What is the management of central cord syndrome?

Management of Central Cord Syndrome

Early spine immobilization followed by multimodal treatment including surgical intervention when indicated is strongly recommended for patients with central cord syndrome to optimize neurological recovery and prevent complications.

Initial Management

• Spine Immobilization: Early immobilization of the spine is crucial in any patient with suspected spinal cord injury to prevent worsening of neurological deficits 1
• Hemodynamic Management:
  • Maintain mean arterial pressure (MAP) ≥70 mmHg during the first week
  • Implement fluid resuscitation combined with vasopressors (typically norepinephrine) for hemodynamic stabilization in neurogenic shock 1
  • Continuous hemodynamic monitoring, especially during procedures

Respiratory Management

• For upper cervical injuries (C2-C5):
  • Consider tracheostomy within the first 7 days 2
  • Use a bundle approach to facilitate respiratory weaning:
    • Abdominal contention belt during spontaneous breathing
    • Active physiotherapy with mechanically-assisted insufflation/exsufflation devices
    • Aerosol therapy combining beta-2 mimetics and anticholinergics 2
• For lower cervical injuries (C6-C7):
  • Consider tracheostomy only after one or more tracheal extubation failures 2

Surgical Management

• Recent evidence suggests that early surgical intervention (≤24 hours) may lead to:
  • Greater neurological recovery
  • Shorter hospital stay
  • Fewer inpatient complications 3
• Surgical decompression is indicated for:
  • Radiographic evidence of spinal cord compression
  • Poor neurological recovery or deterioration
  • Spinal instability 3, 4

Pain Management

• Implement multimodal analgesia:
  • Non-opioid analgesics
  • Antihyperalgesic drugs (ketamine)
  • Opioids during surgical management 2, 1
• For neuropathic pain:
  • Introduce oral gabapentinoid treatment for >6 months
  • Add tricyclic antidepressants or serotonin reuptake inhibitors when monotherapy is inefficient 2, 1

Rehabilitation

• Begin rehabilitation as soon as the patient is medically stable and spine is stabilized 2, 1
• Focus on:
  • Maintaining joint amplitudes
  • Preventing and treating spasticity
  • Strengthening existing musculature 1
• Perform stretching for at least 20 minutes per zone
• Use simple posture orthoses and proper bed/chair positioning to prevent deformities 2
• Consider botulinum toxin injections for focal spasticity 1

Prevention of Complications

Pressure Ulcers Prevention

• Early mobilization once spine is stabilized
• Visual and tactile checks of all risk areas at least once daily
• Repositioning every 2-4 hours with pressure zone checks
• Use pressure-relieving tools (cushions, foam, pillows)
• Use high-level prevention supports (air-loss mattress, dynamic mattress) 2

Bladder Management

• Intermittent urinary catheterization is the reference method
• Remove indwelling catheter as soon as patient is medically stable
• Implement micturition calendar to adapt frequency of catheterization 2

Prognosis

• Central cord syndrome has a relatively favorable prognosis compared to other spinal cord injuries
• Most recovery occurs during the first 9-12 months with plateau at 12-18 months
• Fine motor control of hands often remains impaired despite good overall recovery
• Neuropathic pain may persist even with excellent motor recovery 1, 3

Multidisciplinary Care

• Involve a team including:
  • Neurosurgeons/orthopedic surgeons
  • Intensivists
  • Rehabilitation specialists
  • Physical and occupational therapists
  • Respiratory therapists
  • Specialized nurses 1

Important Clinical Considerations

• Central cord syndrome is the most common form of incomplete spinal cord injury 5, 6, 3
• It typically presents with:
  • Upper extremity weakness greater than lower extremity weakness
  • Motor function more severely impaired than sensory function 6
  • Often occurs in older persons with underlying cervical spondylosis due to hyperextension mechanism 6, 3
• Recent literature suggests using the more precise term "acute traumatic myelopathy" for acute cervical cord injury with stable spine and congenital/degenerative stenosis 5