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J Neurol Surg A Cent Eur Neurosurg 2022; 83(01): 057-065
DOI: 10.1055/s-0041-1735858
Review Article

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

Gerhard Hildebrandt
1   Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
,
Holger Joswig 
2   Division of Neurosurgery, HMU Health and Medical University Potsdam, Ernst von Bergmann Hospital, Potsdam, Brandenburg, Germany
,
Martin Nikolaus Stienen
1   Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
,
Denis Bratelj 
3   Department of Spine Surgery, Swiss Paraplegic Centre, Nottwil, LU, Switzerland
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Abstract

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.

Keywords

AMS - ASIA - central cord syndrome - cervical trauma - spinal cord injury


Publication History

Received: 20 December 2020

Accepted: 09 March 2021

Article published online:
15 November 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Taylor AR, Blackwood W. Paraplegia in hyperextension cervical injuries with normal radiographic appearances. J Bone Joint Surg Br 1948; 30B (02) 245-248
    CrossrefPubMedGoogle Scholar
  • 2 Taylor AR. The mechanism of injury to the spinal cord in the neck without damage to vertebral column. J Bone Joint Surg Br 1951; 33-B (04) 543-547
    CrossrefPubMedGoogle Scholar
  • 3 Bufe W. Isolierte Verletzungen des Halsrückenmarks ohne Beteiligung des Knochens, mit besonderer Berücksichtigung der Hämatomyelie. Mschr Unfallheilk 1937; 44: 427-434
    PubMedGoogle Scholar
  • 4 Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg 1954; 11 (06) 546-577
    CrossrefPubMedGoogle Scholar
  • 5 Aarabi B, Alexander M, Mirvis SE. et al. Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis. J Neurosurg Spine 2011; 14 (01) 122-130
    CrossrefPubMedGoogle Scholar
  • 6 Aito S, D'Andrea M, Werhagen L. et al. Neurological and functional outcome in traumatic central cord syndrome. Spinal Cord 2007; 45 (04) 292-297
    CrossrefPubMedGoogle Scholar
  • 7 Anderson DG, Sayadipour A, Limthongkul W, Martin ND, Vaccaro A, Harrop JS. Traumatic central cord syndrome: neurologic recovery after surgical management. Am J Orthop 2012; 41 (08) E104-E108
    PubMedGoogle Scholar
  • 8 Bosch A, Stauffer ES, Nickel VL. Incomplete traumatic quadriplegia. A ten-year review. JAMA 1971; 216 (03) 473-478
    CrossrefPubMedGoogle Scholar
  • 9 Guest J, Eleraky MA, Apostolides PJ, Dickman CA, Sonntag VKH. Traumatic central cord syndrome: results of surgical management. J Neurosurg 2002; 97 (1, Suppl): 25-32
    CrossrefPubMedGoogle Scholar
  • 10 Katoh S, el Masry WS, Jaffray D. et al. Neurologic outcome in conservatively treated patients with incomplete closed traumatic cervical spinal cord injuries. Spine 1996; 21 (20) 2345-2351
    CrossrefPubMedGoogle Scholar
  • 11 Kawano O, Ueta T, Shiba K, Iwamoto Y. Outcome of decompression surgery for cervical spinal cord injury without bone and disc injury in patients with spinal cord compression: a multicenter prospective study. Spinal Cord 2010; 48 (07) 548-553
    CrossrefPubMedGoogle Scholar
  • 12 Newey ML, Sen PK, Fraser RD. The long-term outcome after central cord syndrome: a study of the natural history. J Bone Joint Surg Br 2000; 82 (06) 851-855
    CrossrefPubMedGoogle Scholar
  • 13 Merriam WF, Taylor TK, Ruff SJ, McPhail MJ. A reappraisal of acute traumatic central cord syndrome. J Bone Joint Surg Br 1986; 68 (05) 708-713
    CrossrefPubMedGoogle Scholar
  • 14 Shrosbree RD. Acute central cervical spinal cord syndrome: aetiology, age incidence and relationship to the orthopaedic injury. Paraplegia 1977; 14 (04) 251-258
