Enger Spinalkanal und osteoligamentäre Verletzung HWS – konservative Therapie

Zusammenfassung

Seit der Beschreibung des traumatischen zentromedullären Syndroms (traumatic central cord syndrome, TCCS) als Rückenmarksschädigung durch Kontusionierung bei vorbestehendem engen zervikalen Spinalkanal durch Schneider 1954 wurden betroffene Patient:innen aufgrund der häufig spontanen neurologischen Erholung in erster Linie konservativ behandelt. Mit der Erkenntnis, dass relativ häufig strukturelle und potentiell instabile Verletzungen in diesen Fällen vorliegen und der zunehmend aggressiven (frühen) chirurgischen Versorgung von Rückenmarkstraumen im Allgemeinen, wird aktuell auch beim TCCS eine operative Therapie propagiert. Bei osteoligamentärer Verletzung und Instabilität macht dies Sinn, während die Datenlage beim klassischen TCCS, also der Rückenmarkskontusionierung alleine durch Hyperextension bei engem Spinalkanal ohne (instabile) Verletzung, unklar ist. Vergleichende Studien konnten keinen Vorteil der operativen Versorgung nachweisen. Da die radiologische Detektion von diskoligamentären Verletzungen bei begleitenden degenerativen Veränderungen schwierig sein kann und nicht selten eine anhaltende Rückenmarkskompression bildgebend vorliegt, ist eine aggressive operative Vorgehensweise durchaus zu rechtfertigen. TCCS-Patient:nnen mit geringer neurologischer Symptomatik, die keine Rückenmarkskompression in der Bildgebung zeigen, können jedoch präferentiell konservativ versorgt werden.

Abstract

Since the description of the traumatic central cord syndrome (TCCS) as a contusional lesion of the spinal cord due to hyperextension and a preexisting cervical stenosis by Schneider in 1954 most patients were managed conservatively, as spontaneous neurological recovery commonly occurred. When spine surgeons realized that many TCCS patients harbored osteoligamentous and potentially unstable injuries and a more aggressive attitude favoring early surgery for spinal cord injury was adapted in general, surgical treatment has also been popularized in TCCS cases. This makes a lot of sense for patients with osteoligamentous and unstable lesions, but the management of the classical TCCS, i.e. spinal cord contusion due to hyperextension and spinal stenosis alone, is largely unclear and comparative studies found no benefit for surgery. With the difficulty to detect discoligamentous injuries in highly degenerated patients and an often ongoing cord compression on imaging, a more aggressive surgical attitude can be justified. Nevertheless, TCCS patients with mild neurologic deficits can be preferentially managed conservatively.

Schlüsselwörter

traumatisches zentromedulläres Syndrom - Rückenmarkstrauma - osteoligamentäre Verletzung - Operation - konservative Therapie

Keywords

traumatic central cord syndrome - spinal cord injury - osteoligamentous injury - surgery - conservative management

