Surgical Interventions (Acute Phase)

Surgery for Traumatic Central Cord Syndrome

Central cord syndrome is a clinical entity with acute SCI that affects the upper extremities more profoundly than the lower extremities. This can include motor deficit or varying degrees of neuropathic pain in the upper extremities. The lamination of the long white matter tracts in the spinal cord puts the upper extremity fibres at greater risk when lesions occur in the centre of the cord. The exact mechanism of this injury is not fully understood. Traumatic aetiologies of central cord are thought to involve a relative ischemia in the central part of the spinal cord, which is a vascular watershed area between the anterior spinal artery and the posterior blood supply. This can be induced by a hyperextension injury in the setting of pre-existing stenosis or degenerative changes, for example. Several case series have assessed the role of surgical decompression in the setting of central cord syndrome and will be reviewed here.

Author Year

Country
Research Design
Score
Total Sample Size

 Methods Outcome
Liu et al. (2017)

China

Case Series

N=11

 Population: Mean age=54.1 yr; Gender: male=10, female=1; Level of injury: not reported; Severity of injury: ASIA A=0, B=1, C=6, D=4, E=0.

Intervention: Individuals with delayed cervical central cord syndrome were retrospectively studied to investigate the efficacy of surgical intervention.

Outcome measures: American Spinal Injury Association (ASIA) motor score; Japanese Orthopedic Association (JOA) score; SF-36; Neurologic status.

Chronicity: The mean time from injury to surgical intervention was 92.4 days.

 1.     ASIA motor scores significantly improved post-surgical intervention (p<0.05).

2.     A significant improvement in JOA scores was observed within the first six mo following surgical intervention (p<0.05).

3.     The mean scores of physical functioning, bodily pain, vitality, social functioning, and mental health of individuals significantly improved post-surgical intervention on the SF-36 questionnaire (p<0.05).

4.     ASIA grade significantly improved after surgical intervention (p<0.05).
Jug et al. (2015)

Slovenia

Cohort

NInitial=48, NFinal=42

 Population: Early group (n=20): Mean age: 52.0 yr; Gender: males=16, females=4; Level of injury: C=19, C/T=1; Level of severity: AIS A=13, B=1, C=6. Very Early group (n=22): Mean age: 44 yr; Gender: males=18, females=4; Level of injury: C=20, C/T=2; Level of severity: AIS A=13, B=5, C=4.

Intervention: Participants received early (8-24 hr) or very early (<8 hr) decompression and fusion. Outcomes were assessed before treatment and at 6 mo follow-up.

Outcome Measures: American Spinal Injury Association (ASIA) Impairment Scale (AIS); ASIA Motor Scale (AMS).

 

 1.     The rate of AIS improvement >1 grade was 28% greater in the very early group than in the early group, but the difference was not significant (RR=1.81, 95%CI=0.76-4.30, p=0.115).

2.     The rate of AIS improvement >2 was 36% greater in the very early group than in the early group (RR=2.08, 95%CI=1.12-3.87, p=0.015).

3.     The odds of AIS improvement >2 was over 100% greater in the very early group than early group after adjusting for pre-operative AIS grade and degree of spinal canal compromise (OR=11.08, p=0.004).

4.     The odds of AIS improvement >2 did not significantly differ based on completeness of injury (OR=0.26, p=0.087) or degree of spinal canal compromise (OR=0.94, p=0.066).

5.     The odds of AIS improvement >2 were at least 2% lower for each additional hr from injury to surgery (OR=0.83, p=0.029).

6.     The median improvement in AMS score was significantly greater in the very early group than early group (+38.5 versus +15.0, p=0.0468).
Kepler et al. (2015)

Canada

Case Control

N=68

 Population: Early surgery (n=19): Mean age=52.1 yr; Gender: male=63%, female=37%; Level of injury: not reported; Severity of injury: mean ISS=18.1.

Delayed surgery (n=49): Mean age=59.2 yr; Gender: male=72%, female=27%; Level of injury: not reported; Severity of injury: mean ISS=19.8.

