Controversies in the Treatment of Central Cord Injuries

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ontroversies in thereatment of Central Cord Injuriesinston Fong, MD, and Frank J. Eismont, MD

Central cord injury or central cord syndrome is an acute cervical spinal cord injurycharacterized by more extensive motor weakness of the upper extremities compared withthe lower extremities, usually with bladder dysfunction, and variable sensory loss below thelevel of the lesion. Central cord syndrome is the most common type of incomplete spinalcord injury pattern and is associated with a moderate to good prognosis. Over the last fivedecades, the role of surgical intervention, as well as the type and timing of surgery,continues to be the subject of considerable debate. These controversies are the focus ofthis article.Semin Spine Surg 19:260-271 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS central, spinal, spine, cord, syndrome, injury

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pproximately 16 to 25% of patients with cervical spinalcord injuries present with central cord syndrome, while

0% of all incomplete cervical spinal cord injuries are centralord lesions.1,2 Multiple authors have demonstrated a bi-odal age distribution to the central cord syndrome popula-

ion.3-7 Schneider and coworkers3 were the first to note anlder age group (mean age, 59) with spondylotic changesompromising the canal but no bony damage, and a youngerge group (mean age, 31) with fractures and/or dislocationsf the cervical spine. Shrosbree,4 Roth and colleagues,5 andenrod and colleagues6 showed approximately equal num-ers of older and younger patients, with two peaks at 21 to 30ears and 61 to 70 years. Merriam and colleagues2 found thatore than half of the patients in their series were under age 30 at

he time of injury, whereas Hardy8 noted that older people sus-ain central cord syndrome more frequently. Motor vehicle ac-idents and falls are the most common causes of injury.

linical Courseatients with acute central cord injuries typically have a fa-orable prognosis for neurological and functional improve-ent. Recovery occurs in a predictable pattern beginningrst in the lower extremities and then progressing to theladder and upper extremities, with the hands improving

epartment of Orthopaedics and Rehabilitation, University of Miami, MillerSchool of Medicine, Miami, FL.

ddress reprint requests to Frank J. Eismont, MD, Department of Orthopae-dics and Rehabilitation, University of Miami, Miller School of Medicine,

oP.O. Box 016960, Miami, FL 33131. E-mail: [email protected]

60 1040-7383/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.doi:10.1053/j.semss.2007.09.008

ast. In a retrospective review of 42 patients who presentedith acute central cord injury, Bosch and colleagues1 noted7% regained ambulatory skills, 56% regained functionalands, and 53% regained bowel and bladder control at long-erm follow-up, although 10/42 had late deterioration afternitial improvement in symptoms. Predictors of a better out-ome include younger age, absence of spasticity, and lesseurological deficit on admission.1,4-7,9-11 Central cord inju-ies with selective upper extremity involvement have beenssociated with better functional improvement than in thoseith both upper and lower extremity involvement.5,11 Inter-

stingly, preinjury employment and formal education levelere also found to correlate with better outcomes.5,10 The

trongest predictor of a poor functional outcome is advancedge, although the elderly may also experience significant neu-ological improvement.5-7,9

rimary Mechanisms of Injurychneider and coworkers reported that central cord syn-rome typically occurred in elderly patients with cervicalpondylosis and stenosis without bony damage, but they alsoound that it rarely occurred in patients with fracture-dislo-ations or compression fractures.12 They believed hyperex-ension to cause a pinching effect of the spinal cord betweenentral osteophytes anteriorly and a buckled ligamentum fla-um posteriorly. Subsequent studies have shown that centralord syndrome can occur in individuals of any age and canesult from fractures, dislocations, and hyperflexion injuries
f the cervical spine at a much higher rate than originally

