The authors retrospectively studied 11 patients with delayed cervical central cord syndrome (CCS) to investigate the efficacy of the surgical intervention on treatment for delayed CCS. The American Spinal Injury Association (ASIA) motor scores, Japanese Orthopedic Association (JOA) scores, SF-36 scores, and neurologic status were analyzed preoperatively and at each time point of postoperative follow-up. The results show that patients with reversible spinal cord injury caused by delayed central cord syndrome can recover significantly after surgical intervention. Therefore, we suggest that surgical intervention is still the ideal choice for delayed cervical central cord syndrome.
Cervical central cord syndrome (CCS) is one of the most common acute incomplete cervical spinal cord injuries, which was first described by Schneider et al. in 1954 [
Surgical treatment for CCS was contraindicated for many years, because the natural history of CCS has been associated with a fairly good prognosis [
Currently, an increasing number of spinal surgeons recommended surgical treatment. Meanwhile, investigators have reported the efficacy and safety of surgical intervention for CCS [
Many patients with CCS undergo delayed surgery because of different causes. However, the information about the efficacy of surgical intervention of delayed CCS is sparse. Therefore, we aimed to evaluate whether surgical treatment would be beneficial for the neurological outcome of patients with delayed CCS.
Between January 2005 and December 2015, 11 patients with traumatic CCS were treated at our institution. The interval time between injury and surgery was more than 30 days (mean time, 90.64 days). Of these, 11 patients (mean age, 54.18 years old, M/F = 10/1) who were followed up for more than 6 months were included in this study. All of the patients were undergoing local spinal cord compression or preoperative kyphosis. Causes of injury include traffic accident in 4 cases, injury due to falling from height in 3 cases, falls in 2 cases, and being injured by falling objects in 2 cases. Concomitant injury elsewhere in the body was observed in 3 cases. There were 10 patients with spondylotic associated changes (disc herniation or ossification of the posterior longitudinal ligament) compressing the canal but no bony damage and 1 patient with fractures and dislocations of the cervical spine. The demographic characteristics of the entire study population are outlined in Table
Demographics of observational study cohort.
Patient | Gender | Age |
The interval time between injury and surgery (days) | Mechanism of injury |
---|---|---|---|---|
1 | Male | 63 | 79 | Traffic accident |
2 | Male | 58 | 136 | Falls |
3 | Male | 40 | 40 | High falling |
4 | Male | 39 | 158 | Injured by falling objects |
5 | Male | 69 | 163 | High falling injury |
6 | Male | 41 | 67 | High falling injury |
7 | Male | 64 | 31 | Falls |
8 | Male | 58 | 129 | Injured by falling objects |
9 | Male | 65 | 57 | Traffic accident |
10 | Female | 46 | 125 | Traffic accident |
11 | Male | 52 | 31 | Traffic accident |
The type of surgery was determined by clinical examination and images and the details of compression segments. Surgical management of CCS consists of posterior, anterior, or combined approaches, in order to achieve spinal cord decompression with or without stabilization. Four patients were operated on using an anterior approach, the primary indication being discectomy and fusion, and 6 patients had a decompressive laminectomy via a posterior approach, with or without fusion. Another patient with C2 fracture was treated by open reduction and internal fixation via a posterior approach. Routine rehabilitation exercises were recommended to postoperative patients.
The ASIA motor scores (AMS) [
Neurologic outcomes were compared using ASIA impairment scale. Patients are classified into classes A–E depending on their motor and sensory function according to ASIA scale [
ASIA impairment scale.
Grade | Functional description |
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A | No sensory or motor function is preserved in the sacral segments S4-S5 |
B | Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5 |
C | Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3 |
D | Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade greater than or equal to 3 |
E | Sensory and motor function are normal |
All values are expressed as means ± standard deviation (SD). A paired
In the study group, the average aAMS was
The mean JOA score at admission was
As presented in Table
Summary of admission and follow-up ASIA motor, JOA, and SF-36 scores.
