Directly measuring spinal cord blood flow and spinal cord perfusion pressure via the collateral network: Correlations with changes in systemic blood pressure

Influence of Blood Pressure on Acute Cervical Spinal Cord Injury Without Fracture and Dislocation: Results From a Retrospective Analysis

OBJECTIVE

The objective of this study was to investigate the influence of blood pressure on the severity and functional recovery of patients with acute cervical spinal cord injury (SCI) without fracture and dislocation.

METHODS

A retrospective case control study analyzed the data of 40 patients admitted to our orthopedics department (Beijing Tiantan Hospital, Capital Medical University) from January 2013 to February 2021. They were diagnosed as acute cervical SCI without fracture and dislocation. Gender, age, height, weight, history of hypertension, postinjury American Spinal Injury Association grade, postinjury modified Japanese Orthopaedic Association (mJOA) score, postoperative mJOA score, 1-year follow-up mJOA score, preoperative mean arterial pressure (MAP), intramedullary T2 hyperintensity, and hyponatremia were collected. The patients were divided into groups and subgroups based on their history of hypertension and preoperative MAP. The effects of history of hypertension and preoperative MAP on the incidence of T2 hyperintensity, hyponatremia, the improvement rate of the postoperative mJOA and 1-year follow-up mJOA scores were analyzed.

RESULTS

Patients with history of hypertension had a lower incidence of intramedullary T2 hyperintensity than patients without history of hypertension (P < 0.05). Patients with history of hypertension and patients with a higher preoperative MAP had better neurological recovery at 1 year of follow-up (P < 0.05).

CONCLUSIONS

Blood pressure has great influence on acute cervical SCI without fracture and dislocation. Maintaining a higher preoperative MAP is advantageous for better recovery after SCI. Attention should be paid to the dynamic management of blood pressure to avoid the adverse effects of hypotension after SCI.

Veno-arterial extracorporeal membrane oxygenation (ECMO VA) as part of a multimodal approach for the protection of spinal cord ischemia in surgical repair of a thoracoabdominal aneurysm

Spinal cord ischaemia leading to paraplegia or paraparesis is one of the most devastating complications of aortic surgery. The risk of ischaemia is particularly high in repairs involving both the thoracic and abdominal segments, because in these cases blood flow to the spinal arteries can be interrupted. Multimodal protocols have now been developed to reduce the incidence of this complication, and include measures such as cerebrospinal fluid (CSF) drainage, avoidance of hypotension and anaemia, systemic hypothermia, neuromonitoring, maintaining distal perfusion during proximal clamping of the aorta, and reimplantation of intercostal or lumbar arteries, whenever feasible. We describe a case in which, due to the special characteristics of the surgery, veno-arterial extracorporeal membrane oxygenation (VA ECMO) was used to maintain distal blood flow in the lumbar, inferior mesenteric, and hypogastric arteries during aortic clamping. This approach reduced the risk of spinal cord and visceral ischaemia, and also eliminated the need for thoracotomy because partial left bypass was not required.

The effects of dexmedetomidine on intraoperative neurophysiologic monitoring modalities during corrective scoliosis surgery in pediatric patients: A systematic review

BACKGROUND

During scoliosis surgery, motor evoked potentials (MEP), and somatosensory evoked potentials (SSEP) have been reported to be affected by the use of higher doses of anesthetic agents. Dexmedetomidine, a sympatholytic agent, an alpha-2 receptor agonist, has been used as an adjunctive agent to lower anesthetic dose. However, there is conflicting evidence regarding the effects of dexmedetomidine on the intraoperative neurophysiological monitoring of MEP and SSEP during surgery, particularly among pediatric patients.

OBJECTIVES

This systematic review aimed to determine whether, during spinal fusion surgery in pediatric patients with scoliosis, dexmedetomidine alters MEP amplitude or SSEP latency and amplitude and, if so, whether different doses of dexmedetomidine display different effects (PROSPERO registration number CRD42022300562).

METHODS

We searched PubMed, Scopus, and Cochrane Library on January 1, 2022 and included randomized controlled trials, observational cohort and case-control studies and case series investigating dexmedetomidine in the population of interest and comparing against a standardized anesthesia regimen without dexmedetomidine or comparing multiple doses of dexmedetomidine. Animal and in vitro studies and conference abstracts were excluded.

