Spinal Cord Reperfusion Injury: Case Report, Review of the Literature, and Future Treatment Strategies

Abstract

A rare complication of cervical spine decompression is acute paralysis following the procedure. This neurologic deficit is thought to be due to reperfusion injury of a chronically ischemic spinal cord and is referred to as "white cord syndrome" given the pathognomonic finding of hyperintensity on T2-weighted MRI. Three prior cases have been reported. We present a case of transient quadriplegia following posterior cervical decompression.A 41-year-old male with cervical spondylotic myelopathy presented with bilateral progressive upper extremity weakness, hyperreflexia, and cervical spine MRI showing severe cord compression at C1 and partial hyperintense signal. Intraoperatively, after C1 bony decompression and without perceptible technical cause, the patient experienced a complete loss of both somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) with an eventual return to baseline prior to completing the operation.The patient awoke from surgery with acute quadriplegia without perceptible technical cause (intraoperative compression or evident anatomic compromise). An immediate postoperative MRI revealed a more pronounced hyperintensity in the central cervical cord on T2-weighted sequences. Treatment with increased mean arterial pressure (MAP) therapy and dexamethasone resulted in the patient regaining some movement over a period of hours and full strength over a period of months.The mechanism of acute weakness following cervical spine decompression in the absence of perceptible technical cause is not fully understood, but current theory suggests that a reperfusion injury is most likely the cause. It remains a diagnosis of exclusion. Familiarity with this potential postoperative complication can aid in appropriate postoperative therapy with early diagnosis and intervention leading to restored spinal cord function and excellent prognosis.

‘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

“…The most widely accepted pathophysiological mechanism underlying ‘white cord syndrome’ is the sudden expansion of the chronically compressed cord and subsequent exposure to a rush of blood supply following decompression surgery, which triggers an inflammatory cascade and releases oxygen free radicals, ultimately leading to neuronal membrane damage ( 15 , 16 ). Chin et al ( 2 ) reported the first case of ‘white cord syndrome’ in a 59-year old male with severe C5/6 disc herniation who had undergone ACDF at the C4/5 and C5/6 level.…”

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

“…[ 1 - 8 ] In theory, such acute cord decompression, and re-expansion disrupts the blood-spine barrier allowing for “rush-in reperfusion”, a “…triggered cascade of reperfusion injuries…”, and potentially, “…oxygen-derived free radical damage” [ Table 1 ]. [ 2 ] Other etiologies include; small artery or anterior spinal artery occlusion, “…microthrombi, and altered perfusion due to internal recoil of the spinal architecture following decompression”, “… direct trauma from blood flow itself or by the oxygen free radicals…”, or “…lipid peroxidation of the neuronal membrane…as a main cause in the secondary injury-induced degenerative cascade.”[ 1 - 5 , 7 , 8 ] In a rat model, RPI/WCS resulted in the “grey matter …(being)..dislodged when acute cord compression was “released”. [ 6 ]…”

“…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. [ 7 ] Critically, however, the two individual cases respectively reported by Bailey et al . and Chin et al .…”

“…Here, we reviewed each of the 7 patients undergoing 5 anterior and 2 posterior procedures, who developed immediate postoperative MR findings consistent with RPI/ WCS [ Table 1 ]. [ 3 - 7 ] However, postoperative deficits for the remaining 2 patients were attributed to MR-documented extrinsic disease (respectively stenosis, and OPLL) that required additional surgery; these were, therefore, not attributable to RPI/WCS [ Table 1 ]. [ 1 , 2 ]…”

“…Following posterior cervical decompressive surgery, the following two patients developed acute postoperative RPI/ WCS. [ 6 , 7 ]…”