Central JSM and Spine

Review Article *Corresponding author Girardi FP, Spine Care Institute, Hospital for Special Surgery, 535 East 70th Street New York, NY 10021, USA, : A Tel: 212-606-1559; Email: Submitted: 19 August 2016 Review of Epidemiology, Accepted: 06 September 2016 Published: 08 September 2016 Copyright Treatment and Prognostic © 2016 Girardi et al. Factors OPEN ACCESS Keywords Schadler Paul, Shue Jennifer, and Girardi FP* • Spine Care Institute, Hospital for Special Surgery, USA • Central cord • Syndrome

Abstract Introduction: Traumatic central cord syndrome is the most common clinical syndrome encountered in the setting of incomplete and is vaguely defined as by disproportionately more impairment in the upper than the lower extremities. Methods: A MEDLINE database search was conducted to review the epidemiology, treatment and prognostic factors of this clinical entity. Results and Discussion: Central cord syndrome typically occurs in white, middle- aged men. Symptoms can be mild to severe, ranging from burning of hands and feet to disproportionate weakness of the upper extremities, variable sensory loss and bladder or bowel dysfunction. The pathogenic mechanism can involve fractures, dislocation and disc herniation caused by hyperextension or flexion injuries of the cervical spine. The prognosis is benign in most cases and the majority of patients, particularly the young, have a high recovery rate. While there is a trend towards surgical intervention in the United States, the management of this syndrome remains controversial due to weak and conflicting evidence. Several prognostic factors have been described, including age and baseline neurologic function. Studies on blood tests and electrophysiological measurement show promising results in predicting a favorable outcome. Conclusion: There are currently no evidence-based guidelines for surgical treatment or the timing of intervention. Future research, conducted as prospective trials of large populations, may provide further insight into this vaguely defined entity.

INTRODUCTION

Spinal cord injuries of the cervical spine can result in a arepresentation warranted [4]. for This a better vague understandingdefinition comprises and treatment a heterogeneous of this entity.population Based of on patients, the concept however, of disproportionate and more accurate motor definitions weakness, complete or incomplete spinal cord injuries [1]. These incomplete injuriesspectrum can of be various further clinical grouped syndromes into 6 syndromes that can bybe theirclassified clinical as presentation: central cord syndrome, Brown-Squared syndrome, syndromerecent studies as a difference proposed newin upper classification and lower systemsmotor weakness for central of anterior cord syndrome, , conus atcord least syndrome. 10 points Pouw on the et Medical al., suggested Research to Council define centralmotor score cord medullar is syndrome and cauda equine syndrome. Traumatic central cord syndrome (TCCS) has a spectrum of by[5,6]. the In American a follow-up Spinal study, Injury however, (ASIA) Impairment the authors scale, concluded has a et al. as “a syndrome that suggests central cervical spinal cord strongerthat the impact severity on of the the prognosis initial neurologicalthan the diagnosis deficit, of expressedtraumatic involvement”mild to severe that symptoms. is “characterized It was defined by disproportionately in 1954 by Schneider more motor impairment of the upper than of the lower extremities, system on predictive factors for the outcome measured with bladder dysfunction, usually urinary retention, and varying thecord Functional syndrome Independence itself [7]. Hohl Measurement et al., based at their 1 year classification follow-up. degrees of sensory loss below the level of the lesion” [2,3].In its Patients are graded as Central Cord Injury Scale 1, 2 or 3 based on mild form, symptoms include burning of hands and feet as the only

