Treatment of Acute Traumatic Central Cord Syndrome: A Study of North American Trauma Centers.

BACKGROUND AND OBJECTIVES: Central cord syndrome (CCS) is expected to become the most common traumatic spinal cord injury, yet its optimal management remains unclear. This study aimed to evaluate variability in nonoperative vs operative treatment for CCS between trauma centers in the American College of Surgeons Trauma Quality Improvement Program, identify patient- and hospital-level factors associated with treatment, and determine the association of treatment with outcomes. METHODS: Adults with CCS were identified from the Trauma Quality Improvement Program database (2014-2016). Mixed-effects modeling with a random intercept for trauma centers was used to examine the adjusted association of patient- and hospital-level variables with nonoperative treatment. The random-effects output of the model assessed the risk-adjusted variability in nonoperative treatment across centers. Outlier hospitals were identified, and the median odds ratio was calculated. The adjusted effect of nonoperative treatment on mortality, morbidity, and hospital length of stay (LOS) was examined at the patient and hospital level by mixed-effects regression. RESULTS: Three thousand, nine hundred twenty-eight patients across 255 centers were eligible; of these, 1523 (38.8%) were treated nonoperatively. Older age, noncommercial insurance (odds ratio [OR] 1.26, 95% CI 1.08-1.48, P = .004), absence of fracture (OR 0.58, 95% CI 0.49-0.68, P < .001), severe head injury (OR 1.41, 95% CI 1.09-1.82, P = .008), and comatose presentation (1.82, 95% CI 1.15-2.89, P = .011) were associated with nonoperative treatment. Twenty-eight hospitals were outliers, and the median odds ratio was 2.02. Patients receiving nonoperative treatment had shorter LOS (mean difference -4.65 days). Nonoperative treatment was associated with lesser in-hospital morbidity (OR 0.49, 95% CI 0.37-0.63, P < .001) at the patient level. There was no difference in mortality. CONCLUSION: Operative decision-making for CCS is influenced by patient factors. There remains substantial variability between trauma centers not explained by case-mix differences. Nonoperative treatment was associated with shorter hospital LOS and lesser inpatient morbidity.

Elderly traumatic central cord syndrome in the USA: a review of management and outcomes.

INTRODUCTION: As the incidence of elderly spinal cord injury rises, improved understanding of risk profiles and outcomes is needed. This review summarizes clinical characteristics, management, and outcomes specific to the elderly (≥65-years) with acute traumatic central cord syndrome in the USA. EVIDENCE AQUISITION: Literature review of the PubMed, Embase, and CINAHL databases (01/2007-03/2020) regarding elderly subjects with acute traumatic central cord syndrome. EVIDENCE SYNTHESIS: Nine studies met inclusion criteria. Acute traumatic central cord syndrome was more common among married (50%), Caucasian (22-71%) males (63-86%) with an annual income <40,999 USA dollars (30%). Mechanisms consisted predominantly of traumatic falls (32-55%) and motor vehicle collisions (15-34%), with admission American Spinal Injury Association Impairment Scale grades D (25-79%) and C (21-51%). Mortality was 2-3%. American Spinal Injury Association Impairment Scale motor score, maximum canal compromise, and extent of parenchymal damage were predictors of one-year recovery. Greater comorbidities (heart failure, weight loss, coagulopathy, diabetes), lower income (<51,000 USA dollars), and age ≥80 were predictors of mortality. A substantial cohort underwent surgery (40-45%). Elderly patients were less likely to receive surgical intervention, and surgery timing had variable effects on recovery. CONCLUSIONS: Elderly patients with acute traumatic central cord syndrome are uniquely at risk due to cumulative comorbidities, protracted recovery times, and unclear effects of surgical timing on outcomes. Prospective research should focus on validating age-specific risk factors, formalizing surgical indications, and delineating the impact of time to surgery on acute and long-term outcomes for this condition.

Central Cord Syndrome Redefined.

This article reviews the historical origins of central cord syndrome (CCS), the mechanism of injury, pathophysiology, and clinical implications. CCS is the most common form of incomplete spinal cord injury. CCS involves a spectrum of neurologic deficits preferentially affecting the hands and arms. Evidence suggests that in the twenty-first century CCS has become the most common form of spinal cord injury overall. In an era of big data and the need to standardize this particular diagnosis to unite outcome data, we propose redefining CCS as any adult cervical spinal cord injury in the absence of fracture/dislocation.

