What are the assessment findings and recommendations for patients with central cord syndrome?

Assessment Findings and Recommendations for Central Cord Syndrome

Early immobilization of the spine and prompt referral to a spine surgeon are essential for patients with suspected central cord syndrome to limit neurological deficit and improve functional outcomes. 1, 2

Clinical Assessment Findings

Neurological Presentation

• Disproportionately greater motor impairment in upper extremities compared to lower extremities 2, 3
• Sensory changes in upper and lower extremities 3
• Bladder dysfunction 3
• Decreased hand dexterity 4
• Gait instability 4

Mechanism of Injury

• Most commonly occurs after trauma to the cervical spine 2
• Often seen in two distinct populations:
  • Older adults with pre-existing cervical spondylosis following low-energy mechanisms (falls, minor trauma) 3
  • Younger patients with high-energy trauma 3
• Frequently associated with hyperextension injuries in patients with cervical stenosis 5

Imaging Findings

• MRI is the imaging modality of choice to visualize cord compression and signal changes 4
• CT myelography may be used in patients with contraindications to MRI 4
• Imaging may reveal:
  • Cervical stenosis
  • Disc herniation
  • Vertebral fracture or dislocation
  • Spinal cord edema or contusion

Management Recommendations

Immediate Management

1. Spine Immobilization:

   • Early immobilization of the spine is recommended to limit onset or aggravation of neurological deficit (GRADE 2+) 1
   • Maintain neutral spinal alignment during transport and initial assessment 6

2. Initial Assessment:

   • Evaluate level of consciousness, specific neurological deficits, respiratory capacity, and oxygen saturation 6
   • Monitor vital signs and blood pressure 6
   • Maintain patent airway and administer oxygen if saturation is less than 92% 6

3. Urgent Neuroimaging:

   • Obtain MRI with diffusion or CT to determine the underlying cause and extent of cord compression 6, 4

Surgical Management

1. Patients with vertebral fracture, dislocation, traumatic disc herniation, or instability:

   • Early surgery (within 24 hours) is recommended for better outcomes 5

2. Patients with central cord syndrome secondary to extension injury in stenotic cervical canal without fracture/dislocation:

   • Surgical decision should be based on:
     • Severity of neurological deficit
     • Presence of spinal cord compression
     • Patient's overall health status
     • Risk of neurological deterioration 5

Rehabilitation

1. Physical Therapy:

   • Task-oriented training
   • Muscle strengthening exercises
   • Balance and trunk control training 6

2. Occupational Therapy:

   • Focus on activities of daily living
   • Environmental adaptation
   • Use of adaptive devices if necessary 6

3. Spasticity Management:

   • Consider botulinum toxin injections for focal spasticity 6
   • Implement gentle stretching and mobilization techniques 6

Prevention of Complications

1. Respiratory Care:

   • Monitor respiratory function
   • Perform breathing exercises
   • Use techniques to clear respiratory secretions 6

2. Pressure Ulcer Prevention:

   • Regular visual and tactile inspections of high-risk areas
   • Use special mattresses and cushions to alleviate pressure
   • Reposition every 2-4 hours 6

3. Swallowing Assessment:

   • Evaluate swallowing capacity before initiating oral feeding
   • Maintain NPO status until safe swallowing is confirmed 6

Prognosis

• Central cord syndrome has the best outcomes among incomplete spinal cord injuries 2
• Significant functional recovery typically occurs during the first 6 months post-injury 6
• Continued improvements are possible beyond this period 6
• Regular assessments of functional progress are recommended to adjust the rehabilitation plan as needed 6

Important Considerations

1. Terminology Evolution:

   • Recent literature suggests using "acute traumatic myelopathy" as a more precise term than "central cord syndrome" 2

2. Controversy in Management:

   • There is ongoing debate regarding early surgery versus conservative management in cases without fracture/dislocation 5
   • High-quality prospective randomized controlled trials are needed to resolve this controversy 5

3. Diagnostic Challenges:

   • Diagnosis is often delayed despite being the most common form of spinal cord injury in adults 4
   • Prompt referral to a spine surgeon is recommended for any patient suspected of having central cord syndrome to prevent long-term disability 4