    CrossrefPubMedGoogle Scholar
  • 15 Stevens EA, Marsh R, Wilson JA, Sweasey TA, Branch Jr CL, Powers AK. A review of surgical intervention in the setting of traumatic central cord syndrome. Spine J 2010; 10 (10) 874-880
    CrossrefPubMedGoogle Scholar
  • 16 Waters RL, Adkins RH, Sie IH, Yakura JS. Motor recovery following spinal cord injury associated with cervical spondylosis: a collaborative study. Spinal Cord 1996; 34 (12) 711-715
    CrossrefPubMedGoogle Scholar
  • 17 Freund P, Seif M, Weiskopf N. et al. MRI in traumatic spinal cord injury: from clinical assessment to neuroimaging biomarkers. Lancet Neurol 2019; 18 (12) 1123-1135
    CrossrefPubMedGoogle Scholar
  • 18 Tow AM, Kong KH. Central cord syndrome: functional outcome after rehabilitation. Spinal Cord 1998; 36 (03) 156-160
    CrossrefPubMedGoogle Scholar
  • 19 Steeves JD, Lammertse D, Curt A. et al; International Campaign for Cures of Spinal Cord Injury Paralysis. Guidelines for the conduct of clinical trials for spinal cord injury (SCI) as developed by the ICCP panel: clinical trial outcome measures. Spinal Cord 2007; 45 (03) 206-221
    CrossrefPubMedGoogle Scholar
  • 20 Frankel HL, Hancock DO, Hyslop G. et al. The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 1969; 7 (03) 179-192
    CrossrefPubMedGoogle Scholar
  • 21 Furlan JC, Noonan V, Cadotte DW, Fehlings MG. Timing of decompressive surgery of spinal cord after traumatic spinal cord injury: an evidence-based examination of pre-clinical and clinical studies. J Neurotrauma 2011; 28 (08) 1371-1399
    CrossrefPubMedGoogle Scholar
  • 22 Brodkey JS, Miller Jr CF, Harmody RM. The syndrome of acute central cervical spinal cord injury revisited. Surg Neurol 1980; 14 (04) 251-257
    PubMedGoogle Scholar
  • 23 Fehlings MG, Vaccaro A, Wilson JR. et al. Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS). PLoS One 2012; 7 (02) e32037
    CrossrefPubMedGoogle Scholar
  • 24 Kirshblum SC, Burns SP, Biering-Sorensen F. et al. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med 2011; 34 (06) 535-546
    CrossrefPubMedGoogle Scholar
  • 25 Grassner L, Wutte C, Klein B. et al. Early decompression (<8 h) after traumatic cervical spinal cord injury improves functional outcome as assessed by spinal cord independence measure after one year. J Neurotrauma 2016; 33 (18) 1658-1666
    CrossrefPubMedGoogle Scholar
  • 26 Jug M, Kejžar N, Vesel M. et al. Neurological recovery after traumatic cervical spinal cord injury is superior if surgical decompression and instrumented fusion are performed within 8 hours versus 8 to 24 hours after injury: a single center experience. J Neurotrauma 2015; 32 (18) 1385-1392
    CrossrefPubMedGoogle Scholar
  • 27 Carlson GD, Gorden CD, Oliff HS, Pillai JJ, LaManna JC. Sustained spinal cord compression: part I: time-dependent effect on long-term pathophysiology. J Bone Joint Surg Am 2003; 85 (01) 86-94
    CrossrefPubMedGoogle Scholar
  • 28 Carlson GD, Minato Y, Okada A. et al. Early time-dependent decompression for spinal cord injury: vascular mechanisms of recovery. J Neurotrauma 1997; 14 (12) 951-962
    CrossrefPubMedGoogle Scholar
  • 29 Delamarter RB, Sherman J, Carr JB. Pathophysiology of spinal cord injury. Recovery after immediate and delayed decompression. J Bone Joint Surg Am 1995; 77 (07) 1042-1049
    CrossrefPubMedGoogle Scholar
  • 30 Dimar II JR, Glassman SD, Raque GH, Zhang YP, Shields CB. The influence of spinal canal narrowing and timing of decompression on neurologic recovery after spinal cord contusion in a rat model. Spine 1999; 24 (16) 1623-1633
