What is the role of surgery in the treatment of central cord syndrome (CCS)?

Updated: May 21, 2020
  • Author: Michelle J Alpert, MD; Chief Editor: Stephen Kishner, MD, MHA  more...
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Answer

Surgery is rarely indicated, because of the inherently favorable prognosis for patients with central cord syndrome. However, surgical intervention should be considered when progress becomes inconsistent after an initial period of improvement, when compression of the spinal cord persists, when gross spinal instability is present, and when neurologic deficits progress. [10, 11, 12, 13]

Using data from the US Nationwide Inpatient Sample, Yoshihara and Yoneoka found that in patients in the United States with traumatic central cord syndrome whose condition did not involve bone injury, the percentage of those treated surgically increased between 2000 (14.8%) and 2009 (30.5%). The investigators also determined that although the overall in-hospital complication rate was higher in the surgical patients (18.6%) than in those treated conservatively (14.5%), the pulmonary embolism rate (0.5% vs 1.2%, respectively) and in-hospital mortality rate (2% vs 2.7%, respectively) were lower. [25]

Another study, by Brodell et al, examining US trends in the treatment of CCS found that nearly 40% of the 16,134 patients in the report underwent surgery for the condition, with anterior cervical decompression and fusion being the most commonly performed procedure. [26]

Based on a literature search of material published between January 1966 and February 2013, Dahdaleh et al concluded that neither class I nor class II evidence exists regarding the efficacy of surgery for traumatic central cord syndrome. They state, however, that class III evidence suggests that surgery is superior to conservative treatment for this condition. [27]

A study by Jin et al of 17 patients with acute traumatic CCS who, following conservative therapy, experienced recurrent neurologic deterioration, found, on subsequent surgical treatment, obvious rupture of the anterior longitudinal ligaments (eight patients), posterior longitudinal ligaments (seven patients), and disks (three patients). These injuries caused cervical instability and secondary spinal cord compression. Moreover, 12 patients displayed serious adhesion between the posterior longitudinal ligaments and cervical disks, and five patients were found to have partial ossification of the posterior longitudinal ligaments. Good neurologic outcome was achieved in all patients via an anterior approach to cervical decompression, as well as internal fixation. [28]

A study by Kepler et al indicated that early surgical treatment of CCS (within 1 day or presentation) does not result in earlier neurologic improvement. The investigators evaluated results from early and delayed surgery and found that there was no significant difference in the American Spinal Injury Association motor score at 7 days between the two groups. Moreover, the percentage of patients who achieved early improvement did not significantly differ between the early and delayed groups, while time in the intensive care unit (ICU) and length of hospital stay also were not significantly different. [29]

A literature review by Park et al indicated that at follow-up of longer than 1 year, patients with CCS with underlying cervical stenosis who undergo early surgical decompression show similar improvement (in motor ability, functional independence, and walking ability) to those who undergo delayed surgery for the condition, but at follow-up of less than 1 year, patients who undergo early surgery show greater improvement than delayed-surgery patients. Complication rates did not differ between the two groups. [30]

A study by Samuel et al indicated that delaying surgery in acute traumatic CCS may be beneficial. The study, which included 1060 patients with the condition, found that the odds of mortality decreased by 19% with each 24-hour delay in time to surgery. Increased time to surgery may offer an advantage by allowing optimization of the patient’s general health and permitting some recovery of the spinal cord. [31]

In contrast, study by Godzik et al, using the National Trauma Data Bank, indicated that in patients with multisystem trauma, early surgery for acute central cord syndrome (CCS) is not linked to increased all-cause mortality. Univariate analysis revealed the mortality rates in the cohort’s early surgery (< 24 h) and late-surgery (>24 h) groups to be 3.8% and 2.7%, respectively. [32]

Moreover, guidelines published in 2016 by Wilson et al for the optimal timing of decompression surgery in CCS and traumatic SCI recommend “that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome.” A literature review by the investigators concluded that significantly greater neurologic and functional improvement is experienced by CCS patients who undergo early decompression (within 24 h) than by those who are decompressed after 24 hours. [33]

According to a consensus statement from a Spine Trauma Society panel, there is “reasonable evidence” that patients with acute traumatic cervical central cord syndrome (CCS) “secondary to vertebral fracture, dislocation, traumatic disc herniation or instability have better outcomes with early surgery (< 24 h).” The statement was derived from a systematic review. [34]


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