The best magazine
Discussion
The causes of TCCS are variable. While most authors agree to surgically manage acute disc herniations and unstable spine fractures in an expedited fashion, there remains controversy regarding managing patients with classical central cord syndrome that occurs as a result of hyperextension injury in the setting of spondylosis without evidence of fracture or instability. There is debate not only in whether to manage these patients surgically, but also in determining the optimal timing of surgical intervention.
We conducted a literature review and created evidentiary tables representing current evidence regarding the management of TCCS. No studies were classified as Class I or II evidence. All 16 articles were retrospective in design and therefore were Class III studies. Most studies had heterogeneous patient populations with TCCS that resulted from acute disc herniations, unstable spine fractures, and classic hyperextension injuries; there was only 1 study that involved patients with pure hyperextension injuries. We then segregated the evidence into 3 categories: 1) those that primarily compared surgery to conservative management; 2) those that addressed the timing of surgery; and 3) those that identified possible prognostic factors other than timing of surgical intervention.
Regarding conservative versus surgical management of TCCS, we identified 4 retrospective studies (Table 1). Three of these studies showed the superiority and safety of surgical intervention compared with conservative management. One study showed no difference in outcome; however, baseline characteristics between both groups were different as the surgically treated group had skeletal and discoligamentous injuries and the conservatively treated group suffered hyperextension injuries.
In regards to timing of surgery (early vs late), 6 studies were identified, all of which were retrospective in nature. The definition of early versus late varied from study to study (Table 2). Only 1 study (Yamazaki et al.) demonstrated improved outcome of early surgical intervention. In this study, early surgery was defined as within 2 weeks of the injury. The study by Guest et al. demonstrated superiority of early surgery (within 24 hours) in patients suffering from TCCS due to fractures. Early surgery did not affect outcome in patients suffering from TCCS due to spondylosis. The other 3 studies did not demonstrate a significant difference between early surgical interventions (within 24–48 hours) and late intervention.
Six studies primarily investigated prognostic factors that would affect outcome in patients with TCCS (Table 3). Five of these studies identified older age as adversely affecting outcome; 1 study did not support this claim. Two studies found neurological state at the time of admission would affect outcome, with better outcomes resulting in patients presenting with better neurological examination results. One study found neurological state at the time of rehabilitation affected patient outcomes. Two studies showed the absence of spasticity correlated with better outcomes. One study showed formal education correlated with better outcomes. Lastly, 1 study demonstrated abnormal MR signal intensity correlated with worse outcomes.
Source: ...