Central Cord Syndrome

Resource Utilization Following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination.

SUMMARY OF BACKGROUND DATA

Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear.

METHODS

Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed.

RESULTS

There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 ( P <0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P <0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P <0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P <0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P <0.001).

CONCLUSIONS

For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.

A Practical Classification System for Acute Cervical Spinal Cord Injury Based on a Three-Phased Modified Delphi Process From the AOSpine Spinal Cord Injury Knowledge Forum

STUDY DESIGN

A modified Delphi study.

OBJECTIVE

To assess current practice patterns in the management of cervical spinal cord injury (SCI) and develop a simplified, practical classification system which offers ease of use in the acute setting, incorporates modern diagnostic tools and provides utility in determining treatment strategies for cervical SCI.

METHODS

A three-phase modified Delphi procedure was performed between April 2020 and December 2021. During the first phase, members of the AOSpine SCI Knowledge forum proposed variables of importance for classifying and treating cervical SCI. The second phase involved an international survey of spine surgeons gauging practices surrounding the role and timing of surgery for cervical SCI and opinions regarding factors which most influence these practices. For the third phase, information obtained from phases 1 and 2 were used to draft a new classification system.

RESULTS

396 surgeons responded to the survey. Neurological status, spinal stability and cord compression were the most important variables influencing decisions surrounding the role and timing of surgery. The majority (>50%) of respondents preferred to perform surgery within 24 hours post-SCI in clinical scenarios in which there was instability, severe cord compression or severe neurology. Situations in which <50% of respondents were inclined to operate early included: SCI with mild neurological impairments, with cord compression but without instability (with or without medical comorbidities), and SCI without cord compression or instability.

CONCLUSIONS

Spinal stability, cord compression and neurological status are the most important variables influencing surgeons' practices surrounding the surgical management of cervical SCI. Based on these results, a simplified classification system for acute cervical SCI has been proposed.

A novel mouse model of central cord syndrome

Patients with potential spinal stenosis are susceptible to central cord syndrome induced by blunt trauma. Suitable animal models are helpful for studying the pathogenesis and treatment of such injuries. In this study, we established a mouse model of acute blunt traumatic spinal cord injury by compressing the C6 spinal cord with 5 and 10 g/mm² compression weights to simulate cervical central cord syndrome. Behavioral testing confirmed that this model exhibited the characteristics of central cord syndrome because motor function in the front paws was impaired, whereas basic motor and sensory functions of the lower extremities were retained. Hematoxylin-eosin staining showed that the diseased region of the spinal cord in this mouse model was restricted to the gray matter of the central cord, whereas the white matter was rarely affected. Magnetic resonance imaging showed a hypointense signal in the lesion after mild and severe injury. In addition, immunofluorescence staining showed that the degree of nerve tract injury in the spinal cord white matter was mild, and that there was a chronic inflammation reaction. These findings suggest that this mouse model of central cord syndrome can be used as a model for preclinical research, and that gray matter is most vulnerable to injury in central cord syndrome, leading to impaired motor function.

Surgery on the Day of Admission Decreases Postoperative Complication Rates for Patients With Central Cord Syndrome: An Analysis of National Surgical Quality Improvement (NSQIP) Data From 2010 to 2020

STUDY DESIGN

Retrospective review.

OBJECTIVE

This study was undertaken to determine what constitutes "early optimal timing" of surgical management of central cord syndrome (CCS) with respect to a reduction of medical complications.

SUMMARY OF BACKGROUND DATA

Data varies on the optimal time for surgical treatment of CCS with some studies favoring early intervention and others advocating that surgery can or should be delayed for 2-6 weeks.

METHODS

This IRB-approved study was a retrospective cross-sectional review of surgical management outcomes for patients diagnosed with CCS using the National Surgical Quality Improvement Program database, which consists of anonymized medical record data from the year 2010 to 2020. Patient data included age, sex, American Society of Anesthesiologists score, current procedural terminology codes, length of stay, and postoperative complications. Patients were grouped into admission-day surgery, next-day surgery, and late-surgery groups.

RESULTS

A total of 738 patients who underwent surgery to treat CCS were identified in the National Surgical Quality Improvement Program database from 2010 to 2020 and included in this study. Admission-day surgery compared with next-day surgery was associated with a decreased postoperative complication rate after multivariate analysis (odds ratio: 0.52; 95% CI: 0.28-0.97; P =0.0387) as well as shorter length of stay ( P <0.0001). Complication rates between the next-day-surgery cohort and late-surgery cohort did not differ after multivariate analysis (odds ratio: 1.02; 95% CI: 0.63-1.65; P =0.9451), but the length of stay was shorter for next-day surgery ( P <0.0001). Two-year rolling averages for the admission-day-surgery rate and next-day-surgery rate show a compound annual growth rate of 2.52% and 4.10%, respectively.

