Spine Lectures/Central Cord Syndrome/References

References

95 verified sources for Central Cord Syndrome. Literature reviewed through September 2026.

  1. 1.
    HistoricalLandmark studiesDefinition & diagnosisPathophysiology
    The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine
    Schneider RC, Cherry G, Pantek H. J Neurosurg. 1954;11(6):546-77.
    Original description of acute central cervical cord injury after hyperextension: arm-predominant weakness, variable sensory loss, sphincter dysfunction, often without fracture.
    PubMed 13222164 doi:10.3171/jns.1954.11.6.0546 Cited on slides 8, 16
  2. 2.
    HistoricalLandmark studiesDefinition & diagnosis
    The syndrome of acute central cervical spinal cord injury
    Schneider RC, Thompson JM, Bebin J. J Neurol Neurosurg Psychiatry. 1958;21(3):216-27.
    Schneider's follow-up series consolidating the clinical syndrome and its natural tendency toward partial recovery, legs before arms.
    PubMed 13576174 doi:10.1136/jnnp.21.3.216 Cited on slide 42
  3. 3.
    HistoricalLandmark studiesPrognosis
    Incomplete traumatic quadriplegia. A ten-year review
    Bosch A, Stauffer ES, Nickel VL. JAMA. 1971;216(3):473-8.
    Classic Rancho Los Amigos ten-year review of incomplete traumatic quadriplegia, widely cited for the favourable natural history of central cord lesions (no PubMed abstract).
    PubMed 5107929
  4. 4.
    HistoricalLandmark studiesPrognosisSurgery
    A reappraisal of acute traumatic central cord syndrome
    Merriam WF, Taylor TK, Ruff SJ, McPhail MJ. J Bone Joint Surg Br. 1986;68(5):708-13.
    Review of 77 TCCS patients: atypical variants are common, outcome is generally good, and good hand function, hyperpathia, Lhermitte's sign and normal perianal sensation predict favourable prognosis.
    PubMed 3782229 doi:10.1302/0301-620X.68B5.3782229 Cited on slide 42
  5. 5.
    HistoricalLandmark studiesPathophysiology
    DESTRUCTION OF THE "PYRAMIDAL TRACT" IN MAN
    Bucy PC, Keplinger JE, Siqueira EB. J Neurosurg. 1964;21:285-98.
    Report of surgical pyramidal tract section in humans, classically cited as evidence that corticospinal lesions chiefly impair fine hand movement rather than locomotion (no PubMed abstract).
    PubMed 14168200
  6. 6.
    RetrospectiveLandmark studiesPrognosis
    Age effect on prognosis for functional recovery in acute, traumatic central cord syndrome
    Penrod LE, Hegde SK, Ditunno JF Jr. Arch Phys Med Rehabil. 1990;71(12):963-8.
    51 consecutive CCS patients: 97% of those under 50 walked independently at discharge versus 41% of those 50 or older; age drives functional prognosis.
    PubMed 2241542 Cited on slide 42
  7. 7.
    RetrospectivePathophysiologyImaging
    Acute traumatic central cord syndrome: MRI-pathological correlations
    Quencer RM, Bunge RP, Egnor M, Green BA, Puckett W, Naidich TP. Neuroradiology. 1992;34(2):85-94.
    MRI-pathology correlation in 11 patients and 3 autopsies: ATCCS is predominantly lateral-column white-matter axonal injury; central hemorrhage is uncommon.
    PubMed 1603319 doi:10.1007/BF00588148 Cited on slide 9
  8. 8.
    RetrospectivePathophysiology
    A histopathological analysis of the human cervical spinal cord in patients with acute traumatic central cord syndrome
    Jimenez O, Marcillo A, Levi AD. Spinal Cord. 2000;38(9):532-7.
    Histopathology of five ATCCS cords showed primary lateral corticospinal tract injury with Wallerian degeneration, without loss of hand motor neurons.
    PubMed 11035473 doi:10.1038/sj.sc.3101052 Cited on slide 9
  9. 9.
    Narrative reviewPathophysiology
    Clinical syndromes associated with disproportionate weakness of the upper versus the lower extremities after cervical spinal cord injury
    Levi AD, Tator CH, Bunge RP. Neurosurgery. 1996;38(1):179-83; discussion 183-5.
    Argues there is no somatotopy in the primate corticospinal tract; arm-predominant weakness reflects the CST's role in hand function, not lamination.
    PubMed 8747967 doi:10.1097/00006123-199601000-00039 Cited on slide 9
  10. 10.
    Systematic review / meta-analysisDefinition & diagnosisSystematic reviews
    Diagnostic criteria of traumatic central cord syndrome. Part 1: a systematic review of clinical descriptors and scores
    Pouw MH, van Middendorp JJ, van Kampen A, Hirschfeld S, Veth RP, Em-sci study group. Spinal Cord. 2010;48(9):652-6.
    Systematic review of 30 studies found no consensus diagnostic criteria; mean UEMS was 10.5 points below LEMS, proposing a 10-point criterion.
    PubMed 20048754 doi:10.1038/sc.2009.155 Cited on slides 15, 16
  11. 11.
    Expert opinionDefinition & diagnosis
    Diagnostic criteria of traumatic central cord syndrome. Part 2: a questionnaire survey among spine specialists
    van Middendorp JJ, Pouw MH, Hayes KC, Williams R, Chhabra HS, Putz C. Spinal Cord. 2010;48(9):657-63.
    Survey of 157 AOSpine surgeons: definitions of TCCS varied widely; 61% accepted a ≥10-point LEMS-over-UEMS motor difference as a diagnostic criterion.
    PubMed 20585327 doi:10.1038/sc.2010.72 Cited on slide 15
  12. 12.
