Intractable postural hypotension resulting from cervical pseudomeningocele after a posterior cervical spinal surgery: a case report

Spinal Cord Series and Cases, 2023 · DOI: 10.1038/s41394-023-00572-8 · Published: March 29, 2023

Spinal Cord Injury Cardiovascular Science Spinal Disorders

Simple Explanation

Postural hypotension (PH) is a common issue for individuals with spinal cord injuries, particularly those with tetraplegia, and can hinder their rehabilitation progress. Identifying and addressing underlying causes of PH is crucial before starting any treatments. This case report describes a patient with a cervical spinal cord injury who experienced persistent PH due to a pseudomeningocele (a collection of fluid outside the spinal cord). The PH resolved after surgical correction of the pseudomeningocele, allowing the patient to progress with rehabilitation. The authors suggest that pseudomeningocele should be considered as a potential cause of PH in patients with tetraplegia, especially when the PH is difficult to explain or treat with standard methods.

Study Duration

Not specified

Participants

1 patient with C6 ASIA Impairment Scale (AIS) A SCI

Evidence Level

Level 4: Case Report

Key Findings

1
A patient with post-acute cervical SCI suffered from intractable PH resulting from pseudomeningocele causing unfavorable rehabilitation outcomes.
2
Surgical correction of the pseudomeningocele led to the immediate disappearance of PH, enabling the patient to progress in their rehabilitation program.
3
The authors propose a mechanism for pseudomeningocele-induced PH related to cerebral perfusion pressure hemostasis, where CSF drainage into the pseudomeningocele in an upright position leads to intracranial hypotension and a compensatory decrease in blood pressure.

Research Summary

This case report highlights an unusual cause of intractable postural hypotension (PH) in a patient with a cervical spinal cord injury (SCI). The patient developed PH that was resistant to conventional treatments. A pseudomeningocele, a collection of fluid outside the spinal cord, was identified as the cause of the PH. Surgical repair of the pseudomeningocele resulted in the resolution of the PH and allowed the patient to proceed with rehabilitation. The authors suggest that clinicians should consider pseudomeningocele as a potential cause of PH in patients with SCI, especially those with tetraplegia and unexplained or intractable PH, and recommend physical examination and MRI in such cases.

Practical Implications

Diagnostic Consideration

Clinicians should consider pseudomeningocele in the differential diagnosis of intractable PH in SCI patients, especially those with tetraplegia.

Physical Examination Importance

Emphasize thorough physical examination of the surgical site for signs of pseudomeningocele in post-surgical SCI patients presenting with PH.

Imaging Recommendation

Consider MRI to rule out pseudomeningocele in SCI patients with intractable and unexplained PH, particularly if physical examination raises suspicion.

Study Limitations

1
This is a single case report, limiting the generalizability of the findings.
2
The proposed mechanism of pseudomeningocele-induced PH is hypothetical and requires further investigation.
3
Lack of continuous blood pressure monitoring during the blacking out episodes limits the ability to directly correlate blood pressure with symptoms.

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