Central cord syndrome: Difference between revisions

	Central Cord Syndrome;
	Central cord syndrome is top diagram
ICD-9	952.18
DiseasesDB	33409
eMedicine	pmr/22
MeSH	D020210

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Latest revision as of 09:59, 1 September 2020

Central cord syndrome (CCS) is an acute cervical spinal cord injury (SCI), characterized by disproportionately greater motor impairment in upper compared to lower extremities, bladder dysfunction, and variable degree of sensory loss below the level of injury. This syndrome is unlike a complete lesion, that causes loss of all sensation and movement below the level of the injury. First described by Schneider in 1954,^[1] CCS has been reported to occur more frequently among older persons with cervical spondylosis who sustain hyperextension injury. Though it also may occur in persons of any age. CCS is the most common incomplete SCI syndrome.

CCS most often occurs after hyperextension injury in an individual with long-standing cervical spondylosis. Historically, spinal cord damage was believed to originate from concussion or contusion of the cord with stasis of axoplasmic flow, causing edematous injury rather than destructive hematomyelia. More recently, autopsy studies have demonstrated that CCS may be caused by bleeding into the central part of the cord, portending less favorable prognosis. Studies also have shown that CCS probably is associated with axonal disruption in the lateral columns at the level of the injury to the spinal cord with relative preservation of the grey matter.

In the US the prevalence rate is 15.7-25% however this syndrome is generally associated with favorable prognosis for some degree of neurologic and functional recovery. CCS predominantly affects men more than women, similar to all other SCI.

Historical Perspective

Central Cord Syndrome was first described by Schneider , et al in 1954.^[2]

Quencer, et al was the first to discover the association between neuroradiological and pathologic findings and the development of Central Cord Syndrome.^[2]

Raynor and Koplik described that the central part of the spinal cord was most affected when a moderate force was applied in an anterior posterior direction using the stress analysis theory.^[2]

In early 1970s surgical treatment was suggested by Quencer, et al to treat Central Cord syndrome.^[2]

Classification

There is no established system for the classification of Central Cord Syndrome.

Pathophysiology

It is thought that Central Cord Syndrome is the result of Compression of the spinothalamic and corticospinal tracts of the spinal cord, is caused by either^[3].

Hyperextension injury.^[3]
Cervical spondylosis.^[3]
Arterial ischemia to the spinal cord^[3]
Central intraparenchymal spinal cord hematoma ^[3]
Isolated injury to the decussating CorticoSpinal tracts in the brain stem. ^[3]

Causes

Central Cord Syndrome can be caused by

Trauma( MVA, Falls, Diving)^[3]
Preexisting cervical spondylosis ^[3]
Ischemia^[3]

Differentiating Central Cord Syndrome from other Diseases

Central Cord Syndrome must be differentiated from

Devic's Syndrome.^[4]
Primary Sjogren syndrome involving the Central Nervous System.^[4]
Multiple Sclerosis.^[4]

Epidemiology and Demographics

The incidence/prevalence of [disease name] is approximately [number range] per 100,000 individuals worldwide.

OR

In [year], the incidence/prevalence of [disease name] was estimated to be [number range] cases per 100,000 individuals worldwide.

OR

In [year], the incidence of [disease name] is approximately [number range] per 100,000 individuals with a case-fatality rate of [number range]%.

Patients of all age groups may develop [disease name].

OR

The incidence of [disease name] increases with age; the median age at diagnosis is [#] years.

OR

[Disease name] commonly affects individuals younger than/older than [number of years] years of age.

OR

[Chronic disease name] is usually first diagnosed among [age group].

OR

[Acute disease name] commonly affects [age group].

There is no racial predilection to [disease name].

OR

[Disease name] usually affects individuals of the [race 1] race. [Race 2] individuals are less likely to develop [disease name].

[Disease name] affects men and women equally.

OR

[Gender 1] are more commonly affected by [disease name] than [gender 2]. The [gender 1] to [gender 2] ratio is approximately [number > 1] to 1.

The majority of [disease name] cases are reported in [geographical region].

OR

[Disease name] is a common/rare disease that tends to affect [patient population 1] and [patient population 2].

Risk Factors

There are no established risk factors for [disease name].

OR

The most potent risk factor in the development of [disease name] is [risk factor 1]. Other risk factors include [risk factor 2], [risk factor 3], and [risk factor 4].

OR

Common risk factors in the development of [disease name] include [risk factor 1], [risk factor 2], [risk factor 3], and [risk factor 4].

OR

Common risk factors in the development of [disease name] may be occupational, environmental, genetic, and viral.

Screening

There is insufficient evidence to recommend routine screening for [disease/malignancy].

OR

According to the [guideline name], screening for [disease name] is not recommended.

OR

According to the [guideline name], screening for [disease name] by [test 1] is recommended every [duration] among patients with [condition 1], [condition 2], and [condition 3].

