Central Cord Syndrome

1
Central Cord Syndrome

• Controversies in Management

?

2

• 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

3
Epidemiology

• 16.5 of spinal cord injuries in Australian
  series
• Mean age 60 yrs, but huge variation amongst
  studies with inherent biases in patient
  population (ie children in some)

4
Etiology Varies by Study
5
Associated Pathology
6
Associated Pathology

• Disc protrusion was most common in younger
  patients
• Followed by the subluxation, dislocation and
  fracture
• Spondolytic bars, discs and ligamentum flavum
  hypertrophy were common in the older age group

7
Pathophysiology

• Classically described, traumatic central
  hematomamyelia
• Most medial fibres of CST within the lateral
  columns affected
• No somatotopic organization has been shown
• Alternative hypothesis suggests CST is more
  important for upper extremity, particularly
  finger dexterity

8
Outcome

• Age is single biggest predictor of outcome
• Patients over 70 show poorer ASIA scores at
  presentation and at discharge
• Most patients under 50 are able to walk and have
  good bladder function
• In one study on long term follow up mean
  8.9yrs), only 1/3 over 70 could walk
  independently and none regained bladder control

9
Outcome

• In the upper limb, the distal roots were more
  severely affected than the proximal roots
• 30 of younger patients had dexterity problems
  and 100 over 70
• Of those who died during study, they lived less
  than 20 of Life expectancy from the time of
  injury

10
Classic Paper

• Schneider RC, Cherry G, Pantek H.
• The syndrome of acute central cervical spinal
  cord injury with special reference to the
  mechanisms involved in hyperextension injuries of
  the cervical spine.
• J Neurosurg 195411546-77

11
Classic Paper

• Hyperextension of a degenerative cervical spine
  was the predominant mechanism of injury
• Recovery followed a set pattern beginning with
  the lower limbs and ending with hand function
• Authors stated that surgery was contraindicated

12
Controversies

• Surgical vs. conservative management
• Early vs. late surgery
• Surgical approach

13
Controversies

• Many advocate all patients be treated
  conservatively unless there is a major fracture
  or dislocation or extrinsic compression of the
  cord at presentation.
• Some authors have suggested that surgery is
  indicated in selected cases, but none of these
  studies were prospective or randomized

14
Controversies

• Surgical treatment has been shown to yield a
  longer period of discomfort from pain and
  weakness in certain cases.
• Removal of offending lesions in the subacute
  period results in significant motor and sensory
  improvement in short-term and long-term
  follow-up. Chen et al

15
(No Transcript)
16
Chen et Al

• Surgery was performed on average 10 days after
  trauma, 3 month follow up
• Indications failure of motor improvement, less
  than grade 3 power at 2 weeks with compression of
  neural tissue on imaging
• Reported rapid resolution of hyperpathia with
  surgery and improved motor function

17
(No Transcript)
18
Controversies

• Chen suggests that aggressive early decompression
  in selected patients, especially younger
  patients, improves outcome retrospective review
• In studies of patients treated by medical therapy
  alone, younger patients faired better anyway
  natural history

19
Scientific Rationale for Surgery(Chen)

• Edema in white matter of lateral columns in acute
  stage, without myelin change
• Resulting from mechanical tear and possible
  secondary ischemia following compression
• Hence, early removal of offending lesions may
  contribute to improve outcomes, especially before
  chronic myelopathy is demonstrated

20
Scientific Rationale for SurgeryFehlings Tator

• Experimental evidence shows that persistent
  compression of the spinal cord is a potentially
  reversible form of secondary injury
• Severity of the pathological changes and the
  degree of recovery are directly related to the
  duration of acute compression
• Experimental studies neurological recovery is
  enhanced by early decompressive surgery

21
(No Transcript)
22
Controversial Case

• 62 yo male
• OPLL
• Minor trauma
• Central Cord Syndrome
• Gr II in U/E
• Gr IV in L/E
• Methylprednisolone
• Steady improvement for two weeks then reached
  plateau

23
Tators Opinion

• Significant space occupying lesion must be
  removed
• Although most patients still have a significant
  neurological deficit postoperatively especially
  in the small muscles of the hand
• Prefers early as possible intervention, but
  admits data lacking to prove this point
• Recommended laminectomy of C3 to C6
• Would supplement with lateral mass screws and
  plates if evidence of instability was found

24
H Nakagawas Opinion

• Notes no evidence of fracture or dislocation
• Given steady improvement over two weeks would not
  to rush into surgery
• However would intervene at Plateau
• Chose expansive laminoplasty
• Tator notes controversy
• Would supplement with lateral mass fixation if
  instability demonstrated

25
TJ Pentelenyi

• Absolute indication for emergency surgery
• Chose anterior approach for anterior pathology

HC Park

• Notes controversy and treatment
• Treatment of choice conservative management
  skeletal traction and methylprednisolone in most
  cases
• Surgical treatment to prevent future injuries
• Anterior approach is dangerous

26
More Controversy

• There are clinical studies to show that early
  decompressive surgery is best
• Studies also showed no difference between early
  and late decompression
• Some studies demonstrated no difference in
  surgical vs. nonoperative management

27
Conclusion

• In cases of central cord syndrome with an obvious
  offending lesion, fracture or dislocation the
  treatment is less controversial
• In cases where differences of opinion exist with
  no evidence to support, a prospective randomized
  controlled trial is required to determine optimal
  therapy