Citation: Spinal Cord Series and Cases (2016) 2, 16014; doi:10.1038/scsandc.2016.

14
© 2016 International Spinal Cord Society All rights reserved 2058-6124/16
www.nature.com/scsandc

CASE REPORT
Traumatic central cord syndrome after blunt cervical trauma: a
pediatric case report
Natalia Betances Ramírez, Rafael E Arias-Berríos, Carmen López-Acevedo and Edwardo Ramos

INTRODUCTION: Traumatic central cord syndrome (CCS) is the most frequently encountered incomplete spinal cord injury (SCI).
The patient presents weakness, which is usually greater in the upper extremities than in the lower extremities, secondary to
damage to the cervical spinal cord and anatomic distribution of the corticospinal tracts. CCS is seen commonly after a
hyperextension mechanism in older patients with spondylotic changes. There are few literature reports regarding CCS in pediatric
patients. We present an unusual case of traumatic CCS in a pediatric patient.
CASE PRESENTATION: A 15-year-old male patient, victim of bullying at school, received cervical blunt trauma with a plastic tube.
Within 3 h, the patient developed generalized weakness, which was greater in the upper extremities than in the lower extremities.
Upon evaluation, the patient was found with marked upper extremity weakness compared to the lower extremities, with a Manual
Muscle Test difference of 11 points. Imaging studies showed contusive changes in the C4-C7 central spinal cord. After rehabilitation
therapies the patient gained 23 points in MMT at the day of discharge.
DISCUSSION: Different etiologies of CCS have previously been described in pediatric patients. However, this is the first case that
describes a bullying event with cervical blunt trauma and subsequent CCS. In this case, history and physical examination, along with
imaging studies, helped in the diagnosis, but it is important to be aware of the possibility of SCI without radiographic abnormalities,
as it is common in the pediatric population. CCS occurs rarely in pediatric patients without underlying pathology. Physicians must
be aware of the symptoms and clinical presentation in order to provide treatment and start early rehabilitation program.
Spinal Cord Series and Cases (2016) 2, 16014; doi:10.1038/scsandc.2016.14; published online 15 December 2016

INTRODUCTION cervical area. Motor strength evaluation showed significant upper

Cervical spinal cord injuries are uncommon and heterogeneous in extremity weakness with a difference of 11 points in the manual
the pediatric population.1 Although rare, traumatic central cord muscle test (MMT) when comparing upper versus lower extremity
syndrome (CCS) is one of the most common incomplete spinal strength (see Table 1). Sensory examination revealed absent soft
cord injury (SCI) syndrome; its epidemiology has not been touch and pin-prick in right C6, C7, C8 and T1 dermatome
reported. It is for this reason that we present an unusual case of distribution. Proprioception and vibration evaluation was intact.
cervical SCI in a young child after receiving blunt trauma to the Initial imaging of plain radiographs showed no evidence of
cervical area with a plastic (polyvinyl chloride) tube, as a victim of fracture, dislocation or cervical spine instability, and a head
bullying at school. It is our intent to describe this entity and to computed tomography without contrast with no acute intracranial
review the literature of this disease related to blunt trauma/ pathology. However, a magnetic resonance imaging of cervi-
bullying. cothoracic region without contrast was positive for spinal cord
contusive changes involving C4–C7, but no evidence of cord
hemorrhage. Vertebral body contusive changes involving C2–T1
CLINICAL CASE was also seen (see Figure 1).
A 15-year-old, right-handed male patient with past medical history Patient was admitted to PICU for close neurological and
of hypothyroidism, attention deficit hyperactive disorder and cardiorespiratory serial evaluation. Initial management included
major depressive disorder, previously independent, suffered intravenous hydration and pain medication. No surgical manage-
cervical trauma with a plastic tube while being a victim of ment was recommended by the neurosurgery service. Laboratory
bullying at school. Although left on the floor alone, the patient workup was essentially normal. After medical stabilization and no
was able to stand and walk back to his classroom asymptomatic. deterioration, the patient was transferred to the general pediatric
After 3 h, the patient developed progressive bilateral numbness ward. The patient started with daily physical and occupational
on the tip of fingers, with associated upper limb distal muscle rehab therapies. In addition, bilateral resting splints for the upper
weakness (wrists and fingers). Weakness progressed rapidly to the extremities and a right ankle-foot orthosis were prescribed.
lower limb muscle, which interfered with ambulation. Owing to Throughout the 3 weeks the patient was hospitalized, and the
worsening of symptoms, the patient was taken to an emergency patient showed improvement in functionality and strength, with a
room for evaluation. total of 23 points improvement in MMT (12 in upper extremities
On physical examination, the patient was found to be alert, (UEx) and 11 in lower extremities (LEx)) on the day of discharge
awake and following commands and with stable vital signs. There (see Table 1). During the hospital stay there were no bladder
were no gross signs of external trauma except for pain in the dysfunction reported by the patient.