ASIA motor score and abnormal MRI findings [8]. More accurate Cite this article: Paul S, Jennifer S, Girardi FP (2016) Central Cord Syndrome: A Review of Epidemiology, Treatment and Prognostic Factors. JSM Neurosurg Spine 4(3): 1075. Girardi et al. (2016) Email: Central understanding of central cord syndrome. found that patients with central cord syndrome were on average definitions will allow physicians and researchers to gain a better 19% of the younger had similar symptoms [17]. This study also The purpose of this article is to review the demographics, In contrast to previous studies, females were diagnosed with etiology, current treatment options, as well as outcomes and central15 years cord older syndrome than other in 33%individuals of cases, with while traumatic males onlycord in injury. 21% prognostic factors of central cord syndrome. METHODS of cases in one study [16]. It is unclear, however, if this finding is We conducted a MEDLINE database search, using Pub Med, Pathophysiologyrelated to the debated and definition etiology of this syndrome. for English articles published between January 2000 and July Injury pattern: Many traumatic and non-traumatic etiologies 2016, on the topic of central cord syndrome. The search keywords for central cord syndrome have been described. In this review we or phrases included “central cord syndrome”. In addition, the will focus on traumatic injuries of the spinal cord. Schneider et al., and Taylor et al., originally hypothesized that hyperextension query: “incidence”, “prevalence”, “epidemiology”, “etiology”, “treatment”,following keywords “outcome”, were as added well as as search “predictors”. criteria Caseto refine reports the anteriorly and compress the spinal cord in an already stenotic of the cervical spine causes the ligamentum flavum to protrude The resulting abstracts were reviewed and sorted for relevance the setting of congenital stenosis. In older patients, this is usually towere this excluded topic. The for search this review. was supplemented This yielded by at indexedtotal of 93 references articles. causedspinal canal by degenerative [2,28]. In younger changes patients including this cervicalcan be facilitated in in the original query. Finally, a total of 62 articles were included of significant importance to this topic cited in articles obtained syndrome,or ossification several of other the posterior injury pattern longitudinal scan lead ligament to central (OPLL) cord the recommendations of the Oxford Centre for Evidence-Based [22,29].In addition to this classic mechanism of central cord in this review. The level of evidence was classified according to distractive forces [30-33]. syndrome, including flexion injuries, as well as compressive and MedicineRESULTS [9]. AND DISCUSSION Accidents associated with central cord syndrome: Demographics Central cord syndrome is most commonly caused by motor Incidence: The estimated incidence of spinal cord injury in vehicle accidents, falls or sport injuries. These findings have The majority of patients are males involved in car accidents, falls been confirmed in many studies [8,18,23,30,32]. Thompson et the United States is 54 per million, or 17,000 new cases each year. or acts of violence. Incomplete injuries are currently the most spinalal., reported cord injuries falls as [17]. the etiology in 50% of cases in central cord frequent neurological category with about 60% [10]. Among syndrome, while this was reported in 29% of other traumatic incomplete cord injuries, central cord syndrome is the most Accidents by different age groups: Various patterns of