Interval | mean ASIA scores | mean JOA scores | SF-36 scores | |||||||
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PF | RP | BP | GH | VT | SF | RE | MH | |||
Admission |
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6 months |
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Final-visit |
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BP: bodily pain; GH: general health; MH: mental health; PF: physical functioning; RE: role-emotional; RP: role-physical; SF: social functioning; VT: vitality.
The change of ASIA impairment scale (modified from Frankel) is showed in Table
The change of ASIA impairment scale.
Preoperative ASIA impairment scale | Number | Postoperative ASIA impairment scale | ||||
---|---|---|---|---|---|---|
A | B | C | D | E | ||
A | 0 | |||||
B | 1 | 1 | ||||
C | 6 | 2 | 3 | 1 | ||
D | 4 | 1 | 3 | |||
E | 0 |
The prevalence of traumatic spinal cord injury (SCI) worldwide is approximately 750 per million with an annual incidence that appears to be rising [
Central cord syndrome (CCS) is the most common form of incomplete spinal cord injury. And about 70% of all incomplete cervical spinal cord injuries are central cord lesions [
Several scholars have demonstrated the biomechanical mechanisms of spinal cord injury in hyperextension injuries.
For a long time, the view of cervical hyperextension violence resulting in corticospinal tract injury leading to CCS has been widely accepted. Laters, Quencer [
A delayed CCS usually occurred because of lack of timely and effective treatment. Common causes of delayed CCS are missed or delayed diagnoses and the choice of conservative treatment.
The identified reasons for a missed or delayed diagnosis of CCS are as follows: (a) first reason is lack of enough understanding and alertness of CCS. In cervical injury, especially during the absence of the typical symptoms, inexperienced emergency or spinal surgeons could not make accurate judgments. At the district hospital, patients without obvious symptoms were given medication and discharged. (b) Second reason is incomplete sets of cervical spinal radiographs. Gale et al. claimed that plain radiographs were inadequate to evaluate the complete cervical spine in 72.2% of patients with blunt trauma in whom cervical spine radiographs were used to screen for cervical spine injury [
Imaging studies obtained in a 69-year-old man injured in a high falling accident. ((a) and (b)) Preoperative CT showing obvious osteophytes of C4-5. (c) and (d) MR image demonstrating C4-5 cord compression and an intramedullary high signal intensity.
The choice of conservative treatment is the other identified reason for a missed or delayed diagnosis of CCS. The surgeons would recommend patients with stable or slowly improving neurologic status to take conservative treatment including cervical spinal fixation with a hard cervical collar and pharmacological interventions. These pharmacological interventions are aimed at limiting the secondary injury cascade. Some of these patients would be stabilized at an unacceptable neurological/functional level. However, some of these patients would undergo late neurologic deterioration. Patients may tend to choose conservative treatment due to religious and personal reasons. Another factor which should be considered is whether the patient has underlying diseases which have a negative effect on surgical intervention.
A retrospective study was performed in 11 patients with delayed CCS, who received operative treatment. The results of this study indicated that the reversible spinal cord injury caused by delayed CCS could obtain recovery in varying degrees. However, few patients could not achieve the desired satisfaction of overall efficacy. Poor hand function and upper limb numbness may be the main reasons troubling patients’ work and quality of life, leading to the low satisfaction. We need a bigger number of cases to improve the credibility of the study. Since this study lacks a comparable nonsurgical treatment of cases and surgical treatment of old CCS cases, whether the effect was significantly better than nonsurgical treatment remains to be determined.
Surgical treatment can relieve spinal cord compression and improve neurological function for delayed CCS. In our opinions, we only perform surgery in the CCS cases with evidence of spinal cord compression. As for the patients without evidence of significant spinal cord compression, we recommend nonsurgical treatment including drugs, physiotherapy, lifestyle modification, and multidisciplinary rehabilitation. After surgery, the satisfaction of overall efficacy is better than the conservative treatment. For delayed CCS with the spinal cord compression, the decompression surgery is necessary, as long as the physical condition of the patients could tolerate the surgery.
The authors declare that they have no conflicts of interest.
Yanan Liu and Zongyi Wang contributed equally to this article.