A rare case of posterior spinal cord syndrome following commando surgery: A case report and review of literature

Bharat R Dave; Saral J Patel; Ravi B Patel; Akruti M Dave

doi:10.4103/isj.isj_103_21

CASE REPORT

Year : 2023 | Volume : 6 | Issue : 1 | Page : 106-109

A rare case of posterior spinal cord syndrome following commando surgery: A case report and review of literature

Bharat R Dave¹, Saral J Patel², Ravi B Patel¹, Akruti M Dave¹
¹ Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Mithakali, India
² Orthopaedic Department, Dr. N. D. Desai Faculty of Medical Science and Research, Ahmedabad, Gujarat, India

Date of Submission	03-Nov-2021
Date of Decision	11-Apr-2022
Date of Acceptance	21-Apr-2022
Date of Web Publication	11-Feb-2023

Correspondence Address:
Bharat R Dave
Department of Spine Surgery, Stavya Spine Hospital and Research Institute, Near Nagri Hospital, Mithakali, Ahmedabad, Gujarat
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/isj.isj_103_21

Abstract

A 60-year-old male who underwent commando surgery for oral cancer in a supine position and 20-degree neck extension developed sensory ataxia with a loss of proprioception in bilateral lower limbs and hands in the immediate postoperative period. The magnetic resonance imaging (MRI) of brain and screening of spine done within 6 h of surgery indicated a degenerative cervical canal stenosis from C3 to C7 level. A final diagnosis of posterior spinal cord syndrome (PCS) was made after excluding other causes clinically and radiologically. Emergency surgical decompression in the form of C3–C7 laminectomy and intravenous methylprednisolone were administered within 12 h of index surgery. An early diagnosis and treatment resulted in a good neurological recovery by the seventh postoperative day and he was ambulatory with minimal support at 3-month follow-up.

Keywords: Commando surgery, dorsal cord dysfunction, posterior spinal cord syndrome

How to cite this article:
Dave BR, Patel SJ, Patel RB, Dave AM. A rare case of posterior spinal cord syndrome following commando surgery: A case report and review of literature. Indian Spine J 2023;6:106-9

How to cite this URL:
Dave BR, Patel SJ, Patel RB, Dave AM. A rare case of posterior spinal cord syndrome following commando surgery: A case report and review of literature. Indian Spine J [serial online] 2023 [cited 2023 Mar 28];6:106-9. Available from: https://www.isjonline.com/text.asp?2023/6/1/106/369567

Introduction

Posterior spinal cord syndrome (PCS) is the least common variety of incomplete spinal cord injury, with an incidence rate of less than 1%.^[1],[2] The dysfunction of the posterior column of the spinal cord results in impaired proprioception, sense of vibration, and fine touch below the level of injury.^[1],[3] The most common cause of PCS is an external compression from a tumor.^[4] The other reasons are cervical spondylotic myelopathy, vitamin B12 deficiency, multiple sclerosis, tabes dorsalis, among others.^[3] To the best of our knowledge, this is the first case with a presentation similar to PCS following commando surgery for oral cancer.

Case History

A 60-year-old male patient underwent commando surgery for oral cancer, performed under general anesthesia in a supine position with the neck placed in 20-degree extension. The surgery lasted for 5 h with a blood loss of 200 mL. Preoperatively, the patient had no complaints suggestive of cervical spine disorder. Once he had fully emerged from anesthesia, the physician noticed an imbalance when the patient was made to sit and stand with support and a decline in function of lower limbs in the recovery room. On further neurological examination, his muscle strength was Medical Research Council grade 4 in both upper and lower extremities with intact touch sensations. His deep tendon reflexes were grade 1 bilaterally; his rectal sensation was preserved, and Babinski reflex was absent. He also had impaired proprioception in bilateral lower limbs and bilateral hand. The emergency magnetic resonance imaging (MRI) of brain and screening of spine done within 6 h of surgery indicated cervical canal stenosis from C3 to C7 level [Figure 1].

Figure 1: A, Preoperative lateral x-ray of the cervical spine showing age-related spondylotic changes in the form of marginal osteophytes. B, Magnetic resonance imaging (MRI) of the cervical spine showing degenerative cervical canal stenosis from C3 to C7 level, with thickened ligamentum flavum, disc–osteophyte complex, and diffuse disc bulge compressing the cervical cord. C, Axial MRI images showing disc bulge and thickened ligamentum flavum compressing the cervical cord at C5–6 and C6–7 levels

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The patient was diagnosed with iatrogenic PCS after clinically and radiologically excluding other pathologies. The patient’s relatives were explained about his diagnosis, and the decision was made for urgent decompression of the cervical spinal cord by a C3–C7 laminectomy. The procedure was performed in the prone position within 12-h post index surgery. The patient received a dose of 30 mg/kg of methylprednisolone stat during the surgery, which was continued for 48 h at the rate of 5.4 mg/kg/h. The patient tolerated the surgery without further complications and there was no change in his neurological condition.

After extubation, the patient was kept in intensive care unit (ICU) for 2 days. During his hospital stay, his neurology continued to improve, and by postoperative day (POD) 7, he had muscle strength of MRC grade 4 in both upper and lower limbs and he had normal bladder and bowel continence. However, the patient developed a deep infection at the primary surgical site, which spread to the cervical spine. Repeat MRI on POD-14 revealed newly developed C5–6 and C6–7 spondylodiscitis without any new neurological deficits [Figure 2]. This was managed conservatively with antibiotics and a rigid cervical collar. He was discharged after the control of surgical site infection.

Figure 2: Magnetic resonance imaging (MRI) of the cervical spine on postoperative day 14 showing adequate posterior decompression following C3–C7 laminectomy with C5–C7 infective spondylodiscitis

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At 3-month postoperative followup visit, the patient was able to walk with minimal support. He had full strength in all extremities with impaired proprioception in bilateral lower limb. Repeat MRI showed adequate spinal cord decompression with healed C5–C7 spondylodiscitis and osteoporosis resulting in mild kyphosis at that level [Figure 3]. He was prescribed medication for symptoms and physiotherapy.

Figure 3: Magnetic resonance imaging (MRI) of the cervical spine at 3 months postsurgery showing healed C5–C7 spondylodiscitis lesion with localized kyphosis

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The patient complained of occasional upper dorsal pain and tingling sensations in both lower limbs in the mornings at 1-year follow-up. He was able to walk without support and had full strength in all his extremities.

Discussion

An injury to fasciculus gracilis and cuneatus can lead to a loss of fine touch, vibration, and proprioception sensations. Clinically, patients present with typical symptoms of dizziness, unsteady gait, and frequent falls, especially during activities in the dark or when the eyes are closed. On examination, patients have a positive Romberg sign and a loss of fine touch, vibration, and proprioception based on the spinal level of injury.^[3] This patient had a dysfunction of the posterior column resulting in sensory ataxia and functional impairment.

PCS can result from an external compression from space-occupying lesions within the posterior spinal canal, such as extramedullary tumors, spondylosis, and epidural abscess.^[4],[5] Vascular ischemia and intrinsic cord disease are other causes of posterior cord disorder.^[4],[5] Many patients with cervical spondylosis are asymptomatic and are diagnosed incidentally on radiographs or MRI.^[4],[6] Bony and ligamentous changes in these patients place them at a higher risk of spinal cord injury due to iatrogenic causes such as surgical positioning with neck extension.^[7] In our case, prolonged neck extension during the commando surgery may have resulted in PCS.

The MRI of the cervical spine must be obtained immediately once spinal cord injury is suspected to confirm the diagnosis and to plan future intervention, as in our patient. The classical radiological sign for a diagnosis of subacute combined degeneration and multiple sclerosis presenting with PCS has been described in the literature.^[3] However, radiological features that may be specific for other causes of PCS have not been described. In our case, no specific radiological signs for the diagnosis of PCS were identified, and hence, it was a diagnosis of exclusion.

Methylprednisolone is an accepted option of treatment if initiated within 8 h of injury.^[8] The ideal timing of surgery is controversial; however, the literature recommends decompression within 72 h for spinal cord injury.^[9] In our case, decompression was achieved within 12 h of injury, and methylprednisolone was administered for 48 h, consistent with the above recommendations. In the study by McKinley et al., the average length of institutional rehabilitation for patients with PCS was 28 days, with 67% patients able to walk independently for at least 150 feet, and 78% and 56% of patients achieved bowel and bladder continence, respectively.^[4] In our case, the patient had a good neurological recovery by the seventh POD and was ambulatory with minimal support at 3-month follow-up.

This case highlights the need for comprehensive neurological assessment, especially in the elderly population who are likely to suffer from cervical spondylosis, and preoperative imaging of the spine in elderly patients, especially before surgeries requiring prolonged extension of the neck. An urgent MRI in patients suspected of cervical spinal cord injury and timely decompression, if needed, may result in good clinical outcomes.

Acknowledgement

None.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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