Acute traumatic central cord syndrome: A comprehensive review

Traumatic Central Cord Syndrome

Central cord syndrome (CCS) is the most common form of incomplete spinal cord injury, with an increasing incidence with the aging population. This is a clinical diagnosis defined by weakness greater in the upper than lower extremities and often prominent sensory complaints in the hands. CCS is typically seen in individuals with underlying cervical canal stenosis from spondylosis who experience sudden forceful movement of the neck, especially hyperextension, resulting in contusion of the spinal cord. The prognosis in CCS is relatively favorable with improvement in neurological deficits, except for fine motor control of the hands. Neuropathic pain may persist even in those with excellent motor recovery. Nonoperative management may be appropriate in selected patients, but surgery is usually necessary in those with poor neurological recovery or further deterioration. The optimal timing of surgical intervention has not been defined, but recent evidence suggests that early surgery (≤24 h) may lead to greater neurological recovery, shorter hospital stay, and fewer inpatient complications. Management in any given patient must be considered in the context of the anatomy and location of spinal cord compression, the presence of fractures or ligamentous instability, the temporal course of signs and symptoms, as well as the patient's overall health.

Timing of decompression in central cord syndrome: a systematic review and meta-analysis

PURPOSE

This study compared the recovery of motor function and the safety of early and delayed surgical intervention in patients with central cord syndrome (CCS).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were employed to retrieve the targeted studies published from inception to February 19, 2023. Comparative studies of early versus delayed surgical decompression in CCS based on American Spinal Injury Association motor score (AMS) recovery, complication rates, and mortality were selected. The statistical analyses were performed using STATA 16.0 and RevMan 5.4.

RESULTS

Our meta-analysis included 13 studies comprising 8424 patients. Results revealed that early surgery improved AMS scores significantly compared with delayed surgery, with an increase in MDs by 7.22 points (95% CI 1.98-12.45; P = 0.007). Additionally, early surgery reduced the complication rates than delayed surgery (OR 0.53, 95% CI 0.42-0.67, P < 0.00001). However, no significant difference was observed in mortality between the two groups (OR 0.97; 95% CI 0.75-1.26; P = 0.84).

CONCLUSIONS

Early surgical decompression for CCS can improve motor function and reduce the incidence of complications without affecting the mortality rate in patients. Future research should focus on investigating and analyzing the optimal window period for early CCS surgery. Additionally, the timing of surgery should be determined based on the patient's condition and available medical resources.

Utilization and timing of surgical intervention for central cord syndrome in the United States

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

CCS is the most common type of incomplete spinal cord injury and can occur without or with bony injury. Surgical intervention and its timing for patients diagnosed with CCS has been controversial. The current study assessed utilization of and factors associated with operative intervention and its timing in patients diagnosed with central cord syndrome (CCS) in the absence of bony injury.

METHODS

Adult patients diagnosed with CCS in the absence of vertebral fracture were queried from the national, multi-insurance, administrative 2015-2020 M151 PearlDiver database. The incidence, trends, and timing of operative intervention following CCS were assessed. Patient characteristics associated with surgical intervention and its timing were determined.

RESULTS

From 2015 to 2020, 11,653 patients meeting inclusion criteria were identified, of which surgical intervention was identified for 2,003 (17.2%) and thus nonsurgical intervention for 9,650 (82.8%). The proportion of patients undergoing operative intervention evolved from 11.5% in 2015 to 19.7% in 2020 (p < 0.0001). Of those undergoing surgical intervention, the greatest increase was seen for those undergoing surgery within two days of diagnosis (5.5% in 2015 to 12.3% in 2020, p < 0.0001). On multivariable analysis, more recent year of service, region of service, younger age, and higher comorbidity burden were independent predictors of operative management (p < 0.05 for all).

CONCLUSION

The majority of a large cohort of patients with first diagnosis CCS in the absence of bony injury were managed non-operatively. Operative management increased over the years of study, were performed earlier after diagnosis, and varied based on patient characteristic and geographic region.

Contemporary Practice Patterns in the Treatment of Cervical Stenosis and Central Cord Syndrome: A Survey of the Cervical Spine Research Society

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia.

SUMMARY OF BACKGROUND DATA

There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia.

METHODS

A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants.

RESULTS

Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms.

CONCLUSIONS

Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present.

LEVEL OF EVIDENCE

Level V.

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.

Navigating Complexity: A Case Report of Concurrent Central Cord Syndrome and Stroke in an Elderly Gentleman

Central cord syndrome (CCS) predominantly manifests in elderly individuals with pre-existing cervical spondylosis resulting from hyperextension mechanisms. However, it is not exclusive to the older population and can occur in younger individuals following traumatic cervical spine injuries or, less frequently, due to nontraumatic causes. The impact of this syndrome is more pronounced in the upper extremities, where motor function experiences greater impairment compared to sensory function. CCS presents itself along a spectrum of severity. At one end, individuals may exhibit weakness confined to the hands and forearms while preserving sensory function. At the other extreme, complete quadriparesis may occur, albeit with sacral sparing being the sole indication of an incomplete spinal cord injury. This spectrum underscores the varied and nuanced clinical presentations within CCS. Moreover, concurrent acute stroke presentations can mimic CCS symptoms, further complicating the diagnostic process. The challenge lies in differentiating these two distinct conditions, particularly in an elderly population with overlapping risk factors. This diagnostic challenge adds a layer of complexity to clinical decision-making and underscores the importance of comprehensive evaluations in patients presenting with neurological symptoms. This case report presents a 73-year-old gentleman with a history of a recent stroke and motor vehicle accidents, highlighting the diagnostic challenges and multidisciplinary management required for concurrent CCS and stroke mimicry. This report is unique, as there are no existing case report publications detailing concurrent CCS and stroke. It emphasizes the necessity for a comprehensive diagnostic approach and coordinated care in managing such intricate cases.