Publication History

Article published online:
07 February 2024

• Literatur

• 1 Brooks NP. Central Cord Syndrome. Neurosurg Clin N Am 2017; 28: 41-47 DOI: 10.1016/j.nec.2016.08.002.
• 2 Segi N, Nakashima H, Machino M. et al. Epidemiology of Cervical Fracture/Cervical Spinal Cord Injury and Changes in Surgical Treatment Modalities in Elderly Individuals During a 10-year Period: A Nationwide Multicenter Study in Japan. Global Spine J 2023; DOI: 10.1177/21925682231151643.
• 3 Schneider RC, Cherry G, Pantek H. The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine. J Neurosurg 1954; 11: 546-577 DOI: 10.3171/jns.1954.11.6.0546.
• 4 Wilson JR, Witiw CD, Badhiwala J. et al. Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now?. Global Spine J 2020; 10 (Suppl. 01) 84S-91S DOI: 10.1177/2192568219877860.
• 5 Phelps RR, Yue JK, Tsolinas RE. et al. Elderly traumatic central cord syndrome in the USA: a review of management and outcomes. J Neurosurg Sci 2021; 65: 442-449 DOI: 10.23736/S0390-5616.21.05078-5.
• 6 Ahuja CS, Schroeder GD, Vaccaro AR. et al. Spinal Cord Injury-What Are the Controversies?. J Orthop Trauma 2017; 31 (Suppl. 04) S7-S13 DOI: 10.1097/BOT.0000000000000943.
• 7 Tosic L, Voglis S, Bellut D. et al. Akutes traumatisches Central-Cord-Syndrom: Ätiologie, Pathophysiologie, klinische Manifestation und Behandlung [Acute Traumatic Central Cord Syndrome: Etiology, Pathophysiology, Clinical Manifestation, and Treatment]. Praxis 2021; 110: 324-335 DOI: 10.1024/1661-8157/a003659.
• 8 Barz M, Janssen IK, Aftahy K. et al. Incidence of discoligamentous injuries in patients with acute central cord syndrome and underlying degenerative cervical spinal stenosis. Brain Spine 2022; 2: 100882 DOI: 10.1016/j.bas.2022.100882.
• 9 Yelamarthy PKK, Chhabra HS, Vaccaro A. et al. Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society-Spine Trauma Study Group position statement. Eur Spine J 2019; 28: 2390-2407 DOI: 10.1007/s00586-019-06085-z.
• 10 Divi SN, Schroeder GD, Mangan JJ. et al. Management of Acute Traumatic Central Cord Syndrome: A Narrative Review. Global Spine J 2019; 9 (Suppl. 01) 89S-97S DOI: 10.1177/2192568219830943.
• 11 Ishida Y, Tominaga T. Predictors of neurologic recovery in acute central cervical cord injury with only upper extremity impairment. Spine 2002; 27: 1652-1658 ; discussion 1658 DOI: 10.1097/00007632-200208010-00011.
• 12 Aito S, D’Andrea M, Werhagen L. et al. Neurological and functional outcome in traumatic central cord syndrome. Spinal Cord 2007; 45: 292-297 DOI: 10.1038/sj.sc.3101944.
• 13 Chen L, Yang H, Yang T. et al. Effectiveness of surgical treatment for traumatic central cord syndrome. J Neurosurg Spine 2009; 10: 3-8 DOI: 10.3171/2008.9.SPI0822.
• 14 Dahdaleh NS, Lawton CD, El Ahmadieh TY. et al. Evidence-based management of central cord syndrome. Neurosurg Focus 2013; 35: E6 DOI: 10.3171/2013.3.FOCUS13101.
• 15 Stevens EA, Marsh R, Wilson JA. et al. A review of surgical intervention in the setting of traumatic central cord syndrome. Spine J 2010; 10: 874-880 DOI: 10.1016/j.spinee.2010.07.388.
• 16 Ramey WL, Reyes AA, Avila MJ. et al. The Central Cord Score: A Novel Classification and Scoring System Specific to Acute Traumatic Central Cord Syndrome. World Neurosurg 2021; 156: e235-e242 DOI: 10.1016/j.wneu.2021.09.037.
• 17 Kumar AA, Wong JYH, Pillay R. et al. Treatment of acute traumatic central cord syndrome: a score-based approach based on the literature. Eur Spine J 2023; 32: 1575-1583 DOI: 10.1007/s00586-023-07626-3.
• 18 Schroeder GD, Kepler CK, Hjelm N. et al. The effect of vertebral fracture on the early neurologic recovery in patients with central cord syndrome. Eur Spine J 2015; 24: 985-989 DOI: 10.1007/s00586-015-3865-6.
• 19 Liu G, Liu L, Wang Y. Surgical Efficacy and Prognostic Factors for Acute Traumatic Central Cord Syndrome Without Fracture and Dislocation. Orthopedics 2022; 45: 325-332 DOI: 10.3928/01477447-20220907-07.
• 20 Pollard ME, Apple DF. Factors associated with improved neurologic outcomes in patients with incomplete tetraplegia. Spine (Phila Pa 1976) 2003; 28: 33-39 DOI: 10.1097/00007632-200301010-00009.
• 21 Stevenson CM, Dargan DP, Warnock J. et al. Traumatic central cord syndrome: neurological and functional outcome at 3 years. Spinal Cord 2016; 54: 1010-1015 DOI: 10.1038/sc.2016.34.
• 22 Salah AM, Al-Shami H, Adel Ali MF. Early Surgical Decompression versus Medical Treatment in Acute Traumatic Central Cord Syndrome: Prospective Randomized Controlled Study. Pan Arab J Neurosurg 2021; 16: 6-12 DOI: 10.21608/pajn.2021.58529.1007.
• 23 Lenehan B, Fisher CG, Vaccaro A. et al. The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability. Spine (Phila Pa 1976) 2010; 35 (Suppl. 21) S180-186 DOI: 10.1097/BRS.0b013e3181f32a44.
• 24 Badhiwala JH, Wilson JR, Harrop JS. et al. Early vs Late Surgical Decompression for Central Cord Syndrome. JAMA Surg 2022; 157: 1024-1032 DOI: 10.1001/jamasurg.2022.4454.
• 25 Fehlings MG, Tetreault LA, Wilson JR. et al. A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus >24 Hours) of Decompressive Surgery. Global Spine J 2017; 7 (Suppl. 03) 195S-202S DOI: 10.1177/2192568217706367.
• 26 Aarabi B, Akhtar-Danesh N. et al. Efficacy of Early (≤ 24 Hours), Late (25–72 Hours), and Delayed (>72 Hours) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades C and D Acute Traumatic Central Cord Syndrome Caused by Spinal Stenosis. J Neurotrauma 2021; 38: 2073-2083 DOI: 10.1089/neu.2021.0040.
• 27 Anderson KK, Tetreault L, Shamji MF. et al. Optimal Timing of Surgical Decompression for Acute Traumatic Central Cord Syndrome: A Systematic Review of the Literature. Neurosurgery 2015; 77 (Suppl. 04) S15-32 DOI: 10.1227/NEU.0000000000000946.