Cervical Spinal Cord Ischemic Reperfusion Injury: A Comprehensive Narrative Review of the Literature and Case Presentation

Abstract

Cervical spinal ischemic reperfusion injury (CSIRI) refers to a state of sudden neurological deterioration after surgical spinal decompression. The CSCIRI refers to a state of sudden neurological deterioration after surgical spinal decompression. The pathophysiology is hypothesized to be due to instant relief of a chronically compressed spinal cord, leading to an inflammatory cascade named ischemic reperfusion injury. Deterioration of neurological function after cervical spine decompression surgery often occurs secondary to direct cord injury, compressing hematoma, or hardware failure. Complete loss of neurological function with no organic explanation is an extremely rare complication, with only a few cases reported in the literature. We are reporting a 67-year-old male patient diagnosed with severe cervical spinal canal stenosis at level C5/6 who underwent anterior cervical discectomy and fusion (ACDF). The patient developed complete transient loss of neurological functions after the surgery and was labeled as a case of CSCIRI after excluding compressing pathology. A literature review of the CSCIRI was carried out, and ten articles were included. Due to the rarity of these cases, there is no class 1 or 2 evidence to establish management protocol nor identifiable risk factors to predict their occurrence. However, we recommend using an intra-operative neurophysiology monitor in cases with long-standing severe cervical canal stenosis with myelomalacia and managing these cases according to the acute spinal cord injury management protocol after excluding compressing pathologies.

Keywords: cervical cord ischemic injury; cervical spinal cord injury; cervical spine reperfusion injury; cervical spine transient deficits; white cord syndrome.

Figure 1. Magnetic resonance imaging scan sagittal view.

Revealed multiple level of cervical spine degenerative changes more at C5/6 causing sever canal stenosis and myelomalacia.

Figure 2. Magnetic resonance imaging sagittal view post anterior cervical discectomy and fusion at level C5/6.

Immediate post-op magnetic resonance imaging scan showed no compressing pathology and good spinal decompression however there is evidence of spinal cord expansion and swelling.

Figure 3. Magnetic resonance imaging scan sagittal view showed stenosis at C4/5.

Magnetic resonance imaging scan after six moths showed worsening of cervical stenosis at level above proximal junction level C4/5.

Figure 4. Magnetic resonance imaging scan sagittal view, post posterior laminectomy showed signal changes at C5/6.

Magnetic resonance imaging scan revealed the high signal changes at the level C5/6 (at level of cord swelling) after the second surgery. The posterior spinal decompression provides the spinal cord enough space to demonstrate signal changes from previous surgery.

Figure 5. PRISMA search flow diagram.

The literature review done according to PRISMA guidelines. Ten articles were included based on inclusion and exclusion criteria. OPLL: ossification of posterior longitudinal ligament, N: number.