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Título

White Cord Syndrome: a rare and severe complication after spinal cord decompressive surgery. Case report and review of literature.

Introdução

A very rare, relatively newly described complication, following cervical decompression, is ischemia-reperfusion injury to the spinal cord1–4. First described as “White Cord Syndrome” in 20135, few cases have been reported since then. The hallmark of this condition is neurological worsening after a meticulous and uneventful decompressive surgery for myelopathy, associated with a postoperatively larger hyperintense T2 image, on magnetic resonance, at the spinal cord6. Here, we present a new case that meets these criteria, which, to our knowledge, is the ninth ever published7. We also present a brief review of the concerning literature.

Relato de caso

An 82-year-old male who suffered from severe cervical myelopathy, with a Nurick Grading System of 48, Japanese Orthopedic Association scale modified by Benzel (mJOA) of 89, and quadriparesis, more severe on the right upper limb was subjected to a two-stage procedure: first, anterior three level cervical decompression and fusion (C3-C6, with C4 and C5 corpectomies); second, three days later, further posterior decompression.

Shortly after anterior decompression and fusion, the patient showed similar neurological conditions as presented previously the intervention. However, during the following 24 hours, severe deterioration occurred, leading to quadriplegia, diffuse dysesthesia and enhanced Babinski and Hoffman reflexes. Nurick and mJOA progressed to 5 and 7, respectively. Encephalic imaging showed no acute events. Magnetic resonance of the cervical and thoracic spine showed a hyperintense signal on T2 sequences, mainly at C4 level, but extending caudally to C5.
Neurological status improved partially over the following week, mainly on the right upper limb. However, significant motor deficit remained. Six months after the procedure, the patient has gained satisfactory function of the right hand, but is still non-deambulatory, has no useful motion of the left upper and lower limbs and has only partial bladder control.
Our review of literature showed many similarities among the described cases1,3–5,10,11. Suboptimal decompression and intra-canal hematoma are the most frequent differential diagnosis, often leading to revision surgery1. High dose corticosteroids are frequently used, once the condition is recognized2,12.

Conclusão

Ischemia reperfusion injury is well established in other organs, such as the heart and the brain13,14. Many protocols have been studied to prevent and possibly treat its occurrence7,15. In concern to spinal surgery, it stands as a rare but devastating condition, which lacks a defined treatment and prevention strategies.