White Cord Syndrome Causing Transient Tetraplegia After Posterior Decompression and Fusion

"White Cord Syndrome" as clinical manifestation of the spinal cord reperfusion syndrome: a systematic review of risk factors, treatments, and outcome

OBJECTIVE

Paralysis subsequent to spinal cord decompression in the cervical or thoracic region is infrequent, with White Cord Syndrome (WCS) being among its several causes. Due to WCS's infrequency, there exists a paucity of high-level evidence concerning its manifestations. Our primary objective is to systematically collate all documented WCS cases, discern prevalent risk and prognostic factors, appraise available treatment modalities, and evaluate patient outcomes.

METHODS

A systematic review was conducted following PRISMA guidelines. The search included PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria required studies to be written in English, be case reports, and contain data on clinical features, management, and treatment outcomes. Exclusion criteria excluded meta-analyses, reviews, editorials, letters, books, studies with insufficient clinical data, and studies not in English or with unavailable full texts. Grey literature was not actively pursued due to identification challenges, potentially introducing selection bias. Two authors independently evaluated papers based on criteria. Disagreements were resolved with a third author. Additionally, the included articles' references were screened for additional relevant articles.

RESULTS

We found a total of 580 articles through our electronic search. After removing duplicates, 399 articles were screened. Out of the remaining 51 studies, 27 were included in the final quantitative analysis. The average age was 54 (3-79 years) with a male-to-female ratio of 2:1, 33% had OPLL, and Common medical histories were hypertension (30%), diabetes mellitus (20%), and previous ACDF surgery (8%). Of all Surgeries, 70% were done with a posterior approach and 30% with the anterior approach. 48% of cases used Intraoperative NeuroMonitoring(IONM), and Loss of Motor Evoked Potentials (MEP) occurred in 37% of cases. Patients received high-dose intravenous steroids. In 26% of cases, additional posterior cervical decompression was performed, and efforts were made to maintain mean arterial pressure above 85 mmHg in 37% of cases. Other medications were administered in 30% of cases. Over an average 26-week follow-up, 37% of patients had good recovery, 40% had partial recovery, and 23% showed no recovery. The average final Nurick grade was 3.2.

CONCLUSIONS

WCS is a rare cause of postoperative neurological deficit following spinal cord decompression surgery. Risk factors for WCS include advanced age, extensive surgery, posterior approach for decompression, and the presence of OPLL. Treatment includes high-dose steroids, posterior cervical decompression, maintaining MAP over 85mmHg, rehabilitation, and sometimes neurotrophic drugs. Most patients can walk with or without assistance during follow-up, but around a quarter never regain neurological function. The only preoperative factor impacting outcomes is the preoperative neurological status (Nurick Grade).

White Cord Syndrome as a Rare Complication Post Cervical Spinal Decompression Surgery: A Case Report

White cord syndrome (WCS) is a rare complication following spinal decompression surgery, characterized by acute neurological deterioration and T2 hyperintensity on MRI. This is a case of a 60-year-old female with cervical myelopathy and significant cord compression who developed WCS after anterior cervical decompression and fusion (ACDF) at C5/6 and C6/7. Preoperatively, she presented with gait disturbances, dexterity issues, and left-sided weakness, progressively worsening over two years. Postoperatively, she experienced significant deterioration, with new motor deficits on the right upper limb and urinary retention. Despite initial improvements, she developed bowel incontinence and a complete loss of power in her left leg three weeks post surgery. Magnetic resonance imaging (MRI) excluded recurrent cord compression but showed progressive myelomalacia. Diagnosed with WCS, she was treated with high-dose dexamethasone, resulting in gradual neurological improvement.  White cord syndrome should be a main differential diagnosis in patients with unexplained neurological deterioration following cervical spinal decompression surgery, especially those with chronic cord compression. Further research is needed to better understand the pathophysiology and risk factors of WCS to improve outcomes.

White Cord Syndrome Following Long Posterior Decompression

Introduction

Ischemia/reperfusion cascade can cause severe tissue damage as documented in myocardial infarction, stroke, and peripheral occlusive vascular; however, Chin et al. first identified unexplained neurological deterioration after decompressive spinal surgery and attributed this to reperfusion injury of the spinal cord. As this appears as hyperintense signal changes in post-operative T2-weighted magnetic resonance image (MRI) sequences, it is termed as "white cord syndrome."