    CrossrefPubMedGoogle Scholar
  • 31 Guha A, Tator CH, Endrenyi L, Piper I. Decompression of the spinal cord improves recovery after acute experimental spinal cord compression injury. Paraplegia 1987; 25 (04) 324-339
    CrossrefPubMedGoogle Scholar
  • 32 Rabinowitz RS, Eck JC, Harper Jr CM. et al. Urgent surgical decompression compared to methylprednisolone for the treatment of acute spinal cord injury: a randomized prospective study in beagle dogs. Spine 2008; 33 (21) 2260-2268
    CrossrefPubMedGoogle Scholar
  • 33 Tator CH, Fehlings MG. Review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. J Neurosurg 1991; 75 (01) 15-26
    CrossrefPubMedGoogle Scholar
  • 34 Bracken MB, Shepard MJ, Collins WF. et al. A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 1990; 322 (20) 1405-1411
    CrossrefPubMedGoogle Scholar
  • 35 Chen L, Yang H, Yang T, Xu Y, Bao Z, Tang T. Effectiveness of surgical treatment for traumatic central cord syndrome. J Neurosurg Spine 2009; 10 (01) 3-8
    CrossrefPubMedGoogle Scholar
  • 36 Lenehan B, Fisher CG, Vaccaro A, Fehlings M, Aarabi B, Dvorak MF. The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability. Spine 2010; 35 (21, Suppl): S180-S186
    CrossrefPubMedGoogle Scholar
  • 37 Pollard ME, Apple DF. Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia. Spine 2003; 28 (01) 33-39
    CrossrefPubMedGoogle Scholar
  • 38 Chen TY, Lee ST, Lui TN. et al. Efficacy of surgical treatment in traumatic central cord syndrome. Surg Neurol 1997; 48 (05) 435-440 , discussion 441
    CrossrefPubMedGoogle Scholar
  • 39 Koyanagi I, Iwasaki Y, Hida K, Imamura H, Fujimoto S, Akino M. Acute cervical cord injury associated with ossification of the posterior longitudinal ligament. Neurosurgery 2003; 53 (04) 887-891 , discussion 891–892
    CrossrefPubMedGoogle Scholar
  • 40 Bose B, Northrup BE, Osterholm JL, Cotler JM, DiTunno JF. Reanalysis of central cervical cord injury management. Neurosurgery 1984; 15 (03) 367-372
    CrossrefPubMedGoogle Scholar
  • 41 Kepler CK, Kong C, Schroeder GD. et al. Early outcome and predictors of early outcome in patients treated surgically for central cord syndrome. J Neurosurg Spine 2015; 23 (04) 490-494
    CrossrefPubMedGoogle Scholar
  • 42 Konomi T, Yasuda A, Fujiyoshi K. et al. Clinical outcomes of late decompression surgery following cervical spinal cord injury with pre-existing cord compression. Spinal Cord 2018; 56 (04) 366-371
    CrossrefPubMedGoogle Scholar
  • 43 Yelamarthy PKK, Chhabra HS, Vaccaro A. et al. Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society-Spine Trauma Study Group position statement. Eur Spine J 2019; 28 (10) 2390-2407
    CrossrefPubMedGoogle Scholar
  • 44 Samuel AM, Grant RA, Bohl DD. et al. Delayed surgery after acute traumatic central cord syndrome is associated with reduced mortality. Spine 2015; 40 (05) 349-356
    CrossrefPubMedGoogle Scholar
  • 45 Park JH, Kim JH, Roh SW, Rhim SC, Jeon SR. Prognostic factor analysis after surgical decompression and stabilization for cervical spinal-cord injury. Br J Neurosurg 2017; 31 (02) 194-198
    CrossrefPubMedGoogle Scholar
  • 46 Kobrine AI, Evans DE, Rizzoli H. Correlation of spinal cord blood flow and function in experimental compression. Surg Neurol 1978; 10 (01) 54-59
    PubMedGoogle Scholar
  • 47 Kobrine AI, Evans DE, Rizzoli HV. Experimental acute balloon compression of the spinal cord. Factors affecting disappearance and return of the spinal evoked response. J Neurosurg 1979; 51 (06) 841-845
    CrossrefPubMedGoogle Scholar