Intervention: A retrospective review was conducted to characterize changes in ASIA motor scores within the first week after traumatic central cord syndrome to identify predictors of improved early outcome in individuals treated with early versus delayed surgical intervention.

Outcome measures: American Spinal Injury Association (ASIA) motor score; Overall Length of Stay (LOS); LOS in Intensive Care Unit (ICU).

Chronicity: The average length of hospital stay in ICU was 3.4 days, while overall hospital length of stay was 10.5 days.

 1.     No significant differences were observed in ASIA motor scores (p=0.36), the change in ASIA motor score within seven days (p=0.34), the number of individuals who had early improvement (p=.94), time spent in ICU (p=0.84), or overall LOS (p=0.59) between the early and delayed groups.
Samuel et al. 2015a

USA

Case Series

N=2636

 Population: Mean age: 56.6 yr; Gender: males=833, females=227; Injury etiology: fall=586, motor vehicle accident=317, bicycle=59, other=98; Level of injury: T12-L3.

Intervention: Individuals with acute traumatic central cord syndrome who underwent surgery were retrospectively analyzed. Individuals were analyzed by time to surgery. Mean time to surgery was 3.5 days.

Outcome Measures: Mortality, Adverse Events.

 1.     Delayed surgery was associated with a decreased odds of inindividual mortality (p=0.04)

2.     Delayed surgery was associated with a 19% decrease in odds of mortality with each 24 hr increase in time until surgery.

3.     The association of time to surgery with serious adverse events was not statistically significant (p=0.09).

4.     The association of time to surgery was associated with increased odds of minor adverse events (p<0.001).
Samuel et al. 2015b

USA

Case Series

N=1060

 Population: Mean age=56.6 yr; Gender: male=833, female=227; Level of injury: not reported; Severity of injury: mean ISS score=19.5.

Intervention: A retrospective review of surgically treated individuals with acute traumatic central cord syndrome to determine the association of time to surgery on mortality and adverse events.

Outcome measures: Mortality; Serious adverse events; Minor adverse events.

Chronicity: The mean time to surgical decompression was 3.5 days, while the mean length of hospital stay was 14 days.

 1.     Delayed surgery was associated with decreased odds of individual mortality (OR=0.81, p=0.04), or a 19% decreased in odds of mortality with each 24 hr increase in time to surgery.

2.     No significant differences were observed between time to surgery and serious adverse events (p>0.05), however, time to surgery was associated with increased odds of minor adverse events (OR=1.06, p<0.001).
Anderson et al. (2012)

USA

Case Series

N=69

 Population: Mean age: 59.0 yr; Gender: males=39, females=30; Injury etiology: falls=49, motor vehicle accident=13, sports=6, traumatic intubation=1; Injury severity: AIS C=28, D=41.

Intervention: Individuals with traumatic central cord syndrome were retrospectively analyzed. Individuals had early surgery (<24 hr, n=14), midrange surgery (24-48 hr, n=30), or late surgery (>48 hr, n=25). Mean length of acute care hospitalization was 13 days and mean follow-up time was 11 mo.

Outcome Measures: American Spinal Injury Association (ASIA) Grade, ASIA Motor Score (AMS).

 1.     There was a significant improvement in mean AMS between initial presentation and hospital discharge, and between hospital discharge and final follow-up (p=0.01 and p<0.001, respectively).

2.     Overall, 74% of individuals improved one or more AIS grades.

3.     ASIA-C individuals: 6 (21.4%) were still ASIA-C at final follow-up, 19 (67.9%) had improved to ASIA-D, and 3 (10.7%) had improved to ASIA-E.

4.     ASIA-D individuals: 12 (29.3%) were still ASIA-D at final follow-up and 29 (70.7%) had improved to ASIA-E.

5.     There was no significant difference in rate of AMS improvement between all surgery groups.
Chen et al. (2009)

China

Case Series

NInitial=56, NFinal=49

 Population: Mean age: 55.9 yr; Gender: males=40, females=9; Injury etiology: motor vehicle accident=29, fall=16, sports=3, Other=1; Level of injury: cervical.