    Prospective cohortDefinition & diagnosisPrognosis
    Diagnostic criteria of traumatic central cord syndrome. Part 3: descriptive analyses of neurological and functional outcomes in a prospective cohort of traumatic motor incomplete tetraplegics
    Pouw MH, van Middendorp JJ, van Kampen A, Curt A, van de Meent H, Hosman AJ. Spinal Cord. 2011;49(5):614-22.
    EM-SCI cohort of 248 motor-incomplete tetraplegics: AIS grade, not the TCCS label, was the best prognostic parameter; functional outcomes did not differ by UEMS-LEMS gap.
    PubMed 21151190 doi:10.1038/sc.2010.171 Cited on slides 16, 42
  13. 13.
    RetrospectiveClassificationPrognosis
    A novel classification system for traumatic central cord syndrome: the central cord injury scale (CCIS)
    Hohl JB, Lee JY, Horton JA, Rihn JA. Spine (Phila Pa 1976). 2010;35(7):E238-43.
    37 TCCS patients: admission ASIA motor score and abnormal MRI cord signal predicted 1-year motor FIM, forming the three-tier Central Cord Injury Scale (CCIS).
    PubMed 20228699 doi:10.1097/BRS.0b013e3181c15887 Cited on slide 16
  14. 14.
    Narrative reviewDefinition & diagnosisReviews
    Central Cord Syndrome Redefined
    Avila MJ, Hurlbert RJ. Neurosurg Clin N Am. 2021;32(3):353-363.
    Reviews history, mechanism and pathophysiology of CCS and proposes redefining it as any adult cervical SCI without fracture or dislocation to standardize outcome data.
    PubMed 34053723 doi:10.1016/j.nec.2021.03.007 Cited on slide 16
  15. 15.
    GuidelineExaminationClassification
    International standards for neurological classification of spinal cord injury (revised 2011)
    Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A. J Spinal Cord Med. 2011;34(6):535-46.
    The 2011 revision of the ISNCSCI (ASIA) standards defining the neurological examination, motor/sensory scoring and AIS grading.
    PubMed 22330108 doi:10.1179/204577211X13207446293695 Cited on slide 17
  16. 16.
    GuidelineExaminationClassification
    International Standards for Neurological Classification of Spinal Cord Injury: Revised 2019
    Rupp R, Biering-Sørensen F, Burns SP, Graves DE, Guest J, Jones L. Top Spinal Cord Inj Rehabil. 2021;27(2):1-22.
    The 2019 ISNCSCI revision, current reference for the standardized neurological examination and AIS classification of SCI.
    PubMed 34108832 doi:10.46292/sci2702-1 Cited on slides 15, 17, 18
  17. 17.
    Narrative reviewPathophysiologyExamination
    Spinal shock revisited: a four-phase model
    Ditunno JF, Little JW, Tessler A, Burns AS. Spinal Cord. 2004;42(7):383-95.
    Proposes a four-phase model of spinal shock (areflexia, initial reflex return, early hyperreflexia, late hyperreflexia) with underlying mechanisms.
    PubMed 15037862 doi:10.1038/sj.sc.3101603 Cited on slides 17, 19
  18. 18.
    RetrospectiveHemodynamicsExamination
    Incidence and Natural Progression of Neurogenic Shock after Traumatic Spinal Cord Injury
    Ruiz IA, Squair JW, Phillips AA, Lukac CD, Huang D, Oxciano P. J Neurotrauma. 2018;35(3):461-466.
    84 SCI patients: reported neurogenic shock incidence varies widely by definition; combined hemodynamic-laboratory criteria gave 29% in cervical SCI, with hypovolemia a major confounder.
    PubMed 29141498 doi:10.1089/neu.2016.4947 Cited on slide 19
  19. 19.
    Expert opinionClassificationImaging
    The subaxial cervical spine injury classification system: a novel approach to recognize the importance of morphology, neurology, and integrity of the disco-ligamentous complex
    Vaccaro AR, Hulbert RJ, Patel AA, Fisher C, Dvorak M, Lehman RA Jr. Spine (Phila Pa 1976). 2007;32(21):2365-74.
    Introduces SLIC, scoring morphology, discoligamentous complex integrity and neurology to guide operative versus nonoperative treatment.
    PubMed 17906580 doi:10.1097/BRS.0b013e3181557b92 Cited on slide 26
  20. 20.
    Expert opinionClassificationImaging
    AOSpine subaxial cervical spine injury classification system
    Vaccaro AR, Koerner JD, Radcliff KE, Oner FC, Reinhold M, Schnake KJ. Eur Spine J. 2016;25(7):2173-84.
    AOSpine subaxial cervical injury classification with morphology types A-C, facet injury descriptors, neurological status and modifiers.
    PubMed 25716661 doi:10.1007/s00586-015-3831-3 Cited on slide 26
  21. 21.
    RetrospectiveEpidemiologyPrognosis
    Incidence and outcomes of spinal cord injury clinical syndromes
    McKinley W, Santos K, Meade M, Brooke K. J Spinal Cord Med. 2007;30(3):215-24.
    Of 839 SCI rehabilitation admissions, 20.9% had a clinical syndrome; CCS was most common (44%), the oldest group and had the lowest admission FIM.
    PubMed 17684887 doi:10.1080/10790268.2007.11753929
  22. 22.
    RetrospectiveEpidemiology
    Traumatic spinal cord injury in the United States, 1993-2012
    Jain NB, Ayers GD, Peterson EN, Harris MB, Morse L, O'Connor KC. JAMA. 2015;313(22):2236-43.
    US NIS 1993-2012 (63,109 patients): SCI incidence stable at ~54/million, with rising incidence in older adults driven by falls.
    PubMed 26057284 doi:10.1001/jama.2015.6250
  23. 23.
    RetrospectiveEpidemiologySurgery
    National trends in the management of central cord syndrome: an analysis of 16,134 patients
    Brodell DW, Jain A, Elfar JC, Mesfin A. Spine J. 2015;15(3):435-42.
    NIS 2003-2010 (16,134 CCS patients): 39.7% had surgery (ACDF most common), surgical rate rose ~40% per year, inpatient mortality 2.6%, higher with age and comorbidity.