CONCLUSIONS

In patients admitted for surgical treatment of CCS, those who receive admission-day surgery have significantly reduced 30-day complication rates as well as shorter length of stays. Therefore, we advocate that "early surgery" should be defined as surgery on the day of admission and should occur in as timely a manner as possible. Prior studies, which define "early surgery" as within 24 hours might, unfortunately, fall short of reaching the optimal threshold for the reduction of 30-day medical complications associated with the treatment of patients with CCS.

Treatment of acute traumatic central cord syndrome: a score-based approach based on the literature

PURPOSE

Acute traumatic central cord syndrome (ATCCS) accounts for up to 70% of incomplete spinal cord injuries, and modern improvements in surgical and anaesthetic techniques have given surgeons more treatment options for the ATCCS patient. We present a literature review of ATCCS, with the aim of elucidating the best treatment option for the varying ATCCS patient characteristics and profiles. We aim to synthesise the available literature into a simple-to-use format to aid in the decision-making process.

METHODS

The MEDLINE, EMBASE, CENTRAL, Web of Science and CINAHL databases were searched for relevant studies and improvement in functional outcomes were calculated. To allow for direct comparison of functional outcomes, we chose to focus solely on studies which utilised the ASIA motor score and improvements in ASIA motor score.

RESULTS

A total of 16 studies were included for review. There were a total of 749 patients, of which 564 were treated surgically and 185 were treated conservatively. There was a significantly higher average motor recovery percentage amongst surgically-treated patients as compared to conservatively treated patients (76.1% vs. 66.1%, p value = 0.04). There was no significant difference between the ASIA motor recovery percentage of patients treated with early surgery and delayed surgery (69.9 vs. 77.2, p value = 0.31). Delayed surgery after a trial of conservative management is also an appropriate treatment strategy for certain patients, and the presence of multiple comorbidities portend poor outcomes. We propose a score-based approach to decision making in ATCCS, by allocating a numerical score for the patient's clinical neurological condition, imaging findings on CT or MRI, history of cervical spondylosis and comorbidity profile.

CONCLUSIONS

An individualised approach to each ATCCS patient, considering their unique characteristics will lead to the best outcomes, and the use of a simple scoring system, can aid clinicians in choosing the best treatment for ATCCS patients.

Acute Traumatic Myelopathy: Rethinking Central Cord Syndrome

Central cord syndrome (CCS) is an incomplete spinal cord injury that consists of both sensory and motor changes of the upper and lower extremities. CCS most commonly occurs after trauma to the cervical spine leading to acute neurological changes. Despite being the most common incomplete spinal cord injury with the best outcomes, optimal treatment remains controversial. Although clinical practice has shifted from primarily conservative management to early surgical intervention, many questions remain unanswered and treatment remains varied. One of the most limiting aspects of CCS remains the diagnosis itself. CCS, by definition, is a syndrome with a very specific pattern of neurological deficits. In practice and in the literature, CCS has been used to describe a spectrum of neurological conditions and traumatic morphologies. Establishing clarity will allow for more accurate decision making by clinicians involved in the care of these injuries. The authors emphasize that a more precise term for the clinical condition in question is acute traumatic myelopathy: an acute cervical cord injury in the setting of a stable spine with either congenital and/or degenerative stenosis.

Combining transcranial direct current stimulation and peripheral electrical stimulation to improve upper limb function in a patient with acute central cord syndrome: a case report

We report the immediate improvement of weakened muscles after combined treatment with transcranial direct current stimulation (tDCS) and peripheral electrical stimulation (PES) in a patient with acute central cord syndrome (CCS) who presented with severe upper limb motor dysfunction. A 70-year-old man sustained CCS with severe motor deficits in the left upper limb, which did not improve with conventional training until 6 days after injury. On the seventh day after the injury, the left upper limb was targeted with combined tDCS (1 mA for 20 minutes/day, anode on the right, cathode on the left) and PES (deltoid and wrist extensors, 20 minutes/day at the motor threshold), and his performance score immediately improved from 0 to 6 on the Box and Block test. After four sessions, the left upper limb function improved to 32 on the Box and Block test, and manual muscle test scores of the stimulated deltoid and wrist extensors improved from 1 to 2. This improvement of the left upper limb led to improved self-care activities such as eating and changing clothes. Exercise combined with tDCS and PES may be a novel treatment for upper limb movement deficits after acute CCS.

