spinal cord ischemia


Summary: Reduced blood flow to the spinal cord which is supplied by the anterior spinal artery and the paired posterior spinal arteries. This condition may be associated with ARTERIOSCLEROSIS, trauma, emboli, diseases of the aorta, and other disorders. Prolonged ischemia may lead to INFARCTION of spinal cord tissue.

Top Publications

  1. Liang C, Lu K, Liliang P, Chen T, Chan S, Chen H. Ischemic preconditioning ameliorates spinal cord ischemia-reperfusion injury by triggering autoregulation. J Vasc Surg. 2012;55:1116-23 pubmed publisher
    The mechanism underlying ischemic preconditioning (IPC) protection against spinal cord ischemia-reperfusion (I/R) injury is unclear...
  2. Yamauchi T, Sakurai M, Abe K, Matsumiya G, Sawa Y. Ubiquitin-mediated stress response in the spinal cord after transient ischemia. Stroke. 2008;39:1883-9 pubmed publisher
    ..Fifteen minutes of spinal cord ischemia in rabbits was applied with the use of a balloon catheter...
  3. Lafci B, Yasa H, Ilhan G, Ortac R, Yilik L, Kestelli M, et al. Protection of the spinal cord from ischemia: comparative effects of levosimendan and iloprost. Eur Surg Res. 2008;41:1-7 pubmed publisher
    The purpose of the study was to investigate and compare iloprost and levosimendan on spinal cord ischemia in an experimental model. The study was done in two stages...
  4. Etz C, Luehr M, Kari F, Bodian C, Smego D, Plestis K, et al. Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: does critical spinal cord ischemia occur postoperatively?. J Thorac Cardiovasc Surg. 2008;135:324-30 pubmed publisher
    ..Spinal cord injury can occur not only during extensive thoracoabdominal aneurysm repair but also postoperatively, causing delayed-onset paraplegia...
  5. Wang L, Li W, Kang Z, Liu Y, Deng X, Tao H, et al. Hyperbaric oxygen preconditioning attenuates early apoptosis after spinal cord ischemia in rats. J Neurotrauma. 2009;26:55-66 pubmed publisher
    ..At 24 h after the last HBO pretreatment, rats underwent 9 min of spinal cord ischemia induced by occlusion of the descending thoracic aorta in combination with systemic hypotension (40 mmHg)...
  6. Stevens R, Bhardwaj A. Eryrthropoietin and the promise of ischemic multiorgan protection. Crit Care Med. 2008;36:2446-7 pubmed publisher
  7. Temiz C, Solmaz I, Tehli O, Kaya S, Onguru O, Arslan E, et al. The effects of splenectomy on lipid peroxidation and neuronal loss in experimental spinal cord ischemia/reperfusion injury. Turk Neurosurg. 2013;23:67-74 pubmed publisher
    ..is to investigate the effects of prior splenectomy on oxidative stress and neuronal loss following spinal cord ischemia and reperfusion injury...
  8. Smith P, Puskas F, Meng X, Lee J, Cleveland J, Weyant M, et al. The evolution of chemokine release supports a bimodal mechanism of spinal cord ischemia and reperfusion injury. Circulation. 2012;126:S110-7 pubmed
    Paraplegia remains a devastating complication of thoracic aortic surgery. The mechanism of the antecedent spinal cord ischemia and reperfusion injury (IR) remains poorly described...
  9. Die J, Wang K, Fan L, Jiang Y, Shi Z. Rosuvastatin preconditioning provides neuroprotection against spinal cord ischemia in rats through modulating nitric oxide synthase expressions. Brain Res. 2010;1346:251-61 pubmed publisher
    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)...

More Information


  1. Awad H, Ankeny D, Guan Z, Wei P, McTigue D, Popovich P. A mouse model of ischemic spinal cord injury with delayed paralysis caused by aortic cross-clamping. Anesthesiology. 2010;113:880-91 pubmed publisher
    b>Spinal cord ischemia and paralysis are devastating perioperative complications that can accompany open or endovascular repair surgery for aortic aneurysms...
