What is the incidence of spinal cord reperfusion injury after cervical cord decompression surgery?

Incidence of Spinal Cord Reperfusion Injury After Cervical Cord Decompression Surgery

Spinal cord reperfusion injury occurs in approximately 13% of patients following cervical spine decompression surgery, with neurological deficits representing a significant portion of post-operative complications. 1

Understanding Spinal Cord Reperfusion Injury

Spinal cord reperfusion injury, also known as "white cord syndrome," is characterized by:

• Sudden neurological deterioration following decompressive surgery without evident technical cause 2, 3
• Pathognomonic finding of hyperintensity on T2-weighted MRI sequences 2
• Hypothesized mechanism involving inflammatory cascade triggered by sudden relief of chronic compression 3

Incidence and Risk Factors

• Overall complication rate following cervical spine decompression ranges from 18-21%, with neurological deficits being significant 1
• Paraplegia/quadriplegia is reported in 13% of cases following cervical spine decompression 1
• Major neurological deficit following anterior cervical decompression and fusion specifically is rarer, with incidences up to 0.2% 4
• Patients with severe, long-standing cervical stenosis with myelomalacia appear to be at higher risk 3

Clinical Presentation and Diagnosis

• Presents as acute neurological deterioration (ranging from mild weakness to quadriplegia) immediately following decompression surgery 2, 5
• MRI findings typically show:
  • New or enlarged T2 hyperintensity in the spinal cord at the decompressed level 5
  • No evidence of hardware failure, hematoma, or other compressive pathology 6
• Diagnosis is primarily one of exclusion after ruling out direct cord injury, compressing hematoma, or hardware failure 3

Management Approaches

When neurological deterioration occurs post-operatively:

1. Immediate Diagnostic Evaluation:

   • Urgent MRI is mandatory to assess for epidural hematoma or other compressive pathology 4
   • Evaluate for adequate decompression versus need for further surgery 4

2. Acute Treatment Options:

   • Increased mean arterial pressure (MAP) therapy to improve spinal cord perfusion 2
   • High-dose corticosteroids (dexamethasone) to reduce inflammation 2
   • Consider additional decompression if MRI suggests ongoing compression 4
   • Management according to acute spinal cord injury protocols after excluding compressive pathologies 3

3. Preventive Measures:

   • Use of intraoperative neurophysiological monitoring (SSEPs and MEPs) to detect early changes 3
   • Staged decompression may be considered in severe cases, though evidence is limited 5

Prognosis

• Prognosis is variable but can be favorable with early intervention 2
• Recovery typically occurs over hours to months 2
• Some patients may regain full strength over time with appropriate management 2
• The overall economic impact of cervical spinal cord injury is substantial, with lifetime care costs estimated at US$1 million per patient with tetraplegia 1

Special Considerations

• In patients with achondroplasia undergoing cervical decompression, 91% had resolution of symptoms, but with 2% mortality, 9% reoperation, and 21% complication rates 7
• Timing of decompression surgery significantly impacts neurological outcomes and complication rates 1
• Cerebrospinal fluid drainage has been shown to reduce the incidence of perioperative spinal cord injury in thoracoabdominal aortic aneurysm repair, but its role in cervical decompression is not well established 7