Central cord syndrome

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Central cord syndrome
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Central cord syndrome is the top diagram
Specialty Neurology
Neurosurgery

Central cord syndrome (CCS) is the most common form of cervical spinal cord injury (SCI). It is characterized by loss of power and sensation in arms and hands. It usually results from trauma which causes damage to the neck, leading to major injury to the central corticospinal tract of the spinal cord. [1] CCS most frequently occurs among older persons with cervical spondylosis, [2] however, it also may occur in younger individuals. [3]

Contents

CCS is the most common incomplete spinal cord injury syndrome. It accounts for approximately 9% of traumatic SCIs. [4] After an incomplete injury, the brain still has the capacity to send and receive some signals below the site of injury. Sending and receiving of signals to and from parts of the body is reduced, not entirely blocked. CCS gives a greater motor loss in the upper limbs than in the lower limbs, with variable sensory loss.

It was first described by Schneider in 1954. [5] It is generally associated with favorable prognosis for some degree of neurological and functional recovery. However, factors such as age, preexisting conditions, and extent of injury will affect the recovery process.

Presentation

CCS is characterized by disproportionately greater motor impairment in upper compared to lower extremities, due to the more centrally-located anterior grey column containing the motor neurons of the upper extremity. CCS also has a classic presentation of "dissociated sensory loss", specifically pain and temperature, due to involvement of the centrally-located anterior white commissure containing decussating fibers of the spinothalamic tract at the affected level. A variable degree of sensory loss below the level of injury in combination with bladder dysfunction and urinary retention may also occur [6]

Causes

In older patients, CCS most often occurs after acute hyperextension injury in an individual with long-standing cervical spondylosis. A slow, chronic cause in this age group is when the cord gets caught and squeezed between a posterior intervertebral disc herniation against the anterior cord and/or with posterior pressure on the cord from hypertrophy of the ligamentum flavum (Lhermitte's sign may be the experience that causes the patient to seek medical diagnosis). However, CCS is not exclusive to older patients as younger individuals can also sustain an injury leading to CCS. Typically, younger patients are more likely to get CCS as a result of a high-force trauma or a bony instability in the cervical spine. [6] [7] Historically, spinal cord damage was believed to originate from concussion or contusion of the cord with stasis of axoplasmic flow, causing edematous injury rather than destructive hematomyelia. More recently, autopsy studies have demonstrated that CCS may be caused by bleeding into the central part of the cord, portending less favorable prognosis. Studies also have shown from postmortem evaluation that CCS probably is associated with selective axonal disruption in the lateral columns at the level of the injury to the spinal cord with relative preservation of the grey matter. [6]

Diagnosis

A patient presenting with signs and symptoms of CCS should undergo imaging of their spinal axis via CT or MRI to determine whether a structural abnormality is causing the symptoms. If imaging does not show an abnormality, consultation with a neurologist for further testing such as nerve conduction studies is warranted.

Management

Nonsurgical

In many cases, individuals with CCS can experience a reduction in their neurological symptoms with conservative management. The first steps of these intervention strategies include admission to an intensive care unit (ICU) after initial injury. After entering the ICU, early immobilization of the cervical spine with a neck collar would be placed on the patient to limit the potential of further injury. [7] Cervical spine restriction is maintained for approximately six weeks until the individual experiences a reduction in pain and neurological symptoms. [7] Inpatient rehabilitation is initiated in the hospital setting, followed by outpatient physical therapy and occupational therapy to assist with recovery.[ citation needed ]

An individual with a spinal cord injury may have many goals for outpatient occupational and physiotherapy. Their level of independence, self-care, and mobility are dependent on their degree of neurological impairment. Rehabilitation organization and outcomes are also based on these impairments. [8] The physiatrist, along with the rehabilitation team, work with the patient to develop specific, measurable, action-oriented, realistic, and time-centered goals.[ citation needed ]

With respect to physical therapy interventions, it has been determined that repetitive task-specific sensory input can improve motor output in patients with central cord syndrome. These activities enable the spinal cord to incorporate both supraspinal and afferent sensory information to help recover motor output. [9] This occurrence is known as "activity dependent plasticity". Activity dependent plasticity is stimulated through such activities as: locomotor training, muscle strengthening, voluntary cycling, and functional electrical stimulation (FES) cycling [10]

