Management of Central Cord Syndrome
Patients with central cord syndrome should undergo early surgical decompression within 24 hours if they have persistent spinal cord compression from dislocation, burst fracture, or disc herniation, or if they show any neurological deterioration. 1
Immediate Acute Management
Hemodynamic Optimization
- Maintain mean arterial pressure >70 mmHg using invasive monitoring in an intensive care setting to prevent secondary ischemic injury from hypoperfusion 1, 2
- Cervical injuries can cause loss of sympathetic innervation leading to profound hypotension requiring aggressive cardiovascular support 1
- Transfer immediately to a specialized spinal cord injury center, as delays beyond 24 hours significantly worsen outcomes 1
Medication Considerations
- Do not administer methylprednisolone - it is not recommended based on Congress of Neurological Surgeons 2013 guidelines due to lack of neurological benefit and increased infectious complications (pulmonary and urinary infections) without improvement in motor function 1, 2
Surgical Decision Algorithm
Indications for Urgent Surgery (Within 24 Hours)
- Persistent spinal cord compression from dislocation, burst fracture, or disc rupture 1
- Any neurological deterioration 1
- Radiographic evidence of ongoing compression on MRI 2
The evidence strongly favors early surgical decompression in central cord syndrome patients with preexisting cervical stenosis, as this syndrome has an unpredictable neurologic course with potential for secondary injury mechanisms and functional deterioration 3. Early decompression within 24 hours improves neurological outcomes and reduces morbidity and mortality across all incomplete spinal cord syndromes 1.
Surgical Approach Considerations
- Central cord syndrome most commonly occurs in older patients with underlying cervical spondylosis after hyperextension trauma 4, 5
- The injury pattern is heterogeneous and may involve high-energy or low-energy mechanisms 5
- Treatment decisions depend on injury mechanism, compressive lesions identified on imaging, neurological examination findings, and preexisting cervical pathology 5
Rehabilitation Protocol
Early Phase (First Days)
- Begin immediate physical and occupational therapy from the first days of injury, as this enhances neurotrophic factor elaboration that promotes axonal regeneration and neuronal recovery 1
- Early vigorous rehabilitation maximizes neurological recovery 1
Ongoing Rehabilitation
- Continue comprehensive rehabilitation through all phases of care 1
- Management in a specialized acute spinal cord injury unit reduces morbidity and mortality 1
Complication Prevention and Management
Monitor and aggressively manage:
- Autonomic dysreflexia 1
- Respiratory dysfunction 1
- Thromboembolism prophylaxis 1
- Pressure ulcer prevention 1
- Bowel dysfunction 1
- Depression screening and treatment 1
Critical Pitfalls to Avoid
- Do not delay transfer to specialized centers - only 20-50% of spinal cord injury patients arrive within the critical 24-hour window for optimal surgical intervention 1
- Do not use outdated methylprednisolone protocols based on the flawed NASCIS trials, which contained scientific irregularities and represent negative Class I evidence when meticulously examined 1, 2
- Do not allow hypotension to persist - failure to maintain adequate blood pressure leads to secondary ischemic injury 1
- Recognize that central cord syndrome represents a spectrum from isolated hand/forearm weakness to complete quadriparesis with only sacral sparing 4
Prognosis and Follow-Up
- Central cord syndrome is the most common incomplete spinal cord injury with the best overall outcomes 6, 4
- Upper extremities are more affected than lower extremities, with motor function more severely impaired than sensory function 4
- Spontaneous improvement of function is typical, though recovery is often incomplete with conservative management alone 4, 7
- Minimum 12-month follow-up is recommended, with 24-month follow-up preferable when evaluating recovery 1