Assessment Findings and Management of Central Cord Syndrome
Clinical Assessment Findings
Central cord syndrome (CCS) presents with a characteristic pattern of disproportionate upper extremity weakness compared to lower extremity weakness, typically following hyperextension injury in older adults with pre-existing cervical stenosis or high-energy trauma in younger individuals. 1, 2, 3
Key Neurological Findings
- Upper extremity motor function is more severely impaired than lower extremity function (defined as lower extremity motor score minus upper extremity motor score ≥5 points) 1
- Sensory deficits affecting upper extremities more than lower extremities 3, 4
- Variable bladder dysfunction 3
- Severity classified using the American Spinal Injury Association (ASIA) Impairment Scale 1, 3
Diagnostic Evaluation
- MRI is the recommended imaging modality to assess spinal cord compression, signal changes, and structural pathology 5
- Baseline neurological examination must be documented within 14 days of injury 1
- Assessment should identify mechanical instability versus isolated stenosis with cord compression 2, 4
Management Strategy
Surgical Timing: The Critical Decision
Early surgical decompression (<24 hours) is recommended for patients with central cord syndrome, particularly those with ASIA Impairment Scale grade C injury, as it results in significantly improved motor recovery. 1, 6
Evidence-Based Surgical Approach:
- For ASIA grade C patients: Early surgery produces significantly greater overall motor score recovery (mean difference 9.5 points at 1 year), with gains in both upper and lower limb function 1
- For ASIA grade D patients: Outcomes are comparable between early and late surgery, though early intervention may still be considered 1
- Upper extremity motor recovery: Early decompression results in significantly improved upper limb function (mean difference 2.3 points) regardless of injury severity 1
Surgical Indications
Surgical decompression and stabilization should be performed in patients with:
- Any mechanical instability 4
- Ongoing cord compression 4
- Significant neurologic deficit 4
- ASIA grade C injury (strong indication for early intervention) 1
Benefits of Early Surgery
- Earlier improvement in neurological status 4
- Shorter hospital stay 4
- Shorter intensive care unit stay 4
- Functions as neuroprotective therapy 1
Perioperative and Critical Care Considerations
Neurocritical Care Monitoring
- Intraspinal pressure (ISP), mean arterial pressure (MAP), and spinal perfusion pressure (SPP) monitoring may help minimize secondary injury, though not yet routine clinical practice 3
- Blood pressure management to optimize spinal cord perfusion 3
Complication Prevention
Common complications requiring proactive management include: 3
- Venous thromboembolism (requires prophylaxis)
- Infection surveillance
- Pressure injury prevention
- Autonomic dysfunction management
Controversial Therapies
- Corticosteroids remain controversial and are not routinely recommended 3
Common Pitfalls to Avoid
Diagnostic Pitfalls
- Misdiagnosis due to imprecise terminology: CCS has been used to describe a spectrum of conditions; the more accurate term is "acute traumatic myelopathy" in the setting of stable spine with stenosis 2
- Delayed diagnosis leading to missed window for early surgical intervention 1, 6
Management Pitfalls
- Defaulting to conservative management in all cases: Historical practice favored observation, but current evidence supports early surgery for appropriate candidates 1, 4
- Treating all ASIA grades identically: ASIA grade C patients derive significantly greater benefit from early surgery than grade D patients 1
- Failing to assess for mechanical instability versus isolated stenosis 2, 4
Timing Pitfalls
- Delaying surgery beyond 24 hours without clear rationale: The neuroprotective window may be lost 1, 6
- Waiting for "neurological improvement" before deciding on surgery in ASIA grade C patients 1
Functional Outcomes and Prognosis
- CCS has the best prognosis among incomplete spinal cord injuries 2, 4
- Early surgical intervention is associated with clinically important improvements at 6 months and following discharge from rehabilitation 6
- Upper extremity recovery is the primary functional limitation and shows significant improvement with early decompression 1
- No significant difference in complication rates between early and late surgery groups 6