  • 48 Anderson KK, Tetreault L, Shamji MF. et al. Optimal timing of surgical decompression for acute traumatic central cord syndrome: a systematic review of the literature. Neurosurgery 2015; 77 (Suppl. 04) S15-S32
    CrossrefPubMedGoogle Scholar
  • 49 Molliqaj G, Payer M, Schaller K, Tessitore E. Acute traumatic central cord syndrome: a comprehensive review. Neurochirurgie 2014; 60 (1–2) 5-11
    CrossrefPubMedGoogle Scholar
  • 50 Wilson JR, Singh A, Craven C. et al. Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study. Spinal Cord 2012; 50 (11) 840-843
    CrossrefPubMedGoogle Scholar
  • 51 Papadopoulos SM, Selden NR, Quint DJ, Patel N, Gillespie B, Grube S. Immediate spinal cord decompression for cervical spinal cord injury: feasibility and outcome. J Trauma 2002; 52 (02) 323-332
    CrossrefPubMedGoogle Scholar
  • 52 Umerani MS, Abbas A, Sharif S. Clinical outcome in patients with early versus delayed decompression in cervical spine trauma. Asian Spine J 2014; 8 (04) 427-434
    CrossrefPubMedGoogle Scholar
  • 53 Penrod LE, Hegde SK, Ditunno Jr JF. Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome. Arch Phys Med Rehabil 1990; 71 (12) 963-968
    PubMedGoogle Scholar
  • 54 McKinley W, Santos K, Meade M, Brooke K. Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med 2007; 30 (03) 215-224
    CrossrefPubMedGoogle Scholar
  • 55 Roth EJ, Lawler MH, Yarkony GM. Traumatic central cord syndrome: clinical features and functional outcomes. Arch Phys Med Rehabil 1990; 71 (01) 18-23
    PubMedGoogle Scholar
  • 56 Dai LY. Acute central cervical cord injury: the effect of age upon prognosis. Injury 2001; 32 (03) 195-199
    CrossrefPubMedGoogle Scholar
  • 57 Ishida Y, Tominaga T. Predictors of neurologic recovery in acute central cervical cord injury with only upper extremity impairment. Spine 2002; 27 (15) 1652-1658 , discussion 1658
    CrossrefPubMedGoogle Scholar
  • 58 Miranda P, Gomez P, Alday R. Acute traumatic central cord syndrome: analysis of clinical and radiological correlations. J Neurosurg Sci 2008; 52 (04) 107-112 , discussion 112
    PubMedGoogle Scholar
  • 59 Zheng C, Yu Q, Shan X. et al. Early surgical decompression ameliorates dysfunction of spinal motor neuron in patients with acute traumatic central cord syndrome: an ambispective cohort analysis. Spine 2020; 45 (14) E829-E838
    CrossrefPubMedGoogle Scholar
  • 60 Jimenez O, Marcillo A, Levi AD. A histopathological analysis of the human cervical spinal cord in patients with acute traumatic central cord syndrome. Spinal Cord 2000; 38 (09) 532-537
    CrossrefPubMedGoogle Scholar
  • 61 Yoo D-S, Lee S-B, Huh P-W, Kang S-G, Cho K-S. Spinal cord injury in cervical spinal stenosis by minor trauma. World Neurosurg 2010; 73 (01) 50-52 , discussion e4
    CrossrefPubMedGoogle Scholar
  • 62 Godzik J, Dalton J, Hemphill C. et al. Early surgical intervention among patients with acute central cord syndrome is not associated with higher mortality and morbidity. J Spine Surg 2019; 5 (04) 466-474
    CrossrefPubMedGoogle Scholar
  • 63 Mirza SK, Krengel III WF, Chapman JR. et al. Early versus delayed surgery for acute cervical spinal cord injury. Clin Orthop Relat Res 1999; (359) 104-114
    CrossrefPubMedGoogle Scholar
  • 64 Uribe J, Green BA, Vanni S, Moza K, Guest JD, Levi AD. Acute traumatic central cord syndrome: experience using surgical decompression with open-door expansile cervical laminoplasty. Surg Neurol 2005; 63 (06) 505-510 , discussion 510
    CrossrefPubMedGoogle Scholar
