Central cord syndrome — to operate or not?

Similar conditions somehow comes in threes. I managed a triplet of central cord syndrome recently…

These sufferers are admitted with acute paralysis in all four limbs following a fall/minor trauma. They may be totally well before the fall but have silent pre-exitising spinal cord compression in the neck. The trauma suffered from hyper flexion of the neck causes spinal cord injury with resultant weakness.

Myelo C1 C3 to7
Spinal cord Compression with Myelomalacia of the spinal cord from C1 to C7

I always see fear in the patients eyes and the insecurity of being dependant on others as they become incapacitated, not being able to dress or walk. As this condition develops acutely, they usually cannot accept and will grasps at any hope offered by surgery.

Surgical decompression— offers a chance for recovery. I would explain to patients it is akin freeing an exsanguinated finger from a knot tied around it, the finger lives at least but no guarantee it will move well and become normal again. Decompressing also prevent further cord injury in future when the patient falls again.

My first patient in the series of three was 63 year old man who could not walk upon admission. He was lying in bed unable to sit even as he lost his truncal balance. His grip was weak and no fine movement were possible. He was desperate for a fix as he could no longer function. Surgical decompression done gave a tremendous result and he began sitting and walking at 3weeks. Lucky guy…

The second gentleman was a 52 year old aircraft technician who fell at work and had temporary paralysis for 30mins. He came in with upper limb weakness, unable to raise his shoulders at all. He also opted to surgery promptly and recovered one shoulder’s power at 2weeks.

The third gentleman presented a dilemma as he was over 90 years old with   a poor heart, renal failure and having diabetes. He could not stand nor walk for 2 weeks and was going down hill. Surgery presented hope but high risk peri-operatively from heart attacks etc. Relatives were called in and there were long family conferences held to inform the choices to them. In the end, patient decided to live with the deficit in a wheelchair and be dependant on his kids and caregiver.

Non-surgical treatment offers no hope of recovery. Surgery offers hope of recovery but a risk of preoperative death. Operating on the elderly has always been a difficult and stressful undertaking as surgeons do not wish for bad outcomes which happens sometimes. But, telling the patients that there is no hope left and he will be confined to a wheelchair rest of his life is equally cruel.

The choices in life are dichotomised for us. Once a route is chosen, there is no backtracking. I wish this elderly gentleman a painless and peaceful remaining life…..

 

 

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