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Acute Traumatic Central Cord Syndrome

History

A 73-year-old male, who was in a motor vehicle accident, presented with diffuse weakness and numbness in both arms and legs; symptoms were worse in his hands.

Examination

  • Significant neck pain
  • 2/5 strength in bilateral lower extremities; all tested muscle groups
  • 2/5 strength in bilateral deltoids, triceps, and biceps
  • 0/5 strength in bilateral wrist extensors and intrinsic hand muscles
  • Incomplete sensory loss below the level of C4
  • Hyperreflexia bilaterally in the upper and lower extremities

Pretreatment Imaging

  • Cervical spine imaging revealed a severely narrow spinal canal with C3 fracture through the left foramen transversarium, rupture of the anterior longitudinal ligament, and high T2 cord signal suggestive of intramdullary hemorrhagic contusion.
  • Computed tomographic angiography (CTA) was suggestive of left vertebral artery occlusion.
  • Cerebral angiogram showed dominant right vertebral artery and good collateral intracranial circulation, given that the left vertebral artery was sacrificed to prevent any embolic disease.

Figures 1A-1E below respectively demonstrate axial CTA at the level of C4 with apparent occlusion of the left vertebral artery; midline and axial CT at the level of C3 with fracture through the foramen transversarium; midline sagittal MRI with rupture of the anterior longitudinal ligament; and axial MRI at the level of C4 with intramedullary hemorrhagic contusion.

C4 axial computed tomographic angiography, occlusion of the left vertebral arteryFigure 1A

midline CT of C3 with fracture through the foramen transversariumFigure 1B

axial CT of C3 with fracture through the foramen transversariumFigure 1C

midline sagittal MRI with rupture of the anterior longitudinal ligamentFigure 1D

axial MRI C4 with intramedullary hemorrhagic contusionFigure 1E

 

Diagnosis

Acute traumatic central cord syndrome

Suggest Treatment

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Selected Treatment

Posterior C3-C6 laminectomy with C3-C6 and T1 posterior instrumented fusion.

Surgical Rationale: We elected for an early surgical decompression given the high-grade neurological deficits and severe cord compression, and to get the patient to rehab early.

Post-Treatment Imaging

Figures 2A-2B (below) demonstrate lateral and AP cervical spine imaging with bilateral C3-C6 lateral mass and T1 pedicle screws.

lateral postop image; bilateral C3-C6 lateral mass and T1 pedicle screwsFigure 2A

AP postop image; bilateral C3-C6 lateral mass and T1 pedicle screwsFigure 2B

Outcome

Postoperatively, the patient's motor exam improved to 3/5 in all muscle groups in the bilateral lower extremities and bilateral upper extremities—except intrinsic hand musculature remained at 0/5. His sensation slighly improved throughout, and he was discharged to a skilled nursing facility.

Case Discussion

Anthony M DiGiorgio, DO
Neurosurgery Resident
Louisiana State University Health Sciences Center
New Orleans, LA

Praveen V Mummaneni, MD
Joan O'Reilly Professor in Spinal Surgery & Vice Chair of Neurological Surgery
Director of Minimally Invasive and Cervical Spine Surgery
Director, Minimally Invasive and Complex Spine Fellowship Program
Co-director, Spinal Surgery and UCSF Spine Center
San Francisco, CA

This case represents a common type of spinal cord injury: traumatic central cord syndrome.  Patients tend to have pre-existing cervical stenosis, often asymptomatic until the traumatic event injures the spinal cord.  The classic clinical presentation involves motor and sensory loss in the upper extremities with preserved function in the lower extremities.

Although some patients may improve spontaneously, surgical decompression provides the best long-term outcome and helps prevent secondary injury to the cord.  Either an anterior or posterior approach can be utilized.  Multilevel anterior approaches can lead to dysphagia, especially in the elderly, so the choice of a posterior laminectomy and fusion or a laminoplasty is suitable in this case. 

Practice guidelines suggest blood pressure support to a mean arterial blood pressure greater than 85 mmHg for any spinal cord injury.1 This is recommended in the pre- and postoperative time period for traumatic central cord syndrome with intravascular fluids and, if needed, vasopressors (phenylephrine).2

Controversy surrounds the optimal timing of surgery, with an early series by Schneider et al opposing acute decompression.  They argued that these patients will often have spontaneous improvement and that early surgery on an acutely damaged spinal cord can lead to worse outcomes.3 Park et al reviewed the literature and did not find any difference in motor improvement, functional recovery or complication rates when patients underwent surgery within 24 hours versus after 24 hours.4 However, a review by Anderson et al did find low-level evidence to suggest surgery within 24 hours leads to improved motor scores one year postoperatively without any increased complication rate.5

In our practice, we typically provide fluid and vasopressor support to keep a mean arterial pressure above 85 mmHg. If the patients are stable for surgery, we will operate within 24 hours of injury.  Our preference is for a posterior decompression and fusion or a laminoplasty in this case, given this patient’s age and multi-level stenosis.  This would avoid dysphagia. Postoperatively, we typically continue vasopressor support and monitoring in the intensive care unit. We typically mobilize patients on postoperative day one.

References

1. Consortium for Spinal Cord, M. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2008;31(4):403-79.

2. Readdy WJ, et al. Complications and outcomes of vasopressor usage in acute traumatic central cord syndrome. J Neurosurg Spine. 2015:Jul 31: 1-7.

3. 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 cervical spine. J Neurosurg. 1954;11(6):546-77.

4. Park MS, et al. Delayed surgical intervention in central cord syndrome with cervical stenosis. Global Spine J. 2015;5(1):69-72.

5. Anderson KK, et al. Optimal Timing of Surgical Decompression for Acute Traumatic Central Cord Syndrome: A Systematic Review of the Literature. Neurosurgery. 2015;77 Suppl 4:S15-32.

Community Case Discussion (2 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


For starters all I can say is
https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Central-Cord-Syndrome
and
http://emedicine.medscape.com/article/321907-treatment#d11 particulalry the literature review.

Ideally academics pursue evidence based treatment and follow the guidelines of their own professional organizations.

Ideally.

No convincing discussion as to why non-operative treatment was not considered. No convincing discussion as to why surgery was chosen over conservative option.

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