1. Controversies in Management
Central Cord Syndrome
Controversies in Management ? =

2. 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

3. 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)

4. Etiology Varies by Study

5. Associated Pathology

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

16. 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

18. 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]

19. 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

20. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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