Delayed spinal cord infarction following anterior cervical surgical decompression

Atraumatic Cervical Disc Herniation With Rapidly Progressive Myelopathy in a 47-Year-Old Male: A Case Report

Atraumatic acute myelopathy caused by idiopathic disc herniation is rare. This case presents a 47-year-old male with a sudden onset of severe neck pain and weakness upon waking that progressively worsened. His rapidly progressive myelopathy led to an MRI of the cervical spine, revealing severe spinal canal stenosis at the C6-C7 level due to a large disc herniation deforming the spinal cord. The patient underwent anterior cervical discectomy and fusion (ACDF) at the C6-C7 level. Postoperatively, he showed significant improvement in pain and paresthesia, though some residual numbness and balance issues persisted. This case highlights the rapid progression and severe neurological impact of cervical spinal stenosis due to disc herniation. Despite reassuring findings on initial CT imaging, the patient's rapidly worsening symptoms on reassessment prompted an MRI, which confirmed the diagnosis and highlighted the urgent need for surgical intervention. The successful outcome for this patient is largely due to the rapid identification and surgical decompression of his severe cervical spinal cord compression. Cervical spinal stenosis, particularly when associated with disc herniation, can lead to profound, irreversible neurological impairment if not promptly addressed. This case demonstrates the critical need for early clinician identification and surgical intervention to prevent permanent deficits and improve patient outcomes.

Delayed Lower Extremity Monoplegia After Anterior Cervical Discectomy and Fusion: A Report of a Rare Case of Cervical Spinal Ischemic Reperfusion Injury

White cord syndrome is an extremely rare type of cervical spinal cord ischemia characterized by sudden neurological deterioration following surgical spinal decompression. The underlying cause is believed to be immediate relief from chronic compression on the spinal cord, triggering an inflammatory response known as ischemic reperfusion injury. A 49-year-old male presented in the office with neck pain and chronic symptoms of progressive cervical myelopathy: clumsiness, gait instability, and dropping things. An MRI of the cervical spine demonstrated severe central canal stenosis with spinal cord compression and myelomalacia at the C3-C4 level. The patient underwent a planned anterior cervical discectomy and fusion procedure from C3 to C5. Following the surgery, he developed monoplegia in his left lower extremity. His postoperative MRI revealed white cord syndrome, characterized by an increase in the signal change of the spinal cord. This finding was consistent with an ischemic reperfusion injury to the spinal cord post-decompression. White cord syndrome is thought to be caused by a reperfusion injury following surgical decompression of a previously compressed segment of the spinal cord, characterized by the rapid return of blood flow. This involves oxidative damage caused by free oxygen radicals and inflammatory molecules, such as reactive oxygen species, which lead to lipid peroxidation of neuronal membranes. Surgeons should be aware of this rare complication and warn patients preoperatively.

Cervical Spinal Cord Ischemic Reperfusion Injury: A Comprehensive Narrative Review of the Literature and Case Presentation

Cervical spinal ischemic reperfusion injury (CSIRI) refers to a state of sudden neurological deterioration after surgical spinal decompression. The CSCIRI refers to a state of sudden neurological deterioration after surgical spinal decompression. The pathophysiology is hypothesized to be due to instant relief of a chronically compressed spinal cord, leading to an inflammatory cascade named ischemic reperfusion injury. Deterioration of neurological function after cervical spine decompression surgery often occurs secondary to direct cord injury, compressing hematoma, or hardware failure. Complete loss of neurological function with no organic explanation is an extremely rare complication, with only a few cases reported in the literature. We are reporting a 67-year-old male patient diagnosed with severe cervical spinal canal stenosis at level C5/6 who underwent anterior cervical discectomy and fusion (ACDF). The patient developed complete transient loss of neurological functions after the surgery and was labeled as a case of CSCIRI after excluding compressing pathology. A literature review of the CSCIRI was carried out, and ten articles were included. Due to the rarity of these cases, there is no class 1 or 2 evidence to establish management protocol nor identifiable risk factors to predict their occurrence. However, we recommend using an intra-operative neurophysiology monitor in cases with long-standing severe cervical canal stenosis with myelomalacia and managing these cases according to the acute spinal cord injury management protocol after excluding compressing pathologies.

