A 54-year-old woman with a history of alcohol use disorder arrived via ambulance in a cervical collar complaining of bilateral upper extremity paresthesia and weakness after a fall at home the previous night while intoxicated. She was unable to recall falling, but woke up on the floor with new facial abrasions and neck pain. She reported weakness when lifting her arms and gripping objects and a burning pain in her hands that worsened with arm and neck movements. She did not report any recent fevers, weight loss, intravenous drug use, bowel or bladder incontinence, lower extremity weakness, or balance issues.
She was afebrile with a heart rate of 70 bpm, a respiratory rate of 18 bpm, and a blood pressure of 102/66 mm Hg. She had abrasions to her chin and nasal bridge. Examination of her cervical spine revealed mild diffuse midline tenderness without deformity. She had no bony tenderness in her arms, and she had full range of motion in all upper extremity joints. Strength was 4/5 in all upper extremity muscle groups except for a 3/5 grip. Sensation to light touch was decreased on her arms, and her hot-cold differentiation was impaired. Proprioception and vibratory sense were intact. A Hoffmann reflex was elicited in her right hand but not the left. Strength and sensation were intact in bilateral lower extremities and the saddle area. Rectal tone was normal.
A laboratory evaluation was unrevealing. A noncontrast CT of the cervical spine was negative for acute fracture but showed moderate age-related cervical spondylolisthesis.
What test can help diagnose this patient? How should you manage her?
Find the diagnosis and case discussion the next page.
Diagnosis: Central Cord Syndrome
Acute traumatic central cord syndrome (ATCCS) is the most common pattern of incomplete spinal cord injury, resulting in a cape-like distribution of sensory impairment or burning dysesthesias and predominantly upper extremity weakness. This is due to injury of the central portions of the lateral corticospinal tract, in which upper extremity motor neurons are organized centrally and lower extremity neurons course laterally.
Depending on the size and severity of the lesion, patients may also present with lower extremity weakness and urinary retention. (Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th Edition. Philadelphia: Elsevier; 2018; pp. 1298-1306.) The mechanism of injury is typically a forced cervical hyperextension from a fall or motor vehicle collision, causing contusion and impaired perfusion to the central portions of the cord. Degenerative cervical stenosis predisposes older adults to ATCCS.
Initial computed tomography of the cervical spine should be used to evaluate for associated vertebral fractures or dislocations. ATCCS can then be confirmed with noncontrast MRI, which also allows for the identification of unstable ligamentous injuries. (J Am Acad Orthop Surg. 2009;17:756.)
The mainstays of ED treatment for ATCCS include rigid cervical immobilization, optimization of spinal cord perfusion, and urgent spinal surgery consultation. Avoid hypoxia and hypotension to reduce the risk of secondary insult to the injured portions of the cord. Guidelines suggest early use of vasopressors to maintain a mean arterial pressure of 85-90 mm Hg for the first week after injury. Such patients should be admitted to intensive care for frequent neurological assessments and respiratory monitoring. (Neurosurgery. 2013;72[Suppl 2]:195.) It is controversial, but patients presenting within eight hours of injury may benefit from high-dose intravenous methylprednisolone for 24-48 hours. (J Am Acad Orthop Surg. 2009;17:756.)
Surgical decompression within 24 hours is indicated for unstable injuries (e.g., fractures, dislocations, ligamentous injuries) and external compression (e.g., central disc herniation, hematoma). Early surgical management of ATCCS in the absence of associated unstable spinal injuries or cord compression is sometimes considered for more severe presentations. (Eur Spine J. 2019;28:2390.)
Our patient was maintained in spinal immobilization and admitted to the intensive care unit on a norepinephrine infusion for blood pressure support with the neurosurgical service. After a prolonged course of rehabilitation, she was discharged with improving strength but persistent burning upper extremity dysesthesia.
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Dr. Burkholderis an assistant professor of clinical emergency medicine at the Keck School of Medicine at the University of Southern California. Follow him on Twitter @tayburkholder.