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Central cord syndrome without instability
Introduction
Central cord syndrome was first described by Schneider et al. in 1954 as a syndrome of disproportionate motor weakness of the upper limbs compared with the lower limbs, bladder dysfunction (urinary retention), and variable sensory changes. It is the result of injury to the spinal cord and falls within the spectrum of acute spinal cord injuries. It is the most common form of incomplete spinal cord injury in adults and results in a characteristic neurological deficit where there is worse deficit in the upper extremities compared with the lower extremities, variable sensory changes, and urinary retention. It is typically seen in patients with either known or undiagnosed spinal canal stenosis of the cervical spine who suffer a traumatic event leading to the deficit. Due to the underlying cervical spondylosis typically associated with central cord syndrome, it is most commonly found in the older adult population. It is most commonly seen following hyperextension injury as a result of a fall in which the neck is extended. This results in contusion at the site of the injury, causing edema of the spinal cord and resulting symptoms. While there is typically no acute fracture associated with the injury on imaging, in some cases there can be a fracture or even an acute disc herniation associated with the injury. The initial diagnosis of central cord syndrome may be difficult given that a patient’s imaging only shows degenerative changes without acute spinal column injury. Additionally, there may be comorbidities or associated injuries that may require optimization prior to addressing the central cord syndrome. While early treatment options of posterior decompression and myelotomy showed poor outcome, recent surgical techniques have shown improved outcomes. Although some still advocate for nonoperative management, the timing of treatment for patients who present with central cord syndrome is highly debated, with some advocating for early intervention and others for delayed surgical intervention.
Example case
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Chief complaint: arm and leg weakness
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History of present illness: A 51-year-old male presented after a syncopal fall following a coughing fit. Immediately upon regaining consciousness, he was unable to move his arms or legs for approximately 1 to 2 hours. He slowly regained some strength and was able to call emergency services. He continued to have significant weakness, in upper greater than lower extremities, upon arrival. Imaging was done and showed compression at the C3-4 region with an osteophyte complex on magnetic resonance imaging and computed tomography ( Figs. 28.1 and 28.2 ).
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Medications: amlodipine, cetirizine, flonase, lisinopril
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Allergies: no known drug allergies
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Past medical and surgical history: hypertension
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Family history: noncontributory
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Social history: construction worker, no smoking history, occasional alcohol
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Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact
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Motor: LUE: 4/5 deltoid, 5/5 biceps, 5/5 triceps, 5/5 wrist extension, 4/5 grip, 4/5 finger abduction
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Right upper extremity: 2/5 deltoid, 2/5 biceps, 2/5 triceps, 2/5 wrist extension, 1/5 grip, 1/5 finger abduction
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Left lower extremity: 5/5 strength psoas, quad, hamstring, tibialis anterior, extensor hallicus longus, gastrocnemius
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Right lower extremity: 5/5 psoas, 5/5 quad, 5/5 hamstring, 4/5 tibialis anterior, 4/5 extensor hallicus longus, 4/5 gastrocnemius
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Sensation intact; decreased to pinprick on left from T3 down; normal patellar and brachioradialis reflexes bilaterally
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| Preoperative | ||||
| Additional tests requested | Medicine evaluation | Complete spine MRI | None | None |
| Adjuvant therapy | None | Monitor and if no improvement, then surgery | Monitor in ICU with MAP >85 for total of 48 hours | Monitor, pursue surgery within 15 days |
| Surgical approach selected | C3-4 laminoplasty | C4 corpectomy and C3-4 ACDF | C3-4, C4-5 ACDF with partial C3 and total C4 corpectomy after neurological status plateaus | C3-4 ACDF |
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| Goal of surgery | Spinal cord decompression, preserving spinal stability and motion | Spinal cord decompression, anterior fixation | Spinal cord decompression from ventral osteophyte-disc complex | Spinal cord decompression, anterior fixation |
| Perioperative | ||||
| Positioning | Prone with Mayfield pins on Jackson table | Supine, no pins | Supine neutral with minimal extension with Mayfield pins | Supine with slight neck extension with Mayfield pins |
| Surgical equipment |
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| Medications | Maintain MAP | Tranexamic acid | MAP goal >85 | Steroids |