Intervention: Individuals with traumatic central cord syndrome who underwent surgical repair were retrospectively analyzed.

Outcome Measures: American Spinal Injury Association (ASIA) Motor Scores, Short Form 36 (SF-36), Walking Index for Spinal Cord Injuries (WISCI).

 1.     Significant improvement in ASIA scores was achieved during the first 6 mo after surgical intervention.

2.     Younger individuals had a significantly greater improvement in the ASIA motor score compared to older individuals (p=0.023).

3.     On the SF-36, many individuals complained that spasticity and neuropathic pain were major factors leading to poor quality of life.

4.     There was no significant difference between individuals who underwent surgery within 4 days of injury or after 4 days of injury.

5.     There was no significant difference in WISCI scores.
Aito et al.  (2007)

Italy

Case Control

N=82

 Population: Mean age: 52.0 yr; Gender: males=72, females=10; Injury etiology: motor vehicle accident=47, falls=30, sports=5; Injury severity: AIS A=2, B=12, C=37, D=31; Time since injury range: >18 mo.

Intervention: Individuals with traumatic central cord syndrome were retrospectively analyzed and compared to those receiving conservative treatment.

Outcome Measures: Type of Treatment, Length of Stay (LOS), Neuropathic Pain, Functional Independence Measure (FIM), Walking Index for Spinal Cord Injuries (WISCI), American Spinal Injury Association (ASIA) Impairment Scale.

 1.     45% of participants were treated surgically and 55% conservatively.

2.     Average LOS was 120 days (24–390), but less for those treated without surgery.

3.     Individuals under 65 years had better outcomes with less neuropathic pain.

4.     FIM and WISCI scores highly correlated with the younger to older age groups (p<0.001).

5.     ASIA impairment scale, both from admission to discharge and from discharge to follow-up, showed a significantly greater improvement for younger age groups (p<0.01).
Dvorak et al. (2005)

Canada

Case Series

Ninitial=114, Nfinal=70

 Population: Mean age: 51±18 yr; Gender: male=57, female=13; Level of injury: C1=2. C2=1, C3=4, C4=10, C5=34, C6=16, C7=6; Severity of injury not reported; Time since injury: not reported.

Intervention: Prospective analysis of cases of traumatic cervical central SCI to determine variables that predict outcomes. Outcomes were assessed 72h following injury and at follow-up, an average of 5.3 yr.

Outcome Measures: ASIA motor score (AMS), generic health related quality of life (Short form-36, SF-36) functional status (Functional Independence Measure, FIM).

 1.     AMS improved from a mean of 58.7 at injury to a mean of 92.3 at follow-up.

2.     Bowel and bladder continence was reported at 81%, while independent ambulation was reported by 86%.

3.     Final AMS was positively correlated with the AMS at injury, formal education and presence of spasticity at follow-up.

4.     AMS was not associated with age at injury, mechanism of injury or surgical treatment.

5.     Functional status (FIM) was positively correlated with higher AMS at injury, formal education, absence of comorbidities, absence of spasticity and younger age.

6.     Generic health related quality of life outcomes (SF-36) were improved in individuals with more formal education, fewer comorbidities, absence of spasticity and anterior column fractures.
Guest et al. (2002)

USA

Case Control

N=50

 Population: Mean age: 45.0 yr; Gender: males=31, females=19; Injury etiology: motor vehicle accident=22, fall=19, sports=9.

Intervention: Individuals with traumatic central cord syndrome (CCS) who underwent surgical repair were retrospectively analyzed based on timing of surgery: early (<24 hr, n=16) and late (>24 hr, n=34). Mean follow-up period was 36 mos.

Outcome Measures: American Spinal Injury Association (ASIA) Motor Score (AMS), Post-Spinal Injury Motor Function Scale (PSIMFS).