Central cord injuries 261

Figure 1 This 82-year-old man had fallen approximately 8 months prior to this visit because of his generalizedweakness. He had severe weakness of his hands and moderate weakness of his legs. He was no longer able to dresshimself. He was no longer able to cut his food. He has recently been using a walker. (A) X-rays show that his cervicalspine is really quite straight. (B) His midsagittal MRI scan shows diffuse stenosis from C3-4 down through C6-7. (C-E)The transverse images show the severe degree of spinal cord compression, especially at the lower levels. (F-I) These MRIimages were taken 4 months following his treatment with a laminoplasty from C3-C7. This shows marked improve-ment in the room available for his spinal cord. He is still tightest at the C5 level but he does have some space availablearound the spinal cord and the spinal cord shape is much more normal. At this time he has had marked improvementin his ability to ambulate. He is able to walk backwards and sideways with no assistance. His strength in his arms hasmarkedly improved and he is able to perform everyday tasks with his hands. His intrinsic muscles of his hand haveimproved from 1/5 to 4/5. (J, K) His CT images were taken at 2 months following his surgery. The hinge side of thelaminoplasty is completely healed. The C5 level has an allograft rib holding the laminoplasty open. The rib grafts areplaced at C3, C5, and C7. (L-N) At 1 year following his laminoplasty, the posture of his neck is unchanged frompreoperative. He has some motion on flexion and extension at each of the levels of the spine treated with thelaminoplasty. At this time he is completely independent for ambulation and self-care and he has maintained his goodinitial improvement. At this visit all muscles have normal strength with the exception of his intrinsic muscles of his
hands, which are still markedly improved.

262 W. Fong and F.J. Eismont

Figure 1 (continued)

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elieved.1,2,7,13-15 Overall, the literature indicates that majorrauma with a high incidence of cervical fractures is associ-ted with younger patients, whereas minor trauma withoutractures is associated with older patients who have cervicalpondylosis and/or stenosis. Central cord syndrome can alsoccur as a result of acute disc herniation,16-18 and this occursuch more frequently than previously expected.

entral Cordyndrome Pathology

chneider and colleagues hypothesized that central cord syn-rome was the result of concussion or contusion of the spinal

Figure 1

ord.12 This caused injuries ranging from cord edema to gross t

emorrhage, the latter portending a less favorable prognosis.hey ascribed the selective impairment of the upper extrem-

ties to the pattern of lamination in the spinal cord as de-cribed by Foerster,19 who believed that the sacral segmentsre the most lateral components of the corticospinal tract,ith the lumbar, thoracic, and cervical components arranged

omatotopically, proceeding medially toward the center. In-tead of having a somatotopic organization, Levi and col-eagues20 contend that the corticospinal tract is profoundlymportant for arm and especially hand function, but not forocomotor activity of the legs. Any type of injury to the cor-icospinal tract would consequently produce a syndromeonsisting of disproportionately greater motor dysfunction in

inued)

he upper than in the lower extremities.

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Recent autopsy studies performed in 3 of 11 subjects withentral cord syndrome by Quencer and colleagues21 and in 1ubject by Martin and colleagues22 revealed diffuse axonalisruption and edema in the surrounding white matter, buto involvement of the gray matter. Magnetic resonance imagingMRI) studies of patients with acute central cord syndrome havelso revealed edematous changes within the cord but no evi-ence of hemorrhage within the gray matter.21-23 These studiesuggest that disruption of axons in the lateral white matter, andot hemorrhage of the gray matter, is most commonly respon-ible for the central cord syndrome.

Although less common than cord swelling and axonal edema,ntramedullary hemorrhage has been described in MRI reportsf central cord syndrome.24-26 Dai24 found hemorrhage on MRIn 3 of 32 patients with central cord syndrome, and Maroon andolleagues26 noted 1 of 10 cases had hemorrhage in their series.ust as Schneider and colleagues12 originally hypothesized, Dai24

ound that the presence of hemorrhage was associated with aorse prognosis.

harmacological Therapyhere has been a longstanding interest in the administrationf pharmacological therapies to improve neurological out-omes in patients suffering from acute spinal cord injury.hese pharmacological interventions are aimed at limiting

he secondary injury cascade. A substantial body of evidencerom animal models supports this concept, but effective neu-oprotection in humans has been difficult to demonstrate.he publication of the second National Acute Spinal Cordnjury Study (NASCIS II)27 in 1990 was heralded as the firstonvincing study to demonstrate pharmacological neuropro-ection in humans and became widely accepted as a standardf care for use in acute spinal cord injury. However, moreecent criticisms28-30 on the presentation and interpretationf this study and the subsequent NASCIS III study31 have ledome groups32,33 to speak out against methylprednisolone asguideline for the treatment of acute spinal cord injury.dditional pharmacological agents such as GM-1 ganglioside

