Central Cord Syndrome Treatment & Management

Physical Therapy

The focus of physical therapy in central cord syndrome (CCS) is the preservation of range of motion (ROM) and the enhancement of mobility skills.^[11] The strengthening of any preserved lower extremity musculature is essential, as are trunk balance and stabilization. Safe transfer and wheelchair mobility are other goals to be accomplished prior to the initiation of gait training. Patients with CCS offer a unique challenge for the physical therapist with regard to ambulation and gait training.^[12] Despite the usual preservation of some lower extremity strength, upper extremity deficits can limit the use of possible assistive devices and, ultimately, the functional quality of ambulation. For example, platform walkers are often used to compensate for deficient hand strength, although walking with this assistive device is frequently of limited functional value.

Occupational Therapy

Given the predominance of upper extremity weakness that occurs in central cord syndrome, the restoration of the basic activities of daily living (ADLs), upper extremity strength, and ROM are the main goals of occupational therapy. Splinting is often used to maintain the functional position of the hand and to prevent the formation of contractures in the fingers. Surface electromyelogram (EMG) biofeedback can often be beneficial to patients in the isolation of specific weak muscles in the upper extremities. Facilitating self-care skills by selecting appropriate assistive devices and training patients in their usage is another priority.

Speech Therapy

A speech therapist should be involved in the treatment of patients with central cord syndrome who have dysphagia from the head position maintained by cervical orthoses or as a result of anterior cervical spine fusion. Various compensatory strategies need to be taught to these patients to make swallowing safer and to prevent aspiration.

Recreational Therapy

The primary goal of recreational therapy is to help patients with central cord syndrome to return to preinjury areas of interest. Potential sources of recreational activities are explored with the patient, and the adaptive devices (for instance, an adapted fishing rod) that will allow the individual to enjoy previous activities are explored and provided.

• Autonomic dysreflexia

  • Autonomic dysreflexia (AD) is a disorder of autonomic homeostasis.
  • Sensory input from bladder distension or other noxious stimuli induce generalized sympathetic activity, resulting in vasoconstriction and hypertension.
  • Proper medical management of the skin, bowel, and bladder should prevent most occurrences. A thorough search should be made for the nociceptive source, and when found, it should be removed/treated immediately.
  • If mechanical means do not resolve the syndrome, medical management should be directed toward the reduction of blood pressure.
  • Nifedipine and transdermal nitroglycerin are often used.
• Neurogenic bladder

  • Acutely injured patients often experience bladder retention that requires the placement of a Foley catheter for drainage.
  • Once fluid status has been stabilized, the indwelling catheter should be discontinued and bladder training, as well as intermittent catheterization, should begin.
  • Bladder function usually returns in the first 6 months.
  • Studies show that 52-84% of patients eventually have normal, spontaneous voids.
  • Patients who do not return to normal bladder function should be taught to do intermittent catheterization if manual dexterity permits.
• Spasticity

  • Initially, reflexes are depressed, but once the period of spinal shock resolves, patients may experience increased spasticity in the upper and lower extremities.
  • Skillful nursing care can reduce the nociceptive and exteroceptive stimuli that exacerbate hypertonia.
  • Proper bed positioning and a regular stretching program are essential to spasticity reduction and contracture prevention.
  • Consider a trial of medication if spasms begin to cause discomfort, interfere with sleep, or cause functional impairment.
  • Lioresal (baclofen) is the initial drug of choice for spasticity.
• Neuropathic pain

  • Patients with central cord syndrome occasionally experience allodynia below the level of injury.
  • The first line of treatment is evaluation and removal of possible exacerbating factors (eg, infections, new pressure ulcers).
  • After that, the possible introduction of anticonvulsant medications should be considered.
• Pressure ulcers

  • Sensory loss, resulting in a patient's decreased awareness of continued pressure and shear forces on the skin, contributes to the formation of pressure ulcers.
  • Prevention involves decreasing the amount of pressure and the length of time that it is applied, as well as eliminating shear. Special mattresses and wheelchair cushions protect bony prominences.
  • Frequent changes in position (ie, turning while in bed, pressure relief when the patient is in a wheelchair) are paramount.
  • The initial treatment of a pressure ulcer is the elimination of pressure, followed by local dressing changes. If the wound progresses, plastic surgery consultation, if indicated, should be considered.
  • Physiatric management should also include patient and/or family education regarding skin care and surveillance.
• Neurogenic bowel

  • Given the lack of bowel control that often results from SCI, patients should be started on a regular bowel program to avoid incontinence. In addition, the patient should have adequate fluid intake to avoid constipation/fecal impaction.
  • The use of evacuants and/or manual removal by way of digital stimulation or other methods should be instituted.

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.^{[6, 13]}

• Neurologic surgeon
• Orthopedic surgeon
• Vocational rehabilitation specialist - These experts also should be consulted to facilitate a return to work or school.