Central cord syndrome is the incomplete injury to the spinal cord with a pattern of resultant neurological deficits. This is the most common type of incomplete cord injury and almost always occurs as a result of a traumatic injury. It results in motor deficits that are worse in the upper extremities when compared to the lower extremities as well as bladder dysfunction (retention) with varying sensory deficits below the level of injury.
Central cord syndrome is an incomplete cord syndrome that results after a hyperextension injury of the cervical spine leading to spinal cord impingement. There are other less common causes of impairment which can result in problems such as compression fractures.
Central cord syndrome predominantly affects males in a bimodal distribution (falls in those who are young and hyperextension injury in elderly patients with likely underlying spinal disease, including osteoarthritis, or cervical spondylosis). It has a prevalence of 15% to25% in the United States and can occasionally be missed if the patient has mild symptoms at initial presentation.
Central cord syndrome occurs most commonly in those who suffer a hyperextension injury. This commonly occurs with a fall forward, striking the chin, and having the neck extend backward at the time of the fall. Elderly patients often have underlying cervical spondylosis (stress defects within the vertebral bodies). This leads to the posterior cord being either irritated or compressed by the posterior ligamentum flavum or can lead to anterior cord compression from underlying spondylosis or osteolytic lesions. These two contusion type injuries to the cord can lead to symptoms secondary to edema of the cord at the site of injury. It could also lead to bleeding into the cord at the site of injury, which understandably has a worse prognosis.
Young patients often suffer from a higher velocity of trauma leading to cervical spine fractures/subluxations that lead to the above-described compression/contusion/bleeding.
The physical exam findings results due to the compression on the Spinothalamic (pain/temperature tract) and the corticospinal (motor) tracts of the spinal cord which can result in motor and sensory deficits. The upper extremity tracts are the most medial compared to the lower extremity/sacral segments being the most lateral, so when compression occurs the central portion becomes more effected then the external segments due to the external pressure.
Historically, these patients will be elderly and present with symptoms after a fall with hyperextension of their neck. On examination, patients will have greater strength impairments in the upper extremities (especially the hands) compared to the lower. They often complain of sensory deficits below the level of injury, but this is variable. Loss of pain and temperature are typically affected, but also the sensation of light touch may be affected. The most common sensory deficits are found in a "cape-like" distribution across their upper back and down their posterior upper extremities. They will often have neck pain at the site of spinal cord impingement.
Urinary retention and priapism can also occur as signs of upper motor neuron dysfunction. The sacral sensation is usually preserved, but rectal tone should be assessed for severity of the compression.
Differential diagnosis should include other cervical spine pathologies including fractures, dislocations, vascular injuries, or bilateral brachial plexus injuries or severe trauma resulting in avulsion of peripheral nerve roots in a bilateral distribution.
All patients with concern for spinal cord injury should have a thorough trauma evaluation performed, and these patients should have cervical immobilization maintained during initial evaluation while obtaining radiologic imaging. Plain radiographs can show fractures/dislocations of the cervical spine. Computed tomography of the cervical spine can show some impingement of the spinal canal, but the most sensitive test to diagnose direct spinal cord impingement is an MRI of the cervical spine.
More severe neurologic findings on an examination should heighten your suspicion for a cervical spine fracture. When associated with a cervical spine fracture, recovery can be significantly prolonged.
At the time of presentation/diagnosis, high-dose methylprednisolone should be considered for administration within the first eight hours. Corticosteroids suppress edema and help promote blood flow to the area of cord injury. This recommendation was initially made in 1990, and a Cochrane review in 2012 supports this therapy, but the decision for administration should be discussed with your surgical consultants.
Those affected by central cord syndrome have an excellent prognosis with the utilization of physical rehabilitation and occupational therapy. The goal is rehabilitation to preserve range of motion by strengthening the preserved muscular activity, especially in the lower extremities. Physical therapy will also focus on strengthening the core and balance. Due to the worsening of symptoms in the upper extremities, using assistive devices for ambulation can be very challenging, so the initial focus will often be on the core and lower extremities. The occupational therapists will work with the upper extremities to help preserve the ability to perform activities of daily living. Splinting may be used when not in therapy to help prevent the development of contractures.
Surgery is rarely indicated. However, orthopedic and neurosurgical physicians should be involved early after diagnosis is made, as occasionally, the amount of cord impingement can progress and worsen. Guidelines published in 2016 recommend that "early surgery be considered as a treatment option in an adult patient with traumatic central cord syndrome."
However, the literature is mixed. Some studies have shown that early surgical treatment has not resulted in improved neurologic improvement and one recent study even showed that delaying surgery in traumatic central cord syndrome may be beneficial where odds of mortality decreased within each day of delay. The thought was to optimize the patient's underlying health and treat other potential comorbidities before the surgery. Be sure to have your surgical consultants involved early as every patient and case is different, and some may do better with early intervention.
Rarely patients will require extensive physical therapy without significant neurologic recovery. These patients may develop chronic issues including autonomic dysregulation with uncontrolled blood pressure, neurogenic bladder requiring catheterization, pressure ulcers, neuropathic pain, and spasticity with chronic pain issues.
Blood pressure can be managed with nifedipine or transdermal nitroglycerin.
Patients with neurogenic bladder may require intermittent self-catheterization but will remain at risk for iatrogenic bladder infections. Many of these patients will have the return of bladder function after six to eight months.
Neuropathic pain and spasticity are often managed with a regular stretching program, antispasmodic medications. Baclofen is the hallmark of spasticity management (oral initially, but can be placed as an intrathecal pump if severe enough). Patients may require additional medicinal therapy in consultation with a pain specialist or neurologist for their neuropathic pain and spasticity.
The diagnosis and management of central cord syndrome is with an interprofessional team consisting of a neurologist, emergency department physician, neurosurgeon, trauma physician, ICU nurses, physical therapist and an internist. Once diagnosed, high dose corticosteroids should be administered. Surgery is rarely required. The majority of patients do show recovery with physical therapy but the recovery is not always complete. In addition, the recovery may take months or even years and these patients are prone to pressure ulcers, DVT, urinary tract infections and muscle wasting. The key is to have the surgeons involved early in the care because in some cases, surgical decompression may help boost recovery. (Level V)
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