Hyperextension Injury

1. Dr. Ahmed Mirza Al-Shammasi, MB ChB
2031040009
KFHU – Saudi Arabia

2. OutlinesOutlines
Introduction
Definition of Traumatic Central Cord
Syndrome
Correlative Anatomy, Pathogenesis,
Pathology
Diagnosis
Management
◦Consevative vs. Operative
◦Timing of Surgery

3. IntroductionIntroduction
First reported by Thorburn in 1887, popularized by
Schneider in 1954.
TCCS is related to Hyperextension of the cervical
spine without concomitant fracture of sublaxation.
TCCS compromises 44% of clinical syndrome
following traumatic SCI.
35-58% of patients with TCCS had underlying
Cervical Canal Stenosis.

4. IntroductionIntroduction
General trend since 1954 has been reluctance to
undertake aggressive treatment:
◦Lack of # or sublaxation on imaging studies.
◦Spontaneous functional recovery.
◦Comorbidities.
◦Risk of Intraoperative worsening of neurological
condition.
Yamazaki demonstrated “Direct” relationship
between outcome and Midsagittal diameter of
the spinal canal.

5. TCCSTCCS
Partial SCI with disproportionate:
◦Motor loss in the distal upper extremities.
◦Significant involvement of bladder function.
◦Variable degrees of sensory impairment below the
level of skeletal injury.
Middle-aged men are mostly affected.
In several recent series the proportion of men
ranged from 56.2-88%.
35-58% of patients with TCCS had underlying Cervical
Canal Stenosis.

15. PathogenesisPathogenesis
Foerster and Schneider:
◦Buckling of Ligamentum flavum + disc
protrusion.
◦Compression of the spinal cord.
◦Formation of a hematoma at the center of the
cord (Hematomyelic cavity).
◦Fibers subserving the upper extremities,
concentrated medially, are involved.
◦Fibers subserving the lower extremities,
concentrated laterally, are spared.

17. PathogenesisPathogenesis
Recent lines of evidence contradict that
assumption.
Pappas and Marchi, Coxe and Landau, Barnard
and Woolsey studies in monkeys
◦No somatotopic organization of the Corticospinal
tract at the level of pyramids or cervical spinal cord.
Studies of Nathan and colleagues in human
patients tend to confirm this finding.

18. PathogenesisPathogenesis
Jimenez, Martin and Quencer:
◦Correlating autopsy with MRI imaging of
TCCS patients.
◦Majority of patients with TCCS had no
evidence of hematomyelia or significant injury
to the centeral gray matter.
◦Axonal disruption and swelling is widespread
in the white matter of the lateral funiculi and
to lesser extent the posterior columns.

20. Alternative hypothesisAlternative hypothesis
Proposed by Levi and Collignon:
◦TCCS may result from pathological entities
affecting the CST anywhere from the pyramids
to the cervical spine.
◦CST primarily subserve fine motor movements
to the distal musculature, especially upper limbs.
◦Preservation of leg movement is mediated by
other descending motor pathways important to
locomotion.

21. PathologyPathology
Lesion of TCCS seem to comprise 3 main
categories:
1.Cervical Spondylosis associated with spinal
canal stenosis
2.Fracture sublaxation
3.Sequestrated disc without evidence of
spinal stenosis.
The proportion of each is different in
every case.

22. DiagnosisDiagnosis
CT, MRI, and when indicated, dynamic studies will
essentially rule out skeletal damage, DLC injuries
and hidden fractures.
New technology even enables the measurement of
the degree of canal compromise and cord
compression. (MCC, LL)

23. i
b
a
MSCC (%) = [1-i/(a+b)/2] x 100
Maximum spinal canal compression

25. ManagementManagement
Surgical vs. ConservativeSurgical vs. Conservative
Factors that discourage urgent surgery,
experience of Schneider and colleagues:
◦Lack of # or sublaxation on imaging studies.
◦Spontaneous functional recovery.
◦Comorbidities.
◦Risk of Intraoperative worsening of neurological condition.

26. ManagementManagement
In 1984, Bose review of patients with
TCCS showed better motor scores in
patients treated surgically.
In 2005, Yamazaki demonstrated “Direct”
relationship between outcome and
Midsagittal diameter of the spinal canal.

27. Timing of SurgeryTiming of Surgery
In 2002, Guest review of patients with TCCS and
disc herniation or skeletal injury:
◦Patient underwent Early surgery (<24 hours) had better
motor recovery than Late surgery.
◦The timing of surgery did not affect motor recovery in
cases with spinal canal stenosis.
Preliminary result of prospective multicenter trial,
reported by Fehlings, indicate better functional
recovery with early decompression.

28. Surgical ObjectivesSurgical Objectives
2.Spinal Cord decompression
3.Restoration of normal spinal alignment
and internal fixation
Prevent and/or interrupt of further
secondary injury.

29. ConclusionConclusion
TCCS is most frequent syndrome after incomplete
SCI.
50% is due to hyperextension injury.
Until now, no standard algorithm of treatment.
Further research should be multicenter, prospective
and analytical rather than descriptive.

30. Thank you for listeningThank you for listening