Comparison of outcomes between people with and without central cord syndrome.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: Central cord syndrome (CCS) is reported to have better outcomes than other cervical lesions, especially for ambulation and bladder recovery. However, a formal comparison between patients with CCS and other incomplete cervical spinal cord injuries (iCSCI) is lacking. Aim of the study is to investigate the neurological and functional outcomes in patients with or without CCS. SETTING: European Multicenter Study. METHODS: Data following SCI were derived from the European Multicenter Study about Spinal Cord Injury Database. CCS was diagnosed based on a difference of at least ten points of motor score in favour of the lower extremities. Patients were evaluated at 30 days, 6 months and 1 year from injury. The neurological and functional data were collected at each time point based on the International Standards for Neurological Classification of Spinal Cord injury (ISNSCI) and Spinal Cord Independence Measure (SCIM). Patients were selected with a matching procedure based on lesion severity, neurological level of injury (NLI) and age. Evaluation of the outcomes was performed by means of two-way Anova for repeated measures. RESULTS: The matching produced 110 comparable dyads. At all time points, upper extremity motor scores remained lower than lower extremity motor scores in CCS compared with iCSCI. With regard to daily life independence, both cohorts achieved comparable improvements in self-care sub-scores between T0 and T2 (6.6 ± 6.5 in CCS vs 8.2 ± 6.9 in iCSCI, p = 0.15) but this sub-score was significantly lower in CCS compared with iCSCI (3.6 ± 5.2 in CCS vs 7.3 ± 7.0 in iCSCI at T0, 13.7 ± 6.2 vs 16.5 ± 5.7 at T2), while the other sub-scores were comparable. CONCLUSIONS: In contrast to previous reports, people with CCS have poorer outcomes of self-care ability compared with iCSCI.

Early Experience with Electric Scooter Injuries Requiring Neurosurgical Evaluation in District of Columbia: A Case Series.

BACKGROUND: To decrease vehicular traffic in major metropolitan cities throughout the United States, multiple ridesharing companies have launched dockless electric scooters and bicycles throughout cities. From September 2017 through November 2018, Washington, DC, launched a 15-month dockless vehicle pilot program to allow for the rapid entry and growth of electric scooters within the metropolitan area. This rapid growth resulted in a number of minor and significant injuries. CASE DESCRIPTION: We reviewed the electronic medical record of The George Washington University Hospital to investigate and characterize the types of electric scooter-related injuries resulting in neurosurgical consultation in the 15-month period of the Washington, DC, scooter pilot program. Thirteen patients sustained injuries serious enough to merit neurosurgical consultation, including 1 patient whose symptoms required procedural intervention by a neurointerventional radiologist and another patient who was pronounced dead soon after arrival to the hospital. CONCLUSIONS: In this case series, we highlight more severe injuries that resulted in hospitalization or intervention, including skull fracture, central cord syndrome, and vertebral compression fracture. This case series aims to illustrate the potential severity of injuries related to electric scooters, raise awareness on the issues of safety and public health, and call for further investigation into injuries relating to electric scooters.

Central Cord Syndrome.

Central cord syndrome is a common spinal cord injury. The purpose of this review article is to provide an overview of the anatomy, pathophysiology, prognosis, and management of this disorder.

Trends in the treatment for traumatic central cord syndrome without bone injury in the United States from 2000 to 2009.

BACKGROUND: Treatment for traumatic central cord syndrome (TCCS) without bone injury is still controversial. The purpose of this study was to examine trends in the treatment for TCCS without bone injury in the United States. METHODS: Clinical data were obtained from the US Nationwide Inpatient Sample from 2000 to 2009. Patients with TCCS without bone injury were identified and divided into those receiving surgical treatment and those receiving conservative treatment according to the International Classification of Diseases-9th Rev.-Clinical Modification codes. Patient and health care system-related demographic data were retrieved. Trends in the treatment and patient outcomes were analyzed. Multivariate logistic regression analysis was then performed to identify the predictors for surgical treatment. RESULTS: The ratio of patients who underwent surgical treatment was 27.1%. This ratio increased from 14.8% in 2000 to 30.5% in 2009 (p = 0.008). A total of 47.2% of surgical procedures were performed between Days 0 and 2. Multivariate analysis revealed that larger hospital size was a significant predictor for surgical treatment and patients who received treatment in Northeastern region were less likely to undergo surgical treatment. Comparisons between patients receiving surgical and conservative treatment revealed that those receiving surgical treatment had significantly higher overall in-hospital complication rate (18.6% vs. 14.5%), lower pulmonary embolism rate (0.5% vs. 1.2%), lower in-hospital mortality rate (2.0% vs. 2.7%), longer hospital stays (11.2 days vs. 9.9 days), and increased total hospital costs ($93,940 vs. $50,701). CONCLUSION: The ratio of patients who underwent surgical treatment for TCCS without bone injury increased from 2000 to 2009. Approximately half of surgical procedures were performed from Days 0 to 2. Patients who received treatment in a small hospital or the Northeastern region were less likely to undergo surgical treatment. Although the overall in-hospital complication rate was higher in patients with surgical treatment, pulmonary embolism and in-hospital mortality rates were higher in patients with conservative treatment than those in patients with surgical treatment. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III. Therapeutic study, level IV.