Benefits of Early Surgical Treatment for Patients with Multilevel Cervical Canal Stenosis of Acute Traumatic Central Cord Syndrome

INTRODUCTION

Currently, there exists considerable debate surrounding the optimal treatment approaches for different subtypes of patients with spinal cord injury (SCI). The purpose of this study was to conduct a comparative analysis of the benefits associated with conservative treatment and treatments with different surgical periods for patients diagnosed with acute traumatic central cord syndrome (ATCCS) and multilevel cervical canal stenosis (CCS).

METHODS

A retrospective cohort study was conducted, and 93 patients who met inclusion and exclusion criteria in our hospital between 2015 and 2020 were followed for a minimum duration of 2 years. Among them, 30 patients (Group A) received conservative treatment, 18 patients (Group B) received early surgery (≤7 days), and 45 patients (Group C) received late surgery (>7 days). The American Spinal Injury Association (ASIA) grade, Japanese Orthopedic Association (JOA) score, and recovery rate (RR) were evaluated. Multivariate linear regression was used to analyze prognostic determinants. Cost-utility analysis was performed based on the EQ-5D scale.

RESULTS

The ASIA grade, JOA score, and RR of all three groups improved compared with the previous evaluation (P < 0.05). During follow-up, the ASIA grade, JOA score, and RR of Group B were all better than for Group A and Group C (P < 0.05), while there was no significant difference between Group A and C (P > 0.05). The EQ-5D scale in Group B was optimal at the last follow-up. The incremental cost-utility ratio (ICUR) of Group A was the lowest, while that of Group B compared to Group A was less than the threshold of patients' willingness to pay. Age, initial ASIA grade, and treatment types significantly affected the outcomes.

CONCLUSIONS

Both conservative and surgical treatments yield good results. Compared with patients who received conservative treatment and late surgery, patients who received early surgery had better clinical function and living quality. Despite the higher cost, early surgery is cost-effective when compared to conservative treatment. Younger age, initial better ASIA grade, and earlier surgery were associated with better prognosis.

The biomechanical effect of different types of ossification of the ligamentum flavum on the spinal cord during cervical dynamic activities

Ossification of the ligamentum flavum (OLF) is thought to be an influential etiology of myelopathy, as thickened ligamentum flavum causes the stenosis of the vertebral canal, which could subsequently compress the spinal cord. Unfortunately, there was little information available on the effects of cervical OLF on spinal cord compression, such as the relationship between the progression of cervical OLF and nervous system symptoms during dynamic cervical spine activities. In this research, a finite element model of C1-C7 including the spinal cord featured by dynamic fluid-structure interaction was reconstructed and utilized to analyze how different types of cervical OLF affect principal strain and stress distribution in spinal cord during spinal activities towards six directions. For patients with cervical OLF, cervical extension induces higher stress within the spinal cord among all directions. From the perspective of biomechanics, extension leads to stress concentration in the lateral corticospinal tracts or the posterior of gray matter. Low energy damage to the spinal cord would be caused by the high and fluctuating stresses during cervical movements to the affected side for patients with unilateral OLF at lower grades.

Posterior spinal decompression in adults with spinal cord injury without traumatic compromise of the spinal canal: what is the data?

Background

Spinal cord injury (SCI) can be caused by a variety of factors and its severity can range from a mild concussion to a complete severing of the spinal cord. Τreatment depends on the type and severity of injury, the patient's age and overall health. Reduction of dislocated or fractured vertebrae via closed manipulation or surgical procedures, fixation and removal of bony fragments and debris that compromise the spinal canal are indicated for decompression of the spinal cord and stabilization of the spine. However, when there is no obvious traumatic obstruction of spinal canal, the question arises as to whether laminectomy is needed to be performed to improve neurological outcome.

Methods

A literature review covering all indexed studies published between 2013 and 2023 was performed using keywords to identify the patient group of interest (spinal cord injury, SCI, spinal cord trauma, cervical, thoracic, lumbar, thoracolumbar),central cord syndrome (CCS) and the interventions (laminectomy, laminoplasty, decompression, duroplasty).

Results

This review includes6 observational studies investigating the outcome of posterior spinal decompression in patients suffering from spinal cord injury without traumatic spinal cord stenosis. Most patients already had degenerative stenosis. From a total of 202, 151 patients (74.7%) improved neurologically by at least one grade at ASIA scale, after being treated with either laminectomy, laminoplasty, duroplasty or a combination of these techniques.

Conclusion

Early decompression in SCI patients remains a reasonable practice option and can be performed safely, but no specific evidence supports the use of laminectomy alone. There is emerging evidence that intended durotomy followed by extended meningoplasty may improve the neurological outcome in patients suffering from SCI when meta-traumatic edema is apparent. However, the lack of high-quality evidence and results support the need for further research.

Five-year mortality after traumatic central cord syndrome in Wales

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Methods

Patients aged ≥ 18 years with a traumatic CCS between January 2012 and December 2017 in Wales were identified. Patient demographics and data about injury, management, and outcome were collected. Statistical analysis was performed to assess mortality and between-group differences.

