Controversies in Management Central Cord Syndrome Controversies in Management ? =

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

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)

Etiology Varies by Study

Associated Pathology

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

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

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

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

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 1954;11:546-77

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

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

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

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

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

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]

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

Scientific Rationale for Surgery Fehlings & 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

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

Tator’s 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

H Nakagawa’s 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

TJ Pentelenyi HC Park 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

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

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