Central Cord Syndrome in an Elderly Patient on Aspirin with a Delayed Theatre Slot
A 72-year-old retired teacher falls from the second rung of a stepladder and cannot move his arms or legs for a few minutes; by the time the paramedics arrive he is moving his legs but not his fingers. In the emergency department he describes burning hands and has deltoid and grip power of grade 3, antigravity elbow flexion, leg power 4+/5, brisk reflexes in all four limbs and upgoing plantar responses. He is in urinary retention and a catheter has drained 900 mL. CT shows no fracture, with multi-level spondylosis and developmental canal narrowing maximal at C5–C6. MRI shows cord signal change at C5–C6, severe stenosis, and no epidural haematoma or disc herniation. He takes aspirin 100 mg daily after a myocardial infarction two years ago, and tamsulosin. Blood pressure is 148/76 mmHg, heart rate 62/min, and he has arrived 9 hours after the injury. The spinal surgeon is away and the next available trauma list is in 4 days.
1. What is the diagnosis, and how would you manage him in the first 24 hours?
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This is an acute traumatic central cord syndrome on a background of degenerative and developmental stenosis, with the classic pattern of greater upper-limb than lower-limb weakness, sacral sparing, bladder dysfunction and burning dysaesthesia in the hands. The injury is a hyperextension event in a narrowed canal, with the cord compressed between the posterior arch and the vertebral body and no fracture.
The single most important early intervention is haemodynamic. I would admit to a high-dependency or intensive-care setting with continuous arterial monitoring and target a mean arterial pressure of 85–90 mmHg for 5–7 days, avoiding any episode of hypotension, which is the strongest modifiable predictor of a poor neurological outcome. Fluids and, if needed, a low-dose vasopressor are used to achieve this. Blood pressure targets must be balanced against his cardiac history and I would involve cardiology if he needed sustained vasopressor support.
High-dose methylprednisolone should not be given. The evidence does not show a clinically meaningful benefit and does show harm, particularly infection and hyperglycaemia, and current guidelines advise against it outside trials. A rigid collar is reasonable until the spine is cleared, but in an elderly kyphotic neck it quickly causes occipital pressure sores, so the CT and MRI already show no instability and the collar can be removed once that is documented. The bladder is being managed with an indwelling catheter initially; I would plan for a trial of removal with intermittent catheterisation and residual-volume checks, and start mechanical thromboprophylaxis with low-molecular-weight heparin once bleeding risk allows, usually after 24–48 hours. Nursing must include pressure-area care, chest physiotherapy and early sitting, because this patient's biggest threat is respiratory and thromboembolic complications, not the cord contusion itself.
2. When should he be decompressed, and how do you handle the aspirin and the 4-day theatre delay?
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The 4-day delay is not defensible for a patient with a focal compressive lesion and a definable neurological deficit. The evidence base contains no definitive randomised trial, but the STASCIS cohort and subsequent meta-analyses suggest that decompression within 24 hours is safe and is associated with better neurological recovery at one year, and the AO Spine clinical practice guideline conditionally recommends early surgery, within 24 hours, for acute spinal cord injury. Leaving a stenotic, contused cord compressed for four days also exposes him to the risks of immobility.
Aspirin is the second issue. He had a myocardial infarction two years ago and is on secondary prevention. Current guidance is to continue aspirin when the bleeding risk is acceptable, and a cervical laminectomy is a procedure in which bleeding can be controlled. Stopping it would create a small but real risk of stent thrombosis and reinfarction, so I would continue it and inform the anaesthetist, rather than stop it for four days. I would discuss the case with cardiology only if he had a recent stent, which he does not.
The practical solution to the theatre delay is escalation: transfer to a spinal unit with an on-call service, or arrange an emergency list at the current hospital with the general or neurosurgical team scrubbed. Which operation depends on the compression. With multi-level stenosis and maximal compression at C5–C6 without a disc herniation or focal anterior osteophyte, a posterior C4–C6 laminectomy with instrumented fusion (or laminoplasty in younger patients with preserved lordosis) is appropriate; an anterior cervical discectomy and fusion is chosen when the compression is predominantly anterior. The randomised evidence comparing these approaches has not shown one to be superior overall.
3. What would you tell the patient and his family about recovery, rehabilitation and long-term risk?
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The name central cord syndrome describes a pattern, not a single disease, and the prognosis varies enormously with age, initial severity and the presence of cord signal change. I would be honest but not nihilistic: the typical pattern is that leg power recovers first, bladder function next, and fine hand function last and often incompletely. Most patients gain substantial walking ability; a smaller proportion regain useful hand dexterity. Older age, severe initial deficit and a long delay to decompression are the adverse features here.
Rehabilitation should start before surgery, not after discharge: chest physiotherapy, positioning, splinting of the hands to prevent contracture, and early sitting once the spine is stable. After surgery he needs an intensive inpatient rehabilitation programme with occupational therapy for hand function, a walking aid assessment and a home visit before discharge. Spasticity and neuropathic hand pain should be anticipated and treated; untreated pain is a major cause of failed rehabilitation.
He and his family should also hear about falls prevention, because a further fall on an already narrowed, operated cervical spine is dangerous, and about the risk of late deterioration adjacent to the fused segment. I would explain that he should not drive until assessed, and that he will need a catheter plan and bowel programme. Finally, the delay to surgery should be acknowledged to the family, and a formal incident review should ask why a paraparetic patient waited four days for a list, since that is the part of this case most likely to be repeated.