J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.21.3.216 on 1 August 1958. Downloaded from J. Neurol. Neurosurg. Psychiat., 1958, 21, 216. THE SYNDROME OF ACUTE CENTRAL CERVICAL SPINAL CORD INJURY BY RICHARD C. SCHNEIDER, JOHN M. THOMPSON, and JOSE BEBIN From the Departments of Surgery and Sections of Neurosurgery of the University of Michigan Hospital, U.S. Veterans Hospital, and St. Joseph's Mercy Hospital, Ann Arbor, Michigan, and the Wayne County General Hospital, Eloise, Michigan, and the Department ofNeuropathology, University Hospital, Ann Arbor Any discussion of the diagnosis and treatment of tissue. The lower extremities tend to recover motor spinal cord injuries inevitably involves controversial power first, bladder function returns next, and finally strength in the upper extremities reappears, with the matters. Among the foremost of these are the indica- finer finger movements coming back last. The varying tions for (Schneider, 1951, 1955) and the contra- degrees of sensory impairment do not follow any set indications for (Schneider, Cherry, and Pantek, 1954) pattern of recovery." surgical intervention. It seems highly important, therefore, to establish criteria which will assist in It was first thought that the acute central cervical determining whether an operation should or should spinal cord injury was found only in severe hyper- Protected by copyright. not be undertaken. In 1955, a paper was published extension injuries. The importance of suspecting on " The Syndrome of Acute Central Cervical such an injury of the cervical spine in the presence Spinal Cord Injury" (Schneider et al., 1954), a of facial lacerations or contusions of the forehead syndrome the presence of which contraindicated any has been emphasized by Taylor and Blackwood surgical procedure. At that time, nine of the (1948). When the hypertrophic arthritic cervical authors' cases which exhibited this neurological spine is hyperextended, there may be simultaneously pattern were described in detail, and six others were compression of the anterior cord caused by a abstracted from the literature. There was no patho- posteriorly placed bony spur and a posterior im- logical material presented, however, which would pingement upon the cord caused by a wrinkling of substantiate firmly the clinical thesis which had been the ligamentum flavum. This mechanism was advanced. effectively demonstrated in myelography on cadavers This paper is written to present 12 additional by Taylor (1951). In younger specimens there was patients who exhibited the syndrome. In one case no distortion of the pantopaque column in the the post-mortem examination confirms the assump- cervical spinal canal when the head was placed in a tions previously made on the basis of clinical flexed or neutral position. When the cervical spine examination. A study of this group of cases permits was forcibly hyperextended, however, there was further consideration of the mechanisms involved in definite encroachment posteriorly upon the pant- http://jnnp.bmj.com/ this type of injury. opaque column in the spinal canal. Taylor suggested The description of the syndrome reads: that this was probably caused by a bulging forward " In acute cervical spinal cord injuries, there is a of the ligamentum flavum. When a cervical myelo- syndrome that suggests acute central cervical spinal gram was made similarly in hyperextension in an cord involvement. It is characterized by dispropor- elderly patient with posterior hypertrophic spurring tionately more motor impairment of the upper than of the lower extremities, by bladder dysfunction, of the cervical vertebral bodies, the bony spur usually by urinary retention, and by varying degrees anteriorly and the wrinkled ligamentum flavum of sensory loss below the level of the lesion. If the posteriorly encroached simultaneously in the canal. on October 1, 2021 by guest. findings are caused by central cord destruction with There are other mechanisms which may result in bleeding, hematomyelia, there may be caudad or a acute cephalad extension of the lesion with further progres- squeezing of the cervical spinal cord. The sion of symptoms, perhaps culminating in complete central cervical spinal cord injury syndrome may tetraplegia or death. But if the symptoms are caused occur in severe cervical compression fractures and by concussion or contusion, with an edematous type in some cervical fracture-dislocations. It is difficult to of central cord involvement, there may be gradual in return of function in a definite sequence. The amount postulate cervical compression fractures whether of recovery depends on the degree of edema present the cervical spinal cord is squeezed in hyperextension compared to the extent of true destruction of nervous or in flexion of the cervical spine. 