    PubMed 25264321 doi:10.1016/j.spinee.2014.09.015 Cited on slide 38
  24. 24.
    RetrospectiveEpidemiology
    The changing demographics of traumatic spinal cord injury: An 11-year study of 831 patients
    Thompson C, Mutch J, Parent S, Mac-Thiong JM. J Spinal Cord Med. 2015;38(2):214-23.
    831 traumatic SCI patients over 11 years: mean age rose 13 years, older patients were mostly fall-related tetraplegics, and CCS incidence rose from 25% to 37%.
    PubMed 25096709 doi:10.1179/2045772314Y.0000000233
  25. 25.
    Prospective cohortImaging
    Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group
    Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. N Engl J Med. 2000;343(2):94-9.
    NEXUS: five clinical criteria identified cervical spine injury with 99.6% sensitivity in 34,069 blunt trauma patients.
    PubMed 10891516 doi:10.1056/NEJM200007133430203 Cited on slides 20, 22
  26. 26.
    Prospective cohortImaging
    The Canadian C-spine rule for radiography in alert and stable trauma patients
    Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ. JAMA. 2001;286(15):1841-8.
    Canadian C-Spine Rule derived in 8,924 alert stable trauma patients with 100% sensitivity for clinically important cervical injury.
    PubMed 11597285 doi:10.1001/jama.286.15.1841 Cited on slide 22
  27. 27.
    GuidelineImagingGuidelines
    Practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee
    Como JJ, Diaz JJ, Dunham CM, Chiu WC, Duane TM, Capella JM. J Trauma. 2009;67(3):651-9.
    EAST guideline: CT replaces plain radiographs as the primary imaging modality for cervical spine clearance after trauma.
    PubMed 19741415 doi:10.1097/TA.0b013e3181ae583b Cited on slide 22
  28. 28.
    GuidelineImagingGuidelines
    Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma
    Patel MB, Humble SS, Cullinane DC, Day MA, Jawa RS, Devin CJ. J Trauma Acute Care Surg. 2015;78(2):430-41.
    EAST guideline conditionally recommending collar removal after a negative high-quality CT in obtunded blunt trauma patients.
    PubMed 25757133 doi:10.1097/TA.0000000000000503 Cited on slide 22
  29. 29.
    Systematic review / meta-analysisImagingSystematic reviews
    Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis
    Holmes JF, Akkinepalli R. J Trauma. 2005;58(5):902-5.
    Meta-analysis: CT pooled sensitivity 98% versus 52% for plain radiography in detecting cervical spine injury.
    PubMed 15920400 doi:10.1097/01.ta.0000162138.36519.2a Cited on slide 22
  30. 30.
    Systematic review / meta-analysisImagingSystematic reviews
    Computed tomography alone versus computed tomography and magnetic resonance imaging in the identification of occult injuries to the cervical spine: a meta-analysis
    Schoenfeld AJ, Bono CM, McGuire KJ, Warholic N, Harris MB. J Trauma. 2010;68(1):109-13; discussion 113-4.
    Meta-analysis of 1,550 patients with negative CT: MRI found abnormalities in 12% and changed management in 6% (5% continued collar, 1% surgery).
    PubMed 20065765 doi:10.1097/TA.0b013e3181c0b67a
  31. 31.
    Systematic review / meta-analysisImagingReviews
    The role of magnetic resonance imaging in the management of acute spinal cord injury
    Bozzo A, Marcoux J, Radhakrishna M, Pelletier J, Goulet B. J Neurotrauma. 2011;28(8):1401-11.
    Literature review with Delphi vote: MRI strongly recommended for prognostication in acute SCI; four sagittal T2 patterns (normal, single-level edema, multilevel edema, hemorrhage) predict outcome.
    PubMed 20388006 doi:10.1089/neu.2009.1236 Cited on slides 20, 22, 25
  32. 32.
    Prospective cohortImagingPrognosisClassification
    The Brain and Spinal Injury Center score: a novel, simple, and reproducible method for assessing the severity of acute cervical spinal cord injury with axial T2-weighted MRI findings
    Talbott JF, Whetstone WD, Readdy WJ, Ferguson AR, Bresnahan JC, Saigal R. J Neurosurg Spine. 2015;23(4):495-504.
    60 cervical SCI patients: the 5-point BASIC score from axial T2 MRI correlated with AIS grade at admission and discharge with excellent interrater reliability.
    PubMed 26161519 doi:10.3171/2015.1.SPINE141033 Cited on slide 25
  33. 33.
    GuidelineImagingGuidelines
    Radiographic assessment
    Ryken TC, Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE. Neurosurgery. 2013;72 Suppl 2:54-72.
    AANS/CNS 2013 guideline: no imaging for awake asymptomatic patients meeting NEXUS/CCR; high-quality CT is the recommended primary study.
    PubMed 23417179 doi:10.1227/NEU.0b013e318276edee Cited on slides 20, 22
  34. 34.
    HistoricalLandmark studiesImagingDefinition & diagnosis
    Spinal cord injury without radiographic abnormalities in children
    Pang D, Wilberger JE Jr. J Neurosurg. 1982;57(1):114-29.
    Original description of SCIWORA in children: elastic pediatric spine, 52% delayed onset of paralysis, worse outcomes under age 8, grim prognosis for severe lesions.
    PubMed 7086488 doi:10.3171/jns.1982.57.1.0114
  35. 35.
    GuidelineGuidelinesSurgeryHemodynamics
    Management of acute traumatic central cord syndrome (ATCCS)
    Aarabi B, Hadley MN, Dhall SS, Gelb DE, Hurlbert RJ, Rozzelle CJ. Neurosurgery. 2013;72 Suppl 2:195-204.
    AANS/CNS 2013 ATCCS guideline: Level III recommendations for ICU care, MAP 85-90 mmHg for the first week and early decompression.