  2. Kieffer E, Chiche L, Cormier E, Guegan H. Recurrent spinal cord ischemia after endovascular stent grafting for chronic traumatic aneurysm of the aortic isthmus. J Vasc Surg. 2007;45:831-3 pubmed
    This report describes the development of recurrent spinal cord ischemia in a patient after insertion of a stent graft into the upper segment of the descending thoracic aorta for the treatment of a chronic traumatic aneurysm of the aortic ..
  3. Sonmez A, Kabakci B, Vardar E, Gurel D, Sonmez U, Orhan Y, et al. Erythropoietin attenuates neuronal injury and potentiates the expression of pCREB in anterior horn after transient spinal cord ischemia in rats. Surg Neurol. 2007;68:297-303; discussion 303 pubmed
    ..b>Spinal cord ischemia was produced by balloon occlusion of the abdominal aorta below the branching point of the left subclavian ..
  4. Shi E, Jiang X, Wang L, Akuzawa S, Nakajima Y, Kazui T. Intrathecal injection of hepatocyte growth factor gene-modified marrow stromal cells attenuates neurologic injury induced by transient spinal cord ischemia in rabbits. Anesthesiology. 2010;113:1109-17 pubmed publisher
    ..gene or transplantation of marrow stromal cells (MSCs) remarkably attenuated neurologic injuries after spinal cord ischemia. We sought to investigate a novel neuroprotective strategy of transplantation of human HGF gene-modified ..
  5. Lioupis C, Tyrrell M, Valenti D. A report of spinal cord ischemia following endovascular aneurysm repair of an aneurysm with a large thrombus burden and complex iliac anatomy. Vasc Endovascular Surg. 2010;44:56-60 pubmed publisher
    ..aneurysms (AAAs) with large volumes of mural thrombus and complex iliac anatomy can be complicated by spinal cord ischemia (SCI)...
  6. Ding Q, Wang Q, Deng J, Gu Q, Hu S, Li Y, et al. Sevoflurane preconditioning induces rapid ischemic tolerance against spinal cord ischemia/reperfusion through activation of extracellular signal-regulated kinase in rabbits. Anesth Analg. 2009;109:1263-72 pubmed publisher
    The protective effect of sevoflurane preconditioning against spinal cord ischemia/reperfusion (I/R) is unclear...
  7. Chronidou F, Apostolakis E, Papapostolou I, Grintzalis K, Georgiou C, Koletsis E, et al. Beneficial effect of the oxygen free radical scavenger amifostine (WR-2721) on spinal cord ischemia/reperfusion injury in rabbits. J Cardiothorac Surg. 2009;4:50 pubmed publisher
    ..study we examined the influence of Amifostine, a triphosphate free oxygen scavenger, on oxidative stress of spinal cord ischemia-reperfusion in rabbits...
  8. Mizukami T, Orihashi K, Herlambang B, Takahashi S, Hamaishi M, Okada K, et al. Sodium 4-phenylbutyrate protects against spinal cord ischemia by inhibition of endoplasmic reticulum stress. J Vasc Surg. 2010;52:1580-6 pubmed publisher
    ..b>Spinal cord ischemia was induced in rabbits by direct aortic cross-clamping (below the renal artery and above the bifurcation) ..
  9. Cheng B, Wang W, Lin L, Li F, Wang X. The change of the spinal cord ischemia-reperfusion injury in mitochondrial passway and the effect of the Ginkgo biloba extract's preconditioning intervention. Cell Mol Neurobiol. 2011;31:415-20 pubmed publisher
    ..GBE inhibit performance has the systemic and local aspects. The apoptosis of nerve cells after spinal cord ischemia-reperfusion has the relationship with the mitochondrial caspase-dependent and caspase-independent pathways ..
  10. Xiong M, Chen S, Yu H, Liu Z, Zeng Y, Li F. Neuroprotection of erythropoietin and methylprednisolone against spinal cord ischemia-reperfusion injury. J Huazhong Univ Sci Technolog Med Sci. 2011;31:652 pubmed publisher
    ..In this study we enrolled patients with spinal cord ischemia-reperfusion (I-R) injury to investigate the clinical application of EPO and methylprednisolone (MP) for the ..
  11. Smith P, Bell M, Puskas F, Meng X, Cleveland J, Weyant M, et al. Preservation of motor function after spinal cord ischemia and reperfusion injury through microglial inhibition. Ann Thorac Surg. 2013;95:1647-53 pubmed publisher
    Paraplegia remains a devastating complication of thoracoabdominal aortic procedures resulting from spinal cord ischemia and reperfusion injury (SCIR)...