RESULTS

We found substantial heterogeneity in the risk of bias (per Cochrane-preferred tools) of the included articles (n = 5); results are summarized without meta-analysis. Articles with the lowest risk of bias indicated that dexmedetomidine was associated with MEP loss and that higher doses of dexmedetomidine increased risk. In contrast, articles reporting no association between dexmedetomidine and MEP loss suffered from higher risk of bias, including suspected or confirmed problems with confounding, outcome measurement, participant selection, results reporting, and lack of statistical transparency and power.

CONCLUSION

Given the limitations of the studies available in the literature, it would be advisable to conduct rigorous randomized controlled trials with larger sample sizes to assess the effects of dexmedetomidine use of in scoliosis surgery in pediatric patients.

Risk Factors for Spinal Cord Injury during Endovascular Repair of Thoracoabdominal Aneurysm: Review of the Literature and Proposal of a Prognostic Score

Despite recent improvements, spinal cord ischemia remains the most feared and dramatic complication following extensive aortic repair. Although endovascular procedures are associated with a lower risk compared with open procedures, this risk is still significant and must be considered. A combined medical and surgical approach may help to optimize the tolerance of the spinal cord to ischemia. The aim of this review is to describe the underlying mechanism involved in spinal cord injury during extensive endovascular aortic repair, to describe the different techniques used to improve spinal cord tolerance to ischemia-including the prophylactic or curative use of spinal drainage-and to propose our algorithm for spinal cord protection and the rational use of spinal drainage.

Effects of fluids vs. vasopressors on spinal cord microperfusion in hemorrhagic shock induced ischemia/reperfusion

OBJECTIVE

Spinal cord injury induced by ischemia/reperfusion is a devastating complication of aortic repair. Despite developments for prevention and treatment of spinal cord injury, incidence is still considerably high majorly impacting patient outcome. Microcirculation is paramount for tissue perfusion and oxygen supply and often dissociated from macrohemodynamic parameters used to guide resuscitation. Effects of fluids vs. vasopressors in the setting of hemodynamic resuscitation on spinal cord microperfusion are unknown. Aim of this study was to compare the effects of vasopressor and fluid resuscitation on spinal cord microperfusion in a translational acute pig model of hemorrhagic shock induced ischemia/reperfusion injury.

METHODS

We designed this study as prospective randomized explorative large animal study. We induced hemorrhagic shock in 20 pigs as a model of global ischemia/reperfusion injury. We randomized animals to receive either fluid or vasopressor resuscitation. We measured spinal cord microperfusion using fluorescent microspheres as well as laser-Doppler probes. We monitored and analyzed macrohemodynamic parameters and cerebrospinal fluid pressure.

RESULTS

Spinal cord microperfusion decreased following hemorrhagic shock induced ischemia/reperfusion injury. Both fluids and vasopressors sufficiently restored spinal cord microperfusion. There were no important changes between groups (percentage changes compared to baseline: fluids 14.0 (0.31-27.6) vs. vasopressors 24.3 (8.12-40.4), p = .340). However, cerebrospinal fluid pressure was higher in animals receiving fluid resuscitation (percentage changes compared to baseline: fluids 27.7 (12.6-42.8) vs. vasopressors -5.56 ((-19.8)-8.72), p = .003). Microcirculatory resuscitation was in line with improvements of macrohemodynamic parameters.

CONCLUSIONS

Both, fluids and vasopressors, equally restored spinal cord microperfusion in a porcine acute model of hemorrhagic shock induced ischemia/reperfusion injury. However, significant differences in cerebrospinal fluid pressure following resuscitation were present. Future studies should evaluate these effects in perfusion disruption induced ischemia/reperfusion conditions of microcirculatory deterioration.

Spinal Cord Protection for Thoracoabdominal Aortic Surgery

Open and endovascular repairs of the descending thoracic and thoracoabdominal aorta are associated with a substantial risk of spinal cord injury, namely paraplegia. Endovascular repairs seem to have a lower incidence of spinal cord injury, but there have been no randomized trials comparing outcomes of open and endovascular repairs. Paraplegia occurs when collateral blood supply to the anterior spinal artery is impaired. The risk of spinal cord injury can be mitigated with perioperative protocols that include drainage of cerebrospinal fluid, avoidance of hypotension and anemia, intraoperative neurophysiologic monitoring, and advanced surgical techniques. Drainage of cerebrospinal fluid using a spinal drain decreases the risk of spinal cord ischemia by improving spinal cord perfusion pressure. However, cerebrospinal fluid drainage has risks including neuraxial and intracranial bleeding, and these risks need to be carefully weighed against its potential benefit. This review discusses current surgical management of descending thoracic and thoracoabdominal aortic disease, incidence of and risk factors for spinal cord injury, and elements of spinal cord protection protocols that pertain to anesthesiologists, with a focus on cerebrospinal fluid drainage.