White Cord Syndrome: A Reperfusion Injury Following Spinal Decompression Surgery

Reperfusion injury of the spinal cord has been scarcely reported. Herein, we present a case of white cord syndrome after spinal decompression. A 61-year-old male, who initially had ossification of the posterior longitudinal ligament at C3-6 level, was admitted to our hospital with a ruptured disc at the C6-7 level. The patient experienced radiating pain in both upper extremities. Anterior cervical discectomy and fusion was performed. However, the patient developed quadriplegia. Emergency magnetic resonance imaging revealed a new and enlarged signal change in the spinal cord at the C4-7 level. Additional posterior decompression surgery was performed. After intense rehabilitation, the patient’s motor function improved to grade 4. White cord syndrome is likely due to reperfusion injury following operative decompression of a compressed spinal cord segment. Although rare, spine surgeons should be aware of this complication and warn patients preoperatively.

Reperfusion Injury (RPI)/White Cord Syndrome (WCS) Due to Cervical Spine Surgery: A Diagnosis of Exclusion

Background:

Following acute cervical spinal cord decompression, a subset of patients may develop acute postoperative paralysis due to Reperfusion Injury (RPI)/White Cord Syndrome (WCS). Pathophysiologically, this occurs due to the immediate restoration of normal blood flow to previously markedly compressed, and under-perfused/ischemic cord tissues. On emergent postoperative MR scans, the classical findings for RPI/ WCS include new or expanded, and focal or diffuse intramedullary hyperintense cord signals consistent with edema/ischemia, swelling, and/or intrinsic hematoma. To confirm RPI/WCS, MR studies must exclude extrinsic cord pathology (e.g. extramedullary hematomas, new/residual compressive disease, new graft/vertebral fracture etc.) that may warrant additional cervical surgery to avoid permanent neurological sequelae.

Methods:

In the English literature (i.e. excluding 2 Japanese studies), 9 patients were identified with postoperative RPI/WCS following cervical surgical procedures. For 7 patients, new acute postoperative neurological deficits were appropriately attributed to MR-documented RPI/WCS syndromes (i.e. hyperintense cord signals). However, for 2 patients who neurologically worsened, MR studies demonstrated residual extrinsic disease (e.g. stenosis and OPLL) warranting additional surgery; therefore, these 2 patients did not meet the criteria for RPI/WCS.

Results:

The diagnosis of RPI/WCS is one of exclusion. It is critical to rule out residual extrinsic cord compression where secondary surgery may improve/resolve neurological deficits.

Conclusions:

Patients with acute postoperative neurological deficits following cervical spine surgery must undergo MR studies to rule out extrinsic cord pathology before being diagnosed with RPI/WCS. Notably, 2 of the 9 cases of RPI/WCS reported in the literature required additional surgery to address stenosis and OPLL, and therefore, did not have the RPI/WCS syndromes.

'White cord syndrome', a rare but disastrous complication of transient paralysis after posterior cervical decompression for severe cervical spondylotic myelopathy and spinal stenosis: A case report

Transient paralysis following spinal decompression surgery is a rare but devastating postoperative complication. Spinal cord ischemia-reperfusion injury has been identified as one of the crucial pathogenic factors contributing to the sudden neurological deterioration associated with spinal decompression surgery. 'White cord syndrome' is a characteristic imaging manifestation of spinal cord ischemia-reperfusion injury, referring to high intramedullary signal changes in the sagittal T2-weighted MRI scan with unexplained neurological deficits following surgical decompression. The present study reported on the case of a 51-year old male patient who suffered from acute left limb hemiplegic paralysis following posterior cervical laminectomy decompression for severe cervical spondylotic myelopathy and spinal stenosis, which were caused by ossification of the posterior longitudinal ligament. The patient's neurological function gradually improved after the immediate administration of high-dose methylprednisolone therapy combined with mannitol and neurotrophic drugs. At the 2-month follow-up, the intensity of the spinal cord signal on MRI had almost returned to normal and the 'white cord syndrome' had disappeared. However, the patient complained of postoperative neck swelling pain caused by cerebrospinal fluid leakage; therefore, an additional cerebrospinal fluid leakage exploration and neoplasty were performed. At 2 weeks after the second surgery, the patient's neck swelling pain was relieved and the area of cerebrospinal fluid leakage was significantly reduced. Despite the low incidence rate, surgeons should be aware of this complication, particularly when treating chronic severe cervical spinal stenosis with anterior or posterior decompression. Once transient paralysis occurs, early diagnosis and interventions are essential to reverse the neurological deficit.