216 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.21.3.216 on 1 August 1958. Downloaded from ACUTE CENTRAL CERVICAL CORD INJURY 217 Cases of cervical fracture-dislocation, however, four hours after he was injured he could move the are a different matter. The acute central cervical thumbs and toes. It was necessary to insert an indwelling in the lower cord injury syndrome may occur in an acute flexion catheter into the bladder. The strength The extremities increased much more rapidly than in the injury accompanied by fracture-dislocation. upper, so that within a period of two weeks he could cervical spinal cord is acutely squeezed anteriorly by manipulate his lower extremities quite well. He could the lower involved, or caudad, vertebral body of a raise his arms to a certain extent. All forearm movements cervical fracture-dislocation and posteriorly by the were poor, however; and, although his thumbs could be lamina of the upper, or cephalad, involved vertebra. wiggled slightly, he could not move his fingers. The 12 patients presented here were admitted to The patient was treated with intermittent halter four different hospitals in the year following the traction until the time of his transfer to the U.S. Veterans publication of the article on the acute central Hospital, Ann Arbor, Michigan, on February 10, 1955. cervical cord injury syndrome (Schneider et al., When he was admitted, a disproportionately better move- ment was noted in the lower extremities than in the 1954). upper, and his hands were very weak. Hypalgesia and Case Reports hypaesthesia were observed over the upper extremities and lower ex- Case 1.-On May 3, 1955, S. B., a 63-year-old woman, and, in a lesser degree, over the trunk fell headlong downstairs, striking upon her face. The tremities. The deep reflexes were symmetrically hyper- patient developed complete tetraplegia accompanied by active and no pathological reflexes were apparent. Vinke of the lower extremities. Within two hours tongs were inserted. Radiographs of the cervical spine numbness arthritis with at after the fall she was examined at Wayne County General demonstrated a hypertrophic spurring and the following positive findings were noted: all the interspaces but no evidence of fracture-dislocation. Hospital, on 1956. on the left paresis of A follow-up examination was made March 4, a large contusion forehead, slight dorsi- the lower extremities, marked weakness of the upper His gait was impaired because of weakness in flexion of the right great toe and foot. Strength was less and complete paralysis of the hands. There Protected by copyright. extremities, than in the lower ones. The was a complete areflexia with no pathological reflexes. in the upper extremities was noted from the shoulder downward. small hand muscles on the right side were atrophied. Hypaesthesia were intact. The Position sense was intact. A radiograph of the cervical Vibration and position sensations spine showed hypertrophic spurring at the C3-C4, C4-C5, remainder of sensation had returned in patches. There and C5-C6 interspaces. was a zone of hyperaesthesia from T1o through T12 derma- after she was admitted, her legs began tome bilaterally. Hypalgesia was demonstrated over the Several hours and and bilaterally to move readily, and on the following day they were dorsum of the right foot, leg, knee, strong. The upper extremities, however, showed almost below the T12 dermatome. The deep tendon reflexes complete paralysis of the forearm and hand muscle were more hyperactive in the right upper and lower on the There were definite groups. Twenty-four hours after admission the hypaes- extremities than in those left. been below C7 bilaterally began pathological reflexes in both upper extremities and in the thesia which had present in to diminish gradually in the lower extremities. It was right lower, with equivocal abnormality the left lower necessary to insert an indwelling catheter in the bladder. extremity. A lumbar puncture on May 5, 1955, produced cerebro- was on his spinal fluid with 21 R.B.C.s per high-power field and a Case 3.-L.R., 61-year-old farmer, working value of 83 mg. per 100 ml. The blood manure spreader on Friday, April 13,1956, when he fell total protein his neck into extreme Kahn test was 3 plus, but the spinal fluid Kahn test was headlong to the ground forcing not move arms or legs. negative. A jugular vein compression test showed no hyperextension. He could his block. Twelve days after the injury movements in the After a short time he found he could move his legs weakly http://jnnp.bmj.com/ patient's hands began to improve. By May 18, bladder and attempted to roll over, but he was unable to do so. A three weeks Four hours later the patient was taken to the hospital. control was good. myelogram performed in and Upon after with the patient in a steep Trendelenburg He felt sharp shooting pains his arms legs. injury there was a loss position showed that the pantopaque did not pass the sensory examination, however, complete of sensation in both upper extremities. He could flex and level of C6 until the neck was flexed. A defect was present extend his lower extremities and could move his shoulders at the C3-C4 interspace on the lateral view with a " step move his or fingers.