What type of spinal cord injury is likely in a patient with neck pain, minimal movement and decreased sensation in upper extremities, but able to move lower extremities after a high-speed motor vehicle crash?

Central Cord Syndrome

This patient most likely has Central Cord Syndrome (Answer C). The classic presentation of disproportionately greater motor impairment and decreased sensation in the upper extremities compared to preserved lower extremity function following a hyperextension mechanism (rear-end collision) in the cervical spine is pathognomonic for this injury pattern 1.

Clinical Presentation

Central cord syndrome (CCS) is characterized by:

• Disproportionately greater motor weakness in the upper extremities compared to the lower extremities 1, 2
• Decreased sensation in the upper extremities, particularly the hands 2
• Preserved or relatively intact lower extremity motor function 1
• Bladder dysfunction (often urinary retention) 1, 2
• Varying degrees of sensory loss below the level of injury 1

This patient's presentation—minimal upper extremity movement with decreased sensation but ability to move lower extremities—fits this pattern precisely 1.

Mechanism and Pathophysiology

CCS typically occurs from a hyperextension mechanism in patients with underlying cervical canal stenosis 1, 2. The rear-end motor vehicle crash described creates the classic hyperextension injury 1. The mechanism involves:

• Sudden forceful hyperextension of the neck causing spinal cord contusion 2
• Compression of the cord between hypertrophic spondylotic disc-osteophyte complex anteriorly and buckled ligamentum flavum posteriorly 1
• Injury predominantly affecting the central portion of the spinal cord 1
• Disruption of medially located upper extremity motor fibers in the corticospinal tracts, while laterally positioned lower extremity fibers are relatively spared 1

CCS is now the most common form of incomplete spinal cord injury and is expected to become even more prevalent with the aging population 1, 2.

Distinguishing from Other Syndromes

Why Not Brown-Séquard Syndrome (A)?

Brown-Séquard syndrome presents with ipsilateral motor weakness and loss of proprioception with contralateral loss of pain and temperature sensation 3. This patient has bilateral upper extremity involvement without the characteristic hemicord pattern.

Why Not Anterior Cord Syndrome (B)?

Anterior cord syndrome causes complete motor paralysis below the level of injury with loss of pain and temperature sensation, but preserved proprioception and vibration sense 3. This patient has preserved lower extremity motor function, ruling out this diagnosis.

Why Not Conus Medullaris (D)?

Conus medullaris syndrome affects the terminal end of the spinal cord (T12-L2 level), presenting with saddle anesthesia, bowel/bladder dysfunction, and lower extremity weakness 1. The cervical injury location and upper extremity predominance exclude this diagnosis.

Immediate Management Priorities

Early surgical decompression within 24 hours is strongly recommended for incomplete spinal cord syndromes to improve neurological outcomes 3. The evidence suggests:

• Surgery within 24 hours leads to greater neurological recovery, shorter hospital stay, and fewer inpatient complications 2, 4
• Immediate optimization of cardiorespiratory and hemodynamic parameters is essential to prevent secondary injury 1, 3
• Management in a specialized acute spinal cord injury unit reduces morbidity and mortality 1, 3

Critical Initial Steps

• Maintain spinal immobilization with manual stabilization of the head to minimize motion of head, neck, and spine 1
• Optimize hemodynamic parameters—cervical injuries can produce profound hypotension from loss of cardiovascular sympathetic innervation 1
• Arrange urgent MRI, which is the gold standard for diagnosing spinal cord contusions and compression 3
• Transfer to a specialized acute SCI center within the critical therapeutic time window 1

Prognosis

The prognosis in CCS is relatively favorable compared to other incomplete spinal cord injuries 2. However:

• Fine motor control of the hands often remains impaired despite good overall motor recovery 2
• Neuropathic pain may persist even in patients with excellent motor recovery 2
• Comprehensive rehabilitation should begin from the first days of injury 3

Common Pitfalls

A substantial proportion of SCI patients (50-80%) arrive at specialized centers outside the critical 24-hour therapeutic window due to transport delays, lack of operating room availability, and system barriers 1. This delay deprives patients of timely therapy that could improve outcomes 1.

Do not delay imaging or transfer based on initial neurological examination alone—the extent of injury may not be immediately apparent, and early intervention is time-critical 1, 3.