Sygen),34 naloxone,27 thyrotropin releasing hormone,35 ni-odipine,36 and tirilazad mesylate31 have undergone human

linical trials but have not demonstrated significant efficacy.ther promising medications undergoing current investiga-

ion include riluzole, minocycline, erythropoietin, and rhontagonists.37

Various controversies have prompted a committee of Ca-adian neurosurgical and orthopedic spine specialists andmergency physicians as well as the Congress of Neurologicalurgeons to conclude that methylprednisolone cannot be es-ablished as a guideline and can only be regarded as a treat-ent option.32,33

urgical Decompressionurgery versus Nonoperative Careespite the numerous animal studies that suggest that early

pinal cord decompression improves neurological out- g

ome,38-42 controversy remains over the role of spinal cordecompression in humans. In their original description ofraumatic central cord syndrome in 1954, Schneider andolleagues12 recommended conservative management for pa-ients with these injuries. This was based on observations thatost patients in their series improved spontaneously and

hat one of two patients whom they treated surgically with aaminectomy and intradural exploration worsened neurolog-cally immediately after surgery. Their recommendation wasidely accepted until 1971 when Bosch and colleagues1 pub-

ished a review of patients with spinal cord injuries that in-luded 42 cases of central cord syndrome that were managedonservatively. While improvement in neurological functionn most patients was seen initially, long-term observationshowed that only 59% of patients retained functional skills at0-year follow-up. They noted a “chronic central cord syn-rome” in which patients who initially improved with con-ervative management later developed increased spasticitynd pyramidal tract involvement. This occurred in 10 (24%)f their 42 patients. Unfortunately, seven of these patientsho had been functional ambulators at the time of discharge

ater became wheelchair dependent because of neurologicaleterioration.After Bosch’s report of “chronic central cord syndrome”

nd the development of new surgical techniques, Brodkeynd colleagues14 revisited the management of central cordyndrome in 1980 in an article that reviewed their experienceith operative treatment of seven patients with traumatic

entral cord injuries. They performed surgery 3 to 6 weeksfter injury in these patients, all of whom had spinal cordompression. All patients had rapid improvement postoper-tively, which distinctly contrasted to their static clinicalourse immediately before surgery. The authors concludedhat decompression of the spinal cord after central cord in-ury may be beneficial if present in the setting of a stable pooreurological condition with residual neural compressionFig. 1).

Subsequent studies have suggested that surgery may bessociated with more rapid neurological recovery than con-ervative treatment in patients with persistent neural com-ression and either neurological deterioration or plateauingf neurological function at an unacceptably low level.13,16,43

ose and colleagues13 evaluated 28 patients with central cordyndrome paralysis with 14 patients managed medically and4 patients managed both medically and surgically. Al-hough no randomization was performed and the two groupsere not comparable, they found that operative interventionrovided better motor recovery than did conservative ther-py alone. In 1997, Chen and colleagues16 reported similarndings in a retrospective review of traumatic central cordyndrome that involved 28 patients managed surgically and6 patients managed medically. Later, Chen and colleagues43

escribed the management of 37 patients with preexistingpondylosis who sustained incomplete injuries after minorervical trauma without fracture, subluxation, or disc protru-ion. Many suffered acute central cord injuries. Patients werereated surgically if they did not improve more than one
rade within 3 to 14 days (mean 9 days) after injury. Al-

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hough there were no statistically significant differences inutcome at 2-year follow-up, they found that surgical de-ompression was associated with more rapid improvementnd a shorter hospital and rehabilitation stay. Recent stud-es17,44 have suggested that surgical treatment is the optimalreatment for patients with central cord injury if MRI revealsvidence of spinal cord compression, even without fracturer dislocation.In 2002, Ishida and Tominaga11 identified a subset of the

entral cord syndrome population in which they recom-ended nonoperative treatment. They studied the course ofeurological recovery of 22 patients with central cord syn-rome with only upper extremity involvement and foundhat their motor and sensory deficits rapidly recovered dur-ng the first 3 weeks after injury and plateaued by 6 weeks.eventy-seven percent of patients had full recovery of motorunction. The remaining 23% had mild dysfunction of theands at 2-year follow-up. Based on the favorable outcome ofheir patients with isolated upper extremity involvement,hese authors recommended an initial nonoperative treat-ent course for this subset of central cord syndrome.

