Reperfusion Injury (RPI)/White Cord Syndrome (WCS) Due to Cervical Spine Surgery: A Diagnosis of Exclusion
- Clinical Professor of Neurological Surgery, School of Medicine, State Univeristy of NY at Stony Brook, New York, United States.
DOI:10.25259/SNI_555_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nancy E. Epstein. Reperfusion Injury (RPI)/White Cord Syndrome (WCS) Due to Cervical Spine Surgery: A Diagnosis of Exclusion. 02-Oct-2020;11:320
How to cite this URL: Nancy E. Epstein. Reperfusion Injury (RPI)/White Cord Syndrome (WCS) Due to Cervical Spine Surgery: A Diagnosis of Exclusion. 02-Oct-2020;11:320. Available from: https://surgicalneurologyint.com/surgicalint-articles/10302/
Background: Following acute cervical spinal cord decompression, a subset of patients may develop acute postoperative paralysis due to Reperfusion Injury (RPI)/White Cord Syndrome (WCS). Pathophysiologically, this occurs due to the immediate restoration of normal blood flow to previously markedly compressed, and under-perfused/ischemic cord tissues. On emergent postoperative MR scans, the classical findings for RPI/ WCS include new or expanded, and focal or diffuse intramedullary hyperintense cord signals consistent with edema/ischemia, swelling, and/or intrinsic hematoma. To confirm RPI/WCS, MR studies must exclude extrinsic cord pathology (e.g. extramedullary hematomas, new/residual compressive disease, new graft/vertebral fracture etc.) that may warrant additional cervical surgery to avoid permanent neurological sequelae.
Methods: In the English literature (i.e. excluding 2 Japanese studies), 9 patients were identified with postoperative RPI/WCS following cervical surgical procedures. For 7 patients, new acute postoperative neurological deficits were appropriately attributed to MR-documented RPI/WCS syndromes (i.e. hyperintense cord signals). However, for 2 patients who neurologically worsened, MR studies demonstrated residual extrinsic disease (e.g. stenosis and OPLL) warranting additional surgery; therefore, these 2 patients did not meet the criteria for RPI/WCS.
Results: The diagnosis of RPI/WCS is one of exclusion. It is critical to rule out residual extrinsic cord compression where secondary surgery may improve/resolve neurological deficits.
Conclusions: Patients with acute postoperative neurological deficits following cervical spine surgery must undergo MR studies to rule out extrinsic cord pathology before being diagnosed with RPI/WCS. Notably, 2 of the 9 cases of RPI/WCS reported in the literature required additional surgery to address stenosis and OPLL, and therefore, did not have the RPI/WCS syndromes.
Keywords: Reperfusion Injury (RPI), White Cord Syndrome (WCS), Diagnosis of Exclusion, Cervical Spine Surgery, Myelopathy, Quadriplegia Cord Injury, Residual Cord Compression
Definition, Pathophysiology, and Etiology of Reperfusion Injury (RPI)/White Cord Syndrome (WCS) Following Cervical Spine Surgery
RPI/WCS is typically defined as an acute spinal cord injury that follows cervical spine surgery where postoperative MR studies document intrinsic cord edema/ischemia, swelling, and/or hemorrhage in the absence of significant new/residual extrinsic pathology. Pathophysiologically, this occurs because spinal cord decompression due to cervical surgery acutely restores normal blood flow to previously under-perfused/ischemic cervical spinal cord tissues.[
RPI/WCS A Diagnosis of Exclusion: Classical Postoperative MR Findings for RPI/WCS
RPI/WCS is a diagnosis of exclusion following multiple cervical surgical procedures; anterior cervical discectomy/fusion (ACDF), anterior corpectomy/fusion (ACF), laminectomy with/without fusion, laminoplasty, or other cervical procedures including those for tumor resection. Postoperative MR studies best document the classical intrinsic cord changes diagnostic for RPI/WCS.[
Frequency of Reperfusion Injury (RPI)/White Cord Syndrome (WCS)
Seichi et al. (2014) Frequency of RPI/WCS Following Laminoplasty
In 2004, Seichi et al. evaluated the frequency of RPI/WCS in 114 patients with severe cervical myelopathy undergoing laminoplasty.[
Frequency of RPI/WCS Best Identified by Seven Cases in the Literature
Several authors defined the RPI/WCS syndrome as “rare”, involving only a small number of cases found in the English literature (i.e. omitting Khan et al. 1973 case, and 2 additional Japanese studies) that met the MR-documented inclusion criteria) [Table1].[
Treatment Options for RPI/WCS
Conservative treatment options for patients with RPI/WCS include; admission to intensive care units for neurological monitoring, elevation of mean arterial pressures (MAP) (i.e. averaging 85-95 mm HG) to perfuse a compromised/ ischemic cord, and the administration of steroids (varying regimens from Decadron to High Dose/Trauma Protocol of Methylprednisolone).
