Neuroscience · Year 2 · from Neuroscience
Case 2: Cervical Spinal Cord Injury - Central Cord Syndrome
Patient Presentation
Demographics: 68-year-old male
Chief Complaint: Weakness in arms greater than legs after a fall
History of Present Illness: A 68-year-old man with a history of cervical spondylosis fell forward onto his face after tripping on a curb, hyperextending his neck. He immediately noticed weakness, more severe in his arms than his legs. He can move his legs somewhat but has very limited arm and hand function. He reports burning pain in both arms and numbness in his hands. He was able to briefly walk with assistance at the scene but his arm weakness has made this difficult.
Physical Examination:
- Vital signs: BP 95/62 (possible spinal shock), HR 58, RR 18, T 36.5C
- Cervical spine: Immobilized; tender to palpation
- Neurological:
- Mental status: Alert, oriented
- Cranial nerves: Intact
- Motor:
- Upper extremities: 2/5 bilateral deltoid, 1/5 wrist extension, 0/5 hand grip
- Lower extremities: 4/5 bilateral hip flexors, 4/5 knee extension, 4/5 ankle dorsiflexion
- Sensory: Decreased pain and temperature sensation in cape-like distribution (C4-T1); sacral sensation preserved
- Reflexes: Absent biceps and brachioradialis; knee jerks 2+; ankle jerks 2+; Babinski upgoing bilaterally
- Rectal tone: Present
Workup:
- CT cervical spine: Severe multilevel cervical spondylosis with narrowed spinal canal; no fracture
- MRI cervical spine: Central cord contusion at C4-C5 with intramedullary T2 hyperintensity; cord compression from degenerative disc disease and ligamentum flavum hypertrophy
- Vital capacity: 75% predicted (monitor closely)
Diagnosis: Central cord syndrome secondary to hyperextension injury in the setting of cervical spondylosis
Treatment:
- Spinal immobilization
- Blood pressure support (vasopressors initially to maintain MAP >85 mmHg)
- Neurosurgical consultation
- Decompressive cervical laminectomy performed on day 3 once stable
- DVT prophylaxis
- Aggressive physical and occupational therapy
- Significant recovery over 6 months; independent ambulation achieved; persistent fine motor deficits in hands
Clinical Pearl: Central cord syndrome is the most common incomplete spinal cord injury pattern, typically occurring in elderly patients with pre-existing cervical stenosis who experience hyperextension injuries. The characteristic pattern is "arms worse than legs" because the motor fibers for the upper extremities are located centrally in the corticospinal tracts while lower extremity fibers are lateral. The central cord hemorrhage or contusion affects the central fibers preferentially. Prognosis is generally favorable - lower extremity function recovers first, followed by bladder, then proximal arms, with fine hand function recovering last (and often incompletely).