iming of Surgeryhe most appropriate timing of surgical intervention for all

ypes of acute spinal cord injury (both complete and incom-lete injuries) remains controversial. This subject is the topicf recent review articles.45,46 La Rosa and colleagues45 pub-ished a meta-analysis of the literature regarding the timing ofurgical decompression after spinal cord injuries in whichhey were able to extract data on 1687 patients. Patients wereivided into three treatment groups: early surgery (�24ours), delayed surgery (�24 hours), and conservative man-gement. Statistically, early decompression resulted in betterutcomes compared with both delayed surgery and conser-ative management. However, analysis of homogeneity re-ealed that only data regarding patients with incomplete spi-al cord injuries who underwent early decompression wereeliable. They concluded that early surgical decompressionan only be considered as a treatment option.45 Fehlings anderrin46 recently performed an evidence-based literature re-iew. They noted that, while there are currently no standardsegarding the role and timing of decompression in acute spi-al cord injury, there is evidence that supports urgent de-ompression in a patient with neurological deterioration fol-owing spinal cord injury and that early (�24 hours) surgeryan be performed safely. They thus recommended urgentecompression as an option following isolated acute cervicalpinal cord injury, provided that the patient is hemodynam-cally stable.46

Most studies investigating the role of surgical timing forcute spinal cord injury, including those reviewed by La Rosand colleagues45 and Fehlings and Perrin,46 involved bothomplete and incomplete injuries. The appropriate timing ofurgery in central cord injury, however, may be different thanther types of cervical spinal cord injuries given its distinctathophysiology. In fact, central cord syndrome was ex-
luded from analysis in some studies on the basis of its spe- l
ific pattern of injury and favorable prognosis for spontane-us recovery.47 Thus, data from these studies, althoughnformative, may not be relevant to central cord injury. Therere only a few studies that address the role of surgical timingpecifically in patients with central cord injury.18,48,49

In 2002, Guest and colleagues18 compared the clinical out-omes of patients with traumatic central cord syndrome whonderwent early (�24 hours) versus late (�24 hours) surgi-al decompression. They also compared the clinical out-omes of those patients with central cord syndrome paralysisecondary to acute disc herniations or cervical fractures/dis-ocations to those with spondylosis or stenosis. Early surgeryor both groups was found to be safe and was associated withdecreased intensive care and hospital stay compared withelayed surgery. With respect to neurological outcomes,arly surgery was associated with improved recovery of blad-er and ambulatory ability for patients with disc herniationsr fracture/dislocations. There was no difference in neurolog-cal improvement with respect to timing of surgery for pa-ients with spondylosis or stenosis.

In contrast, in a review of 412 patients with traumatic,ncomplete cervical spinal cord injuries of which 24% hadentral cord syndrome, Pollard and Apple48 found no signif-cant differences in neurological improvement for early (lesshan 24 hours) versus late (greater than 24 hours) surgicalecompression. This was true for both patients with anteriorord compression from fracture or disc herniation and foratients with cervical stenosis without fracture or instability.s expected, the authors did find that patients with a centralord syndrome or Brown–Sequard syndrome had relativelymproved outcomes compared with other incomplete inju-ies.

In 2005, Yamazaki and colleagues49 retrospectively re-iewed their experience with 47 patients who suffered trau-atic central cord injury, 23 of whom were treated with

urgery. They found that the only factors predictive of excel-ent recovery were the AP diameter of the spinal canal and thenterval from injury to surgery. Patients who underwent sur-ery within 2 weeks had more neurological improvementhan those who underwent surgery after 2 weeks.

