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Central Cord Syndrome

Central cord syndrome (CCS) is a neurological syndrome caused by an injury to the center of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy, affecting the spinothalamic tracts ((STTs) sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology) and medial aspect of the corticospinal tracts ((CSTs) motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology), most often due to trauma in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with cervical spondylosis Cervical Spondylosis Neck Pain. A less frequent but classic cause of CCS is syringomyelia. Clinical manifestations are motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology deficits in the arms more so than the legs and variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology deficits below the level of injury. Diagnosis is made clinically and is supported with neuroimaging Neuroimaging Non-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities. Febrile Infant. Definitive management can be medical or surgical, depending on the severity of the injury. Rehabilitation is the key to maintaining functionality and improving chances of recovery.

Last updated: 23 Jun, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Central cord syndrome (CCS) is a neurological syndrome caused by an injury to the center of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy, affecting the spinothalamic tracts ((STTs) sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology) and medial aspect of the corticospinal tracts ((CSTs) motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology).

Epidemiology 

  • Most common form of incomplete spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury
  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: approximately 9% of those with traumatic spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury
  • Men are more commonly affected.
  • Young patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship: usually due to trauma (e.g., automobile accidents) 
  • Older patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship (> 65 years): usually caused by neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess hyperextension combined with underlying spinal disease (e.g., osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis)

Etiology

  • Blunt trauma (most common)
  • Syringomyelia ( cystic Cystic Fibrocystic Change lesion between C2 and T9)
    • Congenital Congenital Chorioretinitis
    • Postinfectious: transverse myelitis Myelitis Inflammation of the spinal cord. Relatively common etiologies include infections; autoimmune diseases; spinal cord; and ischemia. Clinical features generally include weakness, sensory loss, localized pain, incontinence, and other signs of autonomic dysfunction. Relapsing Fever
    • Inflammatory: multiple sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor ( MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis)
  • Medullary tumor Tumor Inflammation → progressive cervical myelopathy with central cord features
    • Ependymoma Ependymoma Ependymomas are glial cell tumors arising from CSF-producing ependymal cells lining the ventricular system. Ependymomas most commonly occur within the posterior fossa in contact with the 4th ventricle, or within the intramedullary spinal cord. Ependymoma
    • Astrocytoma Astrocytoma Astrocytomas are neuroepithelial tumors that arise from astrocytes, which are star-shaped glial cells (supporting tissues of the CNS). Astrocytomas are a type of glioma. There are 4 grades of astrocytomas. Astrocytoma
    • Rarely metastatic disease
  • Spondylosis
    • Atlantoaxial (C1–C2) instability (e.g., due to rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis (RA))
    • Spinal arthropathies
  • Osteoporosis Osteoporosis Osteoporosis refers to a decrease in bone mass and density leading to an increased number of fractures. There are 2 forms of osteoporosis: primary, which is commonly postmenopausal or senile; and secondary, which is a manifestation of immobilization, underlying medical disorders, or long-term use of certain medications. Osteoporosis ( compression Compression Blunt Chest Trauma fractures)

Pathophysiology

Injury to the vertebral column Vertebral column The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy causes a spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury related to the force and direction of the traumatic event Traumatic event An emotionally painful, shocking, stressful, and sometimes life-threatening experience. It can result from witnessing distressing events such as natural disasters, physical or sexual abuse, and terrorism or other acts of violence. Posttraumatic Stress Disorder (PTSD) and the anatomic vulnerability of individual spinal elements.

Causes of spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy injury involve 1 or more of the following:

  • Vertebral fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
  • Dislocation at 1 or more joints
  • Ligamentous tears
  • Herniation Herniation Omphalocele of the intervertebral disc Intervertebral disc Any of the 23 plates of fibrocartilage found between the bodies of adjacent vertebrae. Vertebral Column: Anatomy

A cervical spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy hyperextension injury can be related to: 

Mechanism of injury:

  • Spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy subluxation Subluxation Radial Head Subluxation (Nursemaid’s Elbow) and/or fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures compression Compression Blunt Chest Trauma of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy anteriorly (by osteophytes or disc) and/or posteriorly (by buckling the ligamentum flavum) 
  • This can result in contusion/ edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, particularly in the central portion of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy

Affected areas of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy by central cord syndrome:

Location of lesion in central cord syndrome

Location of lesion in central cord syndrome (CSS):
Rough depiction of the area affected by CSS (affects lateral spinothalamic tracts (STTs) and lateral corticospinal tracts (CSTs) to varying degrees)

Image by Lecturio.

