrandomized design of this study and the retrospective nature of data collection and analysis, one cannot rule out residual confounding factors that could influence the results. Moreover, as indicated above, it is important to stress that very few patients (10) in the series underwent a formal laminectomy, and hence the potential for Type II error is real. Finally, while the complication rates (7.4%) appear acceptable, few details regarding the impact and severity of these complications are provided. The authors must be congratulated for their work on this paper. The work of Morgalla et al.7 may have clinical and economic implications at a time when our population is aging and our health care expenditures are rising. This study has laid the foundation for future prospective controlled studies with adequate power, appropriate outcome measures, and a longer follow-up to further examine the optimal methods of treating lumbar spinal stenosis in the elderly population. However, based on emerging data in the literature, including the current paper by Morgalla et al., spine surgeons should consider, when clinically appropriate, using less invasive techniques when treating lumbar spinal stenosis in the elderly.

A child with influenza A (H1N1)-associated myocarditis rescued by extracorporeal membrane oxygenation

A 6-year-old boy had cold-like symptoms and was diagnosed with influenza A at a clinic. Administration of oseltamivir and azithromycin did not improve the symptoms. He was referred to our hospital and was diagnosed with H1N1 pneumonia. The patient required ventilator support. However, hypoxia and hypercapnia were uncontrollable. To oxygenate and reduce the carbon dioxide concentration, veno-venous extracorporeal membrane oxygenation (ECMO) was applied 24h after admission. We established outflow via the right internal jugular vein and inflow via the right femoral vein. Six hours later, an electrical storm of ventricular fibrillation occurred, probably due to influenza myocarditis. Chest compression was started immediately. Both cardioversion and medication were ineffective in treating the electrical storm. Therefore, we decided to switch the veno-venous ECMO to veno-arterial ECMO to maintain systemic flow. During chest compression, a 6-mm graft was anastomosed to the left common femoral artery, and an outflow tube was connected to the graft. Consequently, veno-arterial ECMO was established via outflow through the left common femoral artery and inflow through both the right jugular vein and right femoral vein. Veno-arterial ECMO terminated the electrical storm, and cardiac output improved. Veno-arterial ECMO was provided for 107h, and was then replaced by veno-venous ECMO. Forty-three hours later, veno-venous ECMO was discontinued. The patient was successfully weaned from the mechanical ventilator on the 9th day after admission. Unfortunately, spinal infarction appeared as a complication. The patient was discharged from the hospital on the 86th day, and has now returned to primary school.

Opalski syndrome detected on DWI MRI: A rare lateral medullary infarction. Case report and review

Wallenberg's syndrome and ipsilateral paresis due to combined infarction of the lateral medullary and cervical spinal infarction is known as Opalski syndrome. This rarely described syndrome was reported, to our knowledge, with DWI MRI, only once. We report the case of a 43-year-old man with autosomal dominant polycystic kidney disease who, after a brief episode of coma, developed Wallenberg syndrome and ipsilateral hemiparesis. Initial diffusion weighted-imaging MRI showed a high-intensity signal involving the lateral medulla oblongata and the spinal cord; but FLAIR MRI sequences showed bilateral high-intensity signals in the lateral medulla oblongata and spinal cord and high-intensity signals in the right and left cerebellar hemisphere in the PICA territories. MRI performed one year later showed an infarction involving the left medullary area and adjacent spinal segments alone. This observation illustrates a rare syndrome of lateral medullary infarction, associated with spinal cord infarction related to a possible transient basilar occlusion.

Hypothalamo-spinal tract somatotopic organization determined from thermal sudomotor function in patients with localized cervical spinal cord lesions

Hypothalamo-spinal tract somatotopic organization was determined based on thermal sweating (TS) and superficial sensation modes, and magnetic resonance imaging (MRI) findings in three patients with localized cervical spinal cord lesions. A 66-year-old man with probable spinal infarction presented a left-sided MRI T2 high-signal area in the relatively superficial lateral C4 segment, right-sided hypoesthesia in the L2-S2/3 sensory dermatomal region, and hypohidrosis restricted to the left side of the face.

P25-13 Spinal cord injury at birth as a consequence of a postulated prenatal anterior spinal artery ischemic infarct: The value of electromyographic studies

P25-13 Spinal cord injury at birth as a consequence of a postulated prenatal anterior spinal artery ischemic infarct: The value of electromyographic studies

Rosuvastatin preconditioning provides neuroprotection against spinal cord ischemia in rats through modulating nitric oxide synthase expressions