  12. Smith P, Puskas F, Fullerton D, Meng X, Cho D, Cleveland J, et al. Attenuation of spinal cord ischemia and reperfusion injury by erythropoietin. J Thorac Cardiovasc Surg. 2011;141:256-60 pubmed publisher
    ..evolved to reduce the risk of paraplegia, no pharmacologic therapies have proven efficacious in attenuating spinal cord ischemia-reperfusion injury...
  13. Saito T, Tsuchida M, Umehara S, Kohno T, Yamamoto H, Hayashi J. Reduction of spinal cord ischemia/reperfusion injury with simvastatin in rats. Anesth Analg. 2011;113:565-71 pubmed publisher
    Surgery of the thoracic or thoracoabdominal aorta may cause spinal cord ischemia and subsequent paraplegia...
  14. Bell M, Puskas F, Agoston V, Cleveland J, Freeman K, Gamboni F, et al. Toll-like receptor 4-dependent microglial activation mediates spinal cord ischemia-reperfusion injury. Circulation. 2013;128:S152-6 pubmed publisher
    Paraplegia continues to complicate thoracoabdominal aortic interventions. The elusive mechanism of spinal cord ischemia-reperfusion injury has delayed the development of pharmacological adjuncts...
  15. Wang L, Yan Y, Zou L, Jing N, Xu Z. Moderate hypothermia prevents neural cell apoptosis following spinal cord ischemia in rabbits. Cell Res. 2005;15:387-93 pubmed
    ..Regional hypothermia protects against spinal cord ischemia although the protective mechanism is not well know...
  16. Erten S, Kocak A, Ozdemir I, Aydemir S, Colak A, Reeder B. Protective effect of melatonin on experimental spinal cord ischemia. Spinal Cord. 2003;41:533-8 pubmed
    ..Our data also expands on reports that melatonin administration may significantly reduce the incidence of spinal cord injury following temporary aortic occlusion. ..
  17. Lips J, de Jager S, de Haan P, Bakker O, Vanicky I, Jacobs M, et al. Peri-ischemic aminoguanidine fails to ameliorate neurologic and histopathologic outcome after transient spinal cord ischemia. J Neurosurg Anesthesiol. 2002;14:35-42 pubmed
    ..of neurotoxic events that lead to delayed cellular damage may prevent motor function loss after transient spinal cord ischemia. An important effect of the neuroprotective substance aminoguanidine (AG) is the inhibition of inducible ..
  18. Sakurai M, Nagata T, Abe K, Horinouchi T, Itoyama Y, Tabayashi K. Survival and death-promoting events after transient spinal cord ischemia in rabbits: induction of Akt and caspase3 in motor neurons. J Thorac Cardiovasc Surg. 2003;125:370-7 pubmed
    ..We used a rabbit spinal cord ischemia model with use of a balloon catheter...
  19. Peters C, Rogers S, Pomonis J, Egnaczyk G, Keyser C, Schmidt J, et al. Endothelin receptor expression in the normal and injured spinal cord: potential involvement in injury-induced ischemia and gliosis. Exp Neurol. 2003;180:1-13 pubmed
    ..Strategies aimed at blocking vascular ET(A)R/ET(B)R and astrocyte ET(B)Rs following spinal cord injury may reduce the resulting ischemia and astrogliosis and in doing so increase neuronal survival, regeneration, and function. ..
  20. Park H, Jeon Y, Hwang J, Kang H, Lim S, Kim C, et al. Isoflurane preconditioning protects motor neurons from spinal cord ischemia: its dose-response effects and activation of mitochondrial adenosine triphosphate-dependent potassium channel. Neurosci Lett. 2005;387:90-4 pubmed
    We examined in a rabbit model of transient spinal cord ischemia (SCI) whether isoflurane (Iso) preconditioning induces ischemic tolerance to SCI in a dose-response manner, and whether this effect is dependent on mitochondrial adenosine ..
  21. Sakurai M, Takahashi G, Abe K, Horinouchi T, Itoyama Y, Tabayashi K. Endoplasmic reticulum stress induced in motor neurons by transient spinal cord ischemia in rabbits. J Thorac Cardiovasc Surg. 2005;130:640-5 pubmed
    ..We used a rabbit spinal cord ischemia model with a balloon catheter...