Department of Physical Medicine, Rehabilitation, and Sports Medicine, University District Hospital, University of Puerto Rico-School of Medicine, San Juan, Puerto Rico.
Correspondence: NMB Ramírez (nbetances@yahoo.com)
Received 7 December 2015; revised 21 April 2016; accepted 13 May 2016
 Traumatic CCS after blunt cervical trauma
NB Ramírez et al
2
Table 1. International Standards for Classification of Spinal Cord Injury
muscle strength scores of the patient at admission to the pediatric unit
and then after 3 weeks upon discharge home

Admission (5/6/15) Discharge (5/28/15)

R L R L

Elbow flexors–C5 4 5 5 5
Wrist extensors–C6 4 5 4 5
Elbow extensors–C7 3 3 3 4
Finger flexors-C8 0 0 3 4
Finger abduction-T1 0 0 0 3
Total Upper Extremities 24 36
Hip flexos–L2 5 5 5 5
Knee extensors–L3 5 5 5 5
Ankle dorsiflexors–L4 0 5 3 5
Extensor Hallucis Longus–L5 0 5 3 5
Ankle plantar flexors–S1 0 5 5 5
Total Lower Extremities 35 46
Abbreviations: R, Right; L, Left.

CLINICAL FEATURES AND DIAGNOSIS

Diagnosis of CCS is usually based on the clinical criteria
characterized by disproportionately more motor impairment of
the upper extremities compared with the lower extremities, with
variable involvement of bladder dysfunction and sensory abnorm-
ality below the affected level.2 A difference of at least 10 points in
the ASIA (American Spinal Injury Association) MMT should be
found when comparing the upper extremities with the lower
extremities.3,4
Magnetic resonance imaging is the examination of choice for
the diagnosis of traumatic CCS, showing intramedullary hyper-
signal on T2-weighted and STIR (Short TI recovery) sequences Figure 1. Sagittal T2-weighted magnetic resonance imaging of
consistent with edema, as well as lesions of ligaments and cervicothoracic region showing a longitudinal hyperintense region
intervertebral discs.5,6 Magnetic resonance imaging is also useful from C4–C7 (spinal cord contusive changes).
for the assessment of hemorrhage and may show the presence of
prevertebral hematoma or disruption of posterior ligaments, CCS is classically known to affect older persons with cervical
which may suggest spinal column instability.7–9 spondylosis and a hyperextension injury, where a spinal cord
X-rays may be normal if there is no pre-existing pathology. The compression occurs between bony spurs anteriorly and buckling
underlying congenital narrowing can be assessed with the Pavlov or of the ligamentum flavum posteriorly.2,16
Torg ratio.10 This is a ratio of canal size to anterior-to-posterior In general, three main mechanisms have been postulated: (1)
vertebral body dimension on the lateral X-ray that should be 40. young patients sustaining a high speed injury, such as in motor
82.10 Cervical dynamic X-rays have an important role in the vehicle accidents, diving accident or a fall from height; (2) in older
radiographic assessment of the eventually associated discoligamen- patients (450 years) because of a hyperextension force in an
tous instability.11 Significant radiographic pathologic views may or already degenerate spine; (3) low-velocity trauma in a patient with
may not accompany the injury in plain radiographs. The absence of an acute central disc herniation.2,17–21
radiographic evidence is more frequent in children younger than 8 As seen in adults, the most common cause of injury in children
years and in those with high injury severity scores.12 is motor vehicle accidents.22–24 Some recreational activities such
A large multi-institutional series demonstrated that up to 50% as diving place children at greatest risk for cervical spine injury.1
of children with symptomatic SCI presented with no radiologic Violence, including penetrating trauma, is the third leading cause
abnormality, suggesting that even the most accurate of imaging of SCI in children.1 Child abuse as a cause of cervical spine injury is
modalities will not be able to show what should be apparent on rare but may be underreported in the pediatric population.13
careful physical examination.13 Limited data are available on bullying cases.
As discussed previously, differences in the anatomical and Children with a narrow canal, secondary to spinal stenosis or
biomechanical characteristics of the pediatric cervical spine congenital malformation, may be predisposed to spinal cord
predispose children to present with a SCI without radiographic
concussion when the canal is further narrowed in cervical
abnormality and/or relationship to a hyperextension injury.14,15
hyperflexion or in hyperextension.25,26 Upper cervical spine
SCI without radiographic abnormality is specific to children and
injuries (C1–4) are almost twice as common as lower cervical
extremely rare in adults, and occurs in ~ 15–25% of all pediatric
injuries (C5–7); a small subset of patients may present with both
cervical spine injuries.
an upper and lower cervical spine injury. Several differences in the
anatomical and biomechanical characteristics of the pediatric
PATHOPHYSIOLOGY cervical spine predispose children to present with a SCI without
CCS was first described in 1954, characterized by disproportio- radiographic abnormality and/or relationship to a hyperextension
nately more motor impairment of the upper extremities compared injury.14,15
with the lower extremities, with variable involvement of bladder Differences include the relative cephalocervical disproportion
dysfunction and sensory abnormality below the affected level.2 and the ossification status of the spine. The child’s head

