Central Cord Syndrome
This patient has central cord syndrome (CCS), characterized by the classic triad of disproportionately greater upper extremity weakness compared to lower extremity weakness (2/5 arms vs 3/5 legs), bladder dysfunction (urinary incontinence), and traumatic mechanism in an elderly patient. 1, 2
Clinical Presentation and Diagnosis
The hallmark feature distinguishing CCS from other spinal cord syndromes is the disproportionate motor impairment with upper extremities more severely affected than lower extremities, exactly as presented in this case. 2, 3, 4
Key diagnostic features present in this patient:
- Bilateral arm weakness (2/5) worse than bilateral leg weakness (3/5) - this is pathognomonic for CCS 2, 3
- Urinary incontinence indicating bladder dysfunction, which is a core component of the syndrome 2, 3, 4
- Traumatic mechanism (forklift accident) in an elderly patient, consistent with the typical presentation 1, 2
Why Not Other Syndromes?
Anterior cord syndrome would present with motor paralysis and loss of pain/temperature sensation bilaterally, but with preserved proprioception and light touch - this patient's pattern of upper extremity predominance excludes this diagnosis. 1
Brown-Séquard syndrome presents with ipsilateral motor weakness and contralateral sensory loss (hemicord injury) - this patient has bilateral symmetric findings, ruling out this diagnosis. 1
Posterior cord syndrome would present with loss of proprioception and vibration sense with preserved motor function - this patient has significant motor deficits, excluding this diagnosis. 1
Pathophysiology
CCS results from centro-medullary hemorrhage and edema, or more recently proposed Wallerian degeneration from spinal cord compression in a narrowed canal. 4 Nearly 50% of CCS patients have preexisting congenital or degenerative spinal stenosis, with injury occurring during hyperextension mechanisms. 3
Clinical Significance
CCS is the most common incomplete spinal cord injury with the best prognosis for recovery. 1, 2, 3 More than half of patients experience spontaneous recovery of motor weakness, though residual deficits in manual dexterity, neuropathic pain, spasticity, and bladder dysfunction may persist. 3
The correct answer is C: Central cord syndrome.