Results

A total of 65 patients were identified (66.2% male (n = 43), mean age 63.9 years (SD 15.9)). At a minimum of five years' follow-up, 32.3% of CCS patients (n = 21) had died, of whom six (9.2%) had died within 31 days of their injury. Overall, 69.2% of patients (n = 45) had been managed conservatively. There was no significant difference in age between conservatively and surgically managed patients (p = 0.062). Kaplan-Meier analysis revealed no significant difference in mortality between patients managed conservatively and those managed surgically (p = 0.819). However, there was a significant difference in mortality between the different age groups (< 50 years vs 50 to 70 years vs > 70 years; p = 0.001). At five years' follow-up, 55.6% of the patient group aged > 70 years at time of injury had died (n = 15). Respiratory failure was the most common cause of death (n = 9; 42.9%).

Conclusion

Almost one-third of patients with a traumatic CCS in Wales had died within five years of their injury. The type of management did not significantly affect mortality but their age at the time of injury did. Further work to assess the long-term functional outcomes of surviving patients is needed to generate more reliable prognostic information.

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 Spinal Cord Injuries: A Survey Among Iberolatinoamerican Spine Surgeons - Part 2 Timing to Surgery

Objective  The objective of the present study was to evaluate the current practice in terms of timing to surgery in acute spinal cord injury (ASCI) patients among spinal surgeons from Iberolatinoamerican countries. Methods  A descriptive cross-sectional study design as a questionnaire was sent by an email for all members of the Sociedad Ibero Latinoamericana de Columna (SILACO, in the Spanish acronym) and associated societies. Results  A total of 162 surgeons answered questions related to the timing for surgery. Sixty-eight (42.0%) considered that ASCI with complete neurology injury should be treated within 12 hours, 54 (33.3%) performed early decompression within 24 hours, and 40 (24,7%) until the first 48 hours. Regarding ASCI with incomplete neurological injury, 115 (71.0%) would operate in the first 12 hours. There was a significant difference in the proportion of surgeons that would operate ASCI within ≤ 24 hours, regarding the type of injury (complete injury:122 versus incomplete injury:155; p  < 0.01). In the case of patients with central cord syndrome without radiological evidence of instability, 152 surgeons (93.8%) would perform surgical decompression: 1 (0.6%) in the first 12 hours, 63 (38.9%) in 24 hours, 4 (2.5%) in 48 hours, 66 (40.7%) in the initial hospital stay, and 18 (11.1%) after neurologic stabilization. Conclusion  All inquired surgeons favour early decompression, with the majority performing surgery in the first 24 hours. Decompression is performed earlier in cases of incomplete than in complete injuries. In cases of central cord syndrome without radiological evidence of instability, there is a tendency towards early surgical decompression, but the timing is still extremely variable. Future studies are needed to identify the ideal timing for decompression of this subset of ASCI patients.

The clinical efficacy of anterior cervical discectomy and fusion with ROI-C device vs. plate-cage in managing traumatic central cord syndrome

Purpose

To assess the efficacy and complications of anterior cervical discectomy and fusion (ACDF) with ROI-C device vs. conventional anterior plate and cage system (APCS) in managing traumatic central cord syndrome (TCCS).

Methods

A total of 37 patients diagnosed with TCCS who underwent ACDF with ROI-C implant and APCS were recruited in this retrospective study from June 2012 to February 2020. Radiological parameters and clinical results were recorded and compared through follow-up time. Characteristics of patients and complications were also recorded.

Results

All patients tolerated the procedure well. The average follow-up time was 25.00 ± 7.99 months in the ROI-C group, and 21.29 ± 7.41 months in the APCS group. The blood loss and operation time were significantly lower in the ROI-C group than in the APCS group. Radiological parameters and clinical results were all improved postoperatively and maintained at the final follow-up. Fusion was achieved in all patients. ROI-C group had a lower incidence of postoperative dysphagia than the APCS group. Only 1 case of ALD was observed at the final follow-up in the APCS group.

Conclusions

Both ROI-C device and APCS demonstrated satisfactory clinical effects and safety in managing symptomatic single-level traumatic central cord syndrome with underlying instability. Both techniques could improve and maintain cervical lordosis and disc height. ROI-C device was related to a lower incidence of postoperative dysphagia, shorter operation time, and less blood loss.

Postoperative Central Cord Syndrome: Physiologic Decapitation in the PACU

Central cord syndrome is a form of incomplete spinal cord injury appearing in the anesthesia literature primarily in trauma. Our institution recently managed a rare, life-threatening central cord syndrome following an uneventful anterior cervical discectomy and fusion which uniquely presented as respiratory depression progressing to quadriplegia. This patient's dramatic experience began nearly indistinguishably from more common etiologies of respiratory depression in the post-anesthesia care unit before blossoming swiftly into quadriplegia. We review the details of her presentation and pathophysiology with a message of vigilance to the anesthesia provider. Interpretation of her clinical exam and rapid intervention were key to preventing a lethal outcome. Central cord syndrome should be considered by anesthesiologists in the differential for respiratory depression following cervical spine surgery.

Five Different Lives after Suffering from Spinal Cord Injury: The Experiences of Nurses Who Take Care of Spinal Cord Injury Patients

According to statistics of Ministry of Health and Welfare, accidents were the sixth common causes of death in Taiwan in 2016. A total of 1200 new cases of spinal cord injury each year are caused by accidents and adverse effects. This study explored nurses' experience of caring for patients with spinal cord injury. Hermeneutic phenomenology was used in the data analysis. The five themes emerged: dramatic changes in life, life lost control, life after catastrophic injury, life takes turns for the worse for family, and the power of rebirth. This study revealed that accidents were the primary cause of spinal cord injury, and that nurses may neglect patients' mental and social care. Career guidance should be offered to spinal cord injury patients to ensure that they retain sociality. This study provides recommendations regarding a patient's and their family's post-injury adaption process. The sexual desire of patients should be further explored in future research.

