Makindo Medical Notes.com

The most common cause is a hyperextension injury to the neck, often associated with falls, motor vehicle accidents, or sports injuries, particularly in older adults with pre-existing cervical spine degeneration. In older frail patient a bruise to the forehead and weak arms may suggest a central cord syndrome

About

• The most common cause is a hyperextension injury to the neck
• Falls, motor vehicle accidents, or sports injuries
• Often associated with existing cervical spondylosis

Anatomy

Aetiology

• Hyperextension injury causes cord compression between vertebral body and ligamentum flavum
• Results in damage to the centre of the cord and central tracts e.g. spinothalamic and corticospinal
• Central cord carries upper limb fibres > lower limb fibres
• May be due to compromise to the anterior spinal artery
• May be an associated fracture but not always
• Autonomic dysreflexia may be seen in lesions higher than T6

Clinical

• Weakness Arms > legs as arm fibres more central
• Classically a "cape-like" area of sensory loss hands, arms, chest.
• They will often have neck pain at the site of spinal cord impingement.
• Spasticity and UMN signs but may be able to walk
• Bladder dysfunction = retention/incontinence
• Rarely Upper limb areflexia and Horner's syndrome
• Autonomic dysreflexia, neuropathic pain
  • Usually occurs in the first month of the injury
  • Headaches, flushing, piloerection, increased BP
  • Anxiety, and nausea. Usually episodic

Investigations

• MRI is the most useful imaging modality for diagnosing CSCS, as it can reveal the extent of spinal cord compression, oedema, or haemorrhage.
• CT spine if unable to have an MRI but does show bones better
• Electrophysiological Tests: Nerve conduction studies or somatosensory evoked potentials (SSEPs) may be used to assess the extent of nerve damage.

Management

• Basics:ABC. Oxygen. IV fluids. Manage trauma. Neurorehabilitation. Bowel and Bladder care.
• Acute surgical intervention is not usually necessary unless there is significant spinal cord compression
• Many regain use of their legs and can often walk, but cannot effectively use their arms and hands.
• Many have a spontaneous recovery of motor function, but others may have lasting disability after injury.
• Prognosis for CCS in younger patients is better than in older patients.
• Autonomic dysreflexia: prevention by educating patients, caregivers, and hospital staff about the potential for autonomic dysreflexia as well as warning signs. During an acute episode, management should begin by placing the patient upright, removing all tight clothes, and removing any noxious stimuli such as skin pressure, urinary catheter dysfunction, and bowel impaction monitoring may be required in selective cases for the long term, even if the patient is not diagnosed as hypertensive. Control may need nitrates, hydralazine, and labetalol.
• Neuropathic pain at the level of the injury and below the level of injury. Consider gabapentin or Pregabalin) and tricyclic antidepressants (TCA), SSRIs/SNRI
• Spasticity: Consider a trial of Baclofen and other agents.

References

• The National Institutes of Neurological Disorders and Stroke website reiterates the above and additionally discusses clinical trials, patient organizations, and recent publications.
• Central Cord Syndrome