Selective transfer of nerve to supinator to restore digital extension in central cord syndrome: An anatomical study and a case report

BACKGROUND

Nerve transfers are increasingly used to restore upper extremity function in patients with spinal cord injury. However, the role of nerve transfers for central cord syndrome is still being established. The purpose of this study is to report the anatomical feasibility and clinical use of nerve transfer of supinator motor branches (NS) to restore finger extension in a central cord syndrome patient.

MATERIALS AND METHODS

The posterior interosseous nerve (PIN), its superficial division, and branches were dissected in 14 fresh cadavers, with a mean age of 65 (58-79). Measurements included number and length of branches of donor and recipient, diameters, regeneration distance from coaptation site to motor entry point and axonal counts. A NS transfer to extensor carpi ulnaris (ECU), extensor digiti quinti (EDQ) and extensor digitorum communis (EDC) was performed in a 28-year-old patient, with central cord syndrome after a motorcycle accident, who did not recover active finger extension at 10 months post injury.

RESULTS

The PIN consistently divided into a deep and superficial branch between 1.5 cm proximal to, and 2 cm distal to the distal boundary of the supinator. The superficial branch provided a first common branch to the ECU and EDQ. In 12/14 dissections, the EDC was innervated by a 4 cm long branch that entered the muscle on its radial deep surface. In all cases, the superficial branch of the PIN could be separated in a retrograde fashion from the PIN and coapted with NS. The mean myelinated fiber count in nerve to EDC was 401 ± 190 compared to 398 ± 75 in the NS. At 48 months after surgery, with the wrist at neutral, the patient recovered full metacarpophalangeal extension scoring M4. Supination was preserved with the elbow extended or flexed.

CONCLUSIONS

Restoration of finger extension in central cord syndrome is possible with a selective transfer of the NS to EDC, and is anatomically feasible with a short regeneration distance and favorable axonal count ratio.

Central cord syndrome: clinical features, etiological diagnosis, and outcome in 74 dogs

OBJECTIVE

To describe the clinical and neurologic signs, diagnostic investigations, definitive or presumptive diagnosis, treatment, and outcome of dogs presented with acute onset central cord syndrome (CCS).

ANIMALS

74 client-owned dogs evaluated for CCS at 5 referral hospitals between January 2016 and March 2021.

PROCEDURES

Data were collected from the medical records of each dog, including patient signalment, physical and neurologic examination results, presence of signs of respiratory failure, diagnostic imaging findings, definitive or presumptive diagnosis, treatment and follow-up information. Descriptive statistics were calculated and bivariable analysis was performed to identify associations between selected variables.

RESULTS

2 neuroanatomic locations for the CCS were identified: C1-C5 spinal cord segments in 65 of 74 (88%) dogs and C6-T2 in 9 (12%) dogs. Neurolocalization did not correlate with the imaging findings in 43 (58%) dogs. Different diseases were associated with CCS. The most common condition was Hansen type I disk herniation in 27 (36%) dogs and hydrated nucleus pulposus extrusion in 16 (22%) dogs. Main lesion locations within the vertebral column associated with CCS were C3-C4 and C4-C5 intervertebral disk spaces in 21 (28%) and 18 (24%) dogs, respectively. Outcome was favorable in 69 (93%) dogs. Patients presenting with hypoventilation were 14.7 times more likely to have a poor outcome.

CLINICAL RELEVANCE

CCS in dogs may be seen with lesions in the C1-C5 and C6-T2 spinal cord segments. Etiologies are variable. Total or partial improvement was achieved in most dogs with the appropriate treatment. Hypoventilation was associated with death.

Length of Cervical Stenosis, Admission ASIA Motor Scores, and BASIC Scores Are Predictors of Recovery Rate Following Central Cord Syndrome

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

This study aims to determine whether quantitative magnetic resonance imaging (MRI) parameters and radiological scoring systems could be used as a reliable assessment tool for predicting neurological recovery trajectory following acute traumatic central cord injury syndrome (CCS).

SUMMARY OF BACKGROUND DATA

Controversy remains in whether CCS should be managed conservatively or by early surgical decompression. It is essential to understand how clinical and radiological parameters correlate with neurological deficits and how they predict recovery trajectories.

