Central cord syndrome (CCS), an injury often seen in the elderly, is caused by hyperextension of the cervical spine resulting in weakness and sensory changes with the upper extremities more affected than the lower. Recovery is variable and residual deficits are common. Three reports of CCS as a result of endotracheal intubation exist in the literature.[1-3] We present a fourth case that occurred when a patient was emergently re-intubated.
A 77-year-old physically active woman with a history of an ischemic cardiomyopathy presented to an outside hospital with fever and respiratory distress. The patient was intubated in the emergency department, and improved slowly with treatment of community acquired pneumonia. The patient was noted to be neurologically intact at the time of admission and immediately prior to extubation. The patient was extubated on hospital day four but developed respiratory distress within fifteen minutes and was re-intubated. The re-intubation was uncomplicated with a full view of the vocal cords utilizing a Macintosh #3 blade on the first attempt and easy passage of the endotracheal tube. The patient was transferred to our institution on hospital day eight. Admission examination revealed that although she was able to weakly move her legs, her arms were nearly plegic. On questioning, the patient’s family recalled noting diminished movement of her upper extremities following re-intubation. In consultation, neurology and neurosurgery found the patient to have severe flaccid paresis of her bilateral upper extremities, which was more severe on the left, and antigravity strength in her bilateral lower extremities with flexor plantar responses and no clonus. An MRI revealed diffuse spondylosis with moderate to severe stenosis at C4-5 with anterolisthesis and associated cord deformity. Although the patient’s neurological status improved modestly, she had a prolonged hospital course and failed to wean from mechanical ventilation. The family decided not to pursue aggressive care when the patient progressed to aneuric renal failure, supportive care was withdrawn, and the patient expired.
CCS, the most common form of incomplete spinal cord injury, is a well-described phenomenon that produces asymmetric and incomplete tetraplegia and sensory deficit disproportionately affecting the upper extremities. In patients with cervical spondylosis, hyperextension causes compression of the cord between the ligamentum flavum posteriorly and anterior osteophytes resulting in contusion of the cord centrally.Initial theories to explain the degree of involvement of the arms claimed somatotopic organization of the lateral corticospinal tracts, with the hand and arms based medially, near the site of the contused cord, with the legs laterally  have been rejected after animal models proved no basis for this type of organization. The current thinking is that the upper limb, in particular the hand, is more represented in the lateral corticospinal tract than the leg, which has the majority of its descending fibers from other tracts.
We present a case of CCS in a patient with occult cervical stenosis following urgent re-intubation. Extension of the cervical spine during direct laryngoscopy for intubation is capable of producing CCS, in both patients with preexisting cervical pathology, as in our patient, as well in patients with no demonstrable pre-existing cervical pathology. Caution should be used when intubating the elderly and patients with known cervical spine pathology.
Mark Napier, None.