Acute Traumatic Central Cord Syndrome Research Articles

Operative Timing in Cervical Spine Trauma.

Narrative review. To review existing literature regarding surgical timing in cervical trauma with a focus on acute traumatic central cord syndrome. Traumatic central cord syndrome is the most common incomplete spinal cord injury. Substantial basic science literature has proposed ischemic and secondary injury-driven mechanisms underpinning the urgency of operative intervention. However, only recently has a relative consensus emerged in the clinical literature regarding the safety, efficacy, and necessity of early operative intervention for acute traumatic central cord syndrome. A literature search was conducted of studies in PubMed Central and Cochrane Database related to timing in cervical spine trauma. Recently, several major systematic reviews and consensus statements have endorsed the importance and safety of early (<24h) operative decompression in the setting of traumatic spinal cord injury. Despite decades of conflicting data, a similar trend appears to be emerging for traumatic central cord syndrome. These clinical developments join a large body of basic science work regarding the importance of early decompressive surgery in relieving acute ischemic insult and minimizing the effects of secondary injury. However, further work is needed to delineate optimal surgical timing, especially regarding "ultra-early" (<8 h) protocols, and to aid in creating accelerated screening pathways.

P312. Early vs late surgical decompression for patients with acute traumatic central cord syndrome: a systematic review and meta-analysis

P312. Early vs late surgical decompression for patients with acute traumatic central cord syndrome: a systematic review and meta-analysis

Contemporary Practice Patterns in the Treatment of Cervical Stenosis and Central Cord Syndrome: A Survey of the Cervical Spine Research Society.

Cross-sectional study. To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia. There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia. A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants. Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms. Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present. Level V.

Resource Utilization Following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome.

Retrospective cohort study. The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 ( P <0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P <0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P <0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P <0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P <0.001). For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.

Surgical intervention ≤ 24 hours versus > 24 hours after injury for the management of acute traumatic central cord syndrome: a systematic review and meta-analysis.

The objective was to evaluate the efficacy, outcomes, and complications of surgical intervention performed within 24 hours (≤ 24 hours) versus after 24 hours (> 24 hours) in managing acute traumatic central cord syndrome (ATCCS). Articles pertinent to the study were retrieved from PubMed, Scopus, Web of Science, and Cochrane. The authors performed a systematic review and meta-analysis of treatment procedures and outcomes according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines. Seven articles comprising 488 patients were included, with 188 (38.5%) patients in the ≤ 24-hour group and 300 (61.5%) in the > 24-hour group. Significant differences were not found between groups in terms of demographic characteristics, injury mechanism, spinal cord compression level, neuroimaging features, and the American Spinal Injury Association (ASIA) motor score at admission. Both groups had a similar approach to surgery and steroid administration. The surgical complication rate was significantly higher in the > 24-hour group (4.5%) compared to the ≤ 24-hour group (1.2%) (p = 0.05). Clinical follow-up duration was similar at 12 months (interquartile range 3-36) for both groups (p > 0.99). The ≤ 24-hour group demonstrated a not statistically significant greater improvement in ASIA motor score, with a mean difference of 12 (95% CI -20.7 to 44.6) compared to the > 24-hour group. The present study indicates potential advantages of early (≤ 24 hours) surgery in ATCCS patients, specifically in terms of lower complication rates. However, further research is needed to confirm these findings and their clinical implications.

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

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. 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. 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. 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.

Benefits of Early Surgical Treatment for Patients with Multilevel Cervical Canal Stenosis of Acute Traumatic Central Cord Syndrome.

Currently, there exists considerable debate surrounding the optimal treatment approaches for different subtypes of patients with spinal cord injury (SCI). The purpose of this study was to conduct a comparative analysis of the benefits associated with conservative treatment and treatments with different surgical periods for patients diagnosed with acute traumatic central cord syndrome (ATCCS) and multilevel cervical canal stenosis (CCS). A retrospective cohort study was conducted, and 93 patients who met inclusion and exclusion criteria in our hospital between 2015 and 2020 were followed for a minimum duration of 2 years. Among them, 30 patients (Group A) received conservative treatment, 18 patients (Group B) received early surgery (≤7 days), and 45 patients (Group C) received late surgery (>7 days). The American Spinal Injury Association (ASIA) grade, Japanese Orthopedic Association (JOA) score, and recovery rate (RR) were evaluated. Multivariate linear regression was used to analyze prognostic determinants. Cost-utility analysis was performed based on the EQ-5D scale. The ASIA grade, JOA score, and RR of all three groups improved compared with the previous evaluation (P < 0.05). During follow-up, the ASIA grade, JOA score, and RR of Group B were all better than for Group A and Group C (P < 0.05), while there was no significant difference between Group A and C (P > 0.05). The EQ-5D scale in Group B was optimal at the last follow-up. The incremental cost-utility ratio (ICUR) of Group A was the lowest, while that of Group B compared to Group A was less than the threshold of patients' willingness to pay. Age, initial ASIA grade, and treatment types significantly affected the outcomes. Both conservative and surgical treatments yield good results. Compared with patients who received conservative treatment and late surgery, patients who received early surgery had better clinical function and living quality. Despite the higher cost, early surgery is cost-effective when compared to conservative treatment. Younger age, initial better ASIA grade, and earlier surgery were associated with better prognosis.

