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Yen Hsin L, Samynathan C VV, Yilun H. White Cord Syndrome: A Treatment Dilemma. Cureus 2023; 15:e38177. [PMID: 37252488 PMCID: PMC10224717 DOI: 10.7759/cureus.38177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2023] [Indexed: 05/31/2023] Open
Abstract
Spinal cord reperfusion injury following decompressive surgery is extremely rare. This complication is known as white cord syndrome (WCS). A 61-year-old male presented with chronic neck stiffness associated with left C6/C7 radiculopathy and numbness. Magnetic resonance imaging (MRI) of the cervical spine reported a severely narrowed left C6/C7 neural exit canal. C6/C7 anterior cervical decompression and fusion (ACDF) was performed. There was no significant intraoperative injury. On postoperative day 6, the patient developed bilateral C8 numbness, which started post-operation. He was treated for surgical site inflammation and was prescribed prednisolone and amitriptyline. However, his condition progressively worsened. At postoperative six weeks, there was right hemisensory loss, right triceps atrophy, and positive right Lhermitte's and Hoffman's tests. This subsequently progressed to right C7 weakness and bilateral lower limb radiculopathy at postoperative eight weeks. Postoperative MRI of the cervical spine revealed a new focal gliosis/edema within the spinal cord at C6/C7. The patient was treated conservatively with pregabalin and was referred for rehabilitation. Early diagnosis and treatment initiation are crucial in the management of WCS. Surgeons should be aware of this potential complication and counsel patients on the risk prior to surgery. Magnetic resonance imaging (MRI) remains the gold standard in the diagnosis of WCS. The current mainstay of treatment is high-dose steroids, intraoperative neurophysiological monitoring, and early recognition of postoperative WCS.
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Affiliation(s)
- Leong Yen Hsin
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore, SGP
| | | | - Huang Yilun
- Department of Orthopaedic Surgery, Sengkang General Hospital, Singapore, SGP
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Guo X, He J, Zhang R, Wang T, Chen J, Wang J, Wang Z, Chang G, Niu Y, Niu Z, Song J. N-Acetylcysteine alleviates spinal cord injury in rats after early decompression surgery by regulating inflammation and apoptosis. Neurol Res 2022; 44:605-613. [PMID: 35000568 DOI: 10.1080/01616412.2021.2024737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Decompression surgery in patients with spinal cord injury (SCI) has a neuroprotective effect by alleviating secondary injury and improving neurological outcomes. N-Acetylcysteine (NAC), a drug approved by the United States Food and Drug Administration, has been shown to play neuroprotective roles via attenuation of apoptosis and inflammation. The purpose of the present study was to investigate the effects of early or late decompression surgery in combination with NAC administration on acute SCI, as well as investigate the underlying mechanisms of its actions. METHODS In this study, an acute SCI model was established in rats. The rats were treated with decompression surgery 24/48 h post-SCI in combination with or without NAC. RESULTS The results showed that decompression surgery in combination with NAC lead to a better outcome than decompression alone, as demonstrated by the higher Basso, Beattie, and Bresnahan scores. Histopathological examination demonstrated that early decompression surgery in combination with NAC exerted the best therapeutic effect on spinal cord recovery, which was further confirmed by the extent of inflammation and apoptosis. Additionally, we found that NAC might compensate for a lack of late surgery. CONCLUSIONS Collectively, early decompression surgery and NAC could be a promising combination for the treatment of acute SCI, and its therapeutic effects may be associated with the regulation of inflammation and apoptosis.
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Affiliation(s)
- Xing Guo
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Jindong He
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Rongping Zhang
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Tiechui Wang
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Jinjin Chen
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Jinyu Wang
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Zihang Wang
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Guan Chang
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Yubo Niu
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Zhiyong Niu
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
| | - Junjie Song
- Department of Orthopedics, Jincheng General Hospital, Jincheng, China
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Mota AM, Silveira CJ, Nóbrega JJ, Lima PS. Skimboarding: An Increasingly Recognized Cause of Life-Threatening Spinal Cord Injury. Cureus 2022; 14:e20915. [PMID: 35145812 PMCID: PMC8811467 DOI: 10.7759/cureus.20915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 11/26/2022] Open
Abstract
Skimboarding is a sport that combines elements from aquatic and terrestrial sports and has gained popularity with increased riskier maneuvers. Spinal cord injuries associated with this sport have rarely been reported. Here we present a case of a previously healthy 44-year-old male with a life-threatening C2/C3 fracture and dislocation after a skimboarding fall. Traumatic facet dislocations in the cervical spine are usually consequent to high-energy transmission injuries, so it is difficult to explain the mechanism of injury in this clinical case. As this sport’s practice continues to grow, our purpose is to emphasize that these injuries may occur with irreversible consequences as most of the damage occurs at the time of presentation, so the first step is to alert athletes and the community to prevent them.
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McIntyre WB, Pieczonka K, Khazaei M, Fehlings MG. Regenerative replacement of neural cells for treatment of spinal cord injury. Expert Opin Biol Ther 2021; 21:1411-1427. [PMID: 33830863 DOI: 10.1080/14712598.2021.1914582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Traumatic Spinal Cord Injury (SCI) results from primary physical injury to the spinal cord, which initiates a secondary cascade of neural cell death. Current therapeutic approaches can attenuate the consequences of the primary and secondary events, but do not address the degenerative aspects of SCI. Transplantation of neural stem/progenitor cells (NPCs) for the replacement of the lost/damaged neural cells is suggested here as a regenerative approach that is complementary to current therapeutics.Areas Covered: This review addresses how neurons, oligodendrocytes, and astrocytes are impacted by traumatic SCI, and how current research in regenerative-NPC therapeutics aims to restore their functionality. Methods used to enhance graft survival, as well as bias progenitor cells towards neuronal, oligodendrogenic, and astroglia lineages are discussed.Expert Opinion: Despite an NPC's ability to differentiate into neurons, oligodendrocytes, and astrocytes in the transplant environment, their potential therapeutic efficacy requires further optimization prior to translation into the clinic. Considering the temporospatial identity of NPCs could promote neural repair in region specific injuries throughout the spinal cord. Moreover, understanding which cells are targeted by NPC-derived myelinating cells can help restore physiologically-relevant myelin patterns. Finally, the duality of astrocytes is discussed, outlining their context-dependent importance in the treatment of SCI.
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Affiliation(s)
- William Brett McIntyre
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Katarzyna Pieczonka
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Mohamad Khazaei
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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Papaioannou I, Repantis T, Baikousis A, Korovessis P. Late-onset "white cord syndrome" in an elderly patient after posterior cervical decompression and fusion: a case report. Spinal Cord Ser Cases 2019; 5:28. [PMID: 31240122 PMCID: PMC6461846 DOI: 10.1038/s41394-019-0174-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 01/23/2019] [Accepted: 03/02/2019] [Indexed: 11/09/2022] Open
Abstract
Introduction In 2013, a rare early complication following cervical decompression the so-called "white cord syndrome" (WCS) was described for first time. This designation was given on the basis of the postoperative appearance of intramedullary hypertense areas in T2-MRI, resulting in devastating neurological damage. To our knowledge, only three cases of WCS have been published; we hereby present the fourth case, but the first one with late-onset presentation of this syndrome. Case presentation A 79-year-old male patient with Nurick grade 3 CSM was referred to our institution. He had already had a double-level C4-C6 anterior cervical decompression and fusion (ACDF) 2 years ago in another institution. The patient underwent posterior decompression from C3 to C6 plus C2-C7 lateral mass screw fusion. Within the first 24 h following surgery, he gradually developed C6 incomplete paraplegia (ASIA B). Cervical MRI disclosed a hypertensive signal in T2-weighted sequences at C6-C7 levels and the diagnosis of WCS was suspected. Revision surgery was made 30 h following our first surgery, with wider posterior decompression accompanied by intravenous methylprednisolone. The patient's neurologic status was improved, but the final neurologic outcome was worse (Nurick 4) than the preoperative status and subsequently did not change at all. Discussion To the best of our knowledge, this is the first report of a late-onset WCS and the fourth case of WCS per se. Spine surgeons should be aware of this rare but serious complication. We highlight possible risk factors and review the literature on the hypotheses about the pathophysiology of WCS.
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Affiliation(s)
- Ioannis Papaioannou
- Orthopedic Department of General Hospital of Patras Spine and Trauma Unit, Patras, Greece
| | - Thomas Repantis
- Orthopedic Department of General Hospital of Patras Spine and Trauma Unit, Patras, Greece
| | - Andreas Baikousis
- Orthopedic Department of General Hospital of Patras Spine and Trauma Unit, Patras, Greece
| | - Panagiotis Korovessis
- Orthopedic Department of General Hospital of Patras Spine and Trauma Unit, Patras, Greece
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Wang YL, Qi YN, Wang W, Dong CK, Yi P, Yang F, Tang XS, Tan MS. Effects of decompression joint Governor Vessel electro-acupuncture on rats with acute upper cervical spinal cord injury. Neural Regen Res 2018; 13:1241-1246. [PMID: 30028333 PMCID: PMC6065222 DOI: 10.4103/1673-5374.235062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Decompression is the major therapeutic strategy for acute spinal cord injury, but there is some debate about the time window for decompression following spinal cord injury. An important goal and challenge in the treatment of spinal cord injury is inhibiting or reversing secondary injury. Governor Vessel electroacupuncture can improve symptoms of spinal cord injury by inhibiting cell apoptosis and improving the microenvironment of the injured spinal cord. In this study, Governor Vessel electroacupuncture combined with decompression at different time points was used to treat acute spinal cord injury. The rat models were established by inserting a balloon catheter into the atlanto-occipital space. The upper cervical spinal cord was compressed for 12 or 48 hours prior to decompression. Electroacupuncture was conducted at the acupoints Dazhui (GV14) and Baihui (GV 20) (2 Hz, 15 minutes) once a day for 14 consecutive days. Compared with decompression alone, hind limb motor function recovery was superior after decompression for 12 and 48 hours combined with electroacupuncture. However, the recovery of motor function was not significantly different at 14 days after treatment in rats receiving decompression for 12 hours. Platelet-activating factor levels and caspase-9 protein expression were significantly reduced in rats receiving electroacupuncture compared with decompression alone. These findings indicate that compared with decompression alone, Governor Vessel electroacupuncture combined with delayed decompression (48 hours) is more effective in the treatment of upper cervical spinal cord injury. Governor Vessel electroacupuncture combined with early decompression (12 hours) can accelerate the recovery of nerve movement in rats with upper cervical spinal cord injury. Nevertheless, further studies are necessary to confirm whether it is possible to obtain additional benefit compared with early decompression alone.
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Affiliation(s)
- Yan-Lei Wang
- Beijing University of Chinese Medicine, Beijing, China
| | - Ying-Na Qi
- Beijing University of Chinese Medicine, Beijing, China
| | - Wei Wang
- Beijing University of Chinese Medicine, Beijing, China
| | - Chun-Ke Dong
- Beijing University of Chinese Medicine, Beijing, China
| | - Ping Yi
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Feng Yang
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiang-Sheng Tang
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Ming-Sheng Tan
- Department of Spine Surgery, China-Japan Friendship Hospital, Beijing, China
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Sui T, Ge DW, Yang L, Tang J, Cao XJ, Ge YB. Mitomycin C induces apoptosis in human epidural scar fibroblasts after surgical decompression for spinal cord injury. Neural Regen Res 2017; 12:644-653. [PMID: 28553347 PMCID: PMC5436365 DOI: 10.4103/1673-5374.205106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Numerous studies have shown that topical application of mitomycin C after surgical decompression effectively reduces scar adhesion. However, the underlying mechanisms remain unclear. In this study, we investigated the effect of mitomycin C on the proliferation and apoptosis of human epidural scar fibroblasts. Human epidural scar fibroblasts were treated with various concentrations of mitomycin C (1, 5, 10, 20, 40 μg/mL) for 12, 24 and 48 hours. Mitomycin C suppressed the growth of these cells in a dose- and time-dependent manner. Mitomycin C upregulated the expression levels of Fas, DR4, DR5, cleaved caspase-8/9, Bax, Bim and cleaved caspase-3 proteins, and it downregulated Bcl-2 and Bcl-xL expression. In addition, inhibitors of caspase-8 and caspase-9 (Z-IETD-FMK and Z-LEHD-FMK, respectively) did not fully inhibit mitomycin C-induced apoptosis. Furthermore, mitomycin C induced endoplasmic reticulum stress by increasing the expression of glucose-regulated protein 78, CAAT/enhancer-binding protein homologous protein (CHOP) and caspase-4 in a dose-dependent manner. Salubrinal significantly inhibited the mitomycin C-induced cell viability loss and apoptosis, and these effects were accompanied by a reduction in CHOP expression. Our results support the hypothesis that mitomycin C induces human epidural scar fibroblast apoptosis, at least in part, via the endoplasmic reticulum stress pathway.
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Affiliation(s)
- Tao Sui
- Department of Orthopedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Da-Wei Ge
- Department of Orthopedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Lei Yang
- Department of Orthopedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jian Tang
- Department of Orthopedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Xiao-Jian Cao
- Department of Orthopedics, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Ying-Bin Ge
- Department of Physiology, Nanjing Medical University, Nanjing, Jiangsu Province, China
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