The study was aimed to investigate the protective effects of rosuvastatin on spinal cord ischemia in rats and to determine the effects of this agent on the expressions of nitric oxide synthase (NOS). Spinal cord ischemia was induced in male Sprague–Dawley rats by occluding the descending thoracic aorta. Experimental groups ( n = 30 per group) were as follows: sham operation, control (receiving only normal saline), rosuvastatin (5 mg/kg/day for 10 days before occlusion), and rosuvastatin-mevalonate (5 mg/kg/day rosuvastatin and 5 mg/kg/day mevalonate for 10 days before occlusion). Neurological function was assessed at 6, 12, 24, 48, and 72 h after reperfusion. After 72 h reperfusion, spinal cords were harvested for 2,3,5,-triphenyltetrazolium chloride (TTC) staining, TUNEL staining, and nitric oxide (NO) assay. Immunohistochemistry, reverse transcription polymerase chain reaction and western blot were performed to determine the expressions of inducible, endothelial, and neuronal NOS (iNOS, eNOS, and nNOS) in rats with spinal cord ischemia. Spinal cord ischemia thus induced was marked by neurological dysfunction, spinal infarction, and neural cell apoptosis in animals. The results show that rosuvastatin significantly reduced the motor disturbance and the volume of infarctions and attenuated apoptotic neural cells death in the treated rats. Treatment with rosuvastatin remarkably decreased the NO level in spinal cord tissue. In addition, rosuvastatin inhibited iNOS mRNA and protein expression and increased eNOS mRNA and protein expression. However, rosuvastatin had no influence on nNOS mRNA and protein expression. Administrations of mevalonate completely reversed the changes caused by rosuvastatin. These results indicate that rosuvastatin can protect rat spinal cord against ischemia injury by modulation of NOS expressions.

Anterior spinal artery syndrome: a rare complication of head and neck surgery

We report a case of anterior spinal artery syndrome, an extremely rare complication, following head and neck surgery. A case report and literature review concerning anterior spinal artery syndrome is presented. A 64-year-old man developed an anterior spinal artery infarction following total laryngectomy and bilateral neck dissections for post-radiotherapy glottic carcinoma. Anterior spinal artery infarction is a rare syndrome. It typically presents with weakness, loss of pain and temperature sensation below the level of the injury, with relative sparing of position and vibratory sensation. Recovery is variable. To the best of our knowledge, this is the first case report in the English language literature of anterior spinal artery syndrome following a head and neck procedure. This case report highlights a rare complication, and also the susceptibility of head and neck surgery patients to different complications. In head and neck cancer patients suffering anterior spinal artery syndrome following primary surgical treatment, we recommend that the management of this complication should be as aggressive as that of the primary cancer.

Posterior Spinal Artery Infarct due to Patent Foramen Ovale

Case report. To report the first case of posterior spinal artery (PSA) infarct due to patent foramen ovale (PFO). Infarct in the territories of PSA are very rare: till now 38 cases are reported in the literature. Moreover only 1 case of spinal cord infarction was attributed to paradoxical embolism through PFO, but in the anterior spinal artery territory. A 60-year-old woman was hospitalized for sudden numbness of the right leg. Neurologic examination revealed right leg mild paresis and loss of proprioception and dysesthesia at T11. Spine-MRI showed T5-T7 posterolateral cord ischemia. Transesophageal echocardiography disclosed a PFO with severe right-left shunt confirmed by transcranial Doppler. During the hospitalization she was treated with oral-500 mg ticlopidine, because of a mild allergic reaction to acetylsalicylic acid. No steroids were administrated. Physiotherapy was performed daily. Motor and urinary symptoms disappeared in 20 days. At 1-month clinical follow-up only suspended dysesthesia on the right side was present. At 3 months follow-up spine-MRI showed no signal abnormalities within the spinal cord but the patient still complained of dysesthesia. The therapy was changed to oral 75 mg clopidogrel, cause of leucopoenia. At 1-year follow-up dysesthesia was still present, but less complaining and no recurrence and adverse effect due to clopidogrel therapy were reported. This report describe a case of acute nontraumatic myelopathy. At 4 days after onset, PSA infarct was diagnosed on the basis of neurologic findings and MR images. After extensive diagnostic work-up, we were able to identify only PFO, so it was the first case of PSA due to probable paradoxical embolism. The patient was treated with antiplatelet therapy with good recovery and no recurrence at 1-year follow-up.

Modulation of neuronal activity after spinal cord stimulation for neuropathic pain; H215O PET study

Spinal cord stimulation (SCS) is an effective therapy for chronic neuropathic pain. However, the detailed mechanisms underlying its effects are not well understood. Positron emission tomography (PET) with H215O was applied to clarify these mechanisms. Nine patients with intractable neuropathic pain in the lower limbs were included in the study. All patients underwent SCS therapy for intractable pain, which was due to failed back surgery syndrome in three patients, complex regional pain syndrome in two, cerebral hemorrhage in two, spinal infarction in one, and spinal cord injury in one. Regional cerebral blood flow (rCBF) was measured by H215O PET before and after SCS. The images were analyzed with statistical parametric mapping software (SPM2). SCS reduced pain; visual analog scale values for pain decreased from 76.1±25.2 before SCS to 40.6±4.5 after SCS (mean±SE). Significant rCBF increases were identified after SCS in the thalamus contralateral to the painful limb and in the bilateral parietal association area. The anterior cingulate cortex (ACC) and prefrontal areas were also activated after SCS. These results suggest that SCS modulates supraspinal neuronal activities. The contralateral thalamus and parietal association area would regulate the pain threshold. The ACC and prefrontal areas would control the emotional aspects of intractable pain, resulting in the reduction of neuropathic pain after SCS.