Correction to: Treatment of acute traumatic central cord syndrome: a score‑based approach based on the literature

Correction to: Treatment of acute traumatic central cord syndrome: a score‑based approach based on the literature

Variability in Early Surgery for Acute Cervical Spinal Cord Injury Patients: An Opportunity for Enhanced Care Delivery.

Data supporting the benefits of early surgical intervention in acute spinal cord injury (SCI) is growing. For early surgery to be accomplished, understanding the causes of variabilities that effect the timing of surgery is needed to achieve this goal. The purpose of this analysis is to determine factors that affect the timing of surgery for acute cervical SCI within the North American Clinical Trials Network (NACTN) for SCI registry. Patients in the NACTN SCI registry from 2005 to 2019 with a cervical SCI, excluding acute traumatic central cord syndrome, were analyzed for time elapsed from injury to arrival to the hospital, and time to surgery. Two categories were defined: 1) Early Arrival with Early Surgery (EAES) commenced within 24 h of injury, and 2) Early Arrival but Delayed Surgery (EADS), with surgery occurring between 24 to 72 h post-injury. Patients' demographic features, initial clinical evaluation, medical comorbidities, neurological status, surgical intervention, complications, and outcome data were correlated with respect to the two arrival groups. Of the 222 acute cervical SCI patients undergoing surgery, 163 (73.4%) were EAES, and 59 (26.6%) were EADS. There was no statistical difference in arrival time between the EAES and EADS groups. There was a statistical difference in the median arrival time to surgery between the EAES group (9 h) compared with the EADS group (31 h; p < 0.05). There was no statistical difference in race, sex, age, mechanism of injury, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores, or medical comorbidities between the two groups, but the EAES group did present with a significantly lower systolic blood pressure (p < 0.05). EADS patients were more likely to present as an American Spinal Injury Association Impairment Scale (AIS) D than EAES (p < 0.05). Early surgery was statistically more likely to occur if the injury occurred over the weekend (p < 0.05). There were variations in the rates of early surgery between the eight NACTN sites within the study, ranging from 57 to 100%. Of the 114 patients with 6-month outcome data, there was no significant change between the two groups regarding AIS grade change and motor/pin prick/light touch score recovery. A trend towards improved motor scores with early surgery was not statistically significant (p = 0.21). Although there is data that surgery within 24 h of injury improves outcomes and can be performed safely, there remain variations in care outside of clinical trials. In the present study of cervical SCI, NACTN achieved its goal of early surgery in 73.4% of patients from 2005-2019 who arrived within 24 h of their injury. Variability in achieving this goal was related to severity of neurological injury, the day of the week, and the treating NACTN center. Evaluating variations within our network improves understanding of potential systemic limitations and our decision-making process to accomplish the goal of early surgery.

Treatment of acute traumatic central cord syndrome: a score-based approach based on the literature.

Acute traumatic central cord syndrome (ATCCS) accounts for up to 70% of incomplete spinal cord injuries, and modern improvements in surgical and anaesthetic techniques have given surgeons more treatment options for the ATCCS patient. We present a literature review of ATCCS, with the aim of elucidating the best treatment option for the varying ATCCS patient characteristics and profiles. We aim to synthesise the available literature into a simple-to-use format to aid in the decision-making process. The MEDLINE, EMBASE, CENTRAL, Web of Science and CINAHL databases were searched for relevant studies and improvement in functional outcomes were calculated. To allow for direct comparison of functional outcomes, we chose to focus solely on studies which utilised the ASIA motor score and improvements in ASIA motor score. A total of 16 studies were included for review. There were a total of 749 patients, of which 564 were treated surgically and 185 were treated conservatively. There was a significantly higher average motor recovery percentage amongst surgically-treated patients as compared to conservatively treated patients (76.1% vs. 66.1%, p value = 0.04). There was no significant difference between the ASIA motor recovery percentage of patients treated with early surgery and delayed surgery (69.9 vs. 77.2, p value = 0.31). Delayed surgery after a trial of conservative management is also an appropriate treatment strategy for certain patients, and the presence of multiple comorbidities portend poor outcomes. We propose a score-based approach to decision making in ATCCS, by allocating a numerical score for the patient's clinical neurological condition, imaging findings on CT or MRI, history of cervical spondylosis and comorbidity profile. An individualised approach to each ATCCS patient, considering their unique characteristics will lead to the best outcomes, and the use of a simple scoring system, can aid clinicians in choosing the best treatment for ATCCS patients.

