Refractory Coronary Vasospasm After Spine Surgery; A Rare Case Report

Refractory vasospastic angina (RVSA) is a rare condition leading to several episodes of constriction of coronary arteries which eventually leads to myocardial ischemia. Calcium-channel blockers (CCBs) and nitrates are usually used, however, sometimes the vasospasm is refractory and recurrent leading to high morbidity and mortality. A 35-year-old man known case of hypertension underwent two times operation due to T9-T10 discopathy and decompressive laminectomy of three segments T8/T9/ T10 following a previous car accident 4 months before this admission. Three days postoperatively he developed chest pain, dyspnea and diaphoresis. Electrocardiography showed inverted T wave in leads I, II and ST elevation in pericardial leads of V1-V4. Left anterior descending (LAD) artery stenosis was present (99%) at mid part that resolved after Trinitroglycerin (TNG) injection during angiography. Totally, he underwent 3 times coronary angiography due to recurrent chest pain refractory to conventional management of Prinzmetal’s angina. Coronary stent could not be placed due to severe spasm. Finally, he developed refractory chest pain and dyspnea and cardiac arrest in the CCU despite receiving intravenous high dose TNG, Diltiazem, Nicorandil and Hydrocortisone. He expired after several times of cardiopulmonary resuscitation. Refractory VSA after spine surgery has not been reported in the literature yet. This patient was resistant to available medications. There is no consensus regarding the treatment unfortunately. Randomized clinical trials have to be done to find ways regarding unconventional treatment options such as alpha-2-agonists, Corticosteroids, rho-kinase-inhibitors, statins and magnesium. Despite the fact, some surgical interventions with sympathetic denervation like left-stellate-ganglion denervation must be assessed.