Central Cord SyndromeCentral Cord Syndrome

Controversies in ManagementControversies in Management

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•Central cord syndrome typically presents in an elderly patient with pre-existing cervical spondylosis.

•The mechanism of injury involves hyperextension with pinching of the spinal cord between a thickened ligamentum flavum and a protruding anterior osteophyte or disc.

•An associated fracture of a cervical vertebra is uncommon. Bruise on forehead is common.

•The typical neurological deficit is symmetrical quadraparesis affecting the upper more than the lower limbs. Varying degrees of sensory loss

Epidemiology

16.5% of spinal cord injuries in Australian 16.5% of spinal cord injuries in Australian seriesseries

Mean age 60 yrs, but huge variation Mean age 60 yrs, but huge variation amongst studies with inherent biases in amongst studies with inherent biases in patient population (ie children in some)patient population (ie children in some)

Etiology Varies by Study

Associated Pathology

Degen. Changes

48%

Stenosis30%

Fracture22%

Disc protrusion was most common in Disc protrusion was most common in younger patientsyounger patients

Followed by the subluxation, dislocation Followed by the subluxation, dislocation and fractureand fracture

Spondolytic bars, discs and ligamentum Spondolytic bars, discs and ligamentum flavum hypertrophy were common in the flavum hypertrophy were common in the older age groupolder age group

Associated Pathology

Pathophysiology

Classically described, traumatic central Classically described, traumatic central hematomamyeliahematomamyelia

Most medial fibres of CST within the lateral Most medial fibres of CST within the lateral columns affectedcolumns affected

No somatotopic organization has been shownNo somatotopic organization has been shown Alternative hypothesis suggests CST is more Alternative hypothesis suggests CST is more

important for upper extremity, particularly important for upper extremity, particularly finger dexterityfinger dexterity

Outcome

Age is single biggest predictor of outcomeAge is single biggest predictor of outcome Patients over 70 show poorer ASIA scores at Patients over 70 show poorer ASIA scores at

presentation and at dischargepresentation and at discharge Most patients under 50 are able to walk and have Most patients under 50 are able to walk and have

good bladder functiongood bladder function In one study on long term follow up mean = In one study on long term follow up mean =

8.9yrs), only 1/3 over 70 could walk 8.9yrs), only 1/3 over 70 could walk independently and none regained bladder controlindependently and none regained bladder control

Outcome

In the upper limb, the distal roots were In the upper limb, the distal roots were more severely affected than the proximal more severely affected than the proximal rootsroots

30% of younger patients had dexterity 30% of younger patients had dexterity problems and 100% over 70problems and 100% over 70

Of those who died during study, they lived Of those who died during study, they lived less than 20% of Life expectancy from the less than 20% of Life expectancy from the time of injurytime of injury

Classic Paper

Schneider RC, Cherry G, Pantek H. Schneider RC, Cherry G, Pantek H.

The syndrome of acute central cervical The syndrome of acute central cervical spinal cord injury: with special reference to spinal cord injury: with special reference to the mechanisms involved in hyperextension the mechanisms involved in hyperextension injuries of the cervical spine.injuries of the cervical spine.

J Neurosurg 1954;11:546-77J Neurosurg 1954;11:546-77

Hyperextension of a degenerative cervical spine Hyperextension of a degenerative cervical spine was the predominant mechanism of injurywas the predominant mechanism of injury

Recovery followed a set pattern beginning with Recovery followed a set pattern beginning with the lower limbs and ending with hand functionthe lower limbs and ending with hand function

Authors stated that surgery was contraindicatedAuthors stated that surgery was contraindicated

Classic Paper

Controversies

Surgical vs. conservative managementSurgical vs. conservative management Early vs. late surgeryEarly vs. late surgery Surgical approachSurgical approach

Controversies

Many advocate all patients be treated Many advocate all patients be treated conservatively unless there is a major conservatively unless there is a major fracture or dislocation or extrinsic fracture or dislocation or extrinsic compression of the cord at presentation.compression of the cord at presentation.

Some authors have suggested that surgery is Some authors have suggested that surgery is indicated in selected cases, but none of indicated in selected cases, but none of these studies were prospective or these studies were prospective or randomizedrandomized

Controversies

Surgical treatment has been shown to yield Surgical treatment has been shown to yield a longer period of discomfort from pain and a longer period of discomfort from pain and weakness in certain cases.weakness in certain cases.