Comparison of Anterior and Posterior Approaches for Acute Traumatic Central Spinal Cord Syndrome with Multilevel Cervical Canal Stenosis without Cervical Fracture or Dislocation

INTRODUCTION

This is a retrospective comparative study that aims to compare the benefits of different surgical approaches for patients with multilevel cervical canal stenosis (CCS) without cervical fracture or dislocation of acute traumatic central cord syndrome (ATCCS).

METHODS

From January 2015 to December 2018, 59 patients were included in the study. Among them, 35 patients (Group A) received anterior surgery and 24 patients (Group B) received posterior surgery. Primary outcome measures were American Spinal Cord Injury Association (Asia) grade, Japanese Orthopaedic Association (JOA) score, and recovery rate (RR). Secondary outcome measures included operation time, intraoperative blood loss, visual analogue scale (VAS) score, cervical sagittal parameters, and complications. Multivariate linear regression was used to analyze prognostic determinants.

RESULTS

Compared with Group B, Group A had longer operation time and more intraoperative blood loss (P < 0.05). However, the VAS score of Group B was higher than that of Group A at discharge (P < 0.05). There was no significant difference in cervical sagittal plane parameters between the two groups (P > 0.05). Postoperative complications were different in the two groups. During follow-up, the Asia grade, the JOA score, and RR of both groups improved (P < 0.05), but there were no significant differences between the two groups (P > 0.05). Younger age, earlier surgery, and better preoperative Asia grade were correlated with better prognosis.

CONCLUSIONS

For patients with multilevel CCS without cervical fracture or dislocation of ATCCS, both surgical approaches had good outcomes. Although no significant differences were found in the primary outcome measures between the two groups, there were different recommendations for the secondary outcome measures. Younger age, earlier surgery, and better preoperative Asia grade were protective factors for better prognosis.

[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.

Pros and Cons of Early and Very Early Surgery for Traumatic Central Cord Syndrome with Spinal Stenosis: Literature Review and Case Report

BACKGROUND

 The case of a 69-year-old patient with an acute traumatic central cord syndrome (ATCCS) with preexisting spinal stenosis raised a discussion over the question of conservative versus surgical treatment in the acute setting. We provide a literature overview on the management (conservative vs. surgical treatment) of ATCCS with preexisting spinal stenosis.

METHODS

 We reviewed the literature concerning essential concepts for the management of ATCCS with spinal stenosis and cervical spinal cord injury. The data retrieved from these studies were applied to the potential management of an illustrative case report.

RESULTS

 Not rarely has ATCCS an unpredictable neurologic course because of its dynamic character with secondary injury mechanisms within the cervical spinal cord in the early phase, the possibility of functional deterioration, and the appearance of a neuropathic pain syndrome during late follow-up. The result of the literature review favors early surgical treatment in ATCCS patients with preexisting cervical stenosis.

CONCLUSION

 Reluctance toward aggressive and timely surgical treatment of ATCCS should at least be questioned in patients with preexisting spinal stenosis.

Degenerative Cervical Myelopathy: Towards a Personalized Approach

Degenerative cervical myelopathy (DCM) is a recently coined term encompassing a variety of age-related and genetically associated pathologies, including cervical spondylotic myelopathy, degenerative disc disease, and ligamentous aberrations such as ossification of the posterior longitudinal ligament. All of these pathologies produce chronic compression of the spinal cord causing a clinical syndrome characterized by decreased hand dexterity, gait imbalance, and potential genitourinary or sensorimotor disturbances. Substantial variability in the underlying etiology of DCM and its natural history has generated heterogeneity in practice patterns. Ongoing debates in DCM management most commonly center around clinical decision-making, timing of intervention, and the ideal surgical approach. Pivotal basic science studies during the past two decades have deepened our understanding of the pathophysiologic mechanisms surrounding DCM. Growing knowledge of the key pathophysiologic processes will help us tailor personalized approaches in an increasingly heterogeneous patient population. This article focuses on summarizing the most exciting approaches in personalizing DCM patient treatments including biomarkers, factors affecting clinical decision-making, and choice of the optimal surgical approach. Throughout we provide a concise review on the conditions encompassing DCM and discuss the underlying pathophysiology of chronic spinal cord compression. We also provide an overview on clinical-radiologic diagnostic modalities as well as operative and nonoperative treatment strategies, thereby addressing knowledge gaps and controversies in the field of DCM.

Emergency management of older people with cervical spine injuries: an expert practice review

Spinal fractures are the third most common traumatic injury in older people, of which cervical spine injuries make up around 15%. They are predominantly seen in people living with frailty who fall from standing height. Spinal fractures in this patient group are associated with substantial morbidity and mortality (over 40% at 1 year). For many older people who survive, their injuries will be life changing. Practice between EDs varies significantly, with no universally accepted guidelines on either assessment, investigation or management specific to older people experiencing trauma. This expert practice review examines the current evidence and emergency management options in this patient group through clinical scenarios, with the aim of providing a more unified approach to management.

