Delayed spinal cord infarction following anterior cervical surgical decompression

Abstract

Anterior cervical discectomy and fusion (ACDF) for cord compression is a safe and effective procedure with good outcomes. However, worsening of myelopathy is the most feared adverse event of the surgery. We report the case of a 36-year-old male patient who presented with an acute non-traumatic C5-6 cervical disc herniation causing incomplete quadriparesis. He underwent an uncomplicated ACDF at C5-6, and after an initial period of improvement, he developed a delayed onset of an anterior cord syndrome on day 3, without any discerning cause. We have reviewed similar cases reported in the literature and believe that our patient's postsurgical course is consistent with a delayed ischaemic/reperfusion injury to the cord following surgical decompression and restoration of blood flow through the anterior spinal artery and we make suggestions for management of such clinical events.

‘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

“…By contrast, the neurological function of one patient was not restored until an additional cervical posterior decompression procedure was performed. The pathogenesis of the patients was identical to that in the case reported by Khan et al ( 11 ), who described a 36-year-old male who had developed a delayed neurological deficit on day 3 post-ACDF for C5-6 cervical disc herniation.…”

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

“…[ 1 - 8 ] In our review of the English literature, and based upon Epstein’s review of postoperative MR studies, RPI/WCS was accurately diagnosed in 7 of 9 cases. [ 3 , 4 , 6 - 8 ] Notably, analysis of 2 cases originally identifed as having RPI/WCS were excluded as they exhibited new/residual postoperative “extrinsic disease” (e.g. stenosis and OPLL respectively) that the authors’ themselves determined warranted (i.e.…”

“…1973 case, and 2 additional Japanese studies) that met the MR-documented inclusion criteria) [Table1]. [ 1 - 4 , 6 - 8 ] In 2013, Chin et al . noted that;“… paralysis ( with RPI/WCS ) is extraordinarily rare”.…”

“…(2017) later noted: “ Non-traumatic cervical disc herniation is rarely the cause of acute quadriparesis, with the earliest case reported in literature as recent as 1973. Since then, a further nine cases have been added in the English literature, and two cases have been described in the Japanese language.”[ 4 ] Wiginton et al . in their 2019 study also acknowledged that RPI/WCS was a “rare complication of cervical spine decompression…”, and further observed it had been reported in just 3 prior cases.…”

“…motor deficit 2-3/5 in the upper/lower extremities with incomplete sensory dysfunction: ASIA/Frankel Grade C) [ Table 1 ]. [ 4 ] The preoperative cervical MR demonstrated a large C5-C6 ventral-central disc herniation with marked stenosis/cord compression. There was an accompanying “subtle” increased T2 intrinsic cord signal seen just above the C5-C6 level consistent with cord edema.…”