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Abstract

Reperfusion injury of the spinal cord or “white cord syndrome” (WCS) refers to the sudden onset of neurological deterioration after spinal decompressive surgery. It is thought to be caused by reperfusion injury of the spinal cord. The risk of WCS might be increased in elderly and patients with chronic hypertension as commorbidities.  A 50-year-old male suggestive a continuous ossified posterior longitudinal ligament (OPLL) with cervical spinal stenosis from C2-C4 underwent posterior decompression and posterior fixation from C2 to C4. After the patient recover from anesthesia, he developed hemiparesis on right side with motor strength 1/5. Immediate postoperative CT scan imaging revealed no malpositioned screw, on cervical MRI disclosed a hyperintense signal in T2-weighted sequences at C3-C4 levels and the diagnosis of WCS was suspected. A high dose methylprednisolone according to NASCIS II, mannitol, and methylcobalamin were given. On post-operative day (POD)-1 the patient's muscle strength improved to grade 3/5 in the upper extremity and to grade 4/5 in the lower extremity but the elbow flexion muscle strength still 1/5. Two weeks after surgery the patient able to walk normally but the upper extremity still no improvement. There are still no class I, II, and III evidence backing specific treatment of WCS. However, there are several prevention strategies to decrease the risk of WCS such as CSF pressure management, remote ischemic preconditioning (RIPC), intraoperative monitoring, and technique switch to laminoplasty. We recommend that the importance of early recognition and prompt treatment of white cord syndrome to minimize the complication.

Keywords

White cord syndrome Reperfusion injury Ossification of the posterior longitudinal ligament Cervical decompression

Article Details

How to Cite
Permana, C., Hidayat, Y. A. S., Fadhil, Caropeboka, M. S., & Tjahjadi, M. (2021). A devastating complication “white cord syndrome” following posterior cervical decompression for ossification of the posterior longitudinal ligament stenosis. Neurologico Spinale Medico Chirurgico, 4(3). https://doi.org/10.36444/nsmc.v4i3.171

References

  1. Choi B-W, Song K-J, Chang H. Ossification of the posterior longitudinal ligament: A review of literature. Asian Spine J. 2011;5(4):267. DOI: 10.4184/asj.2011.5.4.267
  2. Bakhsh W, Saleh A, Yokogawa N, et al. Cervical ossification of the posterior longitudinal ligament: A computed tomography–based epidemiological study of 2917 patients. Glob Spine J. 2019;9(8):820–5. DOI: 10.1177/2192568219833658
  3. An HS, Al-Shihabi L, Kurd M. Surgical treatment for ossification of the posterior longitudinal ligament in the cervical spine. J Am Acad Orthop Surg. 2014;22(7):420–9. DOI: 10.5435/JAAOS-22-07-420
  4. Head J, Rymarczuk G, Stricsek G, et al. Ossification of the posterior longitudinal ligament: Surgical approaches and associated complications. Neurospine. 2019;16(3):517–29. DOI: 10.14245/ns.1938222.111
  5. Wiginton JG, Brazdzionis J, Mohrdar C, et al. Spinal cord reperfusion injury: Case report, review of the literature, and future treatment strategies. Cureus. 2019;11(7):e5279. DOI: 10.7759/cureus.5279
  6. Fathalla H, Ragab O, Ashry AH. White cord syndrome: The terrible nightmare. Open J Mod Neurosurg. 2020;10(02):275–83. DOI: 10.4236/ojmn.2020.102030
  7. Liao Y-X, He S-S, He Z-M. “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. Exp Ther Med. 2020;20(5):1–1. DOI: 10.3892/etm.2020.9218
  8. Chin KR, Seale J, Cumming V. “White cord syndrome” of acute tetraplegia after anterior cervical decompression and fusion for chronic spinal cord compression: A case report. Case Rep Orthop. 2013;2013:1–5. DOI: 10.1155/2013/697918
  9. Giammalva GR, Maugeri R, Graziano F, et al. White cord syndrome after non-contiguous double-level anterior cervical decompression and fusion (ACDF): A “no reflow phenomenon”? Interdiscip Neurosurg. 2017;7:47–9. DOI: 10.1016/j.inat.2016.12.001
  10. Antwi P, Grant R, Kuzmik G, et al. “White cord syndrome” of acute hemiparesis after posterior cervical decompression and fusion for chronic cervical stenosis. World Neurosurg. 2018;113:33–6. DOI: 10.1016/j.wneu.2018.02.026
  11. Vinodh V, Rajapathy S, Sellamuthu P, et al. White cord syndrome: A devastating complication of spinal decompression surgery. Surg Neurol Int. 2018;9(1):136. DOI: 10.4103/sni.sni_96_18
  12. Papaioannou I, Repantis T, Baikousis A, et al. Late-onset “white cord syndrome” in an elderly patient after posterior cervical decompression and fusion: a case report. Spinal Cord Ser Cases. 2019;5(1):28. DOI: 10.1038/s41394-019-0174-z
  13. Mathkour M, Werner C, Riffle J, et al. Reperfusion “white cord’’ syndrome in cervical spondylotic myelopathy: Does mean arterial pressure goal make a difference? Additional case and literature review. World Neurosurg. 2020;137:194–9. DOI: 10.1016/j.wneu.2020.01.062
  14. Jun DS, Baik J-M, Lee S-K. A case report: White cord syndrome following anterior cervical discectomy and fusion: Importance of prompt diagnosis and treatment. BMC Musculoskelet Disord. 2020;21(1):157. DOI: 10.1186/s12891-020-3162-3
  15. Busack CD, Eagleton BE. White cord syndrome causing transient tetraplegia after posterior decompression and fusion. Ochsner J. 2020;20(3):334–8. DOI: 10.31486/toj.19.0081
  16. Singh RD, Arts MP, de Ruiter GCW. Delayed-onset white cord syndrome after anterior and posterior cervical decompression surgery for symptomatic ossification of spinal ligaments: illustrative cases. J Neurosurg Case Lessons. 2021;1(19):CASE2113 DOI: 10.3171/CASE2113
  17. Epstein NE. Reperfusion injury (RPI)/white cord syndrome (WCS) due to cervical spine surgery: A diagnosis of exclusion. Surg Neurol Int. 2020;11:320. DOI: 10.25259/SNI_555_2020
  18. Hall ED. Neuroprotective actions of glucocorticoid and nonglucocorticoid steroids in acute neuronal injury. Cell Mol Neurobiol. 1993;13(4):415–32. DOI: 10.1007/BF00711581
  19. Hu S, Dong H, Li Y, et al. Effects of remote ischemic preconditioning on biochemical markers and neurologic outcomes in patients undergoing elective cervical decompression surgery: A prospective randomized controlled trial. J Neurosurg Anesthesiol. 2010;22(1):46–52. DOI: 10.1097/ANA.0b013e3181c572bd
  20. Nas K. Rehabilitation of spinal cord injuries. World J Orthop. 2015;6(1):8. DOI: 10.5312/wjo.v6.i1.8