Natural History, Complications, and Prognosis

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

Diagnosis

Diagnostic Study of Choice

The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].

OR

The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].

OR

The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].

OR

There are no established criteria for the diagnosis of [disease name].

History and Symptoms

The majority of patients with [disease name] are asymptomatic.

OR

The hallmark of [disease name] is [finding]. A positive history of [finding 1] and [finding 2] is suggestive of [disease name]. The most common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3]. Common symptoms of [disease] include [symptom 1], [symptom 2], and [symptom 3]. Less common symptoms of [disease name] include [symptom 1], [symptom 2], and [symptom 3].

Physical Examination

Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].

OR

Common physical examination findings of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

The presence of [finding(s)] on physical examination is diagnostic of [disease name].

OR

The presence of [finding(s)] on physical examination is highly suggestive of [disease name].

Laboratory Findings

An elevated/reduced concentration of serum/blood/urinary/CSF/other [lab test] is diagnostic of [disease name].

OR

Laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

OR

[Test] is usually normal among patients with [disease name].

OR

Some patients with [disease name] may have elevated/reduced concentration of [test], which is usually suggestive of [progression/complication].

OR

There are no diagnostic laboratory findings associated with [disease name].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

There are no other diagnostic studies associated with [disease name].

OR

[Diagnostic study] may be helpful in the diagnosis of [disease name]. Findings suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

Other diagnostic studies for [disease name] include [diagnostic study 1], which demonstrates [finding 1], [finding 2], and [finding 3], and [diagnostic study 2], which demonstrates [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Surgery

Surgical intervention is not recommended for the management of [disease name].

OR

Surgery is not the first-line treatment option for patients with [disease name]. Surgery is usually reserved for patients with either [indication 1], [indication 2], and [indication 3]

OR

The mainstay of treatment for [disease name] is medical therapy. Surgery is usually reserved for patients with either [indication 1], [indication 2], and/or [indication 3].

OR

The feasibility of surgery depends on the stage of [malignancy] at diagnosis.

OR

Surgery is the mainstay of treatment for [disease or malignancy].

Primary Prevention

There are no established measures for the primary prevention of [disease name].

OR

There are no available vaccines against [disease name].

OR

Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].

OR

[Vaccine name] vaccine is recommended for [patient population] to prevent [disease name]. Other primary prevention strategies include [strategy 1], [strategy 2], and [strategy 3].

Secondary Prevention

There are no established measures for the secondary prevention of [disease name].

OR

Effective measures for the secondary prevention of [disease name] include [strategy 1], [strategy 2], and [strategy 3].

References

↑ Schneider RC, Cherry G, Pantek H (1954). "The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine". J. Neurosurg. 11 (6): 546–77. PMID 13222164.
↑ ^2.0 ^2.1 ^2.2 ^2.3 Guest, James; Eleraky, Mohammed A.; Apostolides, Paul J.; Dickman, Curtis A.; Sonntag, Volker K. H. (2002). "Traumatic central cord syndrome: results of surgical management". Journal of Neurosurgery: Spine. 97 (1): 25–32. doi:10.3171/spi.2002.97.1.0025. ISSN 1547-5654.
↑ ^3.0 ^3.1 ^3.2 ^3.3 ^3.4 ^3.5 ^3.6 ^3.7 ^3.8 Harrop, James S.; Sharan, Ashwini; Ratliff, Jonathon (2006). "Central cord injury: pathophysiology, management, and outcomes". The Spine Journal. 6 (6): S198–S206. doi:10.1016/j.spinee.2006.04.006. ISSN 1529-9430.
↑ ^4.0 ^4.1 ^4.2 Epstein, NancyE; Hollingsworth, Renee (2015). "Diagnosis and management of traumatic cervical central spinal cord injury: A review". Surgical Neurology International. 6 (5): 140. doi:10.4103/2152-7806.156552. ISSN 2152-7806.

Template:Disease-stub Template:Lesions of spinal cord and brainstem

[1] Schneider RC, Cherry G, Pantek H (1954). "The syndrome of acute central cervical spinal cord injury; with special reference to the mechanisms involved in hyperextension injuries of cervical spine". J. Neurosurg. 11 (6): 546–77. PMID 13222164.

[GuestEleraky2002-2] 2.0 ^2.1 ^2.2 ^2.3 Guest, James; Eleraky, Mohammed A.; Apostolides, Paul J.; Dickman, Curtis A.; Sonntag, Volker K. H. (2002). "Traumatic central cord syndrome: results of surgical management". Journal of Neurosurgery: Spine. 97 (1): 25–32. doi:10.3171/spi.2002.97.1.0025. ISSN 1547-5654.