METHODS

We identified patients with CCS admitted between 2011 and 2018 with a minimum of 1-year follow-up. Cervical MRIs were analyzed for cord/canal dimensions, Brain and Spinal Injury Center (BASIC) scores and sagittal grading as ordinal scales of intraparenchymal cord injury. Japanese Orthopaedic Association (JOA) recovery rates (≥50% as good, < 50% as poor) were analyzed against these variables by logistic regression and receiver operator characteristic (ROC) curves. Additionally, we evaluated American Spinal Injury Association motor scale (AMS) scores/recovery rates.

RESULTS

Sixty patients were included, of which 30 were managed conservatively and 30 via surgical decompression. The average follow-up duration for the entire cohort was (51.1 ± 25.7) months. Upon admission, sagittal grading correlated with AMS and JOA scores (P < 0.01, β = 0.48). Volume of the C2 to C7 canal and axial cord area over the site of maximal compression correlated with AMS and JOA scores respectively (P = 0.04, β = 0.26; P = 0.01, β = 0.28). We determined admission AMS more than 61 to be a clinical cutoff for good recovery (area under the receiver operating curve [AUC] = 0.74, 95% confidence interval [CI]: 0.61-0.85, sensitivity 80.9%, specificity 69.2%, P < 0.01). Radiological cutoffs to identify patients with poor recovery rates were length of cervical spinal stenosis more than 3.9 cm (AUC = 0.76, 95% CI: 0.63-0.87, specificity 91.7%, sensitivity 52.2%, P < 0.01), BASIC score of more than 1 (AUC = 0.69, 95% CI: 0.56-0.81, specificity 80.5%, sensitivity 51.1%, P = 0.02). Surgical decompression performed as a salvage procedure upon plateau of recovery did not improve neurological outcomes.

CONCLUSION

Clinical and radiological parameters upon presentation were prognosticative of neurological recovery rates in CCS. Surgery performed beyond the acute post-injury period failed to improve outcomes.Level of Evidence: 3.

[Skiing Accident with Temporary Tetraparesis]

Skiing Accident with Temporary Tetraparesis Abstract. Summary: We present the case of a 74-year-old patient who initially suffered transient tetraplegia after a skiing accident. On presentation to the general practitioner, pyramidal tract signs as well as disturbances of fine motor function in both hands could be observed. MRI examinations of the cervical spine revealed high-grade spinal stenosis at level C5 with myelon compression. Surgical decompression of the spial cord, followed by fusion of the corresponding cervical vertebral bodies, was performed. After surgery and three weeks of neurological rehabilitation, the patient feels well and has recovered except for still existing hypesthesia of the fingertips.

T1 Mapping for Microstructural Assessment of the Cervical Spinal Cord in the Evaluation of Patients with Degenerative Cervical Myelopathy

BACKGROUND AND PURPOSE

Although current radiologic evaluation of degenerative cervical myelopathy by conventional MR imaging accurately demonstrates spondylosis or degenerative disc disease causing spinal cord dysfunction, conventional MR imaging still fails to provide satisfactory anatomic and clinical correlations. In this context, we assessed the potential value of quantitative cervical spinal cord T1 mapping regarding the evaluation of patients with degenerative cervical myelopathy.

MATERIALS AND METHODS

Twenty patients diagnosed with mild and moderate-to-severe degenerative cervical myelopathy and 10 healthy subjects were enrolled in a multiparametric MR imaging protocol. Cervical spinal cord T1 mapping was performed with the MP2RAGE sequence procedure. Retrieved data were processed and analyzed regarding the global spinal cord and white and anterior gray matter on the basis of the clinical severity and the spinal canal stenosis grading.

RESULTS

Noncompressed levels in healthy controls demonstrated significantly lower T1 values than noncompressed, mild, moderate, and severe stenotic levels in patients. Concerning the entire spinal cord T1 mapping, patients with moderate-to-severe degenerative cervical myelopathy had higher T1 values compared with healthy controls. Regarding the specific levels, patients with moderate-to-severe degenerative cervical myelopathy demonstrated a T1 value increase at C1, C7, and the level of maximal compression compared with healthy controls. Patients with mild degenerative cervical myelopathy had lower T1 values than those with moderate-to-severe degenerative cervical myelopathy at the level of maximal compression. Analyses of white and anterior gray matter confirmed similar results. Strong negative correlations between individual modified Japanese Orthopaedic Association scores and T1 values were also observed.