injury have been observed in different age groups [22,24]: Aito patientscommon withtype, spinal ranging cord from injury 40 [12-16].to 70%of Recent cases studies[11,12]. show Central an et al., found that the mean age for falls was 58 years, while road increasecord syndrome in the proportion has been reported of patients to withbe diagnosed central cord in 4 syndrome to 35%of Similarly,traffic accidents Guest occurred et al. reported more commonly that in adolescents around the and age youngof 50, and finally sport-related accidents at the mean age of 23 years. 37% [17]. among spinal cord injuries, over an 11 year course, from 25 to Prevalence: adults (at the age of around 25 years) sport-related accidents addressed the prevalence of central cord syndrome. The number were most common (60%), while adults from 26 to 64 years In our search results, no study specifically of people in the United States suffering from spinal cord injury Andersonwere victims et al. of reported traffic accidents traumatic (60%) intubation and the(1%) elderly as a cause tended of centralto fall (75%)cord syndrome [34]. Other [31]. rare Additionally, accidents assault have beenwas reported described. as [10]. in 2016 was estimated to range from 243,000 to 347,000 people Age, gender and race: A typical patient with central cord a causeAccidents in one patientand alcohol in a series misuse: of 24 Several patients studies by Dai reported et al., [33]. an syndrome was described as a married, working, white man association of alcohol misuse with traumatic injuries and central of 11 years by Roth et al. . Men and Caucasians seem to be were intoxicated at the time of injury, while Weingarden et al., at a mean age of 45 years�18 with an average educational level cord syndrome [8]. Lenehan et al., reported that 36% of patients of patients were found to be male and about 70% of patients more susceptible to central cord syndrome: about 70 to 90% showed that 68% of patients with central cord syndrome had be more common with advancing age. This was particularly true consumed alcohol prior to their injury, compared to 53% of cases forCaucasian women [18-26]. [27]. The In mean general, age incompletereported in injuriesliterature were ranges found from to in otherBony types and softof spinal tissue cord injuries injury associated [27,35]. with central cord syndrome: A multitude of bony and soft tissue injuries, including however, with about 30% between 10 to 30 years old and 70% fracture, dislocation, acute disc herniation, or spinal cord injuries about 45 to 60 years. Studies reported a bimodal age distribution, without radiographic abnormality (SCIWORA), are associated older than 40 years in one study [22].In another study assessing the demographics of spinal cord injuries, 55% of patients over with central cord injury [18,19,22,24,25,29,31,32,34,36-42]. 55 years were diagnosed with central cord syndrome, while only In a series of 50 patients, Lenehan et al., observed radiological abnormalities indicating trauma in 24% of patients, while 52% JSM Neurosurg Spine 4(3): 1075 (2016) 2/8 Girardi et al. (2016) Email: Central