Select Additional Surgical Decompression for RPI/WCS
Zhang et al. offered several explanations as to why RPI/WCS injuries occurred in their 3 OPLL patients [
In one of Zhang et al.’s patients, following a C4-C6 anterior corpectomy/fusion, the patient was immediately quadriplegic. [
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 [
Risk of Reperfusion Injury After Posterior Cervical Decompression
In Vinodh et al. (2018), a 51-year-old female presented with 1-month of increasing paraparesis, and urinary dysfunction [
A 41-year-old male in the Wiginton et al. study (2019) presented with increasing myelopathy (e.g. 4/5 motor function in the upper and lower extremities accompanied by bilateraal Hoffman’s signs, and diffuse hyperreflexia with clonus) [
Risk of RPI/WCS After Anterior Cervical Surgery
2 Cases of RPI/WCS After Anterior Cervical Diskectomuy and Fusion (ACDF)
In two cases, following ACDF, patients developed RPI/WCS confirmed on postoperative MR studies.
In 2017, Kahn et al. evaluated a 36-year-old male who presented with 2 weeks of vague cervicalgia, and the acute onset of an incomplete quadriparesis over just 2-3 hours (e.g. motor deficit 2-3/5 in the upper/lower extremities with incomplete sensory dysfunction: ASIA/Frankel Grade C) [
The patient was placed on the high-dose steroid trauma protocol of Methylprednisolone (30 mg/kg bolus followed by 5.4 mg/kg/ hour over 24 hours), and brought to surgery 8 hours following the onset of symptoms. A C5-C6 ACDF was routinely performed using an iliac autograft with a plate. Notably, at surgery, there was evidence of prior trauma. Immediately postoperatively, the patient’s motor status improved to the 3/5 level in the upper and lower extremities. However, 3 days later, the patient acutely became fully quadriplegic, requiring immediate ventilatory support. Although the cervical X-rays showed the fusion construct was intact, the STAT MR revealed an intramedullary hemorrhagic cord infarction with edema maximal at the C5-C6 level (hyperintense on T1 and T2 weighted signals) without extrinsic cord compresion. The contrast study showed “patchy enhancement with luxury perfusion” in the cord. The patient’s deterioration was attributed to a RPI/WCS injury characterized as a; “…delayed ischemic/reperfusion injury,…(due to) restoration of blood flow through the anterior spinal artery”. Within a year, the patient’s motor function improved to the 4-/5 level in all four extremities. Although he continued to have a relative C4 pin level, he regained vibratory/position appreciation, and no longer required a ventilator.
Case # 4
A 64-year-old male in Giammalva et al. 2017 study underwent a C3-C4 and C5-6 ACDF for severe cervical cord compromise [
2 Cases of ACDF With Residual Extrinsic Cord Compression Requiring Additional Surgery; These Patients Did Not Have the RPI/WCS Syndrome
In two case reports, the diagnosis of RPI/WCS should have been excluded; both patients’ new postoperative deficits following ACDF were due to MR-documented residual extrinsic cord compression requiring secondary surgery (e.g. stenosis and OPLL respectively) [
Case # 5
Bayley et al. (2015) performed a C6-C7 ACDF in a 30-year-old male who presented with left upper extremity paresthesias accompanied by left leg weakness; the MR demonstrated a large C6-C7 disc herniation [
Case # 6
A 59-year-old male in the Chin et al. (2013) study underwent a two-level C4-C5/C5-C6 ACDF [
Reperfusion Injury After Anterior Cervical Corpectomy and Fusion (ACCF)
Three patients in Zhang et al. series, undergoing multilevel anterior corpectomy/fusions for OPLL, exhibited postoperative RPI/WCS [
Summary of 3 OPLL Cases with RPI/WCS with Specific Presentation of Case #7 Who Required an Additional Posterior Decompression
Zhang et al. (2013) reported 3 patients with OPLL, ranging from 41-61 years of age; all 3 developed acute postoperative quadriplegia (e.g. within 30 minutes-4 hours) following anterior cervical corpectomy and fusion procedures (ACCF: C(5), C(5-6), and C(6-7)) [
Pathophysiologically, the RPI/WCS occurs following acute cervical spinal cord decompression when normal blood flow is restored to previously under-perfused/ischemic spinal cord tissues. To establish the diagnosis of RPI/WCS, postoperative MR studies must demonstrate new or expanded, focal or diffuse hyperintense cord signals on T2 weighted images indicative of cord edema/swelling with occasional additional intramedullary hemorrhages.
However, RPI/WCS is a diagnosis of exclusion. Postoperative MR studies must rule out new/residual extrinsic causes of cord compression; (e.g. extramedullary hematomas, residual/ new disc/stenosis/OPLL/other, graft and/or vertebral fracture/ dislocation, direct cord injury due to overzealous intraoperative dissection, amongst other factors) to determine if further surgery is warranted.[
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