Neurology · Spinal Cord Injury
The facts most likely to be tested
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Central cord syndrome is the most common form of incomplete spinal cord injury.
The classic mechanism of injury is hyperextension of the neck in an elderly patient with cervical spondylosis.
Patients present with a disproportionate loss of motor function in the upper extremities compared to the lower extremities.
Preferential upper-extremity involvement is classically attributed to somatotopic lamination (arm fibers more medial), though modern evidence suggests preferential damage to the lateral corticospinal tract/central gray is the better explanation.
Sacral sparing is a hallmark feature, preserving bowel and bladder function and perianal sensation.
Sensory deficits are typically variable and may present as a cape-like distribution of loss of pain and temperature sensation.
MRI of the cervical spine is the diagnostic modality of choice to evaluate for cord compression and edema.
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A 72-year-old male is brought to the emergency department after a mechanical fall in which he struck his chin on the floor. He complains of significant weakness in both hands and arms, though he is able to move his legs with only mild difficulty. Physical examination reveals bilateral upper extremity weakness and diminished sensation to pain and temperature in a shawl-like distribution over the shoulders. Proprioception and vibration sense are preserved, and he has normal rectal tone.
What is the most likely diagnosis?
Central cord syndrome
The patient's presentation of disproportionate upper extremity motor weakness following a hyperextension injury in the setting of cervical spondylosis is classic for central cord syndrome, which classically reflects preferential injury to the centrally located corticospinal fibers; note that the traditional somatotopic lamination explanation is debated in current literature.
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Etiology / Epidemiology
Most common incomplete spinal cord injury, typically seen in elderly patients following hyperextension injuries.
Clinical Manifestations
Characterized by disproportionate upper extremity motor impairment compared to lower extremities; syringomyelia is a chronic cause.
Diagnosis
MRI of the spine is the gold standard for visualizing cord compression and intrinsic cord signal changes.
Treatment
Management involves cervical stabilization and surgical decompression; avoid hypotension to maintain spinal cord perfusion.
Prognosis
Prognosis is generally favorable for lower extremity recovery, but fine motor hand function often remains permanently impaired.
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Epidemiology & Etiology
Occurs primarily in older adults with pre-existing cervical spondylosis who suffer a minor fall. In younger patients, it is often associated with high-energy trauma. It is the most frequent form of incomplete spinal cord injury.
Pertinent Anatomy
The corticospinal tract is preferentially affected centrally; the classic teaching of medial (cervical) to lateral (sacral) somatotopic lamination explains arm-predominant weakness, though this lamination model is debated in current literature.
Pathophysiology
Hyperextension causes the spinal cord to be compressed between the ligamentum flavum posteriorly and osteophytes anteriorly. This leads to central cord edema and hemorrhage, preferentially damaging the centrally located corticospinal fibers controlling the upper extremities (the traditional medial-lamination explanation is debated).
Clinical Manifestations
Patients present with greater motor weakness in the upper extremities than the lower extremities. A cape-like distribution of sensory loss to pain and temperature is common. Respiratory distress may occur if the injury is high enough to affect the phrenic nerve.
Diagnosis
MRI of the spine is the diagnostic modality of choice to evaluate for cord edema or hematoma. Plain radiographs may show cervical spondylosis or fracture, but lack the sensitivity for soft tissue injury.
Treatment
Initial management focuses on cervical immobilization and hemodynamic stabilization. Surgical decompression is indicated for patients with persistent compression or neurological decline. Avoid systemic hypotension as it exacerbates secondary cord ischemia.
Prognosis
Recovery typically follows a predictable pattern: lower extremity function returns first, followed by bladder control, and finally proximal upper extremity function. Distal hand function is often the last to recover and frequently shows the most significant residual deficit.
Differential Diagnosis
Anterior Cord Syndrome: loss of pain/temp with preserved proprioception/vibration
Brown-Sequard Syndrome: ipsilateral motor loss and contralateral pain/temp loss
Cauda Equina Syndrome: saddle anesthesia and bowel/bladder dysfunction
Transverse Myelitis: rapid onset bilateral weakness with sensory level
Spinal Cord Infarction: sudden onset with preserved dorsal column function