the central area of the spinal cord was the cause for this clinical syndrome [2,3]. This theory was based on the assumption that fracturehad stenotic occurred changes in 26%, only fracture-dislocation [24]. Similar results in were13% and reported pure the corticospinal tract has a somatotopical organization where by Aito et al., who found canal stenosis in 58% of patients, while for the upper extremity medially. Thus, injury to the central dislocation in 3% of patients [19]. Guest et al. found stenosis in the fibers for the lower extremity are found laterally, while those 46% of patients, while disc herniation was demonstrated in 32%, upper extremity more prominently. This hypothesis remains fractures or dislocations in 20% of patients [34]. In a series of 127 controversial,portion of the however. spinal cord Studies would rarely lead to found neurologic hemorrhage deficits on of patients, Kato et al. showed that 38% had evidence of stenosis, histopathologic or MRI examination of the spinal cord. Quencer Furthermore,47% had spondylosis younger or patients ossification compared of the toposterior older patients longitudinal were et al., found no signal changes to suggest intramedullary blood, ligament. These findings were more common in older patients. meningeal adhesions, or hemorrhage, in a series of 11 patients. Instead, focal and damage to the white matter of the moreLevel likely of injury to exhibit no abnormal findings on imaging [29]. The lower cervical spine seems to be most commonly affected found signal changes that suggested presence of intramedullary corticospinal tracts was observed [44]. Similarly, Guest et al. reported that hand dysfunction in central cord syndrome results reportedregion. Bosch that etherniation al., found of that intervertebral the vertebral disc level in theof C5-C6 setting was of hemorrhage in 1 patient only [34]. Recently, Jimenezet al., most commonly involved in the spinal injury [11,19]. Dai et al., No evidence for motor neuron loss was found in the acute or from injury to the large fibers of the lateral corticospinal tract. neurologiccentral cord level syndrome most commonly occurs most involved commonly [22]. at levels C5-C6, followed by C4-C5 [33]. Ishida et al. reported that C4-C5 was the sub acute phases (up to 5 weeks), but neuron loss was presentin Bone injuries chronicTreatment central and cord outcomes injury [45]. Patients with central cord injury sustain fractures or The role of operative treatment and the timing of intervention remain to be a topic of investigation and debate. This section dislocations in 35 to 65% of cases [18,25,31]. Based on the classification system of Allen et al., the most common type of will first give an overview of current trends in treatment and injury was distractive extension injury (42%), followed by conservativethe pattern of treatment, recovery. This and review does not focuses discuss on the conservative scientific isolated posterior element fracture (35%), compression fracture dislocation (3%) [31]. Similarly, Miranda et al. found fractures managementdiscussion on or the surgical benefits techniques or disadvantages in detail. of The surgical interested and (10%), burst fracture (5%), teardrop fracture (5%) and facet reader is referred to pertinent reviews. ligamentin 47% offailure patients, [36]. including odontoid fracture, atlantoaxial Current trends in treatment: While most patients are subluxation, subaxial compressive flexion fracture and complete treated conservatively, there is a trend towards increased surgical Spondylosis and stenosis of the spinal canal management of central cord syndrome in the United States. A recent study by Brodell et al., assessed trends in the treatment of with central cord syndrome in a study by Miranda et al. [36]. IshidaSpondylotic et al., reported changes that were in found patients in 8out without of 15 (53%) fracture, patients signs between 2003 and 2010. The study found that 60% of patients were16,134 treatedpatients with non-operatively. central cord syndrome Patients in treated the United surgically States underwent anterior cervical discectomy and fusion (ACDF) most of congenital narrowing were found in 29% of young patients, inwhile 33% 93% and OPLL of individuals in 13% [22]. older OPLL than was 40 described years had in more preexisting detail fusion (PCDF; 7%) and posterior cervical discectomy (PCD, 7%). conditions, including spondylosis in 86%, developmental stenosis Thecommonly number (19%), of patients followed treated by posterior surgically cervical increased discectomy from about and by Gu et al., who reported that 18% of patients with acute cord injury caused by OPLL suffered from central cord syndrome [39]. with500 patients central cordin 2003 syndrome to more without than 2000 bony in injury2013 [20].between Similarly, 2000 Yamazaki found that 59% of patients had preexisting stenosis Yoshihara et al., assessing treatment trends in 19,451 patients andDisc 10% herniation showed signs of OPLL [40]. and 2009in the United States, reported an increase of surgical treatmentPattern of from recovery 15 to 31% [46]. Studies reported that between 22% to 47% of patients The pattern of recovery was described in detail by Merriam sufferedNo radiographic from acute disc abnormality herniations and[32,38]. other rare findings: A study on spinal cord injury without radiographic abnormality et al. in a series of 77 patients of which 30 patients underwent suffered from central cord syndrome .Rarely,2 to 36 months extremities, followed by bladder function, and motor power in cervical fusion surgery. Motor function first returned in the lower (SCIWORA)after the initial demonstrated trauma, the that formation 7 out�43 of of 59a syrinx (12%) can patients cause the upper extremities. Sensory function did not follow this incomplete lesions of the spinal cord, with incidences of post- pattern, however. Normal bladder function was regained by 94% Cellulartraumatic andsyringomyelia histologic ranging changes from after0.3 to 3.2%injury [44]. years.of patients In this and study, 86% the of effectpatients of surgery were independent was not examined. walkers While after 6 months. About 50% of patients had some hand function after 2 Schneider et al. proposed that necrosis and hemorrhage in some studies report a plateau in recovery after about 6 weeks,