Spinal Cord Series and Cases (2016) 16014 © 2016 International Spinal Cord Society
 Traumatic CCS after blunt cervical trauma
NB Ramírez et al
3
represents ~ 25% of total body mass combined. This in combina- pathologies such as spinal cord edema, hemorrhage or cervical
tion with a poorly developed cervical musculature gives a vertebral ligament disruption.31
mechanical disadvantage to the pediatric cervical spine.15 In
addition, in children the incompletely ossified synchondrosis
through the base of C2 is a point of relative weakness and, COMPETING INTERESTS
therefore, a region prone to disruption from a distracting force.15 The authors declare no conflict of interest.
Other anatomic differences are the anteriorly wedged orientation
of the vertebral bodies, the horizontal orientation of the facets and
REFERENCES
the absence of uncinate processes on the vertebral bodies.15 The
1 Leonard JC. Cervical spine injury. Pediatr Clin N Am 2013; 60: 1123–1137.
net result of these anatomic variations is that children have less 2 Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal
skeletal resistance to flexion and rotation forces, with a greater cord injury; with special reference to the mechanisms involved in hyperextension
degree of the resistance being shifted to the ligaments.15 Also, the injuries of cervical spine. J Neurosurg 1954; 11: 546–577.
spinal cord may be compressed by a transient subluxation or 3 Pouw MH, Van Middendorp JJ, Van Kampen A, Hirschfield S, Veth RPH,
distraction.14,15 This helps explain why children are less prone to Curt A et al. Diagnostic criteria of traumatic central cord syndrome. Part 1: A
spine fractures and more likely to present with SCI without systematic review of clinical descriptors and scores. Spinal Cord 2010; 48:
652–656.
radiographic abnormality.15
4 Van Middendorp JJ, Pouw MH, Hayes KC, Williams R, Chhabra HS, Putz C et al.
Diagnostic criteria of traumatic central cord syndrome. Part 2: A questionnaire
DISCUSSION survey among spine specialists. Spinal Cord 2010; 48: 657–663.
5 Miyanji F, Furlan JC, Aarabi B, Arnold PM, Fehlings MG. Acute cervicaltraumatic
SCI in the pediatric population, especially in children younger than
spinal cord injury: MR imaging findings correlated with neuro-logic outcome—
15 years old, is a rare event but may have serious consequences.27 prospective study with 100 consecutive patients. Radiology 2007; 243: 820–827.
SCI has been reported to occur in o 1% of those of patients 6 Scholtes F, Adriaensens P, Storme L, Buss A, Kakulas BA, Gelan J et al. Correlation
following blunt trauma.13,28 of postmortem 9.4 tesla magnetic resonance imagingand immunohistopathology
Traumatic CCS is the most common incomplete SCI regardless of the human thoracic spinal cord 7 months after traumatic cervical spine injury.
of its mechanism of lesion.29,30 Two large retrospective studies in Neurosurgery 2006; 59: 671–678.
the pediatric trauma databases revealed that the incidence of 7 Collignon F, Martin D, Lenelle J, Stevenaert A. Acute traumatic central cordsyn-
drome: magnetic resonance imaging and clinical observations. J Neurosurg 2002;
traumatic CCS ranges between 1.5 and 5%.13,31
96(Suppl 1): 29–33.
Diagnosis of SCI in the pediatric population may be challenging. 8 Schaefer DM, Flanders A, Northrup BE, Doan HT, Osterholm JL. Magnetic
A potential failure of diagnosis is present because of its resonance imaging of acute cervical spine trauma. Correlation with severity of
heterogeneous presentation in this population, especially after neurologic injury. Spine 1989; 14: 1090–1095.
minor trauma.32 9 Song J, Mizuno J, Inoue T, Nakagawa H. Clinical evaluation of traumatic
In our patient, his past medical history of hypothyroidism, centralcord syndrome: emphasis on clinical significance of prevertebral
attention deficit hyperactive disorder and major depressive hyperintensity, cord compression, and intramedullary high-signal intensity on