Central cord syndrome in Ireland: the effect of age on clinical outcome.

Central cord syndrome is an incomplete spinal cord injury first described by Schneider et al. (J Neurosurg 11:546-547, 1954). The typical neurological deficit is symmetrical incomplete quadriplegia affecting the upper more than the lower limbs; sensory impairment is variable and urinary retention is common. Records of all patients with acute traumatic central cord syndrome admitted to the National Spinal Injuries Unit from 1999 to 2007 were compiled from a prospectively collected computerized spinal database. Data recorded included patient demographic profile, mechanism of injury, initial neurological deficit, treatment instituted, complications of treatment, and final neurological status. A total of 50 patients with acute traumatic central cord syndrome were identified accounting for 6.2% of all admissions to the spinal injuries unit. There were 42 men and 8 women. The mean age was 56.1 years with a range of 41-88 years. We stratified patients according to age at injury to determine the effect of age on clinical outcome. There were 13 patients <50 years of age, 24 aged 50-70, and 13 aged >70 years. The mean follow-up time was 42.2 months. More than one-third of patients were intoxicated with alcohol at the time of the injury. Both upper and lower limb motor scores and total sensory scores improved in all age groups. Absolute and relative improvements were greatest in patients <50 years of age. Sphincter disturbance was documented in 42% of all the patients on admission. At follow up 12% of patients had residual disturbance. At final follow up none of the patients under 70 years of age had residual sphincter disturbance while 60% of those aged >70 years group had. Both of these results reached statistical significance. In conclusion, central cord syndrome is a common cause of acute traumatic neurological deficit, with alcohol intoxication being a common confounder at the time of injury. The clinical outcomes are significantly worse in patients aged 70 years or older.

Incidence and outcomes of spinal cord injury clinical syndromes.

BACKGROUND/OBJECTIVE: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). DESIGN: Retrospective review. SETTING: Tertiary care, level 1 trauma center inpatient rehabilitation unit. PARTICIPANTS: Eight hundred thirty-nine consecutive admissions with acute SCIs. MAIN OUTCOMES MEASURES: Functional independence measure (FIM), FIM subgroups (motor, self-care, sphincter control), length of stay (LOS), and discharge disposition. RESULTS: One hundred seventy-five patients (20.9%) were diagnosed with SCI clinical syndromes. CCS was the most common (44.0%), followed by CES (25.1%) and BSS (17.1%). Significant differences (P < or = 0.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant differences (P < or = 0.01) with respect to age (39.7 vs 53.2 years) and a trend toward significance (P < or = 0.05) with regard to self-care admission and discharge FIM. No significant differences (P < or = 0.01) were found when comparing CMS to CES. CONCLUSIONS: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation, with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Patients with cervical BSS seem to achieve higher functional improvement by discharge compared with patients with CCS. Patients with CMS and CES exhibit similar functional outcomes. Patients with ACS and PCS show functional gains with inpatient rehabilitation, with patients with ACS displaying the longest LOS of the SCI clinical syndromes. These findings have important implications for the overall management and outcome of patients with SCI.

Spinal cord injury without radiographic abnormality: results of the National Emergency X-Radiography Utilization Study in blunt cervical trauma.

BACKGROUND: The purpose of this study was to better define the incidence and characteristics of patients with spinal cord injury without radiographic abnormality (SCIWORA), using the database of the National Emergency X-Radiography Utilization Study (NEXUS). METHODS: This was a prospective, observational study of blunt trauma patients in 21 U.S. medical centers undergoing plain cervical radiography. SCIWORA was defined as spinal cord injury demonstrated by magnetic resonance imaging, when a complete, technically adequate plain radiographic series revealed no injury. RESULTS: Of the 34,069 patients entered, there were 818 (2.4%) with cervical spine injury, including 27 (0.08%) patients with SCIWORA. Over 3,000 children were enrolled, including 30 with cervical spine injury, but none had SCIWORA. The most common magnetic resonance imaging findings among SCIWORA patients were central disc herniation, spinal stenosis, and cord edema or contusion. Central cord syndrome was described in 10 cases. CONCLUSION: In the large NEXUS cohort, SCIWORA was an uncommon disorder, and occurred only in adults.