Introduction: Spinal cord injuries are prevalent and need to be appropriately recognized, diagnosed, and treated so that patients with these injuries can have as much neurological function as possible. Although automobile crashes account for the majority of spinal cord injuries, other mechanisms such as falls and gunshot wounds, may cause this problem. By recognizing these injuries and completing the appropriate work-up, these conditions can be managed most efficiently, providing the best patient care.

Case Presentation: 61-year-old presented to the emergency department with a chief complaint of bilateral upper extremity weakness and paresthesias post syncopal episode while sitting on the commode. Upon waking, she was unable to move any extremities. On arrival in the emergency department, her legs were neurologically intact and some function had returned to her arms. She denied neck pain, back pain, and incontinence. She also denied any constitutional symptoms including fever or chills, as well as chest pain, dyspnea, nausea, and vomiting. She reported she was in her usual state of health until this syncopal episode. Her only medication is a 325 mg aspirin daily.

On admission, her temperature was 98.3 F, pulse 90, respirations 16 per minute with a patent airway, oxygen saturation was 98% on room air, and blood pressure was 119/57. The patient was alert and oriented and did not appear to be in distress. Neurologically, she had difficulty resisting gravity in her upper extremities bilaterally with concomitant paresthesias. She had an NIH Stroke Score of 5 based on presentation, but tPA was not given based on clinical judgement and a concern for a traumatic injury. Her labs were unremarkable and a CT head without contrast was negative for any acute intracranial findings. A CT of the cervical spine demonstrated horizontal, non-displaced fractures in the C3 and C4 vertebral bodies extending to the left lamina, a displaced corner fracture of the C4 body, and a mildly displaced fracture of the C4 spinous process. MRI of the cervical spine demonstrated a 2mm thick epidural hematoma anteriorly and posteriorly, and a ligamentous injury from C2-C3 to C6-C7. The cervical MRI also showed a focal cord signal abnormality at the C4 level consistent with central cord syndrome, which was likely due to her reported hyperextension injury. An MRI of the thoracic spine was negative for any acute findings and CT angiography of the neck was negative for dissection, stenosis, or occlusion.

Diagnosis: central cord syndrome

Management: The patient was transferred for care by neurosurgical and trauma services.

Discussion: This case illustrates the prompt and accurate diagnosis of central cord syndrome in a patient with painless and unexplained post-syncopal neurological findings.