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treatment, bladder control and walking ability recovered on average after less than 6 days. Complications in surgical cases othersComparison show continued of conservative improvement and after surgical 2 years treatment [11,22,42,47]. included loosening of screws, wound infection and additional There are no evidence-based guidelines for the choice of al., compared 16 operative patients to 21 non-operative patients. Neurologicstabilization improvement surgery of the wasspine higher [30]. Similarly, in surgical in 1998 groups Chen at et 6 limitedtreatment. by Current small sample literature size, and heterogeneous studies are confined study population, to lower months. No difference in neurologic outcomes between surgical andlevels possible of evidence, residual specifically confounding. levels Systematic 3 and 4, and reviews most studies are based are and nonsurgical groups at 2-year follow-up was found, however. on this weak evidence, and thus results must be interpreted dysphasia and dysphagia, screw loosening, surgical site infection evidence comparing surgical and conservative treatment. In andSurgical pneumonia. complications Among (25%) nonsurgical included patients, neurologic the deterioration, complication with caution. In this section, we will review the current scientific studies are grouped based on whether the results are supportive oforder conservative to make theor surgical reader treatment.aware of the For conflicting each group evidence, we will rate was 38% and included pneumonia, pulmonary emboli and decubitus ulcer [49]. summarize the results of the studies. that were treated surgically or conservatively and found no More recently, in 2007 Aito et al., described 82 patients Studies supporting conservative treatment difference in short- or long-term outcomes between surgical Schneider et al. initially proposed surgical decompression of the spinal cord in patients with central cord syndrome. patientsand conservative with central treatment cord syndrome. [19]. Similar About results the half were of found these in 2015 by Schroeder et al., who retrospectively examined 80 surgery, while the neurologic status of another patient decreased with fracture spent more days in intensive care unit and had drasticallyTwo patients after described surgery. in Because the case of series this did untoward not benefit outcome, from patients underwent surgical treatment within 24 hours. Patients the remaining patients were treated conservatively. Schneider et al., concluded that “surgical decompression of the spinal increased length of stay. Surgery within 24 hours was not found cord is contraindicated”, because of the benign prognosis of Studiesto significantly supporting affect changes surgical in motor intervention function, however [50]. the syndrome, explaining that “spontaneous improvement or One descriptive study investigated the outcomes after surgical complete recovery may occur” [2,3]. were treated with open-door expansile cervical laminoplasty prognosis. In a case series of60 conservative patients, Bosch et al., intervention. Uribe et al., described a series of 15 patients who Several other descriptive studies have confirmed the benign 7%. After 3 months 71% of patients improved 1 ASIA grade. The authorswithin 1 concludedto 8 days. thatComplications this type ofrate laminoplasty was 13%, mortality can be safely rate ofreported patients that were at the able time to walk.of admission Hand function only 19% increased of patients for were26% applied in the subset of patients with central cord syndrome independent ambulators, but at a mean follow-up of 5 years, 59% without instability [26]. bladder and bowel functions were reported: While 17% and 10% of patients to 56% at the time of follow-up. Similar findings for of patients had bladder and bowel control on admission, these conservative treatment. Dvorak et al. assessed the effect of A few analytical studies found a benefit of surgical over follow-up. The late complication of increasing spasticity, stopping numbers increased to 53% and 53%, respectively, by the time of within 72 hours for instability, or with delayed surgery (after 72surgery hours) in 70 for patients, neurologic of which deterioration. 59% were treated While operatively regression of all 60 patients [11]. More recently, Ishida et al., described a patients from being independent ambulators, was found in 24% Independence Measure Motor Scale, surgical treatment did not predictors of a good neurologic recovery. The study showed full improveanalysis other showed outcomes, a significant such as improvement ASIA motor score on the [21]. Functional motorstudy of recovery 22 patients in 77% treated of patients, non-surgically while the with remaining the aim of had finding mild dysfunction of hands at 2-year follow-up. Full sensation was Gu et al., compared 31 patients who underwent laminoplasty recovered in about 60% of patients. Both motor and sensory recovery occurred rapidly until 3 weeks and remained constant spinal cord injury with signs of cord compression by OPLL and after approximately 6 weeks . In agreement with these to 29 patients treated conservatively in 2014. All patients had �22 central cord syndrome, while this was found in 16% of cases in years of age returned to independent ambulation and full bladder theMRI non-surgicalsignal changes. group. In the Mean surgical hospital group, stay 18% was of shorter patients in had the findings, Newey et al., reported that all patients younger than 50 operative group. Motor scores were higher in the surgical group recovered these functions, respectively, in a case series of 32 compared to the conservative group at 6 months and 3 years. control, while only 69% and 88% of patients from 50 to 70 years Similarly, sensory scores were higher in the surgical group. Surgical complications included cystitis in 6% of patients, while conservativelyA few analytical managed studies patients comparing [42]. surgical and conservative complication rate in the nonsurgical group was 21% and included urinary tract infection, decubitus ulcer, pneumonia and deep vein treatment failed to show a benefit of surgical intervention. In between1997 Chen surgical et al., retrospectivelyand nonsurgical reviewed groups was 114 found patients for functional of which thrombosisStevens [39]. et al., conducted a retrospective review of 126 and25% motorof patients outcome, were treated as well surgically. as bladder No control. significant Regardless difference of non-surgically. Surgical procedures included anterior, posterior patients of which 67 patients were treated surgically and 59 JSM Neurosurg Spine 4(3): 1075 (2016) 4/8 Girardi et al. (2016) Email: Central or combined decompression with or without instrumentation.

