Case Report“White Cord Syndrome” of Acute Hemiparesis After Posterior Cervical Decompression and Fusion for Chronic Cervical Stenosis
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
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Cited by (23)
White cord syndrome secondary to decompressive laminectomy associated with cervical arthrodesis in a patient with diffuse idiopathic skeletal hyperostosis and posterior longitudinal ligament ossification
2023, Interdisciplinary Neurosurgery: Advanced Techniques and Case ManagementSeveral pathologies cause delayed postoperative paralysis following posterior decompression and spinal fusion for thoracic myelopathy caused by ossification of the posterior longitudinal ligament
2022, Journal of Orthopaedic ScienceCitation Excerpt :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.
White cord syndrome in a pediatric patient: A case report and review
2020, Radiology Case ReportsCitation Excerpt :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].
Reperfusion “White Cord’’ Syndrome in Cervical Spondylotic Myelopathy: Does Mean Arterial Pressure Goal Make a Difference? Additional Case and Literature Review
2020, World NeurosurgeryCitation Excerpt :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.
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.