Posterior Reversible Encephalopathy Syndrome: Temporary Visual Loss After Spinal Deformity Surgery
Posterior reversible encephalopathy syndrome (PRES) is a rare cause of temporary postoperative visual loss (POVL) after spinal deformity surgery. We report on 2 patients diagnosed with PRES after spinal deformity surgery, who were closely examined postoperatively. A 78-year-old woman with severe disability due to degenerative lumbar spondylosis after laminectomy was treated with transpsoas lumbar interbody fusion from L1 to L4 and posterior spinal fusion from T10 to pelvis. She developed confusion and bilateral visual loss on postoperative day 7. A second patient, a 51-year-old woman with progressive pain and decompensation caused by adult scoliosis, was treated with posterior spinal fusion from T3 to pelvis and interbody fusion from L4 to S1 via a presacral interbody fusion approach. She developed bilateral visual loss on postoperative day 15. Both patients achieved a complete recovery of their vision after medical management of PRES. Timely diagnosis of PRES and prompt intervention allow for a good patient prognosis and complete recovery of eyesight.
Both patients undergoing spinal deformity surgery in this report suffered from intermittent hypertensive episodes in the postoperative period. One patient also developed acute renal failure during her hospital stay, and demonstrated low albumin levels postoperatively, which has also been associated with PRES.24 Through the immediate diagnosis and primary control of hypertension, both patients achieved complete neurologic recovery after a mean of 1.5 days (range, 1-2 days); this compares to a recovery period of an average 6.2 days (range, 1-14 days) reported by Ni and colleagues.3 The catastrophic effects of a misdiagnosis and incorrect or untimely treatment were well described in this case report. Several patients who were incorrectly diagnosed with demyelinating disorders or lupus encephalopathy received high doses of immunosuppressants and corticosteroids, known risk factors for the development of PRES.3 The patients subsequently rapidly deteriorated; no patients had a full recovery of their preoperative eyesight, and 1 patient developed complete permanent blindness.3 Optimized multidisciplinary collaboration allowing for a rapid neuro-ophthalmic examination and appropriate neuroimaging will permit an accurate and rapid diagnosis, leading to timely intervention and restoration of vision.
Conclusion
Temporary POVL is a potentially devastating complication of spinal surgery and general anesthesia. The more frequent causes such as ischemic optic neuropathy, retinal artery occlusion, and cortical blindness have very limited effective options for treatment and an overall poor prognosis. The inclusion of PRES in the differential diagnosis of POVL may allow early detection, management, and restoration of vision.