[Acute Traumatic Central Cord Syndrome: Etiology, Pathophysiology, Clinical Manifestation, and Treatment]

Acute Traumatic Central Cord Syndrome: Etiology, Pathophysiology, Clinical Manifestation, and Treatment Abstract. The acute traumatic central cord syndrome (ATCCS) represents an injury to the spinal cord with disproportionately greater motor impairment of the upper than the lower extremities, with bladder dysfunction and with varying degrees of sensory loss below the level of the respective lesion. The mechanism of ATCCS is most commonly a traumatic hyperextension injury of the cervical spine at the base of an underlying spondylosis and spinal stenosis. The mean age is 53 years, and segments C4 to Th1 are most frequently affected. In addition to medical history and clinical examination, the definitive diagnosis is made by magnetic resonance imaging, where T2-hyperintense lesions are typically observed in the affected spinal cord segment. Surgical decompression (and fusion) of the respective segment is recommended to prevent repetitive trauma to the spinal cord and to stop progression of clinical symptoms. Patients with diagnosed ATCCS and who are treated adequately usually have a good prognosis.

Outcomes of Spinal Cord Injury: WFNS Spine Committee Recommendations

This comprehensive review article aims to provide some definitive statements on the factors like clinical syndromes, radiological findings, and decompressive surgery, that may influence the outcomes in cervical spinal cord injury management. Literature search on these factors published in the last decade were analyzed and definite statements prepared and voted for consensus opinion by the WFNS Spine Committee members and experts in this field at a meeting in Moscow in June 2019 using Delphi method. This was re-evaluated in a meeting in Pakistan in November 2019. Finally, the consensus statements were brought out as recommendations by the committee to the world literature. Traumatic Spinal Cord Syndromes have good prognosis except in elderly and when the presenting neurological deficit was very poor. Though conservative management provides satisfactory results, results can be improved with surgery when instability and progressive compression was present. Locked facet with spinal cord injury denotes poor prognosis. Magnetic resonance imaging T2 imaging is the essential prognostic indicator that apart from sagittal grade, length of injury, maximum canal compromise, maximum spinal cord compression, axial grading (BASIC) score. Diffusion tensor imaging is the next promising predictor in the pipeline. Decompressive surgery when done earlier especially within 24 hours of injury provides better result and there is no clear evidence to show medical management is better or equivalent to delayed surgical management. Clinical syndromes, radiological syndromes, and surgical decompression have strong impact on the out comes in the management of cervical spinal cord injury. Our comprehensive review and final recommendations on this subject will be of great importance in understanding the complex treatment methods in use.

Numerical investigation of the relative effect of disc bulging and ligamentum flavum hypertrophy on the mechanism of central cord syndrome

BACKGROUND

The pathogenesis of the central cord syndrome is still unclear. While there is a consensus on hyperextension as the main traumatic mechanism leading to this condition, there is yet to be consensus in studies regarding the pathological features of the spine (intervertebral disc bulging or ligamentum flavum hypertrophy) that could contribute to clinical manifestations.

METHODS

A comprehensive finite element model of the cervical spine segment and spinal cord was used to simulate high-speed hyperextension. Four stenotic cases were modelled to study the effect of ligamentum flavum hypertrophy and intervertebral disc bulging on the von Mises stress and strain.

FINDINGS

During hyperextension, the downward displacement of the ligamentum flavum and a reduction of the spinal canal diameter (up to 17%) led to a dynamic compression of the cord. Ligamentum flavum hypertrophy was associated with stress and strain (peak of 0.011 Mpa and 0.24, respectively) in the lateral corticospinal tracts, which is consistent with the histologic pattern of the central cord syndrome. Linear intervertebral disc bulging alone led to a higher stress in the anterior and posterior funiculi (peak 0.029 Mpa). Combined with hypertrophic ligamentum flavum, it further increased the stress and strain in the corticospinal tracts and in the posterior horn (peak of 0.023 Mpa and 0.35, respectively).

INTERPRETATION

The stenotic typology and geometry greatly influence stress and strain distribution resulting from hyperextension. Ligamentum flavum hypertrophy is a main feature leading to central cord syndrome.

Early and short-segment anterior spinal fusion for cervical spinal cord injury without fracture and dislocation can achieve more significant neurological recovery: a retrospective study based on the current medical system in southern China

Objective

The purpose of this study was to investigate the effects of the number of fused segments, the timing of surgery and their interaction on the prognosis of patients with cervical spinal cord injury without fracture and dislocation (CSCIWFD), and to determine the appropriate time restrictions for early surgery in CSCIWFD patients based on the current diagnosis and treatment system in southern China.

Methods

CSCIWFD patients who underwent anterior cervical decompression and internal fusion (ACDF) from January 2012 to June 2017 were selected. The patients were grouped according to the timing of surgery and the number of fused segments and evaluated based on their American Spinal Injury Association (ASIA) score, ASIA impairment scale, and Japanese Orthopaedic Association (JOA) score before and after surgery. SPSS22.0 software was used for the statistical analysis.

Results

The ASIA score, JOA score, and ASIA impairment scale in all follow-ups were significantly higher than before surgery (p < 0.05). The ASIA and JOA scores at 6, 12, and 24 months after surgery of the patients who underwent ACDF within 72 h were significantly better than those of the patients who underwent ACDF after 72 h (p < 0.05). There were significant differences in postoperative ASIA and JOA scores at 12 and 24 months between the short-segment and three-segment fusion groups (p < 0.05). The results of the interaction between the surgical timing and the number of the fused segments showed that the postoperative ASIA and JOA scores at 6, 12, and 24 months were significantly higher in the patients who underwent early short-segment fusion than in those who underwent delayed short-segment fusion (p < 0.05). However, no statistically significant difference was found between early and delayed surgery in the patients who underwent three-segment fusion (p > 0.05).

