Non-Operative Treatment for Central Cord Syndrome
For central cord syndrome, non-operative management should include immediate administration of corticosteroids (dexamethasone 16 mg/day), early rehabilitation focusing on joint mobility and muscle strengthening, and multimodal pain management with gabapentinoids for neuropathic pain. 1
Initial Management
Corticosteroid Administration
- Immediate steroid therapy: Dexamethasone should be administered at moderate doses (16 mg/day) when central cord syndrome is diagnosed clinically or radiologically 1
- The steroids are typically tapered over a 2-week period
- Higher doses (36-96 mg/day) may be considered in severe cases but carry increased risk of complications
Spinal Stabilization
- External cervical immobilization should be maintained until spinal stability is confirmed 2
- Maintain proper positioning to prevent further cord compression
- Avoid flexion or extension of the cervical spine that could exacerbate symptoms
Pain Management
Multimodal Analgesia
- First-line treatment: Introduce multimodal analgesia combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids to prevent prolonged pain 1
- For neuropathic pain: Oral gabapentinoid treatment for at least 6 months is recommended 1
- Add tricyclic antidepressants or serotonin reuptake inhibitors if gabapentinoid monotherapy is insufficient
Rehabilitation Approach
Early Rehabilitation
- Begin rehabilitation as soon as the patient is medically stable 1
- Focus on:
- Maintaining joint amplitudes through stretching (at least 20 minutes per zone)
- Preventing and treating spasticity
- Strengthening existing musculature
- Simple posture orthosis (elbow extension, flexion-torsion of metacarpophalangeal joint)
Positioning and Pressure Ulcer Prevention
- Implement proper bed and chair positioning to correct and prevent predictable deformities 1
- Reposition patients every 2-4 hours with pressure zone checks 1
- Use high-level prevention supports (air-loss mattress, dynamic mattress)
- Perform visual and tactile checks of all areas at risk at least once daily
Bladder Management
- Intermittent urinary catheterization is the reference method for urine drainage 1
- Remove indwelling catheters as soon as the patient is medically stable
- Implement a micturition calendar to adapt the frequency of catheterization
Monitoring and Follow-up
- Regular neurological assessments to track recovery
- Monitor for complications such as respiratory compromise (vital capacity may be reduced by more than 50% in cervical spinal cord injuries) 1
- Consider tracheostomy after 7 days if prolonged airway support is needed
Prognosis and Recovery Considerations
- Central cord syndrome generally has better outcomes compared to other incomplete spinal cord injuries 3
- Recovery is often incomplete with conservative management alone 3
- Upper extremities typically remain more affected than lower extremities
- Motor function is usually more severely impaired than sensory function
Important Caveats
- While non-operative management has been the historical standard, recent evidence suggests early surgical decompression (within 72 hours) may be beneficial in cases with focal anatomical cord compression 2
- Non-operative treatment should be reserved primarily for patients with mild central cord syndrome 2
- Patients without evidence of fracture, younger patients, and those with commercial insurance are more likely to receive operative intervention 4
The management of central cord syndrome requires a multidisciplinary approach involving neurologists, neurosurgeons, rehabilitation specialists, and nursing staff to optimize outcomes and minimize complications.