[HarropSharan2006-3] 3.0 ^3.1 ^3.2 ^3.3 ^3.4 ^3.5 ^3.6 ^3.7 ^3.8 Harrop, James S.; Sharan, Ashwini; Ratliff, Jonathon (2006). "Central cord injury: pathophysiology, management, and outcomes". The Spine Journal. 6 (6): S198–S206. doi:10.1016/j.spinee.2006.04.006. ISSN 1529-9430.

[EpsteinHollingsworth2015-4] 4.0 ^4.1 ^4.2 Epstein, NancyE; Hollingsworth, Renee (2015). "Diagnosis and management of traumatic cervical central spinal cord injury: A review". Surgical Neurology International. 6 (5): 140. doi:10.4103/2152-7806.156552. ISSN 2152-7806.

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@@ Line 22: / Line 22: @@
 In the US the [[prevalence]] rate is 15.7-25% however this syndrome is generally associated with favorable prognosis for some degree of neurologic and functional recovery. CCS predominantly affects men more than women, similar to all other SCI.
 ==Historical Perspective==
-[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].
+*Central Cord Syndrome  was first described by Schneider , et al   in 1954.<ref name="GuestEleraky2002">{{cite journal|last1=Guest|first1=James|last2=Eleraky|first2=Mohammed A.|last3=Apostolides|first3=Paul J.|last4=Dickman|first4=Curtis A.|last5=Sonntag|first5=Volker K. H.|title=Traumatic central cord syndrome: results of surgical management|journal=Journal of Neurosurgery: Spine|volume=97|issue=1|year=2002|pages=25–32|issn=1547-5654|doi=10.3171/spi.2002.97.1.0025}}</ref>
-The association between [important risk factor/cause] and [disease name] was made in/during [year/event].
+*Quencer, et al was the first to discover the association between neuroradiological and pathologic findings  and the development of Central Cord Syndrome.<ref name="GuestEleraky2002">{{cite journal|last1=Guest|first1=James|last2=Eleraky|first2=Mohammed A.|last3=Apostolides|first3=Paul J.|last4=Dickman|first4=Curtis A.|last5=Sonntag|first5=Volker K. H.|title=Traumatic central cord syndrome: results of surgical management|journal=Journal of Neurosurgery: Spine|volume=97|issue=1|year=2002|pages=25–32|issn=1547-5654|doi=10.3171/spi.2002.97.1.0025}}</ref>
-In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].
+*Raynor and Koplik described that the central part of the spinal cord was most affected when a moderate force was applied in an anterior posterior direction using the stress analysis theory.<ref name="GuestEleraky2002">{{cite journal|last1=Guest|first1=James|last2=Eleraky|first2=Mohammed A.|last3=Apostolides|first3=Paul J.|last4=Dickman|first4=Curtis A.|last5=Sonntag|first5=Volker K. H.|title=Traumatic central cord syndrome: results of surgical management|journal=Journal of Neurosurgery: Spine|volume=97|issue=1|year=2002|pages=25–32|issn=1547-5654|doi=10.3171/spi.2002.97.1.0025}}</ref>
-In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].
+*In early 1970s surgical treatment  was suggested by  Quencer, et al to treat Central Cord syndrome.<ref name="GuestEleraky2002">{{cite journal|last1=Guest|first1=James|last2=Eleraky|first2=Mohammed A.|last3=Apostolides|first3=Paul J.|last4=Dickman|first4=Curtis A.|last5=Sonntag|first5=Volker K. H.|title=Traumatic central cord syndrome: results of surgical management|journal=Journal of Neurosurgery: Spine|volume=97|issue=1|year=2002|pages=25–32|issn=1547-5654|doi=10.3171/spi.2002.97.1.0025}}</ref>
-There have been several outbreaks of [disease name], including -----.
-In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].
 ==Classification==
-There is no established system for the classification of [disease name].
+There is no established system for the classification of Central Cord Syndrome.
-OR
-[Disease name] may be classified according to [classification method] into [number] subtypes/groups: [group1], [group2], [group3], and [group4].
-OR
-[Disease name] may be classified into [large number > 6] subtypes based on [classification method 1], [classification method 2], and [classification method 3].
-[Disease name] may be classified into several subtypes based on [classification method 1], [classification method 2], and [classification method 3].
-OR
-Based on the duration of symptoms, [disease name] may be classified as either acute or chronic.
-OR
-If the staging system involves specific and characteristic findings and features:
-According to the [staging system + reference], there are [number] stages of [malignancy name] based on the [finding1], [finding2], and [finding3]. Each stage is assigned a [letter/number1] and a [letter/number2] that designate the [feature1] and [feature2].
-OR
-The staging of [malignancy name] is based on the [staging system].
-OR
-There is no established system for the staging of [malignancy name].
 ==Pathophysiology==
-The exact pathogenesis of [disease name] is not fully understood.
-OR
-It is thought that [disease name] is the result of / is mediated by / is produced by / is caused by either [hypothesis 1], [hypothