White Cord Syndrome after Cervical Decompression: A Narrative Review and Proposed Management Algorithm

Background: White Cord Syndrome (WCS) is a rare but devastating complication of cervical decompression, defined by acute postoperative neurological deterioration with intramedullary T2 hyperintensity on MRI, in the absence of compressive pathology. It is increasingly recognized as a manifestation of ischemia–reperfusion injury of the chronically compressed spinal cord.  Methods: A targeted review of the literature (2010–2025) was performed, including case reports, series, and systematic reviews. Data on clinical presentation, pathophysiology, management, and outcomes were synthesized.  Results: Most patients improved with high-dose steroids and hemodynamic augmentation. Approximately 25–30% underwent additional posterior decompression (laminectomy/laminoplasty). Early surgical rescue was associated with better outcomes than delayed intervention. Controversies remain regarding steroid efficacy, optimal mean arterial pressure (MAP) targets and duration, and timing of surgical escalation.  Conclusions: Medical therapy remains the cornerstone, but urgent posterior decompression may be warranted in refractory cases, especially in multilevel stenosis or ossification of the posterior longitudinal ligament (OPLL). We present an updated synthesis of evidence, highlight controversies, and propose a pragmatic management algorithm.