compared to late and conservative treatment [54]. In a systematic aOf meanthe 67 time surgical of 137 patients, days. Patients16 were treated in the surgicalwithin 24 group hours, were 34 recoveryreview in of 2015, ASIA Andersonmotor scores, et al.,while reported there was low-level weak evidence patients after 24 hours, and 17 patients on readmission after thatsuggesting patients that operated surgery within within 2 weeks 24 hours have significantly a higher recovery improved rate difference in improvement in Frankel grade between surgical measured by the Japanese Orthopaedic Association score . andsignificantly non-surgical younger. groups. The No study difference demonstrated of neurologic a significant outcome Similarly, Fehlings et al., conducted a systematic review in 2006�55,56 between the three surgical subgroups was found. Surgical treatment did not affect length of hospital or intensive care unit etand al., concluded concluded early that decompressive early decompression surgery might (within be 24 indicated hours) can be performed safely [57]. In a systematic review, Molliqaj Finally, in two systematic reviews of case series and stay, or complication rate [25]. Controversy persists, however, and no clear recommendation retrospective studies in 2013, Aarabi et al., and Dahdaleh et al., canin patientsbe proposed, who because exhibit current progressive systematic neurological reviews are deficits. based of surgical treatment in patients with central cord syndrome concluded that there was level 3 evidence to support the benefit onStudies low-level supporting evidence [48]. delayed surgical intervention [51,52].Timing of surgical treatment Controversy also exists over the optimal timing of surgical 1060One patients analytical with study central showed cord benefits syndrome in patients treated treated surgically. with intervention. While some studies advocate early intervention, delayed surgery. In 2015 Samuel et al. retrospectively reviewed and some show no difference at all. This section will present delayedSurgical surgerytiming was was found associated to be associatedwith reduced with odds a 19% of mortality. decrease studiesideally within grouped 24 hours, on their other results, studies supporting support delayed early surgery or late Timein the toodds surgery of mortality was also with associated each 24-hour with aincrease 7% increase in time. in Thusodds intervention,Studies supporting in order to early emphasize surgical the conflicting intervention results. surgery. Delayed surgery was not associated with more severe adverseof minor events, adverse however events [23].with each 24-hour increase in time to A few analytical studies support early surgical intervention. Fehlings et al., conducted a prospective, multicenter study Studies showing no difference in surgical timing A few analytical studies did not show a difference between a follow-up of 6 months. In multivariate analysis, the odds of improvementbetween 2002 of and at 2009,least 2 with grades 222 in spinal ASIA cord Impairment injury patientswith Scale were surgically for spinal instability or declining neurologic status, Andersonearly and delayedet al. found surgical an overall intervention. increase In of 69 63 patients points treated on the 2.8 times higher in patients who underwent surgery within 24 American Spinal Injury Association (ASIA) motor score scale to hours. It is unclear if these findings can be applied to patients with central cord syndrome [53]. the ASIA Impairment Scale. There was no difference in motor syndrome treated surgically. Surgery was performed via 90 points. About 70% of patients improved 1 or more grades on Guest et al., reported on 50 patients with central cord function outcome between early (less than 24 hours after injury), hadposterior a shorter or anterior stay in approaches, the intensive within care 24 unit hours and in the16 patients, hospital surgicalmidrange complication (24 to 48 hours), rate, andwith late the (more most commonthan 48 hours) complications surgical comparedand after 24 to hourslate surgery. in 34 patients. Patients Patients with acute with disc early herniation, surgery beingtreatment. surgical There site was infections, also no difference urinary in tract approach. infection A 25% and cervical fractures or dislocations had a bettermotor recovery dysphagia, was noted [31]. than patients with spondylosis or stenosis, if the surgery was who were treated surgically with an anterior or posterior patients with early intervention for disc herniation, fracture In 2009 Chen et al., assessed a study population of 49 patients performed within 24 hours. After 36 months of follow-up, all patients who underwent delayed surgery had the same outcome. afterapproach surgical within intervention. 4 days or afterNo difference 4 days of with admission. regards Significant to timing Patientsor dislocation with werespondylosis able to or walk stenosis independently, required whileno assistance 88% of ofimprovement surgical intervention in ASIA scores was found. was noted Full bladder during thecontrol first recovered 6 months walking in 66% of early surgical cases and in 61% of delayed