 1.     Individuals with CCS secondary to acute disc herniation or fracture/dislocation who underwent early surgery significantly greater overall motor improvement was observed than in those who underwent late surgery (p=0.04).

2.     Overall motor outcome in individuals with CCS secondary to spinal stenosis or spondylosis who underwent early surgery was not significantly different from that in those who underwent late surgery (p=0.51).

3.     Worse motor outcomes were found in individuals who were older than 60 years of age and in whom initial bladder dysfunction was present (p=0.03 and p=0.02, respectively) compared with younger individuals without bladder dysfunction.

Discussion

The evidence reviewed here consists of retrospective, unselected individuals, and as such represent a biased sample of traumatic central cord individuals. Generally, a common management strategy is to conservatively manage those individuals who have mild pathology or show spontaneous early neurological improvement, and to consider surgery for those that fail to improve or who worsen. As such, these publications likely represent individuals that failed a period of initial observation. Furthermore, most studies here do not enlist a control group to compare surgical versus nonsurgical intervention, which precludes a robust assessment of the efficacy of decompression.

Aito et al. (2007a) reported their retrospective comparison of surgically and non-surgically treated individuals and is the only study here to use a non-surgical control group. They found no effect of surgery on neurologic outcome. This is consistent with Dvorak et al. (2005) who demonstrated no difference in long-term neurologic outcomes in surgically versus non-surgically managed individuals with traumatic central cord syndrome.

The largest case series for this population is that of Samuel et al. (2015) which followed 1060 surgically treated individuals. Using multivariate analysis, they reported an association between earlier surgery and mortality. Earlier surgery was also associated with minor, but not major, adverse events. Because other associations with mortality included advanced age and comorbidity status, it is possible that medically optimizing and stabilizing these individuals before surgical intervention may reduce minor complications and confer some survival advantage. This study did not assess neurologic outcome. This finding regarding advanced age is consistent with the Aito et al. (2007a) and Chen et al. (2009a) studies.

Other assessments of surgical timing in central cord syndrome reveal mixed results with respect to neurologic recovery. Kepler et al. (2015) found that early (<24 hours) surgery conferred no advantage in terms of AIS motor recovery, but that age was a significant predictor of worse neurological outcome. Anderson et al. (2012a) found no association between surgical timing and AIS motor outcome. In a cohort study Jug et al. (2015) found a significant neurological benefit to those receiving very early surgery (<8 hours) compared to “late” surgery which was performed 8-24 hours post SCI. Guest et al. (2002b) found that early surgery conferred a neurological recovery advantage in those individuals with an acute lesion such as an acute disc herniation or a compressive fracture, but not in those with a chronic process such as spondylosis.

Chen et al. (2009a) followed surgically treated individuals and noted that at 6 months, there were improvements in AIS motor score, but there was no non-surgical comparator group. Among surgically treated individuals, there were no differences in health-related quality of life when assessing early (<4 days) versus late surgery. Similar to previous studies, older age was a negative prognostic factor.

Liu et al. (2017) reported on a series of 11 individuals presenting who underwent surgical treatment for central cord syndrome in a delayed fashion (mean of 90 days after injury). In this cohort, postoperative AIS and quality of life scores showed improvement, but the absence of a nonsurgical comparator group again makes conclusions difficult.

Conclusion

There is level 3 evidence (based on one case control: Aito et al. 2007a) that surgical treatment of traumatic central cord syndrome does not confer neurologic benefit compared to conservative management.

There is conflicting level 2 and 4 evidence (based on one cohort and five case series studies: Jug et al. 2015; Chen et al. 2009a; R. Guest et al. 2015a; Kepler et al. 2015; Y. Liu et al. 2017; Bohl et al. 2015a) that early decompression of central cord lesions have similar neurologic outcomes to late surgery but that the latter may have lower mortality, possibly due to age-and-comorbidity-related factors.

With respect to traumatic central cord syndrome, there is no clear evidence of a neurologic benefit from decompression or its timing. Available evidence suggests that age and comorbidities may be appropriate justifications to delay surgery with possible survival benefit for doing so.

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