Lethal hemothorax following thoracic dislocated spinal fracture: the usefulness of arterial embolization

A 68-year-old male fell from a height of 3 m. He was conscious and alert, and complained of back pain, dyspnea, and paraplegia with hemodynamic instability. Initial axial and three-dimensional computed tomographic (CT) scans revealed a massive hemothorax on the right side and a dislocation (Th11) of the thoracic bamboo spine (Fig. 1a, b). We believed that the cause of the hemothorax was from the injured intercostals artery following the dislocation of the thoracic spine; therefore, angiography was performed immediately to isolate the source of bleeding. Angiographic findings revealed extravasation of the contrast medium from the intercostal artery (Th11; Fig. 1c). Selective arterial embolization (AE) was performed with gelatin sponge particles. After AE, the extravasated contrast medium disappeared, and his hemodynamic state stabilized. On the 16th day of hospitalization, the thoracic spine fracture was successfully repaired, and he was kept at the hospital to recuperate. Fig. 1 (a) Axial thoracic CT scan. This CT scan shows massive hemothorax on the right side. (b) Three-dimensional vertebral CT scan. This CT shows a dislocation (Th11) of the thoracic bamboo spine. (c) Right internal arteriogram (Th11). Arteriogram shows extravasation ... Life-threatening hemothorax is uncommon following a thoracic vertebral fracture [1,2]. There are only a few reports on life-threatening hemothorax following a thoracic vertebral fracture; surgical management was adopted in these cases [1,2]. However, treatment for life-threatening hemorrhage following fractures of the spine has not yet been established. This is the first successful treatment report on life-threatening hemothorax following thoracic vertebral fracture. We thought that AE was a good choice of treatment for our patient. However, this method could not be useful if the angiographic finding showed the extravasation of the contrast medium from the great anterior radicular artery (artery of Adamkiewicz) because of spinal infarction. Therefore, the method of management should be changed immediately.

Marked increase in cerebrospinal fluid glial fibrillar acidic protein in neuromyelitis optica: an astrocytic damage marker

Background: Neuromyelitis optica (NMO) is a neurological inflammatory disease associated with autoimmunity to aquaporin 4, predominantly localised in astrocytic foot processes. Recent studies have revealed that loss of aquaporin 4...

Neurovascular complications of cocaine.

Use of cocaine in the USA, has reached epidemic proportions since 1983, when "crack" was introduced, its higher potency compared with cocaine HCl has been associated with a tremendous increase in the incidence of strokes. This study reports our experience with 55 cases of neurovascular events (25 ischemic and 30 hemorrhagic) related to cocaine use in 54 patients. Only 15 patients had other risk factors for stroke. Twenty six patients smoked "crack", 10 snorted cocaine and 12 injected it intravenously. Strokes occurred within 3 h of cocaine use in 15 patients with infarcts and 17 with hemorrhages. Ten infarcts occurred after an overnight binge. Of the hemorrhage group 9 were subarachnoid, 16 intracerebral (8 basal ganglia, 7 hemispheric and one brain stem) and 5 intraventricular. Computerized tomography (CT) showed an aneurysm of the anterior communicating artery, as well as one of the vein of Galen. Four aneurysms and 3 AVMs were identified on angiography. CT revealed 15 infarcts; it was normal in 7 patients with pure motor hemiparesis and in 3 with findings consistent with anterior spinal artery infarction. Several mechanisms may be responsible for the cerebrovascular complications. A sudden rise in systemic arterial pressure may cause hemorrhages, frequently in association with an underlying aneurysm or AVM. Vasospasm, arteritis, myocardial infarction with cardiac arrhythmias and increased platelet aggregation may provoke infarcts.

Rhabdomyolysis following posterior lumbar interbody fusion in prone position: report 2 cases: Two cases report.

The spine surgery performed in the prone position could cause severe complications such as visual acuity impairment, spinal infarct and rhabdomyolysis. When treating rhabdomyolysis, it is important to prevent acute renal failure from accompanying rhabdomyolysis due to the poor prognosis. We have experienced two cases of rhabdomyolysis after spine surgery where dark urine was present during spine surgery under general anesthesia. Anesthesiologists should pay attention for early diagnosis and treatment of the rhabdomyolysis developing during the spine surgery.