  22. Apaydin A, Buket S. Regional lidocaine infusion reduces postischemic spinal cord injury in rabbits. Tex Heart Inst J. 2001;28:172-6 pubmed
    Paraplegia secondary to spinal cord ischemia is a devastating complication in operations on the descending and thoracoabdominal aorta...
  23. Savas S, Delibas N, Savas C, Sutcu R, Cindas A. Pentoxifylline reduces biochemical markers of ischemia-reperfusion induced spinal cord injury in rabbits. Spinal Cord. 2002;40:224-9 pubmed
    ..pentoxifylline (PTX) on cytokine levels, lipid peroxidation, and antioxidant enzymes in a rabbit model of spinal cord ischemia-reperfusion injury induced by aortic occlusion. Isparta, Turkey...
  24. Garcia N, Tehrani H, Morasch M, Pearce W, Matsumura J. Spinal cord ischemia following endovascular repair of an infrarenal aortic aneurysm. Ann Vasc Surg. 2002;16:509-12 pubmed
    b>Spinal cord ischemia following repair of an infrarenal aneurysm is a rare but recognized complication following endovascular repair of an infrarenal aneurysm. Here we discuss its possible mechanism.
  25. Lin R, Roseborough G, Dong Y, Williams G, Wei C. DNA damage and repair system in spinal cord ischemia. J Vasc Surg. 2003;37:847-58 pubmed
    b>Spinal cord ischemia-reperfusion injury may be initiated by a number of mediators, including reactive oxygen species...
  26. Tokumine J, Kakinohana O, Cizkova D, Smith D, Marsala M. Changes in spinal GDNF, BDNF, and NT-3 expression after transient spinal cord ischemia in the rat. J Neurosci Res. 2003;74:552-61 pubmed
    ..Increased astrocyte-derived BDNF/GDNF expression corresponds with transient activation of astrocytes and may play an active role in neuronal plasticity after non-injurious intervals of spinal ischemia. ..
  27. Fujikawa A, Tsuchiya K, Takeuchi S, Hachiya J. Diffusion-weighted MR imaging in acute spinal cord ischemia. Eur Radiol. 2004;14:2076-8 pubmed
    We report diffusion-weighted (DW) MR findings for acute spinal cord ischemia in a 56-year-old patient...
  28. Fan L, Wang K, Cheng B. Effects of Ginkgo biloba extract on lipid peroxidation and apoptosis after spinal cord ischemia/reperfusion in rabbits. Chin J Traumatol. 2006;9:77-81 pubmed
    To study the effects of Ginkgo biloba extract (GBE) on lipid peroxidation and apoptosis after spinal cord ischemia/reperfusion (I/R) in rabbits. Spinal cord I/R injury model was established according to the description of Erten et al...
  29. Sakurai M, Kawamura T, Nishimura H, Suzuki H, Tezuka F, Abe K. Induction of Parkinson disease-related proteins in motor neurons after transient spinal cord ischemia in rabbits. J Cereb Blood Flow Metab. 2009;29:752-8 pubmed publisher
    ..We used a 15-min rabbit spinal cord ischemia model, with use of a balloon catheter...
  30. Shah T, Maldonado T, Bauer S, Cayne N, Schwartz C, Mussa F, et al. Female patients undergoing TEVAR may have an increased risk of postoperative spinal cord ischemia. Vasc Endovascular Surg. 2010;44:350-5 pubmed publisher
    ..This may be associated with a concerning increase in postoperative paraplegia. Women undergoing TEVAR should be considered for prophylactic maneuvers to prevent spinal cord ischemia (SCI), including minimizing length of coverage.
  31. Jánosi R, Gorla R, Tsagakis K, Kahlert P, Horacek M, Bruckschen F, et al. Thoracic Endovascular Repair of Complicated Penetrating Aortic Ulcer: An 11-Year Single-Center Experience. J Endovasc Ther. 2016;23:150-9 pubmed publisher
    ..No patient experienced spinal cord ischemia after TEVAR. Five (7...
