Case Presentation: A sixty-five-year-old man presented to the hospital with coffee ground emesis and generalized abdominal pain. He was hemodynamically stable, and imaging showed a small bowel obstruction with ileitis. He underwent laparoscopic omental band lysis and improved without further episodes of bleeding. On post-operative day two, the patient was to be discharged home and was noted to have bilateral upper extremity weakness 2/5 and lower extremity weakness 3/5. Patient’s gait was noted to be ataxic. Multiple studies were ordered, CT of the brain showed no hemorrhage or infarct. Vitamin B12, folate, thyroid stimulating hormone, and RPR all within normal limits. MRI brain was performed showing no significant abnormalities. MRI cervical and thoracic spine were significant for osteoarthritis with severe stenosis most significant at C5-C6 and C6-C7 with thecal sac indentation at T10 without endplate or cord edema. Neurosurgery found the imaging as well as his exam to be consistent with central cord syndrome. The patient continued with physical therapy with some improvement. The patient was not offered steroids as he was past the acute phase and there was no edema. Patient was offered surgical decompression to avoid further injury in the future but declined the procedure.
Discussion: Central cord syndrome is incomplete injury to the spinal cord with neurological deficits primarily affecting males in a bimodal pattern of distribution. Often, this affects elderly males with underlying spinal disease and can easily be missed if the symptoms are mild at presentation. This usually occurs from hyperextension injury from the posterior cord being irritated or compressed by posterior ligamentum flavum or by the anterior cord compression from underlying spondylosis or osteolytic lesions. These injuries can lead to symptoms secondary to edema. Physical exam findings result from compression on the spinothalamic tract and the corticospinal tract which result in sensory and motor deficits. Evaluation should be with imaging with magnetic resonance imaging (MRI) which is the most sensitive. Treatment at time of presentation includes steroids and physical therapy/occupational therapy (PT/OT); surgery is rarely indicated.
Conclusions: Central cord syndrome is difficult to diagnose early on as symptoms can be mild. This patient’s presentation was unusual as he initially presented to the hospital with coffee ground emesis and had a small bowel obstruction. He subsequently developed weakness of a then unknown etiology. The patient was intubated for the procedure routinely with no difficulties. At the time of surgery no one was aware of the significant arthritis in the cervical spine or the severe canal stenosis. This may have contributed to his development of central cord syndrome after extension during intubation from the procedure. Treatment includes occupational and physical therapy, steroids in the acute phase when there is edema, and sometimes surgical decompression to avoid further injury in the future.