The mixed results of these studies and their methodolog-cal limitations highlight the need for well-designed prospec-ive studies to evaluate the effect of early versus late surgicalecompression. The Surgical Timing in Acute Spinal Cordnjury Study is a multicenter, prospective trial that is cur-ently evaluating the effect of early (�24 hours) versus late�24 hours) decompressive surgery for patients with cervicalpinal cord injury.46 The appropriate timing of surgery inentral cord injury, however, may be different than otherypes of cervical spinal cord injuries and thus also requiresurther detailed investigation.

urgical Approachurgical decompression for central cord injury may be ap-roached either anteriorly or posteriorly and should be tai-

ored to the specific pathology involved. Guest and col-
eagues18 performed an anterior approach for patients with

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isc herniation or significant anterior compression due toertebral body fracture, large focal spondylotic bars, or spon-ylotic stenosis confined to no more than three vertebral

evels. When spinal stenosis was present at three or moreevels, posterior laminectomy or laminoplasty was performedFig. 2). Their strategy was consistent with what others haveeported in the literature9,17,26,43,44,49 and what is typically

Figure 2 (A-H) This 44-year-old man was skiing and fellfalls, he had problems with severe weakness. He had impget off the mountain. He had some significant weakness owithout dropping them. In the past week he has had excimproved but he still has abnormal sensation in his habilaterally. His leg strength is normal. (A-D) The patienspinal canal and significant spinal cord compression at thcord at that level. Because of his young age and his desirbe treated with a posterior cervical laminoplasty from C3MRI scan shows that there is more than adequate room fthe spinal cord remains unchanged. The patient hasmarathons and high-level skiing. At this time he hashigh-energy and high-impact sports.

erformed for cervical myelopathy.50 There are advantages b

nd disadvantages to both the anterior and the posterior ap-roaches.Anterior cervical discectomy and fusion (ACDF) may be

erformed in cases of central cord injury secondary to discerniation or spondylotic degeneration that is limited to theisc level. The indications for corpectomy and strut grafting

nclude neural compression and instability due to vertebral

different times 1 week before this visit. After one of hisent after 15 minutes and was able to continue skiing toght hand; he was unable to hold things in his right handimprovement of his leg strength. His hand function hasthis time his biceps and wrist extensor strength is 4/5injury MRI scan shows that he has a congenitally small

level. He also has an abnormal signal within the spinalback to high-impact-type sports, it was advised that heh C7. (E-H) At 4 months following his laminoplasty hispinal cord at all levels. The area of myelomalacia withinble to return to high-level activities such as runningcleared for return to all types of activities including

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nd two- or three-level spondylosis with stenosis (Fig. 3).otential complications of anterior procedures include air-ay problems, recurrent laryngeal or superior laryngealerve palsy, dysphagia, esophageal injury, vertebral artery

njury, bone graft or instrumentation displacement, predis-osition to adjacent level degeneration, and pseudoarthrosis.he latter has been demonstrated to correlate with poor out-omes and is associated with residual neck pain and recur-ent stenosis.51 Anterior approaches would normally be usedn those patients with kyphosis or significant preinjury neckain.Posterior procedures such as laminectomy and lamin-

plasty may be performed in the absence of cervical kyphosisor multilevel (three levels or more) spondylosis and stenosis.hese procedures avoid the complications associated withnterior approaches as well as problems associated with fu-ion, including loss of motion and adjacent level degenera-ion. Laminectomy has historically yielded poor results dueo late deformity and neurological deterioration52 but re-

Figure 2

ently has shown improved results with good surgical tech- i

ique and by avoiding extensive facetectomy. Laminoplastyas developed in an attempt to eliminate problems such asostlaminectomy instability, progressive kyphosis, and con-trictive postlaminectomy membrane. Yonenobu and col-eagues53 as well as Edwards and colleagues54 have shownhat laminoplasty has similar rates of neurological recoverynd lower complication rates when compared with anteriororpectomy and fusion. Alternatively, laminectomy and fu-ion can be considered if the cervical spine can achieve aeutral or extended posture as a means to avoid postlaminec-omy kyphosis.