Poliomyelomalacia in three dogs that underwent hemilaminectomy for intervertebral disk herniation

CASE DESCRIPTION

3 dogs were examined because of a sudden onset of signs of pain (1 dog) or paraparesis (2 dogs).

CLINICAL FINDINGS

Neurologic findings consisted of myelopathy affecting the lumbar intumescence (1 dog) and T3-L3 myelopathy (2 dogs). In all dogs, MRI revealed spinal cord compression caused by L3-4 disk herniation. All dogs underwent routine surgical decompression of the intervertebral disk herniation. During MRI and decompressive surgery, physiologic variables were monitored. Immediately after surgery, all dogs were paraplegic with pelvic limb neurologic dysfunction consistent with myelopathy affecting the L4 through caudal spinal cord segments.

TREATMENT AND OUTCOME

Within 24 hours after surgery, repeated MRI in all dogs revealed hyperintensity in the spinal cord gray matter of the lumbar intumescence on T2-weighted images. In the absence of neurologic improvement, dogs were euthanized at 3, 91, and 34 days after surgery. Postmortem microscopic examination of each dog's spinal cord at the lumbar intumescence revealed necrosis of the gray matter with relative white matter preservation suggestive of an ischemic injury.

CLINICAL RELEVANCE

Dramatic neurologic deterioration following decompressive surgery for intervertebral disk herniation in dogs may be associated with the development of poliomyelomalacia secondary to ischemia. In these 3 dogs, ischemia developed despite probable maintenance of normal spinal cord blood flow and perfusion during anesthesia. To exclude other causes, such as compression or hemorrhage, MRI was repeated and revealed hyperintensity of the spinal cord gray matter on T2-weighted images, which microscopically corresponded with ischemic neurons and neuronal loss.

A Study to Compare the Efficacy of a Biodegradable Dynamic Fixation System With Titanium Devices in Posterior Spinal Fusion Between Articular Processes in a Canine Model

The objective of this study was to apply a biodegradable dynamic fixation system (BDFS) for lumbar fusion between articular processes and compare the fusion results and biomechanical changes with those of conventional rigid fixation. Twenty-four mongrel dogs were randomly assigned to 2 groups and subjected to either posterior lumbar fusion surgery with a BDFS or titanium rods (TRs) at the L5-L6 segments. Six animals in each group were sacrificed at 8 or 16 weeks. Fusion conditions were evaluated by computed tomography (CT), manual palpation, biomechanical tests, and histological analysis. Biomechanical tests were performed at the L4-7 (for range of motion (ROM)) and L5-6 (for fusion stiffness) segments. Histological examination was performed on organs, surrounding tissues, and the fused area. The magnesium alloy components maintained their initial shape 8 weeks after the operation, but the meshing teeth were almost completely degraded at 16 weeks. The biomechanical analysis revealed an increased lateral bending ROM at 8 weeks and axial torsion ROM at 16 weeks. The L4-5 extension-flexion ROMs in the BDFS group were 2.29 ± 0.86 deg and 3.17 ± 1.08 deg at 16 weeks, respectively, compared with 3.22 ± 0.56 deg and 5.55 ± 1.84 deg in TR group. However, both groups showed similar fusion results. The BDFS design is suitable, and its degradation in vivo is safe. The BDFS can be applied for posterior lumbar fusion between articular processes to complete the fusion well. Additionally, the BDFS can reduce the decline in lateral motion and hypermotion of the cranial adjacent segment in flexion-extension motion.

Severe intraluminal atheroma and iliac artery access affect spinal cord ischemia after thoracic endovascular aortic repair for degenerative descending aortic aneurysm

OBJECTIVES

This study aimed to reveal additional factors potentially contributing to the multifactorial ethiopathogenesis of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) for descending thoracic aortic aneurysm (TAA).

METHODS

The medical records of 293 patients who underwent TEVAR without debranching procedures for descending TAA between 2011 and 2018 were retrospectively reviewed. We excluded the following cases from the study: 72 patients with aortic dissection; 15 with rupture; 14 with anastomotic pseudoaneurysm; 22 with re-TEVAR; 34 without evaluation of the artery of Adamkiewicz (AKA). Sufficient data were available for 136 patients (79% men; mean age of 76 ± 7.4 years). We conducted univariable and multivariable analyzes using the logistic regression analysis to assess the relationship between pre-/intraoperative factors and postoperative SCI.