Early surgical intervention alleviates sensory symptoms following acute traumatic central cord syndrome.

To investigate the impact of early versus delayed surgery on sensory abnormalities in acute traumatic central cord syndrome (ATCCS). Pressure pain threshold (PPT), temporal summation (TS), conditioned pain modulation (CPM) and pain assessments were performed in 72 ATCCS patients (early vs. delayed surgical treatment: 32 vs. 40) and 72 healthy subjects in this ambispective cohort study. These examinations, along with mechanical detection threshold (MDT) and disabilities of arm, shoulder and hand (DASH), were assessed at 2years postoperatively. Preoperatively, more delayedsurgical patients had neuropathic pain below level compared with earlysurgical patients (P < 0.05). Both early and delayedsurgical patients showed reduced PPT in common painful areas and increased TS, while reduced CPM only existed in the latter (P < 0.05). Reduced PPT in all tested areas, along with abnormalities in TS and CPM, was observed in patients with durations over 3months. Both incidences and intensities of pain and pain sensitivities in common painful areas were reduced in both treatment groups postoperatively, but only early surgical treatment improved the CPM and TS. Follow-up analysis demonstrated a higher MDT and lower PPT in hand, greater TS, greater DASH, lower pain intensities and higher incidence of dissatisfaction involving sensory symptoms in delayedsurgical patients than in earlysurgical patients (P < 0.05). Central hypersensitivity may be involved in the persistence of sensory symptoms in ATCCS, and this augmented central processing may commence in the early stage. Early surgical treatment may reverse dysfunction of endogenous pain modulation, thus reducing the risk of central sensitization and alleviating sensory symptoms.

Surgical Efficacy and Prognostic Factors for Acute Traumatic Central Cord Syndrome Without Fracture and Dislocation.

This study was undertaken to evaluate the effectiveness of surgical treatment of acute traumatic central cord syndrome (ATCCS) without fracture and dislocation and explore surgical timing and factors influencing postoperative recovery of spinal cord function. We retrospectively collected the general and clinical data of 112 patients with ATCCS (American Spinal Injury Association impairment scale grade C or D) without fracture and dislocation who underwent surgical treatment in our hospital from January 2013 to August 2019. We used statistical methods to evaluate the safety of the operation and explore the timing of surgery and the factors influencing postoperative recovery of spinal cord function. The mean age of the 112 patients was 60.64±12.91 years. The Japanese Orthopaedic Association score and the American Spinal Injury Association motor score (AMS) of the 112 patients were significantly higher at final follow-up than at admission. No significant difference in recovery of spinal cord function was seen between the early operation group (≤4 days) and the late operation group (>4 days). Comparison of patients with a good prognosis vs a poor prognosis showed that age, intrahand muscle strength at admission, maximum spinal cord compression, maximum canal compromise, length of high-intensity signal in the spinal cord on sagittal T2-weighted magnetic resonance imaging, AMS, and American Spinal Injury Association injury grade D/C at admission had a significant effect on recovery of spinal cord function. Surgical treatment of ATCCS without fracture and dislocation is safe and effective. Age, admission AMS and American Spinal Injury Association impairment scale score, intrinsic hand muscle strength, maximum canal compromise, maximum spinal cord compression, and length of high-intensity signal in the spinal cord can be used to predict postoperative recovery of spinal cord function. [Orthopedics. 2022;45(6):325-332.].

A critical reappraisal of corticospinal tract somatotopy and its role in traumatic cervical spinal cord syndromes.