Surgical

Surgical intervention is usually given to those individuals who have increased instability of their cervical spine, which cannot be resolved by conservative management alone. Further indications for surgery include a neurological decline in spinal cord function in stable patients as well as those who require cervical spinal decompression. [11]

See also

Related Research Articles

Hemiparesis, also called unilateral paresis, is the weakness of one entire side of the body. Hemiplegia, in its most severe form, is the complete paralysis of one entire side of the body. Either hemiparesis or hemiplegia can result from a variety of medical causes, including congenital conditions, trauma, tumors, traumatic brain injury and stroke.

<span class="mw-page-title-main">Syringomyelia</span> Disorder in which a cyst forms in the spinal cord

Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. Often, syringomyelia is used as a generic term before an etiology is determined. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord. The damage may result in loss of feeling, paralysis, weakness, and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. It may also lead to a cape-like bilateral loss of pain and temperature sensation along the upper chest and arms. The combination of symptoms varies from one patient to another depending on the location of the syrinx within the spinal cord, as well as its extent.

<span class="mw-page-title-main">Transverse myelitis</span> Medical condition of the spinal cord

Transverse myelitis (TM) is a rare neurological condition wherein the spinal cord is inflamed. The adjective transverse implies that the spinal inflammation (myelitis) extends horizontally throughout the cross section of the spinal cord; the terms partial transverse myelitis and partial myelitis are sometimes used to specify inflammation that affects only part of the width of the spinal cord. TM is characterized by weakness and numbness of the limbs, deficits in sensation and motor skills, dysfunctional urethral and anal sphincter activities, and dysfunction of the autonomic nervous system that can lead to episodes of high blood pressure. Signs and symptoms vary according to the affected level of the spinal cord. The underlying cause of TM is unknown. The spinal cord inflammation seen in TM has been associated with various infections, immune system disorders, or damage to nerve fibers, by loss of myelin. As opposed to leukomyelitis which affects only the white matter, it affects the entire cross-section of the spinal cord. Decreased electrical conductivity in the nervous system can result.

<span class="mw-page-title-main">Tetraplegia</span> Paralysis of all four limbs and torso

Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis. The paralysis may be flaccid or spastic. A loss of sensory function can present as an impairment or complete inability to sense light touch, pressure, heat, pinprick/pain, and proprioception. In these types of spinal cord injury, it is common to have a loss of both sensation and motor control.

<span class="mw-page-title-main">Whiplash (medicine)</span> Informal term for injuries to the neck

Whiplash is a non-clinical term describing a range of injuries to the neck caused by or related to a sudden distortion of the neck associated with extension, although the exact injury mechanisms remain unknown. The term "whiplash" is a colloquialism. "Cervical acceleration–deceleration" (CAD) describes the mechanism of the injury, while the term "whiplash associated disorders" (WAD) describes the subsequent injuries and symptoms.

<span class="mw-page-title-main">Spondylosis</span> Degeneration of the vertebral column

Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints. If severe, it may cause pressure on the spinal cord or nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

<span class="mw-page-title-main">Spinal cord injury</span> Injury to the main nerve bundle in the back of humans

A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. It is a destructive neurological and pathological state that causes major motor, sensory and autonomic dysfunctions.

Myelopathy describes any neurologic deficit related to the spinal cord. The most common form of myelopathy in humans, cervical spondylotic myelopathy (CSM), also called degenerative cervical myelopathy, results from narrowing of the spinal canal ultimately causing compression of the spinal cord. When due to trauma, myelopathy is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular myelopathy.

<span class="mw-page-title-main">Cauda equina syndrome</span> Nerve damage at the end of the spinal cord

Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control. Onset may be rapid or gradual.

