Central cord syndrome

Background

Sensory dermatome by spinal level.
Spinal cord tracts
Anatomy of central cord injury.

Etiology

  • Hyperextension injury of cervical spine
  • Disruption of blood flow to the spinal cord
  • Cervical spinal stenosis
  • Typically elderly patient with significant DJD (ligamentum flavum compresses cord, causing contusion to central portion of spinal cord)
  • Syringomyelia (progressive, chronic, pain/temperature loss first)
  • Central canal ependymoma

Clinical Features

  • Quadriparesis (characteristically worse function in upper extremities than lower extremities)
  • Rare: loss of pain/temperature sensation in upper > lower extremities
  • +/- bladder dysfunction/urinary retention
  • Has better outcomes than other cord syndromes

Differential Diagnosis

Spinal Cord Syndromes

Evaluation

  • MRI for direct evidence for impingement
  • CT may show central canal stenosis with indirect estimation of impingement

Management

Acute Management of Spinal Cord Injury

  • Neurogenic shock management
  • Consider intubation injuries at C5 or above
    • Manual in-line stabilization reduces cervical movement better than C-collar, but be careful of tracheal pressures inadvertently applied which can worsen laryngeal visualization[1][2]
    • Direct laryngoscopy causes C-spine extension at atlanto-occipital junction, C1-C2, and C4-C7 in order from most to least
    • Consider video laryngoscopy with hyperangulated stylet or bougie assisted DL to intubate higher-grade laryngoscopy views of vocal cords without C-spine overextension[3]
    • Post-intubation sedation takes into consideration hemodynamics and potential intraoperative EMG and evoked potential monitoring by anesthesia
  • Consider surgical intervention for:
  • Steroids are no longer recommended
    • Administration of methylprednisolone (MP) for the treatment of acute spinal cord injury (SCI) is not recommended. Clinicians considering MP therapy should bear in mind that the drug is NOT approved by the FDA for this indication. There is no Class I or Class II medical evidence supporting the clinical benefit of MP in the treatment of acute SCI. Scattered reports of Class III evidence claim inconsistent effects likely related to random chance or selection bias. However, Class I, II, and III evidence exists that high-dose steroids are associated with harmful side effects including death.[6]
    • See EBQ:High Dose Steroids in Cord Injury for further discussion

Disposition

  • Admission for acute injury
  • Surgery within 24 hours is safe and effective, but may be extended to < 2 weeks after injury[7]

External Links

See Also

References

  1. The effect of laryngoscopy of different cervical spine immobilisation techniques. Heath KJ. Anaesthesia. 1994 Oct; 49(10):843-5.
  2. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Anesthesiology. 2009 Jan; 110(1):24-31.
  3. Cervical spinal motion during intubation: efficacy of stabilization maneuvers in the setting of complete segmental instability. Lennarson PJ, Smith DW, Sawin PD, Todd MM, Sato Y, Traynelis VC. J Neurosurg. 2001 Apr; 94(2 Suppl):265-70.
  4. Improvement of motor-evoked potentials by ketamine and spatial facilitation during spinal surgery in a young child. Erb TO, Ryhult SE, Duitmann E, Hasler C, Luetschg J, Frei FJ. Anesth Analg. 2005 Jun; 100(6):1634-6.
  5. Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents. Tobias JD, Goble TJ, Bates G, Anderson JT, Hoernschemeyer DG. Paediatr Anaesth. 2008 Nov; 18(11):1082-8.
  6. Hurlbert RJ et al. Pharmacological therapy for acute spinal cord injury. Neurosurgery. 2013 Mar;72 Suppl 2:93-105 http://www.ncbi.nlm.nih.gov/pubmed/23417182
  7. Anderson KK et al. Optimal Timing of Surgical Decompression for Acute Traumatic Central Cord Syndrome: A Systematic Review of the Literature. Neurosurgery. 2015 Oct;77 Suppl 4:S15-32.