Conclusion

ACDF is safe and effective for the treatment of CSCIWFD. For patients with single- or double-segment injury, early (within 72 h) ACDF is associated with a more satisfactory prognosis. Due to the limitation of the small sample size, we cautiously recommend that 72 h can be used as a time limit for early surgery for CSCIWFD patients in regions where earlier surgery cannot be provided by the current diagnosis and treatment system.

Application of electrophysiological measures in spinal cord injury clinical trials: a narrative review

STUDY DESIGN

Narrative review.

OBJECTIVES

To discuss how electrophysiology may contribute to future clinical trials in spinal cord injury (SCI) in terms of: (1) improvement of SCI diagnosis, patient stratification and determination of exclusion criteria; (2) the assessment of adverse events; and (3) detection of therapeutic effects following an intervention.

METHODS

An international expert panel for electrophysiological measures in SCI searched and discussed the literature focused on the topic.

RESULTS

Electrophysiology represents a valid method to detect, track, and quantify readouts of nerve functions including signal conduction, e.g., evoked potentials testing long spinal tracts, and neural processing, e.g., reflex testing. Furthermore, electrophysiological measures can predict functional outcomes and thereby guide rehabilitation programs and therapeutic interventions for clinical studies.

CONCLUSION

Objective and quantitative measures of sensory, motor, and autonomic function based on electrophysiological techniques are promising tools to inform and improve future SCI trials. Complementing clinical outcome measures, electrophysiological recordings can improve the SCI diagnosis and patient stratification, as well as the detection of both beneficial and adverse events. Specifically composed electrophysiological measures can be used to characterize the topography and completeness of SCI and reveal neuronal integrity below the lesion, a prerequisite for the success of any interventional trial. Further validation of electrophysiological tools with regard to their validity, reliability, and sensitivity are needed in order to become routinely applied in clinical SCI trials.

Management of Acute Traumatic Central Cord Syndrome: A Narrative Review

STUDY DESIGN

Narrative review.

OBJECTIVES

To provide an updated overview of the management of acute traumatic central cord syndrome (ATCCS).

METHODS

A comprehensive narrative review of the literature was done to identify evidence-based treatment strategies for patients diagnosed with ATCCS.

RESULTS

ATCCS is the most commonly encountered subtype of incomplete spinal cord injury and is characterized by worse sensory and motor function in the upper extremities compared with the lower extremities. It is most commonly seen in the setting of trauma such as motor vehicles or falls in elderly patients. The operative management of this injury has been historically variable as it can be seen in the setting of mechanical instability or preexisting cervical stenosis alone. While each patient should be evaluated on an individual basis, based on the current literature, the authors' preferred treatment is to perform early decompression and stabilization in patients that have any instability or significant neurologic deficit. Surgical intervention, in the appropriate patient, is associated with an earlier improvement in neurologic status, shorter hospital stay, and shorter intensive care unit stay.

CONCLUSIONS

While there is limited evidence regarding management of ATCCS, in the presence of mechanical instability or ongoing cord compression, surgical management is the treatment of choice. Further research needs to be conducted regarding treatment strategies and patient outcomes.

Incomplete Spinal Cord Injury With Concurrent Hypertrophic Obstructive Cardiomyopathy

Traumatic spinal cord injuries are significant contributors to the morbidity and mortality burden of trauma patients worldwide, and consume significant resources in both their acute and rehabilitative care. Another cause of mortality and morbidity is hypertrophic obstructive cardiomyopathy, which can cause syncope or sudden cardiac death in patients with no known prior cardiac disease. This case report describes a unique combination of these two high-risk pathologies in a scene trauma patient, and provides an overview of the pathophysiology and treatment of these high-risk disease processes.

[Seronegative symmetrical synovitis with edema in both hands in patient with central cord injury]

A 55-year-old man with post-traumatic central cord injury, diagnosed with remitting seronegative symmetrical synovitis with pitting edema (RS3PE syndrome). The clinical picture begins with an acute pain in hands, swelling and stiffness. The physical examination revealed edema with fovea on the back of both hands, with pain and swelling in the metacarpophalangeal joints. Given this, different analytical tests and radiography of hands were requested. We started treatment with 30mg of prednisone, showing significant clinical improvement, disappearing arthritis and edema, and normalization of the analytical values. The peculiarity of presentation of RS3PE syndrome in a patient with a central cord injury is due to the difficulty of identifying it due to the superposition of clinical manifestations together with the lack of knowledge of it, being in the absence of this lesion, an easily diagnosable pathology, do not require excessive complementary tests, and with an excellent prognosis after the appropriate early treatment.

The impact of spine stability on cervical spinal cord injury with respect to demographics, management, and outcome: a prospective cohort from a national spinal cord injury registry

BACKGROUND CONTEXT

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients.

PURPOSE

The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not.

STUDY DESIGN/SETTING

This is a prospective observational study.

PATIENT SAMPLE

The sample included participants with cervical SCI included in a prospective Canadian registry.

OUTCOME MEASURES

The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality.

METHODS

Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified.

RESULTS

Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p<.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p<.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p<.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p<.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement.

CONCLUSIONS

We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed.

A case of real spinal cord injury without radiologic abnormality in a pediatric patient with spinal cord concussion

INTRODUCTION

Real spinal cord injury without radiologic abnormality (SCIWORA) is a rare clinical entity.