    PubMed 23417191 doi:10.1227/NEU.0b013e318276f64b Cited on slides 34, 37
  36. 36.
    GuidelineGuidelines
    Guidelines for the management of acute cervical spine and spinal cord injuries: 2013 update
    Walters BC, Hadley MN, Hurlbert RJ, Aarabi B, Dhall SS, Gelb DE. Neurosurgery. 2013;60(CN_suppl_1):82-91.
    Summary of the 2013 AANS/CNS guideline update for acute cervical spine and spinal cord injury management.
    PubMed 23839357 doi:10.1227/01.neu.0000430319.32247.7f
  37. 37.
    GuidelineGuidelinesHemodynamics
    The acute cardiopulmonary management of patients with cervical spinal cord injuries
    Ryken TC, Hurlbert RJ, Hadley MN, Aarabi B, Dhall SS, Gelb DE. Neurosurgery. 2013;72 Suppl 2:84-92.
    AANS/CNS 2013 cardiopulmonary guideline: ICU monitoring, avoid systolic BP below 90 mmHg and maintain MAP 85-90 mmHg for 7 days.
    PubMed 23417181 doi:10.1227/NEU.0b013e318276ee16 Cited on slides 28, 29
  38. 38.
    GuidelineGuidelinesSteroids
    Pharmacological therapy for acute spinal cord injury
    Hurlbert RJ, Hadley MN, Walters BC, Aarabi B, Dhall SS, Gelb DE. Neurosurgery. 2013;72 Suppl 2:93-105.
    AANS/CNS 2013 Level I recommendation against methylprednisolone for acute SCI, citing harm without proven benefit.
    PubMed 23417182 doi:10.1227/NEU.0b013e31827765c6 Cited on slide 47
  39. 39.
    GuidelineGuidelines
    Deep venous thrombosis and thromboembolism in patients with cervical spinal cord injuries
    Dhall SS, Hadley MN, Aarabi B, Gelb DE, Hurlbert RJ, Rozzelle CJ. Neurosurgery. 2013;72 Suppl 2:244-54.
    AANS/CNS 2013 guideline recommending VTE prophylaxis (LMWH or heparin plus mechanical) beginning within 72 hours of SCI.
    PubMed 23417195 doi:10.1227/NEU.0b013e31827728c0 Cited on slides 31, 43
  40. 40.
    GuidelineGuidelines
    A Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and Scope
    Fehlings MG, Tetreault LA, Wilson JR, Kwon BK, Burns AS, Martin AR. Global Spine J. 2017;7(3 Suppl):84S-94S.
    Introduction, rationale and scope of the 2017 AOSpine/CNS clinical practice guideline for acute SCI.
    PubMed 29164036 doi:10.1177/2192568217703387
  41. 41.
    GuidelineGuidelinesSurgical timingSurgery
    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
    Fehlings MG, Tetreault LA, Wilson JR, Aarabi B, Anderson P, Arnold PM. Global Spine J. 2017;7(3 Suppl):195S-202S.
    2017 AOSpine guideline suggests early (<24 h) surgery be offered for acute SCI regardless of level and considered for central cord syndrome (low-quality evidence).
    PubMed 29164024 doi:10.1177/2192568217706367 Cited on slide 37
  42. 42.
    GuidelineGuidelinesSteroids
    A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate
    Fehlings MG, Wilson JR, Tetreault LA, Aarabi B, Anderson P, Arnold PM. Global Spine J. 2017;7(3 Suppl):203S-211S.
    2017 AOSpine guideline: suggests a 24-hour high-dose MPSS infusion as an option within 8 hours of injury; not after 8 hours; no 48-hour infusion.
    PubMed 29164025 doi:10.1177/2192568217703085 Cited on slide 47
  43. 43.
    GuidelineGuidelinesSurgical timingSurgery
    An Update of a Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role and Timing of Decompressive Surgery
    Fehlings MG, Tetreault LA, Hachem L, Evaniew N, Ganau M, McKenna SL. Global Spine J. 2024;14(3_suppl):174S-186S.
    2024 AO Spine/Praxis update recommends surgery within 24 hours for all acute SCI (RR 2.76 for ≥2 AIS grade recovery at 6 months); no ultra-early recommendation.
    PubMed 38526922 doi:10.1177/21925682231181883 Cited on slides 37, 39
  44. 44.
    GuidelineGuidelinesHemodynamics
    A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on Hemodynamic Management
    Kwon BK, Tetreault LA, Martin AR, Arnold PM, Marco RAW, Newcombe VFJ. Global Spine J. 2024;14(3_suppl):187S-211S.
    2024 AO Spine/Praxis guideline suggests MAP lower limit 75-80 mmHg, upper limit 90-95 mmHg, for 3-7 days; no recommendation on vasopressor choice or SCPP.
    PubMed 38526923 doi:10.1177/21925682231202348 Cited on slides 28, 29
  45. 45.
    Systematic review / meta-analysisSystematic reviewsGuidelinesSurgical timingPrognosis
    Management and prognosis of acute traumatic cervical central cord syndrome: systematic review and Spinal Cord Society-Spine Trauma Study Group position statement
    Yelamarthy PKK, Chhabra HS, Vaccaro A, Vishwakarma G, Kluger P, Nanda A. Eur Spine J. 2019;28(10):2390-2407.
    Spinal Cord Society/STSG systematic review and position statement on ATCCS management and prognosis, favouring early surgery in selected patients.
    PubMed 31367852 doi:10.1007/s00586-019-06085-z Cited on slides 34, 37
  46. 46.
    Randomized trialSteroidsLandmark studies
    A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study
    Bracken MB, Shepard MJ, Collins WF, Holford TR, Young W, Baskin DS. N Engl J Med. 1990;322(20):1405-11.
    NASCIS II (n=487): methylprednisolone 30 mg/kg bolus plus 5.4 mg/kg/h for 23 h within 8 hours improved motor and sensory scores at 6 months.