  32. Tsang B, Foster E, Kam A, Storey E. Diffusion weighted imaging with trace diffusion weighted imaging, the apparent diffusion coefficient and exponential images in the diagnosis of spinal cord infarction. J Clin Neurosci. 2013;20:1630-2 pubmed publisher
    ..On follow-up at 3 months, there was modest improvement with respect to his quadriparesis and was walking unaided. An extensive literature review on the role of MRI in SCI is discussed. ..
  33. Van Zuuren E, Fedorowicz Z, Pucci E, Jagannath V, Robak E. Percutaneous transluminal angioplasty for treatment of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis patients. Cochrane Database Syst Rev. 2012;12:CD009903 pubmed publisher
    ..Clinical practice should be guided by evidence supported by well-designed randomised controlled trials: closure of some of the gaps in the evidence may be feasible at the time of completion of the six ongoing clinical trials. ..
  34. Cramer D, Maher P, Pettigrew D, Kuntz C. Major neurologic deficit immediately after adult spinal surgery: incidence and etiology over 10 years at a single training institution. J Spinal Disord Tech. 2009;22:565-70 pubmed publisher
    ..Retrospective study of adult patients who underwent spinal surgery over a 10-year period at a single institution...
  35. Nishi H, Nakatsuka T, Takeda D, Miyazaki N, Sakanaka J, Yamada H, et al. Hypothermia suppresses excitatory synaptic transmission and neuronal death induced by experimental ischemia in spinal ventral horn neurons. Spine (Phila Pa 1976). 2007;32:E741-7 pubmed publisher
    ..This finding may help in achieving a better understanding of the mechanisms of hypothermia-mediated neuroprotection in the spinal cord. ..
  36. Hwang J, Kim J, Park S, Cho S, Park S, Han S. Magnesium sulfate does not protect spinal cord against ischemic injury. J Invest Surg. 2011;24:250-6 pubmed publisher
    We tested various doses of MgSO(4) to investigate the effect of Mg on a spinal cord ischemia. Rats were treated with either MgSO(4) (30, 100, or 300 mg/kg; group Mg(low), group Mg(medium), group Mg(high), respectively, n = 10 for each) or ..
  37. Jiang X, Shi E, Li L, Nakajima Y, Sato S. Co-application of ischemic preconditioning and postconditioning provides additive neuroprotection against spinal cord ischemia in rabbits. Life Sci. 2008;82:608-14 pubmed publisher
    ..ischemic preconditioning (IPC) and postconditioning can provide additive neuroprotection against prolonged spinal cord ischemia. Spinal cord ischemia was produced in rabbits by infrarenal aortic occlusion with a balloon catheter for 30 ..
  38. Yang Y, Lu J, Qing E, Dong X, Wang C, Zhang J, et al. Post-conditioning by xenon reduces ischaemia-reperfusion injury of the spinal cord in rats. Acta Anaesthesiol Scand. 2012;56:1325-31 pubmed publisher
    ..29 ± 3.06 vs. 27.34 ± 3.63, P < 0.05, respectively). Xenon post-conditioning exerts a neuroprotective effect on the spinal cord following ischaemia-reperfusion injury via its anti-apoptotic role. ..
  39. Dominguez C, Lidman O, Olsson T, Wiesenfeld Hallin Z, Piehl F, Xu X. Contrasting genetic effects of major histocompatibility complex on ischemic peripheral nerve and spinal cord injury in female rats. Neurosci Lett. 2008;443:95-8 pubmed publisher
  40. Zhou L, Wang X, Xue W, Xie K, Huang Y, Chen H, et al. Beneficial effects of hydrogen-rich saline against spinal cord ischemia-reperfusion injury in rabbits. Brain Res. 2013;1517:150-60 pubmed publisher
    ..b>Spinal cord ischemia was induced by infrarenal aortic occlusion for 20min in male New Zealand white rabbits...
  41. Tan K, Hammond E, Kerr D, Nath A. Fibrocartilaginous embolism: a cause of acute ischemic myelopathy. Spinal Cord. 2009;47:643-5 pubmed publisher
    ..After rehabilitation, the patient made a modest recovery. Diagnosis of FCE can be made by recognition of the characteristic clinical and radiological features and a high index of suspicion. ..