Clinical Presentation and Diagnosis

Understanding Understanding Decision-making Capacity and Legal Competence the structures affected by a central cord lesion is key to their correlation Correlation Determination of whether or not two variables are correlated. This means to study whether an increase or decrease in one variable corresponds to an increase or decrease in the other variable. Causality, Validity, and Reliability with clinical signs and symptoms. Diagnosis of CCS is by clinical exam and diagnostic imaging. 

Clinical presentation

History:

  • Site of injury: impact with the neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess hyperextended
  • Types of injuries that cause cervical fractures:
    • Blunt trauma from a motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology vehicle accident
    • Penetrating trauma from gunshot or knife
    • Falling trauma: downstairs or from a significant height (e.g., off a roof or a ladder)
  • No trauma: 
    • Syringomyelia or tumor Tumor Inflammation
    • Inflammatory/demyelinating ( MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis)
    • Postinfectious inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation (transverse myelitis Myelitis Inflammation of the spinal cord. Relatively common etiologies include infections; autoimmune diseases; spinal cord; and ischemia. Clinical features generally include weakness, sensory loss, localized pain, incontinence, and other signs of autonomic dysfunction. Relapsing Fever)

Physical exam:

Diagnosis

  • Physical exam as above
  • Imaging
    • X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays of the cervical spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy may show:
    • CT: shows impingement of the spinal canal Spinal Canal The cavity within the spinal column through which the spinal cord passes. Spinal Cord Injuries
    • MRI: gold standard for evaluating the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy and surrounding soft tissues

Management and Prognosis

Central cord syndrome has a good prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas, although factors such as older age and more-severe neurologic injury at presentation are associated with a lower likelihood of neurologic recovery. 

Management

Medical management:

  • Conservative treatment is the most common. 
  • With acute severe trauma: 
    • Treat hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension due to neurogenic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock.
    • High-dose steroids Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors ( methylprednisolone Methylprednisolone A prednisolone derivative with similar anti-inflammatory action. Immunosuppressants) to suppress edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Baclofen Baclofen A gamma-aminobutyric acid derivative that is a specific agonist of gaba-b receptors. It is used in the treatment of muscle spasticity, especially that due to spinal cord injuries. Its therapeutic effects result from actions at spinal and supraspinal sites, generally the reduction of excitatory transmission. Spasmolytics (muscle relaxant) for spasticity Spasticity Spinal Disk Herniation

Rehabilitation:

  • PT: for improving strength and range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs (ROM) of lower extremities
  • Occupational therapy Occupational Therapy Skilled treatment that helps individuals achieve independence in all facets of their lives. It assists in the development of skills needed for independent living. Fetal Alcohol Spectrum Disorder: upper limb training
  • External fixation of the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy: 4–6 weeks 
  • Up to 75% of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship show some neurological improvement in functionality.

Surgical management:

  • Considered early on for:
    • Spinal instability 
    • Ongoing spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy compression Compression Blunt Chest Trauma with progressive neurologic deterioration
  • Involves procedures such as decompression laminectomy Laminectomy A surgical procedure that entails removing all (laminectomy) or part (laminotomy) of selected vertebral lamina to relieve pressure on the spinal cord and/or spinal nerve roots. Vertebral lamina is the thin flattened posterior wall of vertebral arch that forms the vertebral foramen through which pass the spinal cord and nerve roots. Neurosurgery 

Complications of CCS

  • Autonomic dysreflexia: lack of a coordinated autonomic response with HR and blood pressure in spinal injuries above T6 
  • Neurogenic bladder Neurogenic bladder Dysfunction of the urinary bladder due to disease of the central or peripheral nervous system pathways involved in the control of urination. This is often associated with spinal cord diseases, but may also be caused by brain diseases or peripheral nerve diseases. Urinary Incontinence

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • Variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables:
    • Functionality depends on the extent of the injury and rehabilitation.
    • Most patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship recover the ability to walk.
  • Cervical fractures prolong recovery time.
  • Bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess function usually returns 6–8 months after injury.

