Answer of April 2010

Clinical History:

A 55 years-old gentleman was presented with head injury by falling frozen meat hitting at vertex at work. He complained of neck pain, bilateral upper limb and right lower limb weakness, right upper limb and left lower limb numbness. Physical examination revealed bilateral upper limb power decreased to 3/5 and right lower limb power decreased to 4/5. There was decreased pinprick and light touch over right C5-C8 and left L4 to S2 dermatomes. No urinary bladder dysfunction was detected. Urgent plain CT brain and CT cervical spine were unremarkable. An urgent MRI C-spine was performed.

                            Fig. 1 T1 Sagittal                                                      Fig. 2 T2 Sagittal

                        Fig. 3 T2* Sagittal

                               Fig. 4 T1 Axial                                                          Fig. 5 T2 Axial

Diagnosis:

Central Cord Syndrome (Acute traumatic central cord syndrome)

Discussion:

MRI of the cervical spine revealed focal posterior disc protrusion at C3/4 level causing spinal stenosis obliterating CSF space and impressing onto the spinal cord. There is increased intramedullary T2 signal without abnormal T1 signal noted. No blooming is seen at T2* sequence. Mild prevertebral soft tissue edema is seen at C2 to C4 level.

Acute traumatic central cord syndrome (ATSCC) is the most frequently encountered incomplete spinal cord injury. It is usually caused by hyperextension force with compression of cervical cord by buckling of ligament flava in patient with pre-existing canal narrowing. 
Patients with ATCCS present with disproportionate weakness of the upper extremities, and variable sensory loss and bladder dysfunction. Nearly 50% of patients with ATCCS suffer from congenital or degenerative spinal stenosis and sustained their injuries during hyperextension as originally described by Schneider in 1954. 

Radiographs and CT findings are usually normal or show spondylosis or congenital canal stenosis. MRI typically shows T1 isointense and T2 hyperintense intramedullary lesion at C3-4 (80%) to C-5 level. T2* sequence is helpful to exclude cord hematoma.

More than one-half of these patients enjoy spontaneous recovery of motor weakness; however, as time goes on, lack of manual dexterity, neuropathic pain, spasticity, bladder dysfunction, and imbalance of gait render their activities of daily living nearly impossible. 

Treatments include initial stabilization if spinal instability suspected. Steroid therapy in first 24 hours may have a role. Decompression if focal stenosis from disc or focal spur is detected in MRI. In general, conservative therapy produces equal outcomes to surgical intervention.