CONCLUSIONS

In this preliminary study, 3D-MP2RAGE T1 mapping demonstrated increased T1 values in the pathology tissue samples, with diffuse medullary alterations in all patients with degenerative cervical myelopathy, especially relevant at C1 (nonstenotic level) and at the maximal compression level. Encouraging correlations observed with the modified Japanese Orthopaedic Association score make this novel approach a potential quantitative biomarker related to clinical severity in degenerative cervical myelopathy. Nevertheless, patients with mild degenerative cervical myelopathy demonstrated nonsignificant results compared with healthy controls and should now be studied in multicenter studies with larger patient populations.

An unusual case of burning hands

Burning Hands Syndrome is an unusual variant of central cord syndrome. There have been few published reports, and none in the emergency medicine literature. We present a case of Burning Hands Syndrome in which there were no computed tomography (CT) findings of cervical spine injury and only subtle magnetic resonance (MR) abnormalities. We discuss the importance of early diagnosis, as the optimal management of these patients ultimately depends upon prompt recognition of the underlying cervical trauma and a spinal cord at risk for further injury.

Traumatic Injuries to the Spinal Cord and Peripheral Nervous System

Both blunt and penetrating trauma can cause injuries to the peripheral and central nervous systems. Emergency providers must maintain a high index of suspicion, especially in the setting of polytrauma. There are 2 major classifications of peripheral nerve injuries (PNIs). Some PNIs are classically associated with certain traumatic mechanisms. Most closed PNIs are managed conservatively, whereas sharp nerve transections require specialist consultation for urgent repair. Spinal cord injuries almost universally require computed tomography imaging; some require emergent magnetic resonance imaging. Providers should work to minimize secondary injury. Surgical specialists are needed for closed reduction, surgical decompression, or stabilization.

C5 pure motor spinal cord injury: A case with a rare manifestation of cervical spinal cord injury

We report an extremely rare case showing a fifth cervical spine (C5) level pure motor cervical spinal cord injury (SCI). A 55-year-old-man lost consciousness and fell into a bathtub. Immediately after regaining consciousness, the patient had right arm drop alone. He was referred to our department for investigation of right arm drop 4 months later. Neurological examination revealed motor weakness of the right deltoid muscle. MRI of the cervical spine revealed a C3-4 level central disc herniation compressing the spinal cord. An electromyogram study revealed bilateral neurogenic discharges in the deltoid, supraspinatus and infraspinatus muscles. We diagnosed a C5 segmental pure motor SCI. We chose conservative therapy for the present patient. At the latest follow-up visit, the patient showed modest recovery of motor weakness. Although it is unusual, this case illustrates the possibility that C5 segmental pure motor palsy can occur as one of the manifestations of cervical SCI.

The analgesic effect of intravenous methylprednisolone on acute neuropathic pain with allodynia due to central cord syndrome: a retrospective study

Background

Central cord syndrome (CCS) may be associated with severe neuropathic pain that often resists to conventional pain therapy regimens and affects the patients’ quality of life (QoL) seriously. Current treatments for CCS-associated neuropathic pain have limited evidence of efficacy. This retrospective study was performed to present the effects of early treatment with methylprednisolone (MP) on acute neuropathic pain relief and the QoL in CCS patients.

Patients and methods

Data were collected from the medical records of CCS patients who suffered from acute neuropathic pain with allodynia. All the patients received intravenous MP treatment for up to 1 week. Patients were evaluated with standard measures of efficacy: neuropathic pain intensity, the area of allodynia, and the QoL at baseline, daily treatment, and at 1 and 3 months after the end of MP treatment.

Results

Thirty-four eligible patients were enrolled in our study. By the end of MP treatment, the proportion of patients who gained total or major (visual analog scale [VAS] score decreased by 50% or more) allodynia relief from the treatment was 91.18%, and a decrease in spontaneous pain was also observed. Moreover, this study showed MP could significantly improve the QoL of patients based on McGill Pain Questionnaire Short Form and EuroQol Five Dimensions Questionnaire. Four patients (11.76%) during MP treatment experienced mild or moderate side effects. None of the patients manifested CCS-associated neuropathic pain recurrence and MP-associated side effects at follow-up.

Conclusion

The current results suggested that MP offered an effective therapeutic alternative for relieving CCS-associated acute neuropathic pain with allodynia. Given the encouraging results of this study, it would be worthwhile to confirm these results in randomized placebo-controlled clinical trials.