Late-onset "white cord syndrome" in an elderly patient after posterior cervical decompression and fusion: a case report

Abstract

Introduction: In 2013, a rare early complication following cervical decompression the so-called "white cord syndrome" (WCS) was described for first time. This designation was given on the basis of the postoperative appearance of intramedullary hypertense areas in T2-MRI, resulting in devastating neurological damage. To our knowledge, only three cases of WCS have been published; we hereby present the fourth case, but the first one with late-onset presentation of this syndrome.

Case presentation: A 79-year-old male patient with Nurick grade 3 CSM was referred to our institution. He had already had a double-level C4-C6 anterior cervical decompression and fusion (ACDF) 2 years ago in another institution. The patient underwent posterior decompression from C3 to C6 plus C2-C7 lateral mass screw fusion. Within the first 24 h following surgery, he gradually developed C6 incomplete paraplegia (ASIA B). Cervical MRI disclosed a hypertensive signal in T2-weighted sequences at C6-C7 levels and the diagnosis of WCS was suspected. Revision surgery was made 30 h following our first surgery, with wider posterior decompression accompanied by intravenous methylprednisolone. The patient's neurologic status was improved, but the final neurologic outcome was worse (Nurick 4) than the preoperative status and subsequently did not change at all.

Discussion: To the best of our knowledge, this is the first report of a late-onset WCS and the fourth case of WCS per se. Spine surgeons should be aware of this rare but serious complication. We highlight possible risk factors and review the literature on the hypotheses about the pathophysiology of WCS.

Fig. 1

Sagittal computed tomography image on admission of the patient to our department. We discern the plate and the cage after the anterior approach and decompression 2 years before at another institution

Fig. 2

Sagittal magnetic resonance imaging image of the cervical spine showing the anterior plate and the cage on admission. This image demonstrates the significant compression of the cord at C4–C6 vertebrae level (blue arrow)

Fig. 3

Sagittal computed tomography image after the first decompression surgery to our department demonstrates the posterior decompression and fusion from C2 to C7, while no screw malposition was observed

Fig. 4

Postoperative sagittal T2 magnetic resonance imaging image demonstrates a wide posterior decompression of the cervical spinal cord. A huge intramedullary hypertense area, exactly below the C6 vertebrae (green arrow) after the second surgery to our department approximately 24–28 h after the first surgery

Fig. 5

Axial T2 magnetic resonance imaging image after the second surgery demonstrates clearly the intramedullary hypertense area (yellow arrow), highlighting the presence of the WCS