Central Cord Syndrome

OVERVIEW

Central cord syndrome (CCS) is an incomplete traumatic injury to the cervical spinal cord – the portion of the spinal cord that runs through the bones of the neck. This injury results in weakness in the arms more so than the legs. The injury is considered “incomplete” because patients are usually not completely paralyzed.

Causes

CCS usually occurs in people with existing arthritis changes in the bones of the neck. In such situations, the canal through which the spinal cord travels can be narrow, so that if the neck is forcefully extended (head tilted back), such as in a car accident, the spinal cord can be squeezed. There is usually no obvious break or fracture in the bones of the neck and spine may be stable. When the spinal cord is squashed, bruising, bleeding and swelling can occur, particularly in the center or central portion of the spinal cord. Since the spinal cord is organized with the nerves that control the movement of the arms in the center and the nerves going to the legs more toward the outside, the arms are affected more than the legs in this situation. As a result, patients with CCS tend to be weaker in the arms than in the legs. Many patients with CCS regain use of their legs and can often walk, but cannot effectively use their arms and hands.

Symptoms

Patients typically complain of weakness in the upper extremities (arms) and less severe weakness of the lower extremities (legs). This weakness may result in difficulty with every-day tasks, such as doing up buttons, writing or even walking. Patients may also note a lack of sensation and difficulty urinating. Depending on the severity of the event that triggered the onset of symptoms, patients may also complain of neck pain.

This syndrome more commonly affects patients age 50 and older, who have sustained a neck (cervical) hyperextension injury. CCS affects males more frequently than females. It is expected that the number of patients with CCS will increase as patients live longer, while at the same time remaining much more physically active than in past generations. However, CCS may occur in patients of any age and can be seen in athletes who present with not only hyperextension injuries to their neck, but associated ruptured disc(s) that cause compression of the spinal cord.

When & How to Seek Medical Care

If the above symptoms develop after an accident or injury, seek urgent medical attention at a local emergency department. There, medical providers are able to evaluate and obtain the appropriate tests to determine the cause of symptoms. Depending on the results of the examination and testing, the emergency medical provider may refer the patient to a spine specialist for further treatment. Alternatively, if symptoms have come on slowly and are not the result of a sudden accident, consult a spine specialist, such as a neurosurgeon.

Testing & Diagnosis

Evaluation of a patient with suspected CCS includes a complete medical history, thorough general and neurological examinations, cervical magnetic resonance imaging (MRI), computed tomography (CT) scan and plain cervical spine X-rays, including supervised flexion and extension views.

• MRI: A diagnostic test that produces three-dimensional images of body structures using powerful magnets and computer technology; can show direct evidence of spinal cord compression from bone, disc or hematoma. MRI can also show ligamentous and soft tissue injuries that might be missed by other imaging tests.
• CT or CAT scan: A computer-enhanced X-ray imaging device that shows boney detail superior to any other imaging device. It also shows shape and size of the spinal canal, its contents and the structures around it. It is usually performed prior to MRI scanning. Combined with MRI scans, it provides a more complete set of information for treatment decision making.
• X-ray: Application of radiation to produce a film or picture of a part of the body can show the structure of the vertebrae and the outline of the joints. X-rays of the spine delineate fractures and dislocations, as well as the degree and extent of arthritis type changes. Flexion/extension views (moving the neck forwards and backwards) assist in the evaluation of spinal stability. Both the MRI and CT scan images are static images, meaning they do not evaluate movement. Flexion/extension plain X-rays can provide a simple means of determining dynamic (movement-related) stability or instability of the spinal column. These views can help determine whether or not a cervical collar or stabilizing cervical spine surgery is necessary.

Treatment

Non-Surgical Treatments

Observed neurological improvement is the most compelling reason not to proceed with surgical treatment in favor of non-surgical management of CCS. Nonsurgical treatment consists of immobilization of the neck with a rigid cervical collar and rehabilitation with physical and occupational therapy.

Surgery

Acute surgical intervention is not usually necessary, unless there is significant spinal cord compression. Prior to the CT/MRI era, surgical intervention was thought to be more harmful because of the risk of injuring a swollen cervical cord and worsening the patient’s neurological problems. However, with advanced imaging technology, patients with compression of the spinal cord secondary to traumatic herniated discs and other structurally compressive lesions can be quickly diagnosed and surgically decompressed. In cases where bony arthritis changes are causing the narrowing of the spinal canal and compression of the spinal cord, surgery is usually not performed until the patient has made significant recovery. Reassessment at that time may lead to surgery, depending on the underlying cause. If there is a surgically treatable lesion with significant residual motor weakness after a period of recovery, or if new neurological deterioration is observed, then surgical intervention may be considered. Additional pre-surgical re-evaluation with a pre-surgical CT scan and/or MRI scan may be necessary beforehand.

Outlook

Many patients with CCS make a spontaneous recovery of motor function, while others experience considerable recovery in the first six weeks after injury.

If the underlying cause is edema or swelling in the spinal cord, recovery may occur relatively soon after an initial period of weakness. Leg function usually returns first, followed by bladder control and then arm function. Hand movement and finger dexterity improve last. If the central lesion is caused by bleeding or a stroke in the spinal cord, then recovery is less likely and the prognosis is not as good.

The prognosis for CCS in younger patients is better than in older patients. Within the short time, a majority of younger patients recover and regain the ability to walk and perform daily activities. However, in elderly patients the prognosis is not as favorable, with or without surgical intervention.

Resources for More Information

1. Guest, J., Eleraky, M. A., Apostolides, P. J., Dickman, C. A., & Sonntag, V. K. (2002). Traumatic central cord syndrome: Results of surgical management. Journal of Neurosurgery: Spine, 97(1), 25-32.
2. The National Institutes of Neurological Disorders and Stroke website reiterates the above and additionally discusses clinical trials, patient organizations, and recent publications.