    PubMed 2278545 doi:10.1056/NEJM199005173222001
  47. 47.
    Randomized trialSteroids
    Administration of methylprednisolone for 24 or 48 hours or tirilazad mesylate for 48 hours in the treatment of acute spinal cord injury. Results of the Third National Acute Spinal Cord Injury Randomized Controlled Trial. National Acute Spinal Cord Injury Study
    Bracken MB, Shepard MJ, Holford TR, Leo-Summers L, Aldrich EF, Fazl M. JAMA. 1997;277(20):1597-604.
    NASCIS III (n=499): 48-hour methylprednisolone improved motor recovery over 24-hour only when started 3-8 hours after injury, with more severe sepsis and pneumonia.
    PubMed 9168289
  48. 48.
    Systematic review / meta-analysisSteroidsSystematic reviews
    Steroids for acute spinal cord injury
    Bracken MB. Cochrane Database Syst Rev. 2012;1(1):CD001046.
    Cochrane review by the NASCIS lead author concluding high-dose methylprednisolone within 8 hours modestly improves motor recovery.
    PubMed 22258943 doi:10.1002/14651858.CD001046.pub2
  49. 49.
    Systematic review / meta-analysisSteroidsSystematic reviews
    Methylprednisolone for the Treatment of Patients with Acute Spinal Cord Injuries: A Systematic Review and Meta-Analysis
    Evaniew N, Belley-Côté EP, Fallah N, Noonan VK, Rivers CS, Dvorak MF. J Neurotrauma. 2016;33(5):468-81.
    Meta-analysis (4 RCTs, 17 observational): no long-term motor benefit from MPSS; increased GI bleeding in observational data; supports guidelines against routine use.
    PubMed 26529320 doi:10.1089/neu.2015.4192 Cited on slide 47
  50. 50.
    RetrospectiveHemodynamics
    Mean Arterial Blood Pressure Correlates with Neurological Recovery after Human Spinal Cord Injury: Analysis of High Frequency Physiologic Data
    Hawryluk G, Whetstone W, Saigal R, Ferguson A, Talbott J, Bresnahan J. J Neurotrauma. 2015;32(24):1958-67.
    Minute-by-minute MAP data in 100 SCI patients: higher MAP and less time below 85 mmHg in the first 2-3 days correlated with neurological recovery.
    PubMed 25669633 doi:10.1089/neu.2014.3778 Cited on slide 29
  51. 51.
    Systematic review / meta-analysisHemodynamicsSystematic reviews
    The impact of blood pressure management after spinal cord injury: a systematic review of the literature
    Saadeh YS, Smith BW, Joseph JR, Jaffer SY, Buckingham MJ, Oppenlander ME. Neurosurg Focus. 2017;43(5):E20.
    Systematic review of blood pressure management after SCI finding low-quality evidence supporting MAP augmentation to 85-90 mmHg for 5-7 days.
    PubMed 29088944 doi:10.3171/2017.8.FOCUS17428
  52. 52.
    RetrospectiveHemodynamicsSurgery
    Complications and outcomes of vasopressor usage in acute traumatic central cord syndrome
    Readdy WJ, Whetstone WD, Ferguson AR, Talbott JF, Inoue T, Saigal R. J Neurosurg Spine. 2015;23(5):574-580.
    34 ATCCS patients on vasopressors (mean age 62): dopamine caused significantly more cardiogenic complications than phenylephrine in patients over 55.
    PubMed 26230417 doi:10.3171/2015.2.SPINE14746 Cited on slides 29, 43
  53. 53.
    RetrospectiveHemodynamicsSurgery
    Medical and surgical management after spinal cord injury: vasopressor usage, early surgerys, and complications
    Inoue T, Manley GT, Patel N, Whetstone WD. J Neurotrauma. 2014;31(3):284-91.
    131 SCI patients on vasopressors: complications independently associated with dopamine (OR 8.97), phenylephrine, age ≥60 and complete SCI; surgery <24 h associated with improved outcome (OR 4.25).
    PubMed 24020382 doi:10.1089/neu.2013.3061
  54. 54.
    Prospective cohortHemodynamics
    Spinal cord perfusion pressure predicts neurologic recovery in acute spinal cord injury
    Squair JW, Bélanger LM, Tsang A, Ritchie L, Mac-Thiong JM, Parent S. Neurology. 2017;89(16):1660-1667.
    92 acute SCI patients with lumbar catheters: SCPP (MAP minus CSF pressure) independently predicted recovery; exposure to SCPP below 50 mmHg reduced likelihood of improvement, MAP alone did not.
    PubMed 28916535 doi:10.1212/WNL.0000000000004519
  55. 55.
    Prospective cohortSurgical timingSurgeryLandmark studies
    Early versus delayed decompression for traumatic cervical spinal cord injury: results of the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS)
    Fehlings MG, Vaccaro A, Wilson JR, Singh A, W Cadotte D, Harrop JS. PLoS One. 2012;7(2):e32037.
    STASCIS (n=313 cervical SCI): decompression <24 h gave ≥2-grade AIS improvement in 19.8% versus 8.8% for late surgery (adjusted OR 2.83).
    PubMed 22384132 doi:10.1371/journal.pone.0032037
  56. 56.
    Prospective cohortSurgical timingSurgery
    The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data
    Badhiwala JH, Wilson JR, Witiw CD, Harrop JS, Vaccaro AR, Aarabi B. Lancet Neurol. 2021;20(2):117-126.
    Pooled individual patient data (n=1548): surgery <24 h improved 1-year motor score by 4.0 points; recovery declined steeply with delay over the first 24-36 h.
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    Time is spine: a review of translational advances in spinal cord injury
    Badhiwala JH, Ahuja CS, Fehlings MG. J Neurosurg Spine. 2019;30(1):1-18.
    Comprehensive 'time is spine' review of secondary injury mechanisms and translational advances supporting early decompression and neuroprotection.