<span class="mw-page-title-main">Brachial plexus injury</span> Medical condition

A brachial plexus injury (BPI), also known as brachial plexus lesion, is an injury to the brachial plexus, the network of nerves that conducts signals from the spinal cord to the shoulder, arm and hand. These nerves originate in the fifth, sixth, seventh and eighth cervical (C5–C8), and first thoracic (T1) spinal nerves, and innervate the muscles and skin of the chest, shoulder, arm and hand.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

<span class="mw-page-title-main">Radiculopathy</span> Medical condition

Radiculopathy, also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly. Radiculopathy can result in pain, weakness, altered sensation (paresthesia) or difficulty controlling specific muscles. Pinched nerves arise when surrounding bone or tissue, such as cartilage, muscles or tendons, put pressure on the nerve and disrupt its function.

<span class="mw-page-title-main">Laminoplasty</span>

Laminoplasty is an orthopaedic/neurosurgical surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The main purpose of this procedure is to provide relief to patients who may have symptoms of numbness, pain, or weakness in arm movement. The procedure involves cutting the lamina on both sides of the affected vertebrae and then "swinging" the freed flap of bone open thus relieving the pressure on the spinal cord. The spinous process may be removed to allow the lamina bone flap to be swung open. The bone flap is then propped open using small wedges or pieces of bone such that the enlarged spinal canal will remain in place.

<span class="mw-page-title-main">Posterior spinal artery syndrome</span> Human spinal cord disorder

Posterior spinal artery syndrome(PSAS), also known as posterior spinal cord syndrome, is a type of incomplete spinal cord injury. PSAS is the least commonly occurring of the six clinical spinal cord injury syndromes, with an incidence rate of less than 1%.

<span class="mw-page-title-main">Lumbar anterior root stimulator</span> Neuroprosthesis

A lumbar anterior root stimulator is a type of neuroprosthesis used in patients with a spinal cord injury or to treat some forms of chronic spinal pain. More specifically, the root stimulator can be used in patients who have lost proper bowel function due to damaged neurons related to gastrointestinal control and potentially allow paraplegics to exercise otherwise paralyzed leg muscles.

Spinal cord injury without radiographic abnormality (SCIWORA) is symptoms of a spinal cord injury (SCI) with no evidence of injury to the spinal column on X-rays or CT scan. Symptoms may include numbness, weakness, abnormal reflexes, or loss of bladder or bowel control. Neck or back pain is also common. Symptoms may be brief or persistent. Some do not develop symptoms until a few days after the injury.

<span class="mw-page-title-main">Monomelic amyotrophy</span> Medical condition

Monomelic amyotrophy (MMA) is a rare motor neuron disease first described in 1959 in Japan. Its symptoms usually appear about two years after adolescent growth spurt and is significantly more common in males, with an average age of onset between 15 and 25 years. MMA is reported most frequently in Asia but has a global distribution. It is typically marked by insidious onset of muscle atrophy of an upper limb, which plateaus after two to five years from which it neither improves nor worsens. There is no pain or sensory loss associated with MMA. MMA is not believed to be hereditary.

<span class="mw-page-title-main">Cervicocranial syndrome</span> Medical condition

Cervicocranial syndrome or is a neurological illness. It is a combination of symptoms that are caused by an abnormality in the neck. The bones of the neck that are affected are cervical vertebrae (C1-C7). This syndrome can be identified by confirming cervical bone shifts, collapsed cervical bones or misalignment of the cervical bone leading to improper functioning of cervical spinal nerves. Cervicocranial syndrome is either congenital or acquired. Some examples of diseases that could result in cervicocranial syndrome are Chiari disease, Klippel-Feil malformation osteoarthritis, and trauma. Treatment options include neck braces, pain medication and surgery. The quality of life for individuals suffering from CCJ syndrome can improve through surgery.

<span class="mw-page-title-main">Bizhan Aarabi</span> Iranian-American neurosurgeon

Bizhan Aarabi is an Iranian-American neurosurgeon, researcher, author, and academic. He is a professor of neurosurgery at University of Maryland and the Director of Neurotrauma at the R Adams Cowley Shock Trauma Center.