from 56% to 80%, while ASIA motor scores improved from 50 surgical cases [34]. respectively. Spasticity and neuropathic pain were major factors syndrome of which 23 were treated with surgical decompression. and 60 to 99 and 90 in the early and delayed surgical group TheYamazaki study showed et al., that studied spinal 47 canal patients diameter with centraland interval cord leading to a poor quality of life as reported by patients [38]. In 2015 Kepler et al., reported of 68 patients who underwent between injury and surgery were significantly associated with a 72% had delayed surgical intervention. Patients in the early surgery within 24 hours in 28% of cases, while the remaining better recovery [40]. intervention group were younger. The study showed no Rosa et al., Early decompression in patients with incomplete difference in length of stay in the hospital or intensive care unit, These results have been confirmed in a meta-analysis by La spinal cord injury resulted in significantly better outcome motor improvement, or morbidity and mortality after 7 days [58]. JSM Neurosurg Spine 4(3): 1075 (2016) 5/8 Girardi et al. (2016) Email: Central

Finally, a systemic review by Aarabi et al., in 2013 concluded signal intensity and prevertebral hyper-intensities correlated that most class III evidence did not show advantages of early negatively with recovery rate [63]. Ouchida et al., described

neurological outcome did not correlate with early MRI (within versusPrognostic late surgical factors treatment for neurologic [52]. outcome similar findings [64]. Liu et al., however, concluded that Demographic and medical factors: Several baseline prognostic factors have been established. Age was found 24 hours) findings in patients with SCIWORA. Thus, a repeat MRI Electrophysiological measurement to be an important factor for recovery in several studies. may be necessary [43]. Neurologic improvement was higher in younger patients Intraoperative electrophysiologic measurement might be a valuable tool to predict neurologic recovery after spinal cord higher formal education were found to have a better neurologic injury. Costa et al., conducted a prospective observational study outcome[14,19,22,30,30,33,38,58-60]. [21]. Furthermore, patients with a traumatic spinal cord injury. The study reported that in central Injury-related and medical factors: Absence of cordon 55 syndrome, patients electrophysiological undergoing posterior measurement spine stabilization showed the for comorbidities and anterior column fracture were associated with presence of a clear D wave and absent low voltage muscular better outcomes in one study [21], and another study reported motor evoked potentials from hand muscle. Patients with this that patients with fracture or dislocation recovered more slowly than other patients [33]. Furthermore, studies indicated that the spinal canal diametermight correlated with the functional patternBlood testsrecovered significantly [65]. outcomeNeurologic [40,61]. factors: The baseline neurologic status was in patients with central cord syndrome and other spinal cord found to be an important factor in recovery by several studies. injuries.Kuhle All et patientsal., examined were serum treated neurofilament with surgical light decompression, chain levels Dvorak et al. found that ASIA motor score at admission and formal education predicted better recovery. Patients with a were highest in patients with central cord syndrome, compared greater rate of motor recovery and higher scores at mean follow- towhile other no patient syndromes, received and steroids. correlated Baseline with motorneurofilament scores. Motorlevels up of 70 months were more likely to suffer from spasticity, outcome plateaued after 3 months in all patients regardless of however. Additionally, functional outcome was higher in young patients and lower in patients with spasticity [21]. In agreement with this Thompson et al. showed that an ASIA motor score of syndrome, and was highly correlated with baseline neurofilament levels.Prognostic Similar factors correlations for morbiditywere seen for and sensory mortality recovery [47]. being able to walk at the time of discharge, while scores lower Brodell et al., showed that mortality in patients with income greater than 60 on admission correlated with an 80% chance of to walk [61]. Several other studies reported a similar association quartiles. Other factors increasing mortality were surgery at a than 50 were correlated with an 80% chance of not being able ruralof $41,000 hospital to and $50,999 congestive was heart higher failure in comparison[20]. Similarly, to Injury other Severity Score and Charleson Comorbidity Index increased the of motor score and outcome [8,33,40]. Furthermore, the percent deficit improvement during the early period after injury was also a study by Samuel et al. aImaging significant predictor of better outcome in one study [22]. risk of severe adverse events at an odds ratio of 1.04 and 1.25 in Magnetic resonance image plays an important prognostic CONCLUSION role in patients with central cord syndrome. In the setting Traumatic spinal cord injury is the most frequent incomplete of a rehabilitation center, Hohl et al., showed that abnormal spinal cord injury, most commonly caused by falls and motor predictor for the motor portion of the Functional Independence this clinical syndrome is controversial as the patient population signal intensity on MRI at the time of injury was a significant withvehicle this accidents diagnosis in middle-aged suffers from white a heterogeneous males. The definition group of Measurement at 1-year follow-up [8]. Aarabi et al., [62] and other T2-weighted signal intensity with poor neurologic status. While treatment and timing of intervention remain a topic of debate. No studies [22,40] reported similar findings of the association of patients with increased T2-weighted signal intensity on MRI recommendationinjury mechanisms for and the pathological choice of treatment findings. can Similarly, be made surgical based on current evidence. Prognostic factors, such as age and baseline neurologic function might help physicians in their treatment demonstrated a stable neurologic status within the first week, patients without this finding experienced a decline in their ASIA T2-weighted signal intensity spent more time in the intensive or MRI studies seem promising. Future research should include motor score of 4.3 points. Furthermore, patients with increased care unit. Aarabi et al., concluded that patients should be treated analyticaldecision. Other prospective prognostic trials tests, and suchcohort as studies serum toneurofilament draw more

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Cite this article Paul S, Jennifer S, Girardi FP (2016) Central Cord Syndrome: A Review of Epidemiology, Treatment and Prognostic Factors. JSM Neurosurg Spine 4(3): 1075.

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