Central Cord Syndrome With Type II Odontoid Fracture

History

The patient is a 63-year-old male who presented after a motor vehicle accident. He was found to have evidence of a central cord syndrome with diffuse arm and leg weakness. Weakness was more profound in his arms and hands. Cervical spine MRI imaging showed a high T2 cord signal and type II odontoid fracture with subluxation.

Examination

On examination, the patient is awake and responsive, and oriented to person, place and time. Cranial nerves (II-XII) intact; bilateral upper extremities 2/5 in proximal muscle groups and 1/5 in distal muscle groups; bilateral lower extremities 3/5 throughout; decreased sensation to light touch and pinprick throughout, worse in both arms; patellar/Achilles reflexes +1; and, bilaterally, toes are downgoing.

Pretreatment Imaging

Figures 1A-1C (below) respectively demonstrate cervical spine MRI T2-weighted imaging showing C3-C6 central canal stenosis with high T2 cord signal at C3-C4 level; cervical mid-sagittal CT view shows a type II odontoid fracture with subluxation; sagittal STIR MRI shows edema along the fracture line and in pre-vertebral tissues around the dens.

Figure 1A: Cervical sagittal MRI T2-weighted shows C3-C6 central canal stenosis, high T2 cord signal at C3-C4.

Figure 1B: Cervical mid-sagittal CT shows a type II odontoid fracture with subluxation.

Figure 1C. Sagittal STIR MRI shows edema along the fracture line and in pre-vertebral tissues around the dens.

Diagnosis

Cervical central cord syndrome; C3-C6 central canal stenosis with type II odontoid fracture with subluxation.

Selected Treatment

Given the patient's severe central canal stenosis and type II odontoid fracture, we selected posterior C3-C6 laminectomy with C1-C6 fusion.

Post-Treatment Imaging

Figures 2A-2C (below). Cervical spine x-rays (lateral and anteroposterior) demonstrate C1 lateral mass screws, C2 pedicle screws, and C3-C6 lateral mass screws.

Figure 2A: Post-operative lateral x-ray; C1 lateral mass screws, C2 pedicle screws, C3-C6 lateral mass screws.

Figure 2B: Post-operative anteroposterior x-ray, C1 lateral mass screws, C2 pedicle screws, C3-C6 lateral mass screws.

Outcome

The patient did very well. At his 3-month post-operative follow-up visit, his upper and lower extremity strength was significantly improved, and he walked using a walker. His upper extremity strength improved to 4/5 and sensation throughout returned to normal.

Peer Discussion

James S. Harrop, MD, FACS

Professor, Departments of Neurological and Orthopedic Surgery

Thomas Jefferson University

Dr. Amer Khalil and his team are commended on the excellent clinical results they obtained for this patient. This case brings up numerous questions of how we treat spinal cord injuries (SCI), particularly in the elderly (although this patient was only 63-years of age) and central cord injury, a "different" subtype of SCI.

When reviewing the history and images, it appears the patient sustained a hyperextension injury due to a motor vehicle accident. The patient's clinical examination is consistent with a central cord type injury, and the MRI clearly shows T2 signal in the spinal cord at the C3-C4 level, an area of stenosis, which supports that diagnosis. Thus the immediate goals for the patient is to stabilize and decompress his spinal cord. However, there is no clear definition or consensus on when this needs to be done in a central cord patient.

There is a suggestion in the literature that decompressing and stabilizing acute traumatic central cord injury patients during the acute hospital setting may be beneficial in terms of: reducing the length of stay, complications, and possibly improving neurological recovery. Further, early surgery (<24 hours) appears to be beneficial for traumatic fracture dislocations with SCI. However, there is no Level I evidence that early surgery is beneficial in isolate central cord injuries.

This patient, however, is more complicated than just a central cord injury. It is interesting that on the images, there is a type II odontoid fracture, which may be chronic. This may be an incidental finding since there is no T2 signal in the pre-vertebral soft tissues around the dens, nor any signal along the fracture line (I am not able to appreciate STIR signal abnormality, but that may be due to the image).

In some individuals, the increased T2 signals on the cervical MRI in the peri-fracture region would suggest an acute trauma with hemorrhage and edema, as well as swelling of the tissues. In addition, the limited CT scan images suggest the margins of the odontoid fracture to be more corticated and sclerotic than one would expect with an acute fracture.

The surgeon must plan their treatment based on the acute traumatic spinal cord injury. Further, he should devise a plan that addresses the type II dens fracture. This gives the treating surgeon several issues to address with the patient. These options are reviewed in the treatment algorithm choices. The surgeon and patient should discuss the advantages and risks of each option to come up with an optimal treatment algorithm.

Similar to Dr. Khalil, I would have also treated the patient with a posterior cervical decompression and instrumented fusion during his initial hospitalization. I would most likely include the posterior C1-C2 fusion, in that there is significant literature that supports operative treatment for type II dens fractures.

Once again, I congratulate the entire team on the excellent outcome for the patient.

Author's Reply to Peer Discussion

Amer Khalil, MD

Director of Spine Surgery
Department of Neurological Surgery

University of California at Irvine

Thank you, Dr. Harrop for your comments.

First, regarding the timing for surgical intervention in patients with acute spinal cord injuries. I am more inclined to intervene as soon as these patients are medically stable within the acute hospital setting; it shortens their hospital stay, with early entry into rehabilitation and physical therapy and therefore, better neurological outcomes. I prefer surgical intervention within 24-hours if possible. Recent literature supports early intervention.

Regarding the dens fracture, I think it is an acute fracture. The cervical spine CT shows the fracture line along the dens is more consistent with an acute fracture since there are no sclerotic changes along the fracture line. Also, the STIR sagittal MRI shows edema along the fracture line and in the pre-vertebral soft tissues around the dens.