Spinal cord stroke is a rare type of stroke with compromised blood flow to any region of spinal cord owing to occlusion or bleeding, leading to irreversible neuronal death. It can be classified into two types, ischaemia and haemorrhage, in which the former accounts for 86% of all cases, a pattern similar to cerebral stroke. The disease is either arisen spontaneously from aortic illnesses or postoperatively. It deprives patients of motor function or sensory function, and sometimes both. Infarction usually occurs in regions perfused by anterior spinal artery, which spans the anterior two-thirds of spinal cord. Preventions of the disease include decreasing the risk factors and maintaining enough spinal cord perfusion pressure during and after the operation. The process of diagnosing the ischemic and hemorrhagic spinal cord stroke includes applying different MRI protocols and CT scan. Treatments for spinal cord stroke are mainly determined by the symptoms and the causes of the disease. For example, antiplatelet and corticosteroids might be used to reduce the risk of blood clots in ischaemic spinal stroke patients, while rapid surgical decompression is applied to minimize neurological injuries in haemorrhagic spinal stroke patients instead. Patients may spend years for rehabilitation after the spinal cord stroke.

References

  1. ↑ Quencer RM, Bunge RP, Egnor M, Green BA, Puckett W, Naidich TP, Post MJ, Norenberg M (1992). "Acute traumatic central cord syndrome: MRI-pathological correlations". Neuroradiology. 34 (2): 85–94. doi:10.1007/BF00588148. PMID   1603319. S2CID   23666330.
  2. ↑ "Disease course". Myelopathy.org. Archived from the original on 2018-06-26. Retrieved 2018-06-26.[ unreliable source? ]
  3. ↑ Rich V, McCaslin E (2006). "Central Cord Syndrome in a High School Wrestler: A Case Report". J Athl Train . 41 (3): 341–4. PMC   1569555 . PMID   17043705.
  4. ↑ McKinley W, Santos K, Meade M, Brooke K (2007). "Incidence and Outcomes of Spinal Cord Injury Clinical Syndromes". J Spinal Cord Med. 30 (3): 215–24. doi:10.1080/10790268.2007.11753929. PMC   2031952 . PMID   17684887.
  5. ↑ Schneider RC, Cherry G, Pantek H (1954). "The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine". J. Neurosurg. 11 (6): 546–77. doi:10.3171/jns.1954.11.6.0546. PMID   13222164.
  6. 1 2 3 Harrop, James S; Ashwini Sharan; Jonathon Ratliff (2006). "Central cord injury: pathophysiology, management, and outcomes". The Spine Journal. 6 (Suppl. 1): 198S–206S. doi:10.1016/j.spinee.2006.04.006. PMID   17097539.
  7. 1 2 3 Nowak, Douglas D.; Joseph K. Lee; Daniel E. Gelb; Kornelis A. Poelstra; Steven C. Ludwig (December 2009). "Central Cord Syndrome". Journal of the American Academy of Orthopaedic Surgeons. 17 (12): 756–765. doi:10.5435/00124635-200912000-00004. PMID   19948700. S2CID   25827586.
  8. ↑ Behrman, Andrea, L.; Harkema, Susan J. (2007). "Physical Rehabilitation as an Agent for Recovery After Spinal Cord Injury". Physical Medicine and Rehabilitation Clinics of North America. 18 (2): 183–202. doi:10.1016/j.pmr.2007.02.002. PMID   17543768.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ↑ Behram, A.L.; Harkema, S.J. (2007). "Physical Rehabilitation as an Agent for Recovery After Spinal Cord Injury". Physical Medicine and Rehabilitation Clinics of North America. 18 (2): 183–202. doi:10.1016/j.pmr.2007.02.002. PMID   17543768.
  10. ↑ Yadla, S.; Klimo, J.; Harrop, J.S. (2010). "Traumatic Central Cord Syndrome: Etiology, Management, and Outcomes". Topics in Spinal Cord Injury Rehabilitation. 15 (3): 73–84. doi: 10.1310/sci1503-73 .
  11. ↑ Yadla, Sanjay; Paul Klimo; James S. Harrop (2010). "Traumatic Central Cord Syndrome: Etiology, Management, and Outcomes". Topics in Spinal Cord Injury Rehabilitation. 15 (3): 73–84. doi: 10.1310/sci1503-73 .
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