Definition

  • Central Cord Syndrome (CCS) is considered an “incomplete” spinal cord injury (SCI), meaning it does not result in complete paralysis or loss of sensation
  • CCS is a cervical spinal cord injury that causes motor weakness more prominent in the upper extremities than lower, a mixed sensory impairment below the level of the lesion, and bladder dysfunction
  • Because of its mixed distribution of sensory impairment, CCS can be described as being a “man in a barrel” or having “cape-like” sensory loss

Anatomy of the spinal cord

https://www.orthobullets.com/spine/2008/incomplete-spinal-cord-injuries

Epidemiology

  • CCS comprises 9.0% of adult SCIs and 6.6% of pediatrics SCIs (Brooks 2017)
  • The most common cause of CCS is blunt trauma
  • Traumatic injuries include c-spine fracture with displacement, ligamentous injury, central disc herniation
  • Nontraumatic causes include spinal cord tumors or formation of a syrinx, a fluid-filled cavity that forms within the spinal cord
  • Age distribution for CCS is bimodal:
    • Patients younger than 50 are affected by high-impact traumatic injuries: MVCs, sports injuries, diving accidents, and assaults
    • Patients older than 50 are more likely to have low-impact MVCs and falls from standing; trauma does not have to be significant to cause injury
  • Most common “board question” presentation: elderly patient with existing cervical spondylosis who suffers hyperextension injury, such as a rear-end motor vehicle accident

Pathophysiology

  • CCS results from an injury or lesion to the lateral corticospinal tracts (CST) or anterior horn gray matter
    • Lateral spinothalamic tract is responsible for pain and temperature sensation explaining sensory deficits below the lesion level
    • Hand and forearm musculature are also primarily located in the lateral CST; this accounts for the classic clinical presentation of weakness arms > legs

Clinical Features

  • Motor impairment with upper extremities affected more than lower extremities
  • Bladder dysfunction, more often urinary retention than incontinence
  • Variable sensory loss below the level of the lesion – often referred to as “suspended” or “floating” sensory levels
  • Preservation of vibration and position sense (located in the spared posterior column), giving a “dissociated” sensory loss
  • A spectrum of severity of symptoms ranging from isolated bilateral hand/forearm weakness to quadriplegia with sacral sparing only

Sensory area affected in central cord syndrome

https://uihc.org/health-topics/what-happens-spinal-cord

Prognosis and Outcomes

  • In the realm of incomplete spinal cord injuries, the prognosis for CCS is typically good
  • Patients can be expected to recover motor and sensory function in the 1-2 year period
  • Factors predicting better recovery outcomes: age less than 50 years, MRI findings, and initial severity of injury, with less severe initial presentations (i.e. lesser degree of lower extremity weakness)
  • However, many patients experience lasting neuropathic pain and difficulty with spontaneous voiding

Diagnosis

  • Maintain a high suspicion for young patients with significant mechanism of injury to head, neck, or face
  • In older patients, even minor trauma with hyperextension injury should raise concern for CCS: any neurologic complaint or finding on physical exam should raise suspicion for spinal cord injury
  • Plain radiographs rarely show evidence of CCS and many institutions have moved away from X-ray in suspected C-spine trauma
  • CT scan can show details of bony deformities but is not the gold standard
  • MRI of the cervical spine is very sensitive to central cord injury and should be obtained to assess for spinal instability as well as for the presence of intraparenchymal spinal cord hemorrhage
    • discuss with your ED radiology team on preference of contrast (some prefer with and without contrast versus no contrast)
    • IV contrast can help identify mimics of central cord syndrome such as myelitis or tumour

ED Management

  • There are mixed studies and opinions as to the best management of spinal cord injury in general, as well as CCS as a specific diagnosis
  • There is Level I evidence that high-dose methylprednisolone is not recommended for neuroprotection in acute SCI (Hurlbert 2013)
  • Not every patient with CCS will require neurosurgical intervention; however, certain populations, such as patients with high-energy injuries, unstable fractures, and spinal cord compression may benefit from surgery 
  • When surgical management is indicated, surgery within 24 hours improves outcomes compared to delayed intervention
  • Timely recognition of CCS, imaging, and neurosurgical or orthopedic consultation is imperative in the ED

Pearls

  • Central cord syndrome should be suspected when older patients +/- existing spondylosis or cervical degenerative changes have a low-force hyperextension injury
  • Neurologic exam demonstrates a prominent upper extremity weakness, variable sensory loss, and possibly bladder dysfunction
  • After obtaining imaging per institution trauma protocols, cervical spine MRI should be obtained if injury to the spinal cord is suspected
  • Not all patients will need surgery; however, surgery is best performed within 24 hours of injury, so involve orthopedic or neurosurgery in a timely manner if CCS is diagnosed

References

  • Brooks N. Central Cord Syndrome. Neurosurg. Clin. N. Am, 2017; 28(1): 41-47. PMID 27886881.
  • Drislane FW. Blueprints Neurology, 4e Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2009.
  • Nowak D et al. Central Cord Syndrome. J Am Acad Orthop Surg, 2009; 17(12):756–765. PMID 19948700.
  • Harrop JS et al. Central Cord Injury: Pathophysiology, Management, and Outcomes. Spine J, 2006; 6(6): S198-S206. PMID 17097539.
  • Dan J. Spine Trauma. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli’s Emergency Medicine Manual, 8eNew York, NY: McGraw-Hill; http://accessemergencymedicine.mhmedical.com.ezproxy.med.nyu.edu/content.aspx?bookid=2158&sectionid=162274166. 
  • Hurlbert RJ et al. Pharmacological Therapy for Acute Spinal Cord Injury. Neurosurgery, 2013; 72(3 Suppl): 93-105. https://doi.org/10.1227/NEU.0b013e31827765c6.
  • Fehlings MJ et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery. Global Spine J. 2017; 7(3 Suppl): 195S-202S. PMID 29164024.
  • Image case courtesy of Dr Arthur Daire, <a href=”https://radiopaedia.org/”>Radiopaedia.org</a>. From the case <a href=”https://radiopaedia.org/cases/30935″>rID: 30935</a>