RESULTS

SCI was observed in nine patients (6.8%). Severe intraluminal atheroma [odds ratio (OR), 6.23; p = 0.014] and iliac artery access (OR 4.65; p = 0.043) were identified as the positive predictors of SCI by univariable analysis. Risk factors of SCI were determined additionally as follows: coverage of the intercostal artery branching AKA (ICA-AKA) (OR 4.89; p = 0.054); coverage of the ICA-AKA combined with iliac access (OR 10.1; p = 0.002); that combined with severe intraluminal atheroma (OR 13.7; p = 0.001).

CONCLUSION

Severe intraluminal atheroma and iliac artery access were the independent predicting factors of SCI after TEVAR for degenerative descending TAA. In patients with complicated aortoiliofemoral access route, coverage of the ICA-AKA is associated with the risk of SCI.

Relationships between spinal cord blood flow measured with flow-sensitive alternating inversion recovery (FAIR) and neurobehavioral outcomes in rat spinal cord injury

In the traumatically injured spinal cord, decreased perfusion is believed to contribute to secondary tissue damage beyond the primary mechanical impact, and restoration of perfusion is believed to be a promising therapeutic target. However, methods to monitor spinal cord perfusion non-invasively are limited. Perfusion magnetic resonance imaging (MRI) techniques established for the brain have not been routinely adopted to the spinal cord. The purpose of this study was to examine the relationship between spinal cord blood flow (SCBF) and injury severity in a rat thoracic spinal cord contusion injury (SCI) model using flow-sensitive alternating inversion recovery (FAIR) with two variants of the label position. SCBF as a marker of severity was compared to T₁ mapping and to spinal cord-optimized diffusion weighted imaging (DWI) with filtered parallel apparent diffusion coefficient. Thirty-eight rats underwent a T10 contusion injury with varying severities (8 sham; 10 mild; 10 moderate; 10 severe) with MRI performed at 1 day post injury at the lesion site and follow-up neurological assessments using the Basso, Beattie, Bresnahan (BBB) locomotor scoring up to 28 days post injury. Using whole-cord regions of interest at the lesion epicenter, SCBF was decreased with injury severity and had a significant correlation with BBB scores at 28 days post injury. Importantly, estimates of arterial transit times (ATT) in the injured spinal cord were not altered after injury, which suggests that FAIR protocols optimized to measure SCBF provide more value in the context of acute traumatic injury to the cord. T₁-relaxation time constants were strongly related to injury severity and had a larger extent of changes than either SCBF or DWI measures. These findings suggest that perfusion decreases in the spinal cord can be monitored non-invasively after injury, and multi-parametric MRI assessments of perfusion, diffusion, and relaxation capture unique features of the pathophysiology of preclinical injury.

Neurophysiologic Detection of Spinal Cord Ischemia During Anterior Vertebral Tethering

STUDY DESIGN

Case report.

OBJECTIVE

The aim of this study was to present how computed tomographic angiography (CTA) and intraoperative neurophysiologic monitoring (IONM) detect spinal cord ischemia during anterior spine surgery. These data directed expedient surgical and anesthetic interventions that restored IONM signals and prevented neurologic sequalæ.

SUMMARY OF BACKGROUND DATA

Anterior vertebral tethering (AVT) is a fusionless surgical treatment of adolescent idiopathic scoliosis (AIS).

METHODS

AVT was performed on a skeletally immature patient with AIS. Preoperative CTA detailed location of the dominant radicular artery (DRA). Transcranial motor (tcMEP) and somatosensory (SEP) evoked potentials were monitored during operation.

RESULTS

There was significant decline in tcMEP, but not SEP, after compression of the DRA during cable tensioning of AVT. There was complete tcMEP recovery following release of instrumentation.

CONCLUSION

This article identifies a rare but potentially catastrophic vascular hazard associated with anterior spine operation, including AVT. Sacrifice of multiple unilateral segmental vessels may overwhelm the capacity of collateral spinal cord perfusion to compensate for DRA blood supply. This vascular risk may be eliminated by identifying the DRA in order that it may be preserved during the procedure.

LEVEL OF EVIDENCE

5.