CASE PRESENTATION

The patient was a 13-year-old girl whose body was overturned anteriorly after crashing her bicycle into a curb. Following the accident, in which her neck and upper back hit the ground, she could not move due to paralysis. On arrival, she had paresis of the bilateral upper extremities and experienced a painful sensation when her upper extremities were touched. Cervical roentgenography and whole-body computed tomography revealed no traumatic lesions in either the intracranium or the cervical bone. Urgent spinal magnetic resonance imaging (MRI) showed no significant spinal cord lesions or spinal canal stenosis. She was put on complete bed rest with a cervical collar. On the 2nd hospital day (24 h after the accident), her motor weakness had almost completely subsided, and she felt only mild dysesthesia in both forearms. Roentgenography revealed no instability. Her motor weakness completely recovered on the third day after accident and she was diagnosed with spinal cord concussion.

DISCUSSION

The present case study, in which MRI was performed, showed that an immediate improvement was obtained in a patient who experienced real SCIWORA. The importance of not only spinal cord lesions, but also perispinal soft tissue injury on MRI has been emphasized for predicting patient outcomes. Accordingly, immediate MRI is essential for evaluating patients with signs and symptoms of spinal cord injury, even when plain neck roentgenography and cervical CT are negative.

Imaging of post-surgical treatment and of related complications in spinal trauma

Spinal trauma is a devastating event with a high morbidity and mortality. The rationale of imaging is to diagnose the traumatic abnormalities and characterize the type of injury, to estimate the severity of the lesions, to evaluate the potential spinal instability. In case of spinal instability, the goals of operative treatment are decompression of the spinal cord canal and stabilization of the disrupted vertebral column. Particularly, diagnostic imaging, mainly by CT and MR, has a main role in the post-treatment evaluation. The neuroradiological evaluation of the postoperative spine requires a general knowledge of the surgical approach to each spinal region and of the normal temporal evolution of expected postoperative changes. The neuroradiologist should evaluate the devices implanted, their related complications and promptly alert the surgeon of acute complications, mainly vascular and infective. During the follow-up, it is mandatory to know and search chronic complications as pseudomeningocele, accelerated degenerative disease, arachnoiditis, peridural fibrosis. Knowledge of specific complications relating to each surgical approach will assist the neuroradiologist in interpretation of postoperative images.

Traumatic central cord syndrome after blunt cervical trauma: a pediatric case report

INTRODUCTION

Traumatic central cord syndrome (CCS) is the most frequently encountered incomplete spinal cord injury (SCI). The patient presents weakness, which is usually greater in the upper extremities than in the lower extremities, secondary to damage to the cervical spinal cord and anatomic distribution of the corticospinal tracts. CCS is seen commonly after a hyperextension mechanism in older patients with spondylotic changes. There are few literature reports regarding CCS in pediatric patients. We present an unusual case of traumatic CCS in a pediatric patient.

CASE PRESENTATION

A 15-year-old male patient, victim of bullying at school, received cervical blunt trauma with a plastic tube.  Within 3 h, the patient developed generalized weakness, which was greater in the upper extremities than in the lower extremities. Upon evaluation, the patient was found with marked upper extremity weakness compared to the lower extremities, with a Manual Muscle Test difference of 11 points. Imaging studies showed contusive changes in the C4-C7 central spinal cord. After rehabilitation therapies the patient gained 23 points in MMT at the day of discharge.

DISCUSSION

Different etiologies of CCS have previously been described in pediatric patients. However, this is the first case that describes a bullying event with cervical blunt trauma and subsequent CCS. In this case, history and physical examination, along with imaging studies, helped in the diagnosis, but it is important to be aware of the possibility of SCI without radiographic abnormalities, as it is common in the pediatric population. CCS occurs rarely in pediatric patients without underlying pathology. Physicians must be aware of the symptoms and clinical presentation in order to provide treatment and start early rehabilitation program.

Optimal Timing of Surgical Decompression for Acute Traumatic Central Cord Syndrome: A Systematic Review of the Literature

BACKGROUND

Traumatic central cord syndrome (TCCS) is an incomplete spinal cord injury defined by greater weakness in upper versus lower extremities, variable sensory loss, and variable bladder, bowel, and sexual dysfunction. The optimal timing of surgery for TCCS remains controversial.

OBJECTIVE

To determine whether timing of surgery for TCCS predicts neurological outcomes, length of stay, and complications.

METHODS

Five databases were searched through March 2015. Articles were appraised independently by 2 reviewers, and the evidence synthesized according to Grading of Recommendation Assessment, Development and Evaluation principles.

RESULTS

Nine studies (3 prognostic, 5 therapeutic, 1 both) satisfied inclusion criteria. Low level evidence suggests that patients operated on <24 hours after injury exhibit significantly greater improvements in postoperative American Spinal Injury Association motor scores and the functional independence measure at 1 year than those operated on >24 hours after injury. Moderate evidence suggests that patients operated on <2 weeks after injury have a higher postoperative Japanese Orthopaedic Association score and recovery rate than those operated on >2 weeks after injury. There is insufficient evidence that lengths of hospital or intensive care unit stay differ between patients who undergo early versus delayed surgery. Furthermore, there is insufficient evidence that timing between injury and surgery predicts mortality rates or serious or minor adverse events.

CONCLUSION

Surgery for TCCS <24 hours after injury appears safe and effective. Although there is insufficient evidence to provide a clear recommendation for early surgery (<24 hours), it is preferable to operate during the first hospital admission and <2 weeks after injury.

