Updated review of cervical white cord syndrome (WCS)/reperfusion injury (RI); A "diagnosis of inclusion" requiring magnetic resonance (MR) confirmation, not just a "clinical diagnosis".

Abstract

Background: The Cervical White Cord Syndrome (WCS)/Reperfusion Injury (RI) rarely causes new major postoperative neurological deficits, and is attributed to the rapid surgical decompression of a chronically compressed/ischemic cord. Never a diagnosis based on "clinical judgment" alone, the WCS/RI is a diagnosis of inclusion that requires emergent postoperative MR confirmation of the classical "white cord" (i.e., high intrinsic T2W MR cord signal reflecting edema/swelling).

Methods: Most frequently, postoperative MR studies in newly paretic/injured patients following cervical operations will show evidence of direct intraoperative ("iatrogenic") spinal cord injury. Less frequently, findings may include new non-operative vs. operative pathology (i.e., hematomas/hematomyelia, graft extrusions/malpositioning, new/residual/recurrent disc/stenosis/Ossification of the Posterior Longitudinal Ligament (OPLL), and other pathology).

Results: WCS/RI after cervical spine surgery is extremely rare, being reported in only 17 cases as of 2020, and cannot be diagnosed based on "clinical judgment" alone; rather, it requires a STAT corroborate postoperative MR to demonstrate the classical "white cord". However, most likely postoperative MR studies document "iatrogenic" cord injuries, and less likely show new non-surgical and/or new surgical compressive pathology warranting reoperations to remediate the extent/severity of neurological injuries.

Conclusion: The postoperative diagnosis of WCS/RI should never be established based on "clinical judgment alone". Rather, WCS/RI is a diagnosis of inclusion that requires STAT postoperative MR documentation of the classical swollen/edematous "white cord".