Central Cord Syndrome

Definition

 

Incomplete spinal cord injury secondary to trauma

 

Motor weakness upper limb > lower limb

 

Lower extremity motor score [LEMS] - upper extremity motor score [UEMS] ≥ 5

 

Epidemiology

 

Most common pattern cord injury

- 25% of all spinal cord injuries

 

Bimodal age distribution

1. <45

- high velocity injury

- vertebral fractures

 

2. Older patients with low energy injuries

- pre-existing cervical degeneration and stenosis

- simple fall with hyper-extension injury

 

Usually C3/4 and C4/5

 

Anatomy

 

Spinal cord anatomy

 

Dorsal Columns 

- light touch, vibration & proprioception

- cervical fibres central, sacral fibres lateral

 

Lateral Corticospinal Tract

- motor tract

- cervical fibres central, sacral fibres peripheral

 

Mechanism

 

Central cord

 

Injury of central gray matter

- affects upper limb tracts > lower limb tracts

- distal affected more than proximal

- LMN in arms 

- UMN in legs

- sacral sparing common

 

Xray

 

Usually normal

 

MRI

 

MRI central cord syndrome 1MRI central cord syndrome 2

 

Stenosis

 

Cord injury

- high signal intensity on T2

- localise level of injury

 

Natural history

 

Usually regain walking and bladder function

Hands have the worst prognosis

 

Prognosis

 

Aarabi et al J Neurosurg Spine 2011

- 42 patients, 82% men, average age 58

- admission ASIA scores and midsagittal diameter of cord most related to prognosis

 

Management

 

Operative versus nonoperative management

 

Aito et al Spinal Cord 2007

- 82 patients with acute traumatic central cord syndrome

- 45% treated surgically

- no difference in long-term neurological outcome

 

Chen et al Spine 1998

- 37 patients with acute traumatic central cord syndrome

- 16 treated surgically

- immediate neurological improvement / better long-term neurological outcome with surgery

- 60% nonoperative group improved to at least grade 3 over time

 

Early versus late decompression

 

Badhiwala et al JAMA Surg 2022

- 186 patients undergoing surgery for central cord syndrome

- improved upper limb function at one year with early surgery

 

Aarabi et al J Neurotrauma 2021

- 101 patients over 19 year period

- no difference in outcomes with decompression < 24 hours, < 72 hours, > 72 hours

 

Andersen et al Neurosurg 2015

- systematic review of 9 studies

- evidence of improved outcomes with surgery < 2 weeks post injury

 

Algorithm

 

Spinal cord injury management

- maintain blood pressure / steroids

 

If early improvement - non operative treatment

 

No improvement - operative management