Removal of offending lesions in the Removal of offending lesions in the subacute period results in significant motor subacute period results in significant motor and sensory improvement in short-term and and sensory improvement in short-term and long-term follow-up. long-term follow-up. Chen et alChen et al

Chen et Al

Surgery was performed on average 10 days Surgery was performed on average 10 days after trauma, 3 month follow upafter trauma, 3 month follow up

Indications: failure of motor improvement, Indications: failure of motor improvement, less than grade 3 power at 2 weeks with less than grade 3 power at 2 weeks with compression of neural tissue on imagingcompression of neural tissue on imaging

Reported rapid resolution of hyperpathia Reported rapid resolution of hyperpathia with surgery and improved motor functionwith surgery and improved motor function

Chen suggests that aggressive early Chen suggests that aggressive early decompression in selected patients, especially decompression in selected patients, especially younger patients, improves outcome younger patients, improves outcome [retrospective review][retrospective review]

In studies of patients treated by medical In studies of patients treated by medical therapy alone, younger patients faired better therapy alone, younger patients faired better anyway [natural history]anyway [natural history]

Controversies

Scientific Rationale for Surgery(Chen)

Edema in white matter of lateral columns in Edema in white matter of lateral columns in acute stage, without myelin changeacute stage, without myelin change

Resulting from mechanical tear and possible Resulting from mechanical tear and possible secondary ischemia following compressionsecondary ischemia following compression

Hence, early removal of offending lesions Hence, early removal of offending lesions may contribute to improve outcomes, may contribute to improve outcomes, especially before chronic myelopathy is especially before chronic myelopathy is demonstrateddemonstrated

Scientific Rationale for SurgeryFehlings & Tator

Experimental evidence shows that persistent Experimental evidence shows that persistent compression of the spinal cord is a potentially compression of the spinal cord is a potentially reversible form of secondary injuryreversible form of secondary injury

Severity of the pathological changes and the Severity of the pathological changes and the degree of recovery are directly related to the degree of recovery are directly related to the duration of acute compressionduration of acute compression

Experimental studies: neurological recovery is Experimental studies: neurological recovery is enhanced by early decompressive surgeryenhanced by early decompressive surgery

Controversial Case 62 yo male62 yo male OPLLOPLL Minor traumaMinor trauma Central Cord SyndromeCentral Cord Syndrome

Gr II in U/EGr II in U/E Gr IV in L/EGr IV in L/E

MethylprednisoloneMethylprednisolone Steady improvement for two Steady improvement for two

weeks then reached plateauweeks then reached plateau

Tator’s Opinion

Significant space occupying lesion must be removedSignificant space occupying lesion must be removed Although most patients still have a significant Although most patients still have a significant

neurological deficit postoperatively especially in the neurological deficit postoperatively especially in the small muscles of the handsmall muscles of the hand

Prefers early as possible intervention, but admits Prefers early as possible intervention, but admits data lacking to prove this pointdata lacking to prove this point

Recommended laminectomy of C3 to C6Recommended laminectomy of C3 to C6 Would supplement with lateral mass screws and Would supplement with lateral mass screws and

plates if evidence of instability was foundplates if evidence of instability was found

H Nakagawa’s Opinion

Notes no evidence of fracture or dislocationNotes no evidence of fracture or dislocation Given steady improvement over two weeks Given steady improvement over two weeks

would not to rush into surgerywould not to rush into surgery However would intervene at PlateauHowever would intervene at Plateau Chose expansive laminoplastyChose expansive laminoplasty

Tator notes controversyTator notes controversy Would supplement with lateral mass fixation if Would supplement with lateral mass fixation if

instability demonstratedinstability demonstrated

TJ Pentelenyi Absolute indication for emergency surgeryAbsolute indication for emergency surgery Chose anterior approach for anterior pathologyChose anterior approach for anterior pathology

HC Park Notes controversy and treatmentNotes controversy and treatment Treatment of choice conservative management Treatment of choice conservative management

skeletal traction and methylprednisolone in skeletal traction and methylprednisolone in most casesmost cases

Surgical treatment to prevent future injuriesSurgical treatment to prevent future injuries Anterior approach is dangerousAnterior approach is dangerous

More Controversy

There are clinical studies to show that early There are clinical studies to show that early decompressive surgery is bestdecompressive surgery is best

Studies also showed no difference between Studies also showed no difference between early and late decompressionearly and late decompression

Some studies demonstrated no difference in Some studies demonstrated no difference in surgical vs. nonoperative managementsurgical vs. nonoperative management

Conclusion

In cases of central cord syndrome with an In cases of central cord syndrome with an obvious offending lesion, fracture or obvious offending lesion, fracture or dislocation the treatment is less controversialdislocation the treatment is less controversial

In cases where differences of opinion exist In cases where differences of opinion exist with no evidence to support, a prospective with no evidence to support, a prospective randomized controlled trial is required to randomized controlled trial is required to determine optimal therapydetermine optimal therapy