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    Timing of Decompression in Patients With Acute Spinal Cord Injury: A Systematic Review
    Wilson JR, Tetreault LA, Kwon BK, Arnold PM, Mroz TE, Shaffrey C. Global Spine J. 2017;7(3 Suppl):95S-115S.
    Systematic review underpinning the 2017 guideline: early decompression associated with improved neurological outcome, including in central cord syndrome.
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    Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now?
    Wilson JR, Witiw CD, Badhiwala J, Kwon BK, Fehlings MG, Harrop JS. Global Spine J. 2020;10(1 Suppl):84S-91S.
    State-of-the-art review of early surgery for traumatic SCI summarizing STASCIS-era evidence and remaining questions, including CCS.
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    The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability
    Lenehan B, Fisher CG, Vaccaro A, Fehlings M, Aarabi B, Dvorak MF. Spine (Phila Pa 1976). 2010;35(21 Suppl):S180-6.
    STSG data: surgery within 24 h for CCS without instability gave 6.31 more motor points at 12 months; experts endorse early surgery for AIS C.
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  61. 61.
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    Optimal Timing of Surgical Decompression for Acute Traumatic Central Cord Syndrome: A Systematic Review of the Literature
    Anderson KK, Tetreault L, Shamji MF, Singh A, Vukas RR, Harrop JS. Neurosurgery. 2015;77 Suppl 4:S15-32.
    Systematic review of nine TCCS studies: surgery <24 h appears safe and effective, with moderate evidence favouring surgery within 2 weeks.
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    Delayed surgery after acute traumatic central cord syndrome is associated with reduced mortality
    Samuel AM, Grant RA, Bohl DD, Basques BA, Webb ML, Lukasiewicz AM. Spine (Phila Pa 1976). 2015;40(5):349-56.
    NTDB analysis of 1,060 surgically treated ATCCS patients: each 24-hour delay was associated with 19% lower odds of inpatient mortality.
    PubMed 25757037 doi:10.1097/BRS.0000000000000756
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    The role of decompression for acute incomplete cervical spinal cord injury in cervical spondylosis
    Chen TY, Dickman CA, Eleraky M, Sonntag VK. Spine (Phila Pa 1976). 1998;23(22):2398-403.
    37 spondylotic patients with incomplete cord injury: 81% of 16 surgical patients improved within 2 days, with faster recovery and shorter stay than 21 nonoperative patients.
    PubMed 9836353 doi:10.1097/00007632-199811150-00007
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    Traumatic central cord syndrome: results of surgical management
    Guest J, Eleraky MA, Apostolides PJ, Dickman CA, Sonntag VK. J Neurosurg. 2002;97(1 Suppl):25-32.
    50 surgically treated CCS patients: surgery ≤24 h shortened ICU and hospital stay and improved motor recovery in disc herniation/fracture cases but not in stenosis/spondylosis.
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    A review of surgical intervention in the setting of traumatic central cord syndrome
    Stevens EA, Marsh R, Wilson JA, Sweasey TA, Branch CL Jr, Powers AK. Spine J. 2010;10(10):874-80.
    126 CCS patients (67 surgical): surgery improved Frankel grade versus medical management; timing did not significantly change neurological outcome, with a trend to fewer complications when early.
    PubMed 20869001 doi:10.1016/j.spinee.2010.07.388
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    Efficacy of Ultra-Early (< 12 h), Early (12-24 h), and Late (>24-138.5 h) Surgery with Magnetic Resonance Imaging-Confirmed Decompression in American Spinal Injury Association Impairment Scale Grades A, B, and C Cervical Spinal Cord Injury
    Aarabi B, Akhtar-Danesh N, Chryssikos T, Shanmuganathan K, Schwartzbauer GT, Simard JM. J Neurotrauma. 2020;37(3):448-457.
    72 AIS A-C cervical SCI patients with MRI-confirmed decompression: AIS improvement did not differ by timing (65.6% ultra-early, 60% early, 80% late); intramedullary lesion length predicted outcome.
    PubMed 31310155 doi:10.1089/neu.2019.6606
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    Early versus late surgery for traumatic spinal cord injury: the results of a prospective Canadian cohort study
    Wilson JR, Singh A, Craven C, Verrier MC, Drew B, Ahn H. Spinal Cord. 2012;50(11):840-3.
    84 SCI patients (35 early surgery): more ≥2-grade AIS improvement with surgery <24 h, and adjusted motor score gain significantly favoured early surgery.
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    Management of Acute Traumatic Central Cord Syndrome: A Narrative Review
    Divi SN, Schroeder GD, Mangan JJ, Tadley M, Ramey WL, Badhiwala JH. Global Spine J. 2019;9(1 Suppl):89S-97S.
    Narrative review of ATCCS management summarizing epidemiology, imaging, timing evidence and surgical approaches.
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    Early outcome and predictors of early outcome in patients treated surgically for central cord syndrome
    Kepler CK, Kong C, Schroeder GD, Hjelm N, Sayadipour A, Vaccaro AR. J Neurosurg Spine. 2015;23(4):490-4.
    68 surgically treated CCS patients: no difference in 7-day motor score change between surgery within 1 day and delayed surgery; older age was the only predictor of early change.
    PubMed 26161520 doi:10.3171/2015.1.SPINE141013
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    Predictors of outcome in acute traumatic central cord syndrome due to spinal stenosis
    Aarabi B, Alexander M, Mirvis SE, Shanmuganathan K, Chesler D, Maulucci C. J Neurosurg Spine. 2011;14(1):122-30.
    42 ATCCS-stenosis patients: admission ASIA motor score, midsagittal diameter, canal compromise, T2 lesion length and age predicted 1-year outcomes.
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    Factors predicting motor recovery and functional outcome after traumatic central cord syndrome: a long-term follow-up
    Dvorak MF, Fisher CG, Hoekema J, Boyd M, Noonan V, Wing PC. Spine (Phila Pa 1976). 2005;30(20):2303-11.
