Makindo Medical Notes

⚠️ Central Spinal Cord Syndrome is the most common incomplete spinal cord injury. 💡 Classic clue: an older patient after a fall with a forehead bruise, neck pain, and disproportionately weak arms. 🧠 Typically follows hyperextension injuries in a background of cervical spondylosis.

About

• Most commonly caused by hyperextension injury to the neck.
• Associated with falls, motor vehicle accidents, or sports trauma.
• Frequently linked to pre-existing cervical spondylosis.

🔑 Key Red Flags

• 👴 Elderly patient, forehead bruise, weak arms > legs.
• 🧩 "Cape-like" loss of pain/temperature across shoulders & arms.
• 🚽 Bladder dysfunction (retention → later incontinence).
• ❌ Neck fracture may not be visible on plain films — MRI is key.

🧠 Anatomy

• Affects central cervical cord, especially corticospinal & spinothalamic tracts.
• Somatotopy: medial fibres = upper limbs, lateral = lower limbs → arm weakness more marked.
• Spinothalamic tract → cape-like sensory loss.

Aetiology

• Hyperextension injury → cord pinched between vertebral body & ligamentum flavum.
• Anterior spinal artery compromise may contribute.
• Fracture may or may not be present.
• Autonomic dysreflexia if lesion above T6.

Clinical Features

• 💪 Arm weakness > leg weakness (may still walk but struggle with fine hand tasks = "walking but not writing").
• 🧩 Sensory loss in cape distribution (pain/temperature).
• ⚡ UMN signs (spasticity, brisk reflexes).
• 🚽 Bladder dysfunction (retention or incontinence).
• 🔥 Neuropathic pain common.
• 😵 Horner’s syndrome possible if high cervical lesion.
• Autonomic dysreflexia: episodic flushing, headaches, sweating, hypertension.

Investigations

• MRI: Gold standard → cord oedema/haemorrhage, compression.
• CT spine: Best for bone injury; may miss cord involvement.
• Electrophysiology: NCS, SSEPs if unclear severity.

Management

• 🚑 Trauma care: ABCs, cervical immobilisation, oxygen, IV fluids.
• 🧠 MRI to confirm diagnosis and exclude unstable fractures.
• 💊 Steroids: controversial — not routine per NICE.
• 🔪 Surgery: if ongoing compression, instability, or progressive neurological deficit.
• ♿ Rehabilitation: physio, OT, bladder & bowel support.
• 💊 Neuropathic pain: gabapentin, pregabalin, TCAs, SNRIs.
• 💊 Spasticity: baclofen ± botulinum toxin if refractory.
• 📚 Education: teach carers and staff about autonomic dysreflexia.

📚 Teaching Pearls

👉 Most common incomplete spinal cord injury. 👉 Classic: older patient with fall, forehead bruise, weak arms > legs. 👉 MRI essential even if X-ray/CT is normal. 👉 Prognosis: younger patients recover best; many regain walking, but hand function often remains impaired. 👉 Remember: "Walking but not writing" = classic description.

References

• NINDS: Central Cord Syndrome
• NCBI: Central Cord Syndrome Clinical Overview

Cases — Central Spinal Cord Syndrome

• Case 1 — Elderly fall on hyperextended neck: A 72-year-old man falls forward, striking his chin. CT shows degenerative cervical spondylosis but no fracture. On exam, he has marked weakness in the upper limbs (unable to grip), milder weakness in the lower limbs, and preserved sacral sensation. Reflexes brisk. Diagnosis: Central cord syndrome from hyperextension injury on background of cervical canal narrowing. Teaching point: Classically affects older patients with cervical spondylosis after a hyperextension injury; motor deficit greater in arms than legs due to somatotopy of corticospinal tracts. Bladder involvement may occur. 🚑
• Case 2 — Young patient after trauma: A 25-year-old motorcyclist presents after a road traffic collision with neck hyperextension. He is alert but has disproportionate weakness in the hands compared with the legs, plus burning dysaesthesia in the upper limbs. MRI shows cord oedema at C4–C6 without compression fracture. Teaching point: Central cord syndrome can also occur in younger patients with severe trauma; often manifests with upper limb motor and sensory involvement out of proportion to lower limb findings. Prognosis is generally favourable for ambulation, but fine hand function may remain impaired. 🏍️