Differential Diagnosis

  • Ventral (anterior) cord syndrome (ACS): an injury to the anterior, or ventral, ⅔ of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy (or incomplete cord syndrome) that spares the dorsal columns Dorsal Columns Posterior Cord Syndrome. The syndrome is caused by occlusion of the anterior spinal artery Anterior Spinal Artery Anterior Cord Syndrome or trauma causing disc herniation Herniation Omphalocele and bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types fragments that disrupt the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy. Clinical manifestations are loss of motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology and sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function below the level of injury. Diagnosis of ACS is by clinical exam and neuroimaging Neuroimaging Non-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities. Febrile Infant with MRI. Management is directed at resolving the underlying cause.
  • Posterior cord syndrome Posterior cord syndrome Posterior cord syndrome (PCS) is an incomplete spinal cord syndrome affecting the dorsal columns, the corticospinal tracts (CSTs), and descending autonomic tracts to the bladder. Posterior cord syndrome is rare but has a diverse range of etiologies, including demyelinating disorders, degenerative spinal conditions, neoplastic causes, vascular abnormalities, and hereditary neurodegenerative disorders. Posterior Cord Syndrome ( PCS PCS Posterior cord syndrome (PCS) is an incomplete spinal cord syndrome affecting the dorsal columns, the corticospinal tracts (csts), and descending autonomic tracts to the bladder. Posterior cord syndrome is rare but has a diverse range of etiologies, including demyelinating disorders, degenerative spinal conditions, neoplastic causes, vascular abnormalities, and hereditary neurodegenerative disorders. Posterior Cord Syndrome): an incomplete cord syndrome that affects the posterior aspect of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: Anatomy and is characterized by loss of vibration Vibration A continuing periodic change in displacement with respect to a fixed reference. Neurological Examination and position senses below the level of injury. As a very rare condition, the status of PCS PCS Posterior cord syndrome (PCS) is an incomplete spinal cord syndrome affecting the dorsal columns, the corticospinal tracts (csts), and descending autonomic tracts to the bladder. Posterior cord syndrome is rare but has a diverse range of etiologies, including demyelinating disorders, degenerative spinal conditions, neoplastic causes, vascular abnormalities, and hereditary neurodegenerative disorders. Posterior Cord Syndrome as a separate clinical entity is still under debate in the literature and can overlap with CCS. Diagnosis is made clinically and supported by neuroimaging Neuroimaging Non-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities. Febrile Infant. Management can be medical/rehabilitative or surgical if indicated.
  • Cruciate paralysis: a rare neurological condition that affects the cervicomedullary junction. The condition presents with bilateral upper limb paresis Paresis A general term referring to a mild to moderate degree of muscular weakness, occasionally used as a synonym for paralysis (severe or complete loss of motor function). In the older literature, paresis often referred specifically to paretic neurosyphilis. ‘general paresis’ and ‘general paralysis’ may still carry that connotation. Bilateral lower extremity paresis is referred to as paraparesis. Spinal Disk Herniation without the involvement of the lower limbs. The etiologies of cruciate paralysis include traumatic injuries, postsurgical complications, and metabolic disorders. Diagnosis and management are similar to other incomplete cord syndromes.

References

  1. Ameer, MA, Tessler, J, & Gillis, CC. (2021). Central cord syndrome. In StatPearls. StatPearls Publishing. Retrieved September 1, 2021, from http://www.ncbi.nlm.nih.gov/books/NBK441932/ 
  2. Go, S. (2020). Spine trauma. In J. E. Tintinalli, et al. (Ed.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, Chapter 258 (9th ed.). http://accessmedicine.mhmedical.com/content.aspx?aid=1167028097 
  3. Kim, E, et al. (2021). Disorders, diseases, and injuries of the spine. McMahon, PJ, & Skinner, HB (Eds.). Current Diagnosis & Treatment in Orthopedics (6th ed.). http://accessmedicine.mhmedical.com/content.aspx?aid=1181616865
  4. Ropper, AH, Samuels, MA, Klein, JP, & Prasad, S. (2019). Diseases of the spinal cord. Ropper, AH, et al. (Eds.). Adams and Victor’s Principles of Neurology (11th ed.). McGraw-Hill Education. Retrieved September 1, 2021, from http://accessmedicine.mhmedical.com/content.aspx?aid=1162599484 
  5. Hansebout, RR, & Kachur, E. (2018). Acute traumatic spinal cord injury. UpToDate. Retrieved September 1, 2021, from https://www.uptodate.com/contents/acute-traumatic-spinal-cord-injury
  6. Eisen, A. (2020). Anatomy and localization of spinal cord disorders. UpToDate. Retrieved September 1, 2021, from https://www.uptodate.com/contents/anatomy-and-localization-of-spinal-cord-disorders
  7. Brooks, NP. (2017). Central cord syndrome. Neurosurg Clin N Am. (28)41–47. http://dx.doi.org/10.1016/j.nec.2016.08.002

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