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January Image Quiz

Spinal Cord Injury

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A 55-year-old woman presents to your office with neck pain and upper-extremity weakness after a motor vehicle accident that occurred 1 week prior. She reports that her car had been hit from behind, and she had sustained a whiplash injury. She notes that she had not lost consciousness, and she had been transferred from the accident scene to the emergency department for additional evaluation. Computed tomography (CT) was negative for cervical fractures and instability, and she had been discharged home wearing a soft cervical collar. Upon presentation to your office 1 week later, she notes severe bilateral arm weakness, “clumsy hands,” and mild lower-extremity weakness with walking. On examination, the bilateral upper-extremity muscle groups have a strength of 3 of 5, and the lower-extremity muscle groups have a strength of 5 of 5. Sensation remains intact throughout the upper and lower extremities. The patient does not report any bowel or bladder changes. Anteroposterior and lateral radiographs were made in the office (Figs. 1 and 2).

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What is the most likely diagnosis?

    1. Central cord syndrome
    2. Brown-Séquard syndrome
    3. Anterior cord syndrome
    4. Posterior cord syndrome

The patient most likely is presenting with symptoms of central cord syndrome (CCS). CCS, along with Brown-Séquard syndrome, anterior cord syndrome, and posterior cord syndrome, is an incomplete spinal cord injury. Patients with incomplete spinal cord injuries have some neurological function below the level of injury, whereas patients with complete spinal cord injuries have no motor function or sensation below the injured level. Classic symptoms of CCS include motor deficits that are worse in the upper extremity than in the lower extremity. Brown-Séquard syndrome is a hemitransection of the cord that causes ipsilateral loss of motor function and contralateral loss of pain and temperature. Anterior cord syndrome is characterized by greater lower-extremity neurological deficits than upper-extremity deficits. Posterior cord syndrome is a rare injury that is characterized by loss of proprioception below the level of spinal cord injury.

CCS is the most common incomplete spinal cord injury. The classic presentation includes a hyperextension injury in a patient >50 years of age. However, CCS can occur at any age, and in athletes who sustain a hyperextension injury resulting in a disc herniation that compresses the cord. Patients who are >50 years of age are more likely to have cervical spondylosis, which decreases the sagittal diameter of the spine, leaving it more prone to injury. Even a mild hyperextension injury in patients with cervical spondylosis can cause neurological injury. The spinal cord most often is injured in the middle to lower portion as a result of compression anteriorly from osteophytes and posteriorly by the buckled ligamentum flavum. Recent studies have demonstrated that a compression injury causes central cord edema, with resulting pathology in the white matter of the lateral columns. The location of the upper-extremity fibers medially (or more central) and the lower-extremity fibers more laterally within the corticospinal tract results in disproportionate impairment of the arms compared with the legs.

Injury severity can range from mild weakness in the arms with sensory preservation to quadriplegia with sacral sparing. In severe cases, bowel, bladder, and sexual dysfunction may be present. Patients with CCS can often walk, but have trouble with upper-extremity strength and hand dexterity. In the emergency department setting, radiographs are commonly bypassed and CT is used for initial imaging to identify cervical spondylosis and to rule out cervical fractures. Initial imaging will not typically show spinal instability or fracture with CCS. Magnetic resonance imaging (MRI) identifies signal changes in the cord that are usually seen with CCS and can help to identify other soft-tissue injuries. MRI is also essential in differentiating complete from incomplete spinal cord injuries because the only clinical difference may be sacral sparing.

The initial treatment for most cases of CCS is nonoperative, and includes immobilization of the neck with a hard cervical collar. If cervical spine fractures and instability have been ruled out, the hard cervical collar is typically worn for a period of 6 weeks. Neurological recovery starts in the lower extremities and progresses in a cephalad direction. Persistent neurological deficits are most commonly seen in the upper extremities. Patients who present late for diagnosis may note permanent “clumsy hands.” Advanced age, severity of cervical spondylosis, and spinal cord signal abnormalities on MRI are associated with a worse prognosis. Physical therapy should be initiated early to focus on regaining strength and mobility. Considerable neurological recovery is expected in the first 6 weeks after injury; however, full functional recovery is uncommon. Patients with substantial neurological impairment should be admitted to the hospital for blood pressure maintenance, and are often administered intravenous steroids for the first 24 to 48 hours, although the clinical benefit of steroid treatment has been debated.

Indications for surgical treatment and time to surgery continue to be subjects of debate with CCS. Absolute indications for early surgery with decompression include pathological abnormalities such as spinal instability and a herniated disc and, in some cases, patients who present with severe neurological impairment. Surgery within the first 24 hours is thought to improve neurological outcome in patients who have a high-grade cord compression on MRI and an American Spinal Injury Association (ASIA) grade-C impairment rating. An ASIA grade-C injury is when <50% of the motor function below the injured level is strong enough to move against gravity (muscle grade <3). Relative indications for surgery may include patients whose neurological status plateaus or worsens; however, surgery often is performed after 24 hours in these patients so that neurological function can be observed and to confirm that the patient has stabilized clinically. Because of the comorbidities of surgery, including the potential for death, delaying surgery until the patient is medically optimized is recommended unless a sooner time is absolutely indicated. The patient described herein most likely presented with an ASIA grade-D impairment, with the lower-extremity and trunk strength intact (she was noted to have bilateral arm weakness). Therefore, a period of observation to monitor for neurological improvement would be recommended.

Answer A.

The patient was informed that data concerning the case would be submitted for publication, and she provided consent.

Suggested Reading

American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). http://asia-spinalinjury.org/wp-content/uploads/2016/02/International_Stds_Diagram_Worksheet.pdf. Accessed 2015 Nov 29.

Anderson KK, Tetreault L, Shamji MF, Singh A, Vukas RR, Harrop JS, Fehlings MG, Vaccaro AR, Hilibrand AS, Arnold PM. Optimal timing of surgical decompression for acute traumatic central cord syndrome: a systematic review of the literature. Neurosurgery. 2015 Oct;77(Suppl 4):S15-32.

Choma TJ, Brodke DS. What’s new in spine surgery. J Bone Joint Surg Am. 2016 Jun 15;98(12):1052-8.

Guest J, Eleraky MA, Apostolides PJ, Dickman CA, Sonntag VK. Traumatic central cord syndrome: results of surgical management. J Neurosurg. 2002 Jul;97(1)(Suppl):25-32.

Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC. Central cord syndrome. J Am Acad Orthop Surg. 2009;17:756-65.

Samuel AM, Grant RA, Bohl DD, Basques BA, Webb ML, Lukasiewicz AM, Diaz-Collado PJ, Grauer JN. Delayed surgery after acute traumatic central cord syndrome is associated with reduced mortality. Spine (Phila Pa 1976). 2015 Mar 01;40(5):349-56.

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