Case Report

A 63-year-old man presented with cervical myelopathy due to an ossified posterior longitudinal ligament and ossified ligamentum flavum, having Nurick's Grade IV posted for surgery. The patient underwent posterior instrumented decompression from 2nd cervical to 5th dorsal spine. Postoperatively, he had neurological deterioration and was investigated and found to have extensive cervical cord edema on MRI. There was no implant malposition.

Conclusion

WCS has to be ruled out in a case of unexplained neurological deterioration after decompressive spinal surgery, especially in the cervical and dorsal spine. The exact mechanism and treatment of WCS remain unexplained; spine surgeons should warn patients about WCS before surgery to prevent ethical and medicolegal issues.

White Cord Syndrome Following Cervical Surgery in a Patient With Klippel-Feil Syndrome: A Case Report

White cord syndrome is a rare entity, as there are very few cases described in the current literature. Postoperative MRI examination reveals cord intrinsic changes, including edema and ischemia. It is also described as a reperfusion injury of the spinal cord. This report depicts a rare case of "white cord syndrome" with tetraplegia after posterior laminectomy and fusion of the cervical spine in a patient with Klippel-Feil syndrome. A 33-year-old male patient with Klippel-Feil syndrome presented to our department with cervical myelopathy, claudication, deteriorating neurological status, imbalance, and lower limb spasticity. Due to kyphotic malformation of the cervical spine, a two-stage surgical intervention was scheduled. The patient first underwent anterior spinal fusion of C4-C6 with corpectomy of C5, where many anatomical and visceral differentiations were signed, so the surgical team was enhanced by a vascular surgeon. The postoperative period was uneventful and the patient was discharged after a week of hospitalization without any neurological deterioration. A second surgical intervention was scheduled after two months where laminectomy of C5-C7 and posterior fusion of C5-T1 were carried out. However, due to intraoperative spinal instability and various anatomical spinal variations, a third surgery, which would be occipitocervical fusion, was decided as the final surgical solution. During the third surgical operation, after the laminectomy of C1 to C5 and the placement of the occipital plate, the screws, and the two rods in situ, complete nullification of the intraoperative neurophysiologic control was signed. The internal fixation was removed immediately, the wake-up test revealed tetraplegia below C5, and the patient was transferred to the ICU. Immediate MRI revealed no spinal cord hematoma; however, spinal cord edema was present. The patient underwent a tracheostomy and remained quadriplegic with a sensory level of T8 and motor level of C5 and was discharged to a rehabilitation center. The possibility of white cord syndrome should be explained by surgeons before any cervical decompression surgery, as well as a thorough neurological examination should be performed postoperatively. The early recognition and prompt management of white cord syndrome is recommended.

White Cord Syndrome After Cervical Laminoplasty in an 81-Year-Old Man

White cord syndrome (WCS) shows high intramedullary signaling in T2-weighted MRI with worsening motor nerve symptoms after cervical spinal decompression surgery. It has been reported in only 13 cases. An 81-year-old man had numbness, weakness, and impaired fine motor control in both upper limbs for the previous five years. C3, C4, C6, open-door laminoplasty, and C5 laminectomy were performed. Intraoperative transcranial motor evoked potential normalization by compound muscle action potential showed an 80% reduction in amplitude in the right abductor pollicis brevis and a 96% reduction in the right abductor hallucis. Tetraplegia occurred immediately after the operation. Magnetic resonance imaging (MRI) on the day after the operation showed intramedullary T2 high signals at the C4 and C5 levels. According to Brunnstrom's staging, the upper and lower right limbs and the lower left limb were at stage two, and the upper left limb was at stage three, six months after the operation. Thirteen cases of WCS have been reported in the literature. These were thought to be caused by reperfusion due to decompression.

