A case report: white cord syndrome following anterior cervical discectomy and fusion: importance of prompt diagnosis and treatment

BACKGROUND

Objective: White cord syndrome is extremely rare and search of the literature has revealed very few cases. Postoperative MR scan revealed hyperintense intrinsic cord signal changes within cord ischemia and edema. It is thought to be caused by reperfusion injury of the spinal cord. This is called white cord syndrome. This report is very rare case of 'White Cord Syndrome' with paraplegia after anterior cervical discectomy and fusion (ACDF).

CASE PRESENTATION

A 49-year-old woman presented with neck pain lasting for several months and second and third finger radiating pain. Severe cervical herniated intervertebral disc findings could be identified at C6-7 level on C-spine MRI. ACDF C6-7 surgery was performed. Immediately after the operation, physical examination revealed paraplegia and emergency MRI was performed. On MR images, T2 high signal myelopathy suspected as reperfusion injury at C6-7 level, and emergency surgery was performed under diagnosis of white cord syndrome. After the emergency operation, the paraplegic problem was gradually resolved. Before discharge, motor power and sensory deficit of bilateral lower extremity were fully recovered.

CONCLUSION

Surgeons should explain the possibility of white cord syndrome before cervical decompression surgery and should perform a neurological examination immediately after surgery. We recommend that the importance of early recognition and prompt treatment of white cord syndrome.

Does stopping at C7 in long posterior cervical fusion accelerate the symptomatic breakdown of cervicothoracic junction?

OBJECT

To compare the clinical and radiological outcomes between patients with long posterior cervical fusion (PCF) in which fusion stopped at C7 versus patients in which fusion crossed the cervicothoracic junction (CTJ).

METHODS

The patients were divided into 2 groups on the basis of the lower-most instrumented vertebra (LIV); C7 group patients (n = 25) and upper thoracic (UT) group (n = 21). We analyzed the visual analogue scale of arm/neck pain, Japanese Orthopedic Association (JOA) score, and neck disability index (NDI). And we also measured the following parameters: (1) pseudomotion of fused segments; (2) C2-C7 sagittal vertical axis; (3) T1 slope; and (4) C2-C7 lordosis.

RESULTS

Arm and neck pain were similar in both groups pre- and postoperatively. Interestingly, mean postoperative NDI score in the UT group was significant worse when compared with the C7 group (9.7±4.6 vs. 14.2±3.7, p = 0.006). Although UT patients had longer fusion levels, the fusion rates were not significantly different between the C7 and UT groups (96.0% vs. 90.5%; p = 0.577). The radiographic parameters did not show any significant differences between the groups at final follow-up.

CONCLUSIONS

Our study demonstrates that multi-level PCF stopping at C7 does not negatively affect C7-T1 segment failure, fusion rate, neck pain, neurologic outcomes, and global sagittal alignment of the cervical spine. Hence, it is unnecessary to extend the long PCF levels caudally across the healthy CTJ for fear of development of adjacent segmental disease (ASD) at the C7-T1 segment.

Pharmacological target therapy of neuropathic pain and patient-reported outcomes in patients with chronic low back pain in Korea: Results from the NLBP Outcomes Research