Spinal Cord Anatomy and Clinical Syndromes

We review the anatomy of the spinal cord, providing correlation with key functional and clinically relevant neural pathways, as well as magnetic resonance imaging. Peripherally, the main descending (corticospinal tract) and ascending (gracilis or cuneatus fasciculi and spinothalamic tracts) pathways compose the white matter. Centrally, the gray matter can be divided into multiple laminae. Laminae 1-5 carry sensitive neuron information in the posterior horn, and lamina 9 carries most lower motor neuron information in the anterior horn. Damage to the unilateral corticospinal tract (upper motor neuron information) or gracillis-cuneatus fasciculi (touch and vibration) correlates with ipsilateral clinical findings, whereas damage to unilateral spinothalamic tract (pain-temperature) correlates with contralateral clinical findings. Damage to commissural fibers correlates with a suspended bilateral "girdle" sensory level. Autonomic dysfunction is expected when there is bilateral cord involvement.

A model of acute central cervical spinal cord injury syndrome combined with chronic injury in goats

PURPOSE

To develop a large animal model for acute central cervical spinal cord injury syndrome (ACCSCIS.

METHODS

Twenty-four adult male goats were randomized into four groups including group A with acute compression injury, group B with anterior chronic compression, group C as the test group that received anterior chronic compression by screw and acute compression by posterior balloon insertion, and group D as normal controls that received sham surgery. Neurological function (modified Tarlov motor function), CT, MRI, cortical somatosensory evoked potentials (CSEP), and pathological analysis were evaluated. The data were analyzed statistically.

RESULTS

The motor function of the goats in group C was significantly lower than other groups. CSEP before spinal cord compression showed a stable pattern. Spinal cord compression resulted in a gradual decrement in the peak latency and significant increment in the peak amplitude. Cervical spinal canal occupying ratio was significantly lower in group C than the other groups. MRI revealed focal low signal in T1 weighted images and focal high signal in T2 weighted images in group C. Pathological analysis showed more severe lesions in the gray matter than that in the white matter in group C.

CONCLUSIONS

The model well simulated the pathogenesis and resembled the clinical characteristics of ACCSCIS. This model seems to have the potential to contribute to the development of effective therapies for ACCSCIS.

Analysis of Delays to Surgery for Cervical Spinal Cord Injuries

STUDY DESIGN

A retrospective study of surgically treated patients with cervical spinal cord injury (SCI) from the National Trauma Data Bank Research Data Set.

OBJECTIVE

To determine how time to surgery differs between SCI subtypes, where delays before surgery occur, and what factors are associated with delays.

SUMMARY OF BACKGROUND DATA

Studies have shown that patients with cervical SCI undergoing surgery within 24 hours after injury have superior neurological outcomes to patients undergoing later surgery, with most evidence coming from the incomplete SCI subpopulation.

METHODS

Surgically treated patients with cervical SCI from 2011 and 2012 were identified in National Trauma Data Bank Research Data Set and divided into subpopulations of complete, central, and other incomplete SCIs. Relationships between surgical timing and patient and injury characteristics were analyzed using multivariate regression.

RESULTS

A total of 2636 patients with cervical SCI were identified: 803 with complete SCI, 950 with incomplete SCI, and 883 with central SCI. The average time to surgery was 51.1 hours for patients with complete SCI, 55.3 hours for patients with incomplete SCI, and 83.1 hours for patients with central SCI. Only 44% of patients with SCI underwent surgery within the first 24 hours after injury, including only 49% of patients with incomplete SCI.The vast majority of time between injury and surgery was after admission, rather than in the emergency department or in the field. Upper cervical SCIs and greater Charlson Comorbidity Index were associated with later surgery in all 3 SCI subpopulations.

CONCLUSION

The majority of patients with SCI do not undergo surgery within the first 24 hours after injury, and the majority of delays occur after inpatient admission. Factors associated with these delays highlight areas of focus for expediting care in these patient populations.

LEVEL OF EVIDENCE

4.

Delayed surgery after acute traumatic central cord syndrome is associated with reduced mortality

STUDY DESIGN

A retrospective study of surgically treated patients with acute traumatic central cord syndrome (ATCCS) from the National Trauma Data Bank Research Data Set.

OBJECTIVE

To determine the association of time to surgery, pre-existing comorbidities, and injury severity on mortality and adverse events in surgically treated patients with ATCCS.

SUMMARY OF BACKGROUND DATA

Although earlier surgery has been shown to be beneficial for other spinal cord injuries, the literature is mixed regarding the appropriate timing of surgery after ATCCS. Traditionally, this older population has been treated with delayed surgery because medical optimization is often indicated preoperatively.

METHODS

Surgically treated patients with ATCCS in the National Trauma Data Bank Research Data Set from 2011 and 2012 were identified. Time to surgery, Charlson Comorbidity Index, and injury severity scores were tested for association with mortality, serious adverse events, and minor adverse events using multivariate logistic regression.

RESULTS

A total of 1060 patients with ATCCS met inclusion criteria. After controlling for pre-existing comorbidity and injury severity, delayed surgery was associated with a decreased odds of inpatient mortality (odds ratio = 0.81, P = 0.04), or a 19% decrease in odds of mortality with each 24-hour increase in time until surgery. The association of time to surgery with serious adverse events was not statistically significant (P = 0.09), whereas time to surgery was associated with increased odds of minor adverse events (odds ratio = 1.06, P < 0.001).

CONCLUSION

Although the potential neurological effect of surgical timing for patients with ATCCS remains controversial, the decreased mortality with delayed surgery suggests that waiting to optimize general health and potentially allow for some spinal cord recovery in these patients may be advantageous.

LEVEL OF EVIDENCE

3.