disorder did not predispose him for CCS. Nevertheless, there are magnetic resonance imaging. Surg Neurol 2006; 65: 117–123.
10 Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with
literatures that have shown that subjects with attention deficit
vertebral body ratio method. Radiology 1987; 164: 771–775.
hyperactive disorder and depression are at an increased risk of 11 Molliqaj G, Payer M, Schaller K, Tessitore E. Acute traumatic central cord
being bullied.33 syndrome: a comprehensive review. Neurochirurgie 2014; 60: 5–11.
12 Aarabi B, Koltz M, Ibrahimi D. Hyperextension cervical spine injuries and traumatic
central cord syndrome. Neurosurg Focus 2008; 25: E9.
RECOVERY 13 Patel JC, Tepas DL III, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining
Prognosis of functional recovery is generally better in the pediatric the disease. J Pediatr Surg 2001; 36: 373–376.
population when compared with adults. The rate of recovery 14 Bosch PP, Vogt MT, Ward WT. Pediatric spinal cord injury without radiographic
following SCI in the pediatric population is also thought to be abnormality (SCIWORA): the absence of occult instability and lack of indication for
faster. More than one-half of these patients experienced bracing. Spine (Phila Pa 1976) 2002; 27: 2788–2800.
15 Proctor MR. Spinal cord injury. Crit Care Med 2002; 30: S489–S499.
spontaneous recovery of motor weakness; however, as time went
16 Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine
on, lack of manual dexterity, neuropathic pain, spasticity, bladder (Phila Pa 1976) 1988; 13: 831–837.
dysfunction and imbalance of gait rendered their activities of daily 17 Harrop JS, Sharon A, Ratliff J. Central cord injury: pathophysiology management
living nearly impossible.12 Overall prognosis for functional and outcomes. Spine J 2006; 6: 198S–206S.
recovery is good. 18 Ishida Y, Tominaga T. Predictors of neurological recovery in acute cervical
cord injury with only upper limb extremity impairment. Spine 2002; 27:
1652–1657.
CONCLUSION 19 Dai L, Jia L. Central cord injury complicating acute disc herniation in trauma. Spine
Pediatric SCI remains a relatively rare condition relative to its 2000; 25: 331–336.
prevalence in the adult population. Although CCS is the most 20 Hayes KC, Askes HK, Kakulas BA. Retropulsion of intervertebral disc associated
common incomplete spinal cord syndrome, literature in the with traumatic hyperextension of the cervical spine and absence of vertebral
fracture: an uncommon mechanism of spinal cord injury. Spinal Cord 2002; 40:
pediatric population is very limited. Prognosis of functional
544–547.
recovery is generally better in the pediatric population when 21 Taylor AR, Blackwood W. Paraplegia in hyperextension cervical injuries with
compared with adults. Anatomical and biomechanical character- normal radiological appearances. J Bone Surg 1948; 30B: 245–248.
istics of pediatric cervical spines are obviously different relatively 22 Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical
to adults. This makes diagnosis of SCI in the pediatric population spine injuries. J Pediatr Surg 2001; 36: 100–105.
more challenging. 23 McKinley W, Santos K, Meade M, Brooke K. Incidence and outcomes of spinal cord
Accuracy in the diagnosis of CCS is based on the history of injury clinical syndromes. J Spinal Cord Med 2007; 30: 215–224.
24 Dietrich AM, Ginn-Pease ME, Bartkowski HM, King DR. Pediatric cervical
trauma to the cervical area and a careful physical examination,
spine fractures: predominantly subtle presentation. J Pediatr Surg 1991; 26:
where there is disproportionately more motor impairment of the 995–999.
upper extremities compared with the lower extremities of at least 25 Grabb PA, Pang D. Magnetic resonance imaging in the evaluation of spinal cord
10 points in the ASIA MMT. Imaging studies, mostly magnetic injury without radiographic abnormality in children. Neurosurgery 1994; 35:
resonance imaging, can assist in the diagnosis showing different 406–414.