A number of studies have demonstrated an association of neuropathic pain and chronic low back pain (CLBP), but the outcome difference in each medical management is poorly understood. This study is aimed to investigate treatment patterns of neuropathic pain in CLBP patients and to explore patient-reported outcomes (PROs) including quality of life (QoL) and functional disability by treatment patterns.Data were extracted from the neuropathic low back pain (NLBP) outcomes research. It was a multicenter and cross-sectional study in which 1200 patients were enrolled at 27 general hospitals, from 2014 to 2015. Of total, 478 patients classified as neuropathic pain were used for this subgroup analysis. The patients were divided into 2 groups according to treatment patterns (with vs. without the targeted therapy [TT] of neuropathic pain). Demographic and clinical features were collected by chart reviews and PROs were measured by patient's survey. QoL was assessed by EuroQoL 5-dimension (EQ-5D) questionnaire. Functional disability was measured by the Quebec Back Pain Disability Scale (QBPDS). Multiple linear regression analyses were conducted to compare the PROs between TT group and non-targeted therapy (nTT) group.Among the NLBP patients (mean age 63years, female 62%), EQ-5D index, EuroQoL-Visual Analog Scale (EQ-VAS), and QBPDS Scores (mean ± standard deviation) were 0.40 ± 0.28, 54.98 ± 19.98, and 46.03 ± 21.24, respectively. Only 142 (29.7%) patients had pharmacological TT of neuropathic pain. Univariate analyses revealed no significant mean differences between TT group and nTT group in the EQ-5D index (0.41 ± 0.27 and 0.39 ± 0.28), EQ-VAS (56.43 ± 18.17 and 54.37 ± 20.69), and QBPDS (45.31 ± 21.32 and 46.31 ± 21.24). After adjustment with covariates, TT group had higher scores of EQ-5D index (β = 0.07; P < 0.01) and EQ-VAS (β = 4.59; P < 0.05) than the nTT group. The TT group's QBPDS score was lower than the nTT group, although its statistical significance still has not been reached (β = -4.13; P = 0.07).We found that considerable proportion of the NLBP patients remains untreated or undertreated. Although TT group had significantly better QoL than nTT group, only 29.7% of NLBP patients had pharmacological TT. Therefore, clinicians should consider using TT for better QoL of neuropathic pain patients.

Practical use of bone scan in patients with an osteoporotic vertebral compression fracture

Rib fractures are one of main causes of chest or flank pain when related to an osteoporotic vertebral compression fracture (OVCF). The authors investigated the incidence and risk factors of rib fracture in 284 patients with OVCF using bone scans and evaluated the feasibility as to whether bone scans could be utilized as a useful screening tool. Hot uptake lesions on ribs were found in 122 cases (43.0%). The factors analyzed were age, sex, number and locations of fractured vertebrae, BMD, and compression rates as determined using initial radiography. However, no statistical significances were found. In 16 cases (5.6%), there were concurrent multiple fractures of both the thoracic and lumbar spines not detected by single site MRI. Sixty cases (21.1%) of OVCF with the a compression rate of less than 15% could not be identified definitely by initial plain radiography, but were confirmed by bone scans. It is concluded that a bone scan has outstanding ability for the screening of rib fractures associated with OVCF. Non-adjacent multiple fractures in both thoracic and lumbar spines and fractures not identified definitely by plain radiography were detected on bone scans, which provided a means for determining management strategies and predicting prognosis.

Tibial tunnel area changes following arthroscopic anterior cruciate ligament reconstructions with autogenous patellar tendon graft

We investigated radiographic changes in tibial tunnel area after ACL reconstructions with autogenous patellar tendon grafts on anteroposterior and lateral radiographs over 3 years. Fifty patients followed up for at least 1 year were included in the study. Radiographs were taken on the day of surgery and 3, 6, 9, 12, 24, and 36 months postoperatively. Tibial tunnels on both radiographs were divided into proximal, middle, and distal one-third. The area of each one-third and the greatest diameter of the tibial tunnel on both radiographs was measured using an image-processing software. According to the tunnel area changes, the shape of tibial tunnel was classified into one of four shapes; cylinder, mallet, reverse bottle, and reverse triangle. The correlations between area, diameter and shape of the tunnel, and clinical variables including arthrometer measurement and clinical score were determined. The areas of each one-third of the tibial tunnels on lateral radiographs was always greater than that on anteroposterior radiographs, although the diameters on the two radiographs did not differ significantly. The area of proximal one-third largest and that of distal one-third smallest on both radiographs at any time point. The enlargement and reduction occurred within 3 months and tended to continue for 9 months. Thereafter the tunnel change stabilized on both radiographs. The most common shape of the enlarged tunnels was cylindrical on anteroposterior radiographs reverse triangle on lateral radiographs. No negative effects of enlarged area, diameter, or tunnel shape on clinical results were found in our study.