| Anatomical considerations | Paraspinal muscular attachments to C2, spinal cord and nerve roots | Vertebral artery, internal carotid artery, esophagus | Esophagus/pharynx, trachea, carotid sheath, vertebral arteries | Carotid sheath, cervical spinal column, intervertebral disc, PLL, osteophyte, spinal cord |
| Complications feared with approach chosen | C5 palsy, loss of cervical spine motion, progressive kyphotic malalignment, persistent neck pain | Dural tear, neurological worsening | Dysphagia, dysphonia, airway compromise | Dysphonia, spinal cord injury, implant failure, esophageal injury, vascular injury |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | C3-4 | Anterior C3-4 | Anterior C3-5 | Anterior C3-4 |
| Levels decompressed | C3-4 | C3-4 | C3-5 | C3-4 |
| Levels fused | None | C3-4 | C3-5 | C3-4 |
| Surgical narrative | Fiberoptic intubation, preflip IOM, midline incision centered over C3-4 levels, preserve paraspinal attachments to C2, expose junction of lamina with lateral masses on left hinge side and preserving facet capsules on opening side, confirm levels with x-ray, gently rotate posterior arches of C3 and 4 toward hinge side while using curette to release ligament along opening side, instrument across laminoplasty defect using 6 mm bicortical screws through the lamina medially and 8 mm screws into the lateral mass laterally, x-rays to confirm alignment and hardware position, vancomycin powder in wound, layered closure over drain | Intubation with fiberoptic intubation and avoid further neck extension, IOM, standard Smith-Robinson approach from left, C3-4 discectomy under microscope with C4 partial corpectomy, gradual burring of ossified posterior longitudinal ligament, avoid use of Kerrison, use nerve hook to lift ossified ligament fragments, leave ossified ligament floating to dura if adherent, large ACDF cage filled with calcium phosphate, cervical locking plate with screws in C3 and lower half of C4, complete C4 corpectomy if not possible to place screws in C4 and use corpectomy with plate fixation, from C3-5 | Intubation with fiberoptic scopes, maintain MAPs >85, IOM with MEP/SSEP baselines, neutral head position with Mayfield pins, extend head after baseline IOM obtained, ENT approach, expose C3-5, Caspar pins on C3 and C5 for distraction, discectomy at C3-4 and C4-5 with resection of PLL and posterior osteophytes, intraoperative cone beam CT and navigation registration, C4 corpectomy with navigated drill, partial inferior C3 corpectomy to remove posterior osteophyte, place expandable interbody, remove Caspar pins, place anterior plate with bicortical purchase using lateral fluoroscopy, subplatysmal drain | Position supine, incision made parallel to disc spaced localized by x-ray, undermine platysma, plane medial to sternocleidomastoid identified and bluntly dissected, carotid palpated, plane medial to carotid developed with blunt dissection, spine palpated, prevertebral fascia entered, disc level confirmed with x-ray, Cloward retractors and distractors used, disc annuelctomy performed, cartilaginous end plate is removed from bony end plate with curettes, osteophyte drilled down to PLL, PLL entered with nerve hook and resected with Kerrison punches, visualize dural plane, PEEK/carbon cage filled with bone and placed in disc space, place anterior cervical plate aligned in midline and fixed with screws with x-ray, layered closure |
| Complication avoidance | Baseline IOM, preserve paraspinal attachments to C2, laminoplasty using 6 mm bicortical screws through the lamina medially and 8 mm screws into the lateral mass laterally | Baseline IOM, avoid Kerrison rongeurs if possible, leave ossified ligament floating to dura if adherent, complete corpectomy if needed | Baseline IOMs, ENT approach for high cervical region, intraoperative cone beam CT and navigation | Limit to one level, blunt dissection toward spine, prepare endplates |
| Postoperative | ||||
| Admission | ICU | ICU | ICU | Floor |
| Postoperative complications feared | C5 palsy, loss of cervical spine motion, progressive kyphotic malalignment, persistent neck pain |
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Dysphagia, dysphonia, airway compromise from neck hematoma | Dysphonia, spinal cord injury, implant failure, esophageal injury, vascular injury |
| Anticipated length of stay | 2–3 days | 1–2 days | 1–2 days | 5 days |
| Follow-up testing |
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CT C-spine prior to discharge |
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MRI C-spine 3 months after surgery |
| Bracing | Soft collar for 2 weeks | Soft collar for 2–3 weeks | Rigid collars for 8 weeks | None |
| Follow-up visits | 3 weeks, 3 months, 6 months, 12 months after surgery | 1 week, 2 weeks after surgery | 2 weeks after surgery with nurse visit, 6 weeks with AP/lateral x-rays, 12 weeks with AP/lateral flexion/extension cervical CT | 2 weeks, 3 months after surgery |
ACDF , Anterior cervical decompression and fusion; AP , anteroposterior; BMP , bone morphogenic protein; CT , computed tomography; DEXA , dual-energy x-ray absorptiometry; ENT , ear nose and throat; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; PEEK , polyetheretherketone; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potential.
Differential diagnosis
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Spinal cord injury
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Transverse myelitis
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Multiple sclerosis
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