Studies on posterior procedures performed in spondyloticatients with central cord syndrome have shown adequateesults at short-term follow-up.55,56 In 1995, Levi and col-eagues55 reported their experience with cervical laminecto-

ies performed in 20 cases. Laminectomy was performedfter neurological recovery had plateaued (mean 17 daysostinjury). They noted neurological improvement in 12 pa-ients, stable function in 7 patients, and progression of deficit

inued)

n 1 patient at 3 month follow-up. In 2005, Uribe and col-


Figure 3 (A) This 44-year-old gentleman had congenital stenosis with early myelopathy. Following a traumatic event,he had a transient quadriparesis. He regained his function to the point that he was ambulatory but with a significantmyelopathy. He had burning in his hands and more dysfunction in his hands than in his legs. (A, B) These X-rays weretaken after his traumatic event. (C-F) These MRI scans show severe stenosis and changes in signal within the spinalcord. (G, H) These X-rays were taken 5 years after his two level anterior cervical corpectomy and fusion. At this timehe still has residual myelopathy and persistent burning in his hands. The burning in his hands has persisted despiteposterior foraminotomies, which were performed 2[1/2] years following his anterior decompression procedure. (I-J)This MRI scan 4[1/2] years after his surgery shows that his decompression at the areas of severe stenosis remain open
but he is beginning to develop stenosis at the C3-4 level above his fusion.


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eagues56 reviewed their experience using open-door lamin-plasty in 15 cases of central cord syndrome associated withpondylosis. Open-door expansile laminoplasty was per-ormed as soon as possible after injury (average, 3 daysostinjury). At 3 month follow-up, 10 patients had neuro-

ogical improvement; 4 patients had stable function, and 1atient had died due to respiratory failure unrelated to sur-ery.

enior Author Preferencesny patient with a central cord syndrome after a traumaticvent who has proven spinal cord compression is best treatedith surgical decompression.For those patients with multilevel (level 3 or 4) canal ste-

osis who have either a lordotic spine or at least a straightpine, a posterior C3-C7 cervical laminoplasty would be myreatment of choice. I would normally block the laminoplastypen with allograft rib at C3, C5, and C7 and immobilize theatient in a rigid orthosis for 8 weeks.For those patients with only one or two levels of spinal

ord compression and with the remainder of the cervicalanal being clearly normal in size, I would perform an ante-ior discectomy and/or corpectomy with fusion using allo-raft bone and titanium plate with screws. I would immobi-ize the patient in a rigid cervical collar until the fusion wasolid.

Another factor which should be considered includeshether the patient has kyphosis. If kyphosis is present, then

nterior decompression and fusion would be recommendedegardless of the numbers of levels involved. If it involvedore than three disc levels or two corpectomy levels, a con-

omitant posterior fusion would be recommended.If the patient has significant preinjury neck pain, the usual

aminoplasty would not be recommended. An anterior de-ompression and fusion or a laminoplasty combined with aosterior fusion would then be recommended.As regards the timing of surgery, the only patient who

ould benefit from an emergency decompression would bene who was deteriorating neurologically and who hadlearly demonstrated spinal cord decompression on MRI im-ging and who was medically stable enough to predictablyolerate the surgery. Other patients with stable or slowly im-roving neurologic status are best treated on an elective basisnce medically stabilized and when the optimal surgical teaman be assembled. There is also a role for late decompres-ion for those patients who have either stabilized at annacceptable neurologic/functional level or who are un-ergoing late neurologic deterioration. I would follow theame criterion as listed above considering anterior versusosterior approaches.

ummaryhe pathophysiology of central spinal cord injuries and mostppropriate treatment for patients who have sustained thesenjuries have been the subjects of considerable debate since
heir original description by Schneider and colleagues in
954. Central cord injury occurs in all age groups and isaused by a variety of mechanisms that traumatically com-ress the spinal cord, resulting in cord swelling and dysfunc-ion. Multiple animal studies have shown evidence that phar-acological therapies and urgent surgical decompression

mprove neurological outcomes after spinal cord trauma.his has not been convincingly demonstrated in humantudies, although recent literature indicates that surgery isafe and may be associated with more rapid neurologicalecovery than conservative treatment. Currently, the admin-stration of methylprednisolone within 8 hours of injury andarly surgical decompression are regarded as treatment op-ions, not the standards of care, for patients suffering acuteentral cord injuries. Further investigation, including pro-pective, randomized controlled trials, is needed to establishhe roles and timing of these interventions.

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Controversies in the Treatment of Central Cord Injuries