67 year-old female with a history of rheumatoid arthritis (RA) and pulmonary hypertension (PH) presented for urgent C4-C5 anterior diskectomy and C3-C6 posterior fusion for cervical subluxation. C-spine MRI showed severe cord impingement. The patient was brought to the operating room with minimal sedation to avoid exacerbation of PH. The radial artery was inaccessible due to flexion deformities, thus a brachial arterial line was placed. Awake fiberoptic intubation was performed with dexmedetomidine, followed by demonstration of movement of all four extremities. The anesthesia was maintained with dexmedetomidine and desflurane. The anterior and posterior portions of the procedure were performed uneventfully with no change in baseline somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP). The patient was extubated at the end of the case and was followed in the intensive care unit (ICU) and was discharged to rehabilitation in good condition.