    Long-term TCCS follow-up: ASIA motor score improved from 58.7 to 92.3; initial motor score, age, education, comorbidity and spasticity predicted function.
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    Predictors of neurologic recovery in acute central cervical cord injury with only upper extremity impairment
    Ishida Y, Tominaga T. Spine (Phila Pa 1976). 2002;27(15):1652-8; discussion 1658.
    22 nonoperatively treated patients with upper-extremity-only central cord injury recovered nearly fully by 6 weeks; absence of MRI cord signal change was the strongest predictor (OR 64).
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    The long-term outcome after central cord syndrome: a study of the natural history
    Newey ML, Sen PK, Fraser RD. J Bone Joint Surg Br. 2000;82(6):851-5.
    Natural history of 32 conservatively managed CCS patients at 8.6 years: all under 50 walked with bladder control, whereas those over 70 did poorly and most had died.
    PubMed 10990310 doi:10.1302/0301-620x.82b6.9866
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    Traumatic central cord syndrome: analysis of factors affecting the outcome
    Yamazaki T, Yanaka K, Fujita K, Kamezaki T, Uemura K, Nose T. Surg Neurol. 2005;63(2):95-9; discussion 99-100.
    47 CCS patients: AP canal diameter and injury-to-surgery interval predicted excellent recovery; authors recommend timely surgery, preferably within 2 weeks, in selected patients.
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    A clinical prediction model for long-term functional outcome after traumatic spinal cord injury based on acute clinical and imaging factors
    Wilson JR, Grossman RG, Frankowski RF, Kiss A, Davis AM, Kulkarni AV. J Neurotrauma. 2012;29(13):2263-71.
    Prediction model from 376 SCI patients: 1-year FIM predicted by admission AIS grade, motor score >50, younger age and absence of MRI edema/hemorrhage (AUC 0.93).
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    Spinal cord injury associated with cervical spinal canal stenosis: Outcomes and prognostic factors
    Ronzi Y, Perrouin-Verbe B, Hamel O, Gross R. Ann Phys Rehabil Med. 2018;61(1):27-32.
    63 patients with SCI on cervical stenosis without instability (mean age 60, 78% falls): 60% walked, 75% regained bladder control; higher AIS, age under 60 and CCS/Brown-Sequard-plus predicted good outcome.
    PubMed 28993290 doi:10.1016/j.rehab.2017.09.003 Cited on slide 42
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    Incidence and severity of acute complications after spinal cord injury
    Grossman RG, Frankowski RF, Burau KD, Toups EG, Crommett JW, Johnson MM. J Neurosurg Spine. 2012;17(1 Suppl):119-28.
    NACTN prospective cohort (n=315): 58% had a complication, 84% of AIS A versus 25% of AIS D, mostly within 14 days; respiratory failure and pneumonia led; mortality 3.5%.
    PubMed 22985378 doi:10.3171/2012.5.AOSPINE12127 Cited on slide 43
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    Central cord syndrome
    Nowak DD, Lee JK, Gelb DE, Poelstra KA, Ludwig SC. J Am Acad Orthop Surg. 2009;17(12):756-65.
    JAAOS review of central cord syndrome covering mechanism, presentation, imaging, treatment controversy and outcomes for orthopaedic surgeons.
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    Central cord injury: pathophysiology, management, and outcomes
    Harrop JS, Sharan A, Ratliff J. Spine J. 2006;6(6 Suppl):198S-206S.
    Spine Journal review of central cord injury pathophysiology, management and outcomes.
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    Acute traumatic central cord syndrome: a comprehensive review
    Molliqaj G, Payer M, Schaller K, Tessitore E. Neurochirurgie. 2014;60(1-2):5-11.
    Comprehensive review of ATCCS: epidemiology, pathophysiology, imaging, treatment and prognosis.
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    Update on critical care for acute spinal cord injury in the setting of polytrauma
    Yue JK, Winkler EA, Rick JW, Deng H, Partow CP, Upadhyayula PS. Neurosurg Focus. 2017;43(5):E19.
    Update on critical care for acute SCI in polytrauma: airway, hemodynamic targets, VTE prophylaxis and systemic complications.
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    Early vs Late Surgical Decompression for Central Cord Syndrome
    Badhiwala JH, Wilson JR, Harrop JS, Vaccaro AR, Aarabi B, Geisler FH. JAMA Surg. 2022;157(11):1024-1032.
    Propensity-matched analysis of 186 CCS patients: surgery <24 h improved 1-year upper-limb motor recovery (MD 2.3); AIS C gained 9.5 points, AIS D no difference.
    PubMed 36169962 doi:10.1001/jamasurg.2022.4454 Cited on slides 16, 17, 34, 39
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    Treatment of Acute Traumatic Central Cord Syndrome: A Study of North American Trauma Centers
    Badhiwala JH, Witiw CD, Wilson JR, da Costa LB, Nathens AB, Fehlings MG. Neurosurgery. 2024;94(4):700-710.
    TQIP 2014-2016 (3,928 CCS patients, 255 centers): 38.8% treated nonoperatively; large unexplained inter-center variability (median OR 2.02).
    PubMed 38038474 doi:10.1227/neu.0000000000002767
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    Early versus late surgical decompression for patients with acute traumatic central cord syndrome: a systematic review and meta-analysis
    Sattari SA, Antar A, Theodore JN, Hersh AM, Al-Mistarehi AH, Davidar AD. Spine J. 2024;24(3):435-445.
    Meta-analysis of 9 studies (5,619 ATCCS): early (<24 h) surgery improved 1-year motor score by 4.89 points and reduced VTE, complications and LOS.
    PubMed 37890727 doi:10.1016/j.spinee.2023.10.013 Cited on slide 43
  85. 85.
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    Timing of decompression in central cord syndrome: a systematic review and meta-analysis
    Xu L, Zhong W, Liu C, Zhao H, Xiong Y, Zhou S. Eur Spine J. 2024;33(9):3593-3601.