Late‑onset white cord syndrome following anterior cervical discectomy and fusion: A case report

White cord syndrome refers to an emerging neurological dysfunction occurring after spinal decompression surgery with hyperenhancing changes on T2-weighted magnetic resonance imaging (T2WI). The pathophysiological mechanism is hypothesized to be an ischemia-reperfusion injury following chronic ischemic spinal cord decompression. A 54-year-old man was admitted to Jinhua Municipal Central Hospital with complaints of numbness and weakness in the extremities and swelling in the neck. MRI showed degeneration and herniation of the C4-C7 intervertebral discs. The patient underwent anterior cervical corpectomy and fusion (ACCF). On the 7th postoperative day, the patient reappeared with weakness of the limbs. Physical examination revealed paralysis. Emergency MRI suggested T2 high signal myelopathy and emergency surgery was performed following the diagnosis of white cord syndrome. Following the operation, the patient's neurological system gradually improved. The motor ability and sensory function of the extremities recovered at 7-month follow-up. Spine surgeons should be aware of this serious complication. The present case serves to provide experience for clinical treatment and diagnosis and encourage research into its pathophysiology.

White cord syndrome following posterior decompression and fusion for severe OPLL and an acute traumatic cervical injury – A case report and review of literature

Background:

White cord syndrome (WCS) refers to the observation of intramedullary hyperintensity due to edema/ischemia and swelling on postoperative T2-weighted MRI sequences in the setting of unexplained neurological deficits after cervical spinal cord decompression. Pathophysiologically, WCS/reperfusion injury (RPI) occurs due to oxygen derived free radicals as a result of acute reperfusion or direct trauma from blood flow itself. Intraoperative neurophysiologic monitoring (IONM) can give early warning and detect neurologic deficits. Here, we are presenting a case of a patient who had a chronic severe ossification of posterior longitudinal ligament (OPLL) of cervical cord, underwent decompressive surgery, and developed quadriplegia postoperatively without any perceptible iatrogenic cord trauma, documented by IONM and postoperative MRI with classical signs of WCS.

Case Description:

A 63-year-old male presented with low velocity fall at home followed by quadriparesis. X-ray images on presentation showed C6 fracture and local kyphosis. MRI images showed that there is marked spinal canal stenosis from C2 down to C4 due to OPLL with intrinsic signal changes in the cord. On decompression, motor-evoked potential signals were not present below C4. Immediate postoperative MRI was done to rule out any compressive pathology. MRI showed T2 hyperintensity of the cord at C3 level with cord edema. No evidence of epidural hematoma or other compressive lesion was found and the diagnosis of WCS/RPI was established.

Conclusion:

WCS is essentially a diagnosis of exclusion. Very rarely, patients sustain severe/new neurological deficits postoperatively attributed to WCS. Unless, this is confirmed postoperatively with classical MRI signs of intramedullary hyperintensity, the diagnosis should not be invoked.

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.

White Cord Syndrome after Thoracic Cord Decompression in a Pediatric Patient

INTRODUCTION

White cord syndrome (WCS) is a rare phenomenon which causes acute neurologic deterioration after a chronically compressed spinal cord is surgically decompressed, resulting in a T2-hyperintense signal to appear in the cord. We present the first case of pediatric WCS in the thoracic spine and the first to show complete resolution of symptoms.

CASE PRESENTATION

A 3-year-old girl presented with difficulty ambulating due to pain caused by T4-8 spinal cord compression from a mass of ganglioneuromatous tissue, consistent with her previously treated mediastinal neuroblastoma. She underwent laminoplasty and microsurgical debulking of the mass. She developed severe bilateral leg weakness on postoperative day 1. Magnetic resonance imaging (MRI) showed T2 hyperintensity in the spinal cord from T1 to T10 without enhancement, concerning for WCS. She was started on high-dose steroids and monitored. Her strength improved to 3/5 in both legs prior to discharge to inpatient rehabilitation. On the latest follow-up, 4 months after surgery, she did not demonstrate any neurologic deficits and was ambulating well. Follow-up MRIs have showed continued improvement in the T2 hyperintensity.

DISCUSSION/CONCLUSION

Most cases in the literature occur in older adults with chronic cervical compression. Only 1 pediatric case, caused by a cervical arachnoid cyst, has been reported and only resulted in partial improvement. Our case is the first pediatric case of WCS to occur in the thoracic spine, the first pediatric case to demonstrate complete resolution, and the first case of any age to start to establish a length of time the compression is needed to be at risk for WCS.