The corticospinal tract (CST) is the preeminent voluntary motor pathway that controls human movements. Consequently, long-standing interest has focused on CST location and function in order to understand both loss and recovery of neurological function after incomplete cervical spinal cord injury, such as traumatic central cord syndrome. The hallmark clinical finding is paresis of the hands and upper-extremity function with retention of lower-extremity movements, which has been attributed to injury and the sparing of specific CST fibers. In contrast to historical concepts that proposed somatotopic (laminar) CST organization, the current narrative summarizes the accumulated evidence that 1) there is no somatotopic organization of the corticospinal tract within the spinal cord in humans and 2) the CST is critically important for hand function. The evidence includes data from 1) tract-tracing studies of the central nervous system and in vivo MRI studies of both humans and nonhuman primates, 2) selective ablative studies of the CST in primates, 3) evolutionary assessments of the CST in mammals, and 4) neuropathological examinations of patients after incomplete cervical spinal cord injury involving the CST and prominent arm and hand dysfunction. Acute traumatic central cord syndrome is characterized by prominent upper-extremity dysfunction, which has been falsely predicated on pinpoint injury to an assumed CST layer that specifically innervates the hand muscles. Given the evidence surveyed herein, the pathophysiological mechanism is most likely related to diffuse injury to the CST that plays a critically important role in hand function.

The Relationship Between Preoperative Cervical Sagittal Balance and Clinical Outcome of Acute Traumatic Central Cord Syndrome

To explore the sagittal radiological parameters related to clinical recovery of patients with acute traumatic central cord syndrome (ATCCS) and determine the diagnostic value of related variables. A retrospective review was performed of 104 patients with ATCCS. Six cervical sagittal balance parameters were collected: Cobb angle, T1 slope, neck tilt, thoracic inlet angle (TIA), C2-C7 sagittal vertex axis, T1 slope- C2-C7 Cobb angle. The patients were assigned to an ideal improvement group and poor improvement group according to their recovery rate. Receiver operating characteristic curve and area under the curve were used to evaluate the significant results of logistic regression and the optimal diagnostic value. Preoperative and postoperative Japanese Orthopaedic Association scores indicated a good recovery after surgical intervention. Radiological findings revealed that neck tilt and TIA were risk factors for poor neurological improvement of patients with ATCCS. Area under the curve (95% confidence interval) values of neck tilt and TIA were 0.763 (0.660-0.866) and 0.749 (0.643-0.855), and cutoff values were 39.1° and 65.6°, respectively. Lower neck tilt and TIA are risk factors for poor outcomes in patients with ATCCS after surgery. Neck tilt <39° and TIA <66° had significant diagnostic value for poor prognosis.

Comparison of Anterior and Posterior Approaches for Acute Traumatic Central Spinal Cord Syndrome with Multilevel Cervical Canal Stenosis without Cervical Fracture or Dislocation.

Introduction This is a retrospective comparative study that aims to compare the benefits of different surgical approaches for patients with multilevel cervical canal stenosis (CCS) without cervical fracture or dislocation of acute traumatic central cord syndrome (ATCCS). Methods From January 2015 to December 2018, 59 patients were included in the study. Among them, 35 patients (Group A) received anterior surgery and 24 patients (Group B) received posterior surgery. Primary outcome measures were American Spinal Cord Injury Association (Asia) grade, Japanese Orthopaedic Association (JOA) score, and recovery rate (RR). Secondary outcome measures included operation time, intraoperative blood loss, visual analogue scale (VAS) score, cervical sagittal parameters, and complications. Multivariate linear regression was used to analyze prognostic determinants. Results Compared with Group B, Group A had longer operation time and more intraoperative blood loss (P < 0.05). However, the VAS score of Group B was higher than that of Group A at discharge (P < 0.05). There was no significant difference in cervical sagittal plane parameters between the two groups (P > 0.05). Postoperative complications were different in the two groups. During follow-up, the Asia grade, the JOA score, and RR of both groups improved (P < 0.05), but there were no significant differences between the two groups (P > 0.05). Younger age, earlier surgery, and better preoperative Asia grade were correlated with better prognosis. Conclusions For patients with multilevel CCS without cervical fracture or dislocation of ATCCS, both surgical approaches had good outcomes. Although no significant differences were found in the primary outcome measures between the two groups, there were different recommendations for the secondary outcome measures. Younger age, earlier surgery, and better preoperative Asia grade were protective factors for better prognosis.

Impact of timing of surgery on traumatic central cord syndrome without fracture or dislocation

ObjectiveThe management of acute traumatic central cord syndrome (ATCCS) remains controversial. The purpose of this study was to evaluate the impact of timing of surgery on patients with ATCCS without fracture or dislocation. MethodsForty-one patients with ATCCS without fracture or dislocation were identified and divided into three groups described as the conservative treatment group, early surgery group, and delayed surgery group. Clinical outcomes including ASIA Motor Score (AMS), Japanese Orthopaedic Association (JOA) score upon admission and follow-up, change in AMS, and JOA recovery rate were analyzed. Logistic regression analysis was performed to show the correlation between timing of surgery and clinical outcomes. ResultsAll patients received a minimum of 1-year follow-up and showed significant neurological recovery at the final follow-up. No statistical differences in final AMS and JOA scores were observed between the three groups. Patients who underwent early surgery achieved a faster motor recovery at the first 6-months postoperatively compared to conservative treatment(p < 0.01). There was a significant negative correlation between the timing of surgery and the change in AMS (r = -0.41, p = 0.02) in the initial 6-months postoperatively and throughout the follow-up period (r = -0.42, p = 0.02). ConclusionsThe present study indicated that both conservative and surgical treatments can lead to good neurological recovery in patients with ATCCS without fracture or dislocation. Early surgery allowed for rapid early motor recovery compared to conservative treatment. The choice of timing of surgery still requires individualized decision-making.

Diagnosis and management of acute traumatic central cord syndrome: Present consensus and narrative review

This is a narrative review to get an overview of the diagnosis and management of the acute traumatic cervical central cord syndrome (ATCCS) with an evidence-based approach. We considered articles that addressed the gray areas in the management of ATCCS, that is, the need for surgical intervention and its timing. The ATCCS is the most common form of incomplete spinal cord injury. The presence of instability and deteriorating neurology have been absolute indications for surgery. The opinion has been divided between early surgeries vis-à-vis monitoring for recovery and delayed surgery if neurological recovery plateaus. An extensive search revealed a low level of evidence. With the advent of modern anesthetic as well as surgical techniques and perioperative management, there may be better and faster neurological recovery with surgery. Considering the timing of surgery, even though many articles are propagating the need for early surgery the level of evidence remains low. This narrative review highlights the need for well-conducted prospective studies to resolve the controversy regarding early surgery versus conservative management and delayed surgery if recovery plateaus or on neurological deterioration. Since there is only a low level of evidence in favor of early surgery for ATCCS with no instability and deteriorating neurology, the decision of the surgery and its timing should be left to the surgeon’s judgment, with a plan tailored after assessing risks and benefits.

Cervical Spine and Spinal Cord Injury:Keys for Diagnosis and Treatment

Spinal cord injuries are not rare in neurosurgical practice. As cervical spine injuries are frequently associated with head injuries, neurosurgeons have critical roles of immediate evaluation and treatment in an emergency room in Japan. It is crucial to make a correct initial diagnosis and provide appropriate treatment for cervical spine injuries because missed injuries or delayed diagnosis might result in unwarranted neurological sequelae. This paper focuses on tips regarding 1)screening for cervical spine injury in head injury patients, 2)diagnosis and treatment of cranio-vertebral junction injuries, and 3)diagnosis and treatment of acute traumatic central cord syndrome because these conditions are most likely encountered by neurosurgery residents and fellows in their practice.

The Central Cord Score: A Novel Classification and Scoring System Specific to Acute Traumatic Central Cord Syndrome

Acute traumatic central cord syndrome (ATCCS) is the most common form of spinal cord injury in the United States. Treatment remains controversial, which is a consequence of ATCCS having an inherently different natural history from conventional spinal cord injury, thus requiring a separate classification system. We devised a novel Central Cord Score (CCscore), which both guides treatment and tracks improvement over time with symptoms specific to ATCCS. Medical records of patients with a diagnosis of ATCCS were retrospectively reviewed at a single institution. The CCscore was devised based on signs, symptoms, and imaging findings we believed to be critical in assessing severity of ATCCS. Numeric values were assigned for distal upper extremity motor strength, upper extremity sensation, ambulatory status, magnetic resonance imaging cord signal, and urinary retention. We identified 51 patients with follow-up data; there were 17 cases of mild injury (CCscore 1-5), 23 moderate cases (CCscore 6-10), and 11 severe cases (CCscore 11-15). Patients treated surgically had significantly greater improvement in upper extremity motor scores and total CCscore only up to 3 months. In terms of timing of surgery, patients treated <24 hours after injury had significantly improved upper extremity motor scores and overall CCscores at last follow-up of ≥3 months. Based on these data and their alignment with past literature, the CCscore is able to objectively and specifically categorize the severity and outcome of ATCCS, which represents a step forward in the quest to determine the ultimate efficacy and timing of surgery for ATCCS.

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

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. Literature review of the PubMed, Embase, and CINAHL databases (01/2007-03/2020) regarding elderly subjects with acute traumatic central cord syndrome. 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. 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.