  42. Messe S, McGarvey M, Bavaria J, Pochettino A, Szeto W, Cheung A, et al. A pilot study of darbepoetin alfa for prophylactic neuroprotection in aortic surgery. Neurocrit Care. 2013;18:75-80 pubmed publisher
    ..DA repair is a promising model of prophylactic neuroprotection. ..
  43. Korkmaz A, Oyar E, Kardes O, Omeroglu S. Effects of melatonin on ischemic spinal cord injury caused by aortic cross clamping in rabbits. Curr Neurovasc Res. 2008;5:46-51 pubmed
    ..Melatonin attenuated ischemia-induced necrosis. Melatonin administration may significantly reduce the incidence of spinal cord injury following temporary aortic occlusion. ..
  44. Mommertz G, Langer S, Koeppel T, Schurink G, Mess W, Jacobs M. Brain and spinal cord protection during simultaneous aortic arch and thoracoabdominal aneurysm repair. J Vasc Surg. 2009;49:886-92 pubmed publisher
    ..Monitoring of cerebral and spinal cord function contributes to improved neurologic outcome. ..
  45. Robles L. Traumatic spinal cord infarction in a child: case report and review of literature. Surg Neurol. 2007;67:529-34 pubmed
    ..Because the conventional radiographic tests are normal, TSCIf can be considered as a special type of SCIWORA. ..
  46. Banzić I, Sladojević M, Ilic N, Koncar I, Davidovic L, Branković M. Complete Immediate Paraplegia Reversal after Performing Aorto-Lumbar Bypass on the Patient who Underwent Aortoiliac Reconstruction. Ann Vasc Surg. 2016;35:203.e1-3 pubmed publisher
    ..during operation, the patient developed paraplegia immediately after aortoiliac reconstruction due to the spinal cord ischemia. We report a successfully treated immediate postoperative paraplegia by performing second operation and ..
  47. Liu S, Wang Y, Zhang Y, He X, Ma T, Song W, et al. ZL006 protects spinal cord neurons against ischemia-induced oxidative stress through AMPK-PGC-1α-Sirt3 pathway. Neurochem Int. 2017;108:230-237 pubmed publisher
    b>Spinal cord ischemia (SCI) induces a range of cellular and molecular cascades, including activation of glutamate receptors and downstream signaling...
  48. Eagleton M, Farivar B, Dias A. Large, single-center databases and the evolution of endovascular therapy for complex aortic aneurysms. Surgery. 2017;162:963-973 pubmed publisher
    ..areas of high risk for these patients including perioperative renal failure and the development of spinal cord ischemia. Long-term outcomes are being developed with a special interest in evaluating branch patency, renal ..
  49. Nardone R, Pikija S, Mutzenbach J, Seidl M, Leis S, Trinka E, et al. Current and emerging treatment options for spinal cord ischemia. Drug Discov Today. 2016;21:1632-1641 pubmed publisher
    ..In this review, we discuss the current state of the art for the therapy and prevention of SCI and highlight potential emerging treatment concepts awaiting translational adoption. ..
  50. Smith K, Zhu L. Theoretical evaluation of a simple cooling pad for inducing hypothermia in the spinal cord following traumatic injury. Med Biol Eng Comput. 2010;48:167-75 pubmed publisher
    ..b>Spinal cord ischemia, often observed after traumatic spinal cord injury, promotes cooling penetration...
  51. Lieske J, Cameron B, Drinkwine B, Goretzke S, Alemi L, Needham K, et al. Surfer's myelopathy-demonstrated by diffusion-weighted magnetic resonance imaging: a case report and literature review. J Comput Assist Tomogr. 2011;35:492-4 pubmed publisher
    ..characterized by nontraumatic paraparesis/paraplegia in novice surfers and theorized to result from spinal cord ischemia secondary to surfing-related positional hyperextension...
  52. Paolillo V, Gastaldo D. Acute spinal cord ischemia during aortography. Tex Heart Inst J. 2007;34:134-5 pubmed
  53. Coselli J, Tsai P. Motor evoked potentials in thoracoabdominal aortic surgery: CON. Cardiol Clin. 2010;28:361-8 pubmed publisher
    ..motor evoked potentials (MEPs) can be used to guide TAAA repair procedures and may potentially minimize spinal cord ischemia. However, the use of MEP monitoring techniques requires important changes to anesthetic management, entails ..