    Meta-analysis of 13 studies (8,424 CCS): early surgery improved motor score (MD 7.22) and lowered complications (OR 0.53) with no mortality difference.
    PubMed 38625584 doi:10.1007/s00586-024-08244-3
  86. 86.
    Systematic review / meta-analysisSurgical timingSystematic reviews
    Surgical intervention ≤ 24 hours versus > 24 hours after injury for the management of acute traumatic central cord syndrome: a systematic review and meta-analysis
    Bin-Alamer O, Qedair J, Abou-Al-Shaar H, Mallela AN, Balasubramanian K, Alnefaie N. J Neurosurg Spine. 2024;40(5):653-661.
    Meta-analysis of 7 studies (488 ATCCS): surgery ≤24 h had fewer surgical complications (1.2% vs 4.5%); motor gain not statistically significant.
    PubMed 38335527 doi:10.3171/2023.11.SPINE23789
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    RetrospectiveSurgical timingSurgeryPrognosis
    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
    Aarabi B, Akhtar-Danesh N, Simard JM, Chryssikos T, Shanmuganathan K, Olexa J. J Neurotrauma. 2021;38(15):2073-2083.
    101 AIS C/D ATCCS-stenosis patients with MRI-confirmed decompression: timing (≤24 h, 25-72 h, >72 h) did not affect 6-month motor score; admission AMS did.
    PubMed 33726507 doi:10.1089/neu.2021.0040 Cited on slides 17, 25, 38
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    Central cord syndrome definitions, variations and limitations
    Engel-Haber E, Snider B, Kirshblum S. Spinal Cord. 2023;61(11):579-586.
    Reviews and classifies competing CCS definitions (including the ≥10-point LEMS-UEMS criterion), highlighting inconsistency and need for universal criteria.
    PubMed 37015975 doi:10.1038/s41393-023-00894-2 Cited on slide 16
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    RetrospectiveEpidemiologySurgical timing
    Trends in Operative Timing for Acute Traumatic Central Cord Syndrome: National Inpatient Sample Analysis 2013-2019
    Gagliardi TA, Fleisher I, Lapow J, Spirollari E, Sullivan T, Carr A. Clin Spine Surg. 2025;38(10):486-492.
    NIS 2013-2019 (21,265 operated ATCCS): early surgery rising over time; early surgery independently associated with less prolonged LOS and AKI.
    PubMed 39950670 doi:10.1097/BSD.0000000000001770
  90. 90.
    RetrospectivePrognosisEpidemiology
    Five-year mortality after traumatic central cord syndrome in Wales
    Stanley AL, Jones TJ, Dasic D, Kakarla S, Kolli S, Shanbhag S. Bone Joint J. 2023;105-B(8):920-927.
    Welsh population cohort (n=65): 32% five-year mortality after traumatic CCS, 56% in patients over 70; management type did not affect mortality.
    PubMed 37524347 doi:10.1302/0301-620X.105B8.BJJ-2022-1104.R2 Cited on slide 43
  91. 91.
    RetrospectiveEpidemiologySurgerySurgical timing
    Utilization and timing of surgical intervention for central cord syndrome in the United States
    Dhodapkar MM, Halperin SJ, Seddio AE, Dahodwala T, Rubio DR, Grauer JN. Eur Spine J. 2024;33(9):3645-3651.
    PearlDiver 2015-2020 (11,653 CCS without fracture): only 17.2% had surgery, rising from 11.5% to 19.7%, increasingly within two days.
    PubMed 39103615 doi:10.1007/s00586-024-08431-2
  92. 92.
    Systematic review / meta-analysisSurgical timingSystematic reviews
    Timing of Decompressive Surgery in Patients With Acute Spinal Cord Injury: Systematic Review Update
    Fehlings MG, Hachem LD, Tetreault LA, Skelly AC, Dettori JR, Brodt ED. Global Spine J. 2024;14(3_suppl):38S-57S.
    SR update (21 studies): moderate evidence that surgery ≤24 h doubles ≥2-grade AIS recovery (RR 2.76) and adds 4.5 motor points without more complications; ultra-early inconclusive.
    PubMed 38526929 doi:10.1177/21925682231197404
  93. 93.
    Systematic review / meta-analysisHemodynamicsSystematic reviews
    Interventions to Optimize Spinal Cord Perfusion in Patients With Acute Traumatic Spinal Cord Injury: An Updated Systematic Review
    Evaniew N, Davies B, Farahbakhsh F, Fehlings MG, Ganau M, Graves D. Global Spine J. 2024;14(3_suppl):58S-79S.
    SR update (28 studies): effect of MAP support on recovery is uncertain (low/very low quality); higher SCPP may improve recovery; no reliable guidance on agents, ranges or duration.
    PubMed 38526931 doi:10.1177/21925682231218737
  94. 94.
    Expert opinionSurgical timingReviews
    Central Cord Syndrome Is Likewise a Surgical Emergency-Time Is Spine
    Okonkwo DO, Mushlin HM. JAMA Surg. 2022;157(11):1032-1033.
    Invited commentary on Badhiwala 2022 arguing that central cord syndrome should be treated as a surgical emergency.
    PubMed 36169970 doi:10.1001/jamasurg.2022.4455
  95. 95.
    RetrospectiveClassificationPrognosis
    The Central Cord Score: A Novel Classification and Scoring System Specific to Acute Traumatic Central Cord Syndrome
    Ramey WL, Reyes AA, Avila MJ, Hurlbert RJ, Chapman JR, Dumont TM. World Neurosurg. 2021;156:e235-e242.
    51 ATCCS patients scored on distal UE strength, sensation, ambulation, MRI signal and urinary retention; surgery <24 h gave better upper-extremity motor scores at ≥3 months.
    PubMed 34536617 doi:10.1016/j.wneu.2021.09.037 Cited on slide 16