Novel insights into the clinical trajectory and outcomes with surgical intervention for traumatic central cord syndrome: Impact of mechanism of injury

Introduction: Outcomes in central cord syndrome (CCS) exhibits significant variability, and patient phenotypes continue to evolve over time. High impact cervical injuries typically results in fractures and rapid cord compression, whereas milder cases often arise from hyperextension injuries without fractures. Despite these distinctions, direct comparisons between these two groups using standard CCS criteria are lacking. This study aims to establish a framework to address the heterogeneity of the CCS population by characterizing stable and unstable CCS patients.

Methods: CCS patients from four major SCI trials conducted between December 1991 and March 2017 were stratified into either CCS-S (stable) and CCS-U (unstable). Outcomes differences at one year, along with the proportion of patients achieving the minimum clinically important difference (MCID), were assessed using ASIA motor and the functional independence measure (FIM) score. A subgroup analysis, adjusted by propensity score matching, compared surgically treated CCS-S patients. Multivariable regression analysis was conducted to identify independent predictors of one-year outcomes.

Results: Among the 2,452 SCI patients, 268 were diagnosed with CCS. Among these, 124 (46%) patients were classified as CCS-S with significantly older mean age (49.74 vs 44.06 years, p=0.01) and predominantly male sex compared to CCS-U. Falls were the primary cause of injury in the CCS-S group, while vehicular crashes dominated in CCS-U. CCS-S patients showed greater improvement in UEMS (MD=3.61, p=0.03), FIM motor (MD=7.07, p=0.02) and FIM total scores (MD=7.07, p=0.03). Patients undergoing surgery achieved significantly greater functional independence, with a higher proportion reaching the FIM Motor MCID (67.6% vs 35.7%, p=0.004). CCS-S emerged as an independent predictor of neurological and functional improvement at one-year follow up.

Conclusion : CCS-S patients showed superior neurological and functional improvement despite worse baseline status. Surgical intervention was associated with better functional outcomes. Adopting uniform terminology for CCS-S will facilitate treatment optimization and help address the heterogeneity of this condition.