Elsevier

World Neurosurgery

Volume 113, May 2018, Pages 33-36
World Neurosurgery

Case Report
“White Cord Syndrome” of Acute Hemiparesis After Posterior Cervical Decompression and Fusion for Chronic Cervical Stenosis

https://doi.org/10.1016/j.wneu.2018.02.026Get rights and content

Highlights

  • White cord syndrome manifests as acute neurologic deficits after cervical decompression surgery.

  • New hyperintensity on T2 MRI of the cervical cord is suggestive of the syndrome.

  • Ischemic-reperfusion injury is a likely mechanism.

  • High-dose steroid therapy and acute rehabilitation prove beneficial.

Background

“White cord syndrome” is a very rare condition thought to be due to acute reperfusion of chronically ischemic areas of the spinal cord. Its hallmark is the presence of intramedullary hyperintense signal on T2-weighted magnetic resonance imaging sequences in a patient with unexplained neurologic deficits following spinal cord decompression surgery. The syndrome is rare and has been reported previously in 2 patients following anterior cervical decompression and fusion. We report an additional case of this complication.

Case Description

A 68-year-old man developed acute left-sided hemiparesis after posterior cervical decompression and fusion for cervical spondylotic myelopathy. The patient improved with high-dose steroid therapy.

Conclusions

The rare white cord syndrome following either anterior cervical decompression and fusion or posterior cervical decompression and fusion may be due to ischemic-reperfusion injury sustained by chronically compressed parts of the spinal cord. In previous reports, patients have improved following steroid therapy and acute rehabilitation.

Introduction

Posterior cervical decompression and fusion is a frequently performed technique for cervical spondylotic myelopathy. The procedure is known to have good clinical outcomes, usually improving or halting progression of symptoms in most patients. Neurologic deficits associated with the procedure are rare, occurring at a rate of approximately 0.18%, and are usually secondary to expanding hematomas or iatrogenic injuries.1 In very rare cases, the etiology of the neurologic deficits is not readily identified and is suspected to be due to reperfusion injury—the so-called “white cord syndrome.” First described by Chin et al.,2 white cord syndrome refers to the observation of intramedullary hyperintensity on postoperative T2-weighted MRI sequences in the setting of unexplained neurologic deficits after cervical spinal cord decompression. Hypothetically, decompression of a chronically compressed cervical cord results in reperfusion injury owing to damage caused by free radical oxygen species and potentially direct trauma from the quick flow of blood back into the area. We report the third case of this complication after cervical cord decompression.

Section snippets

Case Description

A 68-year-old man with a 2- to 3-year history of worsening intermittent paresthesias, numbness, intermittent balance difficulties, and pain in the bilateral upper extremities was referred to our neurosurgical team. Cervical MRI demonstrated moderate to severe cervical stenosis with bilateral neuroforaminal narrowing at C4-C6 levels secondary to multilevel degenerative changes, C4-C5 spondylolisthesis, and a nonspecific hyperintense intramedullary signal at C5 on the left (Figure 1). At initial

Discussion

White cord syndrome is a rare complication of surgery of the spinal cord. This ischemic-edematous lesion of the cord is attributed to injury owing to immediate reperfusion of the newly decompressed cord. Chin et al.2 reported the first case of the syndrome: a 59-year-old man who sustained acute tetraplegia at and below the C6 level after a C5-C6 anterior cervical decompression and fusion for C5-C6 disc herniation causing cord compression. The patient was managed with intraoperative intravenous

Conclusions

White cord syndrome is a rare complication that may follow anterior cervical decompression and fusion or posterior cervical decompression and fusion. A hyperintense spinal cord signal on T2-weighted MRI in a patient with otherwise unexplained neurologic deficits after loss of SSEPs and MEPs in a cervical decompression should raise suspicion for this syndrome. Future studies may identify risk factors (radiographic or epidemiologic) for this complication and elucidate the mechanisms behind this

References (9)

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    Such severely-compressed spinal cords likely suffer prolonged ischemic conditions. Rapid reperfusion of the blood flow in the central nerve system after ischemia causes further damage to hypoxic tissues, which is called as ischemia-reperfusion injury or white cord syndrome [20–23]. Such pathomechanisms may also be related to delayed neurological deterioration.

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    The etiology of white cord syndrome is unknown. Nevertheless, the most widely accepted theory is that it develops from a reperfusion injury on a chronically compressed cord [1,2]. In this sense, the chronically compressed cord becomes susceptible to ischemia due to occlusive thrombi and the presence of edema from an increase in vascular permeability and venous congestion [4].

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    The most common postoperative complications include C5 palsy, wound infection, and cerebrospinal fluid leak. Neurologic deficits associated with the procedure are rare, with a reported rate of 0.18%, and are generally secondary to compressive hematomas or iatrogenic injury.3 Recently, there have been several reports of severe neurological deficits after routine cervical decompression surgeries without apparent intraoperative complications.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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