© 2016 International Spinal Cord Society Spinal Cord Series and Cases (2016) 16014
 Traumatic CCS after blunt cervical trauma
NB Ramírez et al
4
26 Rathbone D, Johnson G, Letts M. Spinal cord concussion in pediatric athletes. 30 Li XF, Dai LY. Acute central cord syndrome: injury mechanisms and stress features.
J Pediatr Orthop 1992; 12: 616–620. Spine 2010; 35: E955–E964.
27 Parent S, Mac-Thion J. Spinal Cord Injury in the Pediatric Population: A Systematic 31 Apple DF, Anson CA, Hunter JD, Bell RB. Spinal cord injury in youth. Clin Pediatr
Review of Literature. J Neurotrauma 2011; 28: 1515–1524. 1995; 34: 90–95.
28 Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR et al. 32 Junk SK, Shin HJ, Kang HD, Oh SH. Central cord syndrome in a
A prospective multicenter study of cervical spine injury in children. Pediatrics 7-year-old boy secondary to standing high jump. Pediatr Emerg Care 2014; 30:
2001; 108: E20. 640–642.
29 Yamazaki T, Yanaka K, Fujita K, Kamezaki T, Uemura K, Nose T. Traumatic central 33 Roy A, Hartman CA, Veenstra R, Oldehinkel AJ. Peer dislike and victimisation in
cord syndrome: analysis of factors affecting the outcome. Surg Neurol 2005; 63: pathways from ADHD symptoms to depression. Eur Child Adolesc Psychiatry 2015;
99–100. 24: 887–895.

Spinal Cord Series and Cases (2016) 16014 © 2016 International Spinal Cord Society