White cord syndrome after non-contiguous double-level anterior cervical decompression and fusion (ACDF): A “no reflow phenomenon”?

Study design Case report and review of literature. Objective To report a rare complication of anterior cervical decompression and fusion (ACDF) in a patient with severe cervical cord compression and review of relevant literature. Introduction The white cord syndrome is a very rare condition characterized by an ischemic-edematous lesion of the spinal cord following a surgical procedure, lacking intra o perioperative surgical or anesthesiological complications. Case report A 64-years old male affected by a severe cervical stenosis at multiple levels, with voluminous C3–C4 and C5–C6 disc herniations associated to T2-hyperintense myelomalacic area at C3–C4 level was admitted to our Unit of Neurosurgery in July 2015. A double-level anterior cervical decompression and fusion (ACDF) procedure was performed without intraoperative complications and, in the immediate post-operative period, the patient developed a severe motor weakness to four limbs. The post-operative cervical spine MRI revealed an extension of the hyperintensity on the C5–C6 level. In the immediate post-operative course high doses of dexamethasone were administered, in order to treat the secondary spinal damage. The patient was, after few days, transferred to a Rehabilitation Unit where a partial improvement of the motor weakness was gradually observed. We report the second case of this complication in Literature to support the theory of a possible reperfusion injury after a double ACDF. We speculate an ethiologic mechanism similar to a long-term no-reflow phenomenon, likely during the post-ischemic period in myocardial or cerebral infarction. Conclusions Despite the pathophysiology of non-reflow phenomenon is not widely known, we suspect that an improper blood flow after the double-level discectomy could have led to the changes in medullar hemodynamics.