  • 65 Krappinger D, Lindtner RA, Zegg MJ. et al. Spondylotic traumatic central cord syndrome: a hidden discoligamentous injury?. Eur Spine J 2019; 28 (02) 434-441
    CrossrefPubMedGoogle Scholar
  • 66 Jin W, Sun X, Shen K. et al. Recurrent neurological deterioration after conservative treatment for acute traumatic central cord syndrome without bony injury: seventeen operative case reports. J Neurotrauma 2017; 34 (21) 3051-3057
    CrossrefPubMedGoogle Scholar
  • 67 Maeda T, Ueta T, Mori E. et al. Soft-tissue damage and segmental instability in adult patients with cervical spinal cord injury without major bone injury. Spine 2012; 37 (25) E1560-E1566
    CrossrefPubMedGoogle Scholar
  • 68 Mattiassich G, Gollwitzer M, Gaderer F. et al. Functional outcomes in individuals undergoing very early (<5 h) and early (5–24 h) surgical decompression in traumatic cervical spinal cord injury: analysis of neurological improvement from the Austrian Spinal Cord Injury Study. J Neurotrauma 2017; 34 (24) 3362-3371
    CrossrefPubMedGoogle Scholar
  • 69 Pouw MH, van Middendorp JJ, van Kampen A. et al; EM-SCI study group. Diagnostic criteria of traumatic central cord syndrome. Part 1: a systematic review of clinical descriptors and scores. Spinal Cord 2010; 48 (09) 652-656
    CrossrefPubMedGoogle Scholar
  • 70 Pouw MH, van Middendorp JJ, van Kampen A, Curt A, van de Meent H, Hosman AJF. Diagnostic criteria of traumatic central cord syndrome. Part 3: descriptive analyses of neurological and functional outcomes in a prospective cohort of traumatic motor incomplete tetraplegics. Spinal Cord 2011; 49 (05) 614-622
    CrossrefPubMedGoogle Scholar
  • 71 Yoshihara H, Yoneoka D. Trends in the treatment for traumatic central cord syndrome without bone injury in the United States from 2000 to 2009. J Trauma Acute Care Surg 2013; 75 (03) 453-458
    CrossrefPubMedGoogle Scholar
  • 72 Li X-F, Dai L-Y. Acute central cord syndrome: injury mechanisms and stress features. Spine 2010; 35 (19) E955-E964
    CrossrefPubMedGoogle Scholar
  • 73 Brodell DW, Jain A, Elfar JC, Mesfin A. National trends in the management of central cord syndrome: an analysis of 16,134 patients. Spine J 2015; 15 (03) 435-442
    CrossrefPubMedGoogle Scholar
  • 74 van Middendorp JJ, Hosman AJF, Doi SAR. The effects of the timing of spinal surgery after traumatic spinal cord injury: a systematic review and meta-analysis. J Neurotrauma 2013; 30 (21) 1781-1794
    CrossrefPubMedGoogle Scholar
  • 75 Fehlings MG, Perrin RG. The role and timing of early decompression for cervical spinal cord injury: update with a review of recent clinical evidence. Injury 2005; 36 (Suppl. 02) B13-B26
    CrossrefPubMedGoogle Scholar
  • 76 Fehlings MG, Rabin D, Sears W, Cadotte DW, Aarabi B. Current practice in the timing of surgical intervention in spinal cord injury. Spine 2010; 35 (21, Suppl): S166-S173
    CrossrefPubMedGoogle Scholar
  • 77 Rosenfeld JF, Vaccaro AR, Albert TJ, Klein GR, Cotler JM. The benefits of early decompression in cervical spinal cord injury. Am J Orthop 1998; 27 (01) 23-28
    PubMedGoogle Scholar
  • 78 Aarabi B, Hadley MN, Dhall SS. et al. Management of acute traumatic central cord syndrome (ATCCS). Neurosurgery 2013; 72 (Suppl. 02) 195-204
    CrossrefPubMedGoogle Scholar
  • 79 Fountas KN, Smith JR. Historical evolution of stereotactic amygdalotomy for the management of severe aggression. J Neurosurg 2007; 106 (04) 710-713
    CrossrefPubMedGoogle Scholar
  • 80 Saadoun S, Werndle MC, Lopez de Heredia L, Papadopoulos MC. The dura causes spinal cord compression after spinal cord injury. Br J Neurosurg 2016; 30 (05) 582-584
    CrossrefPubMedGoogle Scholar