Dr. Ahmed Mirza Al-Shammasi, MB ChB2031040009

KFHU – Saudi Arabia

OutlinesOutlinesIntroductionDefinition of Traumatic Central

Cord SyndromeCorrelative Anatomy,

Pathogenesis, PathologyDiagnosisManagement

◦Consevative vs. Operative◦Timing of Surgery

IntroductionIntroductionFirst reported by Thorburn in 1887,

popularized by Schneider in 1954.

TCCS is related to Hyperextension of the cervical spine without concomitant fracture of sublaxation.

TCCS compromises 44% of clinical syndrome following traumatic SCI.

35-58% of patients with TCCS had underlying Cervical Canal Stenosis.

IntroductionIntroductionGeneral trend since 1954 has been

reluctance to undertake aggressive treatment:◦Lack of # or sublaxation on imaging studies.◦Spontaneous functional recovery.◦Comorbidities.◦Risk of Intraoperative worsening of

neurological condition.Yamazaki demonstrated “Direct”

relationship between outcome and Midsagittal diameter of the spinal canal.

TCCSTCCSPartial SCI with disproportionate:

◦ Motor loss in the distal upper extremities. ◦ Significant involvement of bladder function. ◦ Variable degrees of sensory impairment

below the level of skeletal injury.

Middle-aged men are mostly affected.

In several recent series the proportion of men ranged from 56.2-88%.

35-58% of patients with TCCS had underlying Cervical Canal Stenosis.

PathogenesisPathogenesisFoerster and Schneider:

◦Buckling of Ligamentum flavum + disc protrusion.

◦Compression of the spinal cord.◦Formation of a hematoma at the center

of the cord (Hematomyelic cavity).◦Fibers subserving the upper

extremities, concentrated medially, are involved.

◦Fibers subserving the lower extremities, concentrated laterally, are spared.

PathogenesisPathogenesisRecent lines of evidence contradict that

assumption.

Pappas and Marchi, Coxe and Landau, Barnard and Woolsey studies in monkeys◦No somatotopic organization of the

Corticospinal tract at the level of pyramids or cervical spinal cord.

Studies of Nathan and colleagues in human patients tend to confirm this finding.

PathogenesisPathogenesisJimenez, Martin and Quencer:

◦Correlating autopsy with MRI imaging of TCCS patients.

◦Majority of patients with TCCS had no evidence of hematomyelia or significant injury to the centeral gray matter.

◦Axonal disruption and swelling is widespread in the white matter of the lateral funiculi and to lesser extent the posterior columns.

Alternative hypothesisAlternative hypothesis

Proposed by Levi and Collignon:◦TCCS may result from pathological

entities affecting the CST anywhere from the pyramids to the cervical spine.

◦CST primarily subserve fine motor movements to the distal musculature, especially upper limbs.

◦Preservation of leg movement is mediated by other descending motor pathways important to locomotion.

PathologyPathologyLesion of TCCS seem to comprise

3 main categories:1. Cervical Spondylosis associated

with spinal canal stenosis2. Fracture sublaxation3. Sequestrated disc without

evidence of spinal stenosis.

The proportion of each is different in every case.

DiagnosisDiagnosis

CT, MRI, and when indicated, dynamic studies will essentially rule out skeletal damage, DLC injuries and hidden fractures.

New technology even enables the measurement of the degree of canal compromise and cord compression. (MCC, LL)

i

b

a

MSCC (%) = [1-i/(a+b)/2] x 100Maximum spinal canal compression

ManagementManagementSurgical vs. ConservativeSurgical vs. Conservative

Factors that discourage urgent surgery, experience of Schneider and colleagues:◦ Lack of # or sublaxation on imaging studies.◦ Spontaneous functional recovery.◦ Comorbidities.◦ Risk of Intraoperative worsening of neurological

condition.

ManagementManagementIn 1984, Bose review of patients

with TCCS showed better motor scores in patients treated surgically.

In 2005, Yamazaki demonstrated “Direct” relationship between outcome and Midsagittal diameter of the spinal canal.

Timing of SurgeryTiming of SurgeryIn 2002, Guest review of patients with

TCCS and disc herniation or skeletal injury:◦ Patient underwent Early surgery (<24 hours)

had better motor recovery than Late surgery.◦ The timing of surgery did not affect motor

recovery in cases with spinal canal stenosis.

Preliminary result of prospective multicenter trial, reported by Fehlings, indicate better functional recovery with early decompression.

Surgical ObjectivesSurgical Objectives

1. Spinal Cord decompression2. Restoration of normal spinal

alignment and internal fixation

Prevent and/or interrupt of further secondary injury.

ConclusionConclusion

TCCS is most frequent syndrome after incomplete SCI.

50% is due to hyperextension injury.

Until now, no standard algorithm of treatment.

Further research should be multicenter, prospective and analytical rather than descriptive.

Thank you for listeningThank you for listening