The focus of physical therapy in central cord syndrome (CCS) is the preservation of range of motion (ROM) and the enhancement of mobility skills.  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.  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.
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.
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.
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.
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- 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.
- 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.
- 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.
- 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.
- 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.
- 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. [5, 14]
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. 
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. 
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. 
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. 
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. 
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. 
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. 
On the other hand, 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. 
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Vocational rehabilitation specialist - These experts also should be consulted to facilitate a return to work or school.
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