Collateral Circulation in Spinal Cord Injury: A Comprehensive Review

Surgery is the most common cause of spinal cord ischemia; it is also caused by hemodynamic changes, which disrupt the blood flow. Direct ligation of the spinal arteries, especially the Adamkiewicz artery is involved as well. Other causes of spinal cord ischemia include arteriography procedures, thoracic surgery, epidural and rachianesthesia, foraminal infiltration, arterial dissection, systemic hypotension, emboligenic heart disease, thoracic disc herniation, and compression. Understanding the vascular anatomy of the spinal cord is essential to develop optimal strategies for preventing ischemic injuries to the spinal cord. During ischemia, a rich network of intra and paraspinal collaterals allow enough blood flow to compensate the intensity of spinal cord ischemia. In case of interruption of flow of a main artery, the collateral artery increases its flow to maintain perfusion to the tissues. Avoiding spinal cord ischemia by using collateral circulation is necessary to prevent the establishment of hypovolemia, hyperthermia and elevations in venous pressures. The objective of this narrative review is to present the current concepts of spinal collateral circulation and its role in the setting of ischemic events, affecting the vascular supply of the spinal cord.

Time-Course Changes and Role of Autophagy in Primary Spinal Motor Neurons Subjected to Oxygen-Glucose Deprivation: Insights Into Autophagy Changes in a Cellular Model of Spinal Cord Ischemia

Spinal cord ischemia is a severe clinical complication induced by thoracoabdominal aortic surgery, severe trauma, or compression to the spinal column. As one of the most important functional cells in the spinal cord, spinal motor neurons (SMNs) suffer most during the process since they are vulnerable to ischemic injury due to high demands of energy. Previous researches have tried various animal models or organotypic tissue experiments to mimic the process and get to know the pathogenesis and mechanism. However, little work has been performed on the cellular model of spinal cord ischemia, which has been hampered by the inability to obtain a sufficient number of pure primary SMNs for in vitro study. By optimizing the isolation and culture of SMNs, our laboratory has developed an improved culture system of primary SMNs, which allows cellular models and thus mechanism studies. In the present study, by establishing an in vitro model of spinal cord ischemia, we intended to observe the dynamic time-course changes of SMNs and investigate the role of autophagy in SMNs during the process. It was found that oxygen-glucose deprivation (OGD) resulted in destruction of neural networks and decreased cell viability of primary SMNs, and the severity increased with the prolonging of the OGD time. The OGD treatment enhanced autophagy, which reached a peak at 5 h. Further investigation demonstrated that inhibition of autophagy exacerbated the injury, evidencing that autophagy plays a protective role during the process.

Direct Monitoring of Reconstructed Segmental Arterial Pressure during Deep Hypothermic Thoracoabdominal Aortic Aneurysm Surgery

Deep hypothermia in thoracoabdominal aortic aneurysm operations is considered extremely useful for ensuring sufficient time to reconstruct the segmental arteries feeding the spinal cord. However, because the amplitude of motor evoked potentials (MEPs) decrease or disappear during deep hypothermia, feasible methods for assessing spinal cord circulation have not yet been reported. Performing additional segmental arterial reconstructions that rely on MEPs is also impractical. In the present case, to ascertain spinal cord circulation under deep hypothermia, we intraoperatively measured the reconstructed segmental arterial pressure in real time and investigated whether sufficient spinal cord blood flow had been attained.

Transapical aortic perfusion using a deep hypothermic procedure during descending thoracic or thoracoabdominal aortic surgery

BACKGROUND

In descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) surgery, though proximal anastomosis using deep hypothermic circulatory arrest (DHCA) is often selected, there are issues surrounding brain and heart protection. In this study, the usefulness of concomitant upper body perfusion via transapical aortic cannulation during deep hypothermic surgery was examined.

METHODS

Between October 2014 and May 2019, 5 patients (Crawford extent II chronic dissection, N.=3; extent IV aneurysms, N.=1; DTAA, N.=1) underwent DTAA/TAAA repair under deep hypothermia using transapical aortic perfusion. A proximal anastomosis and artery of Adamkiewicz (AKA) reconstruction were performed under continuous perfusion of the upper and lower body at 20 °C.

RESULTS

The time from aortic cross-clamping to proximal anastomosis was 69±33 minutes, and it took 86±47 minutes to AKA reperfusion. There was no spinal cord ischemic injury or brain or heart complications. One patient required tracheostomy, and the average postoperative intubation time for the other patients was 57±52 hours. All patients were discharged, and the average postoperative hospital stay was 25.6±8.1 days.

CONCLUSIONS

Concomitant upper body perfusion by the transapical aortic approach contributes to avoidance of brain and heart complications and maintaining spinal cord circulation under deep hypothermic DTAA/TAAA surgery.

In vivo assessment of spinal cord elasticity using shear wave ultrasound in dogs

OBJECTIVE

Evaluation of living tissue elasticity has wide applications in disease characterization and prognosis prediction. Few previous ex vivo attempts have been made to characterize spinal cord elasticity (SCE). Recently, tissue elasticity assessment has been clinically feasible using ultrasound shear wave elastography (SWE). The current study aims to characterize SCE in healthy dogs, in vivo, utilizing SWE, and to address SCE changes during compression.

METHODS

Ten Greyhound dogs (mean age 14 months; mean weight 14.3 kg) were anesthetized and tracheally intubated, with hemodynamic and neurological monitoring. A 3-level, midcervical laminectomy was performed. SCE was assessed at baseline. Next, 8- and 13-mm balloon compressions were sequentially applied ventral to the spinal cord.

RESULTS

The mean SCE was 18.5 ± 7 kPa. Elasticity of the central canal, pia mater, and dura mater were 21.7 ± 9.6 kPa, 26.1 ± 14.8 kPa, and 63.2 ± 11.5 kPa, respectively. As expected, the spinal cord demonstrated less elasticity than the dura mater (p < 0.0001) and pia mater (trend toward significance p = 0.08). Notably, the 13-mm balloon compression resulted in a stiffer spinal cord than at baseline (233 ± 73 kPa versus 18.5 ± 7 kPa, p < 0.0001) and 8-mm balloon compression (233 ± 73 kPa versus 185 ± 68 kPa, p < 0.048).

CONCLUSIONS

In vivo SCE evaluation using SWE is feasible and comparable to earlier reports, as demonstrated by physical sectioning of the spinal cord. The compressed spinal cord is stiffer than a free spinal cord, with a linear increase in SCE with increasing mechanical compression. Knowledge of the biomechanical properties of the spinal cord including SCE has potential implications for disease management and prognosis.

Posterior reversible encephalopathy syndrome following elevated mean arterial pressures for cervical spinal cord injury

BACKGROUND

Increasing the mean arterial pressure (MAP) is an accepted treatment modality to minimize the risk for irreversible neurologic damage secondary to spinal cord ischemia. Posterior reversible encephalopathy syndrome (PRES) is a rare complication occurring after transplantation surgery, in persons having an autoimmune disorder or after abrupt increases in blood pressure of various etiologies.

STUDY DESIGN

Case report.

METHODS

Retrospective evaluation of medical records.

RESULTS

A 68-year-old female with long-standing diabetes, and rheumatoid arthritis (treated with methotrexate) presented with bilateral upper extremity weakness and numbness developing several days after a motor vehicle accident. Physical examination confirmed decreased upper extremity motor strength and decreased sensation to light touch and pinprick in the C5-C6 dermatomal distribution. Magnetic resonance imaging (MRI) demonstrated C5-C6 subluxation with spinal cord compression. The patient had traction applied and mean arterial pressures were elevated greater than 85 mmg. The following day the patient underwent anterior and posterior cervical spine fusion and decompression. Immediately post-operatively, the patient developed status epilepticus. Head MRI revealed areas of high T2 signal intensity in the bilateral occipital lobes, consistent with a diagnosis of PRES. Two weeks later, the patient had resolution of her symptoms and resolution of PRES on imaging.

CONCLUSION

This is the first report of posterior reversible encephalopathy syndrome secondary to therapeutic blood pressure increase in the setting of cervical spine fracture with neurological deficits. The patients had resolution of symptoms following discontinuation of the MAP goals. Posterior reversible encephalopathy syndrome (PRES) is a life-threatening condition characterized by seizures, confusion, visual disturbance, and headaches alongside neuroradiological findings indicative of posterior cerebral hemispheric white matter edema.^1,2 PRES has been described in association with abrupt blood pressure elevation, autoimmune disorders, or transplantation.^1-4 In this case report PRES presented with typical status epilepticus⁵ but in an unexpected clinical setting, immediately after anterior cervical decompression and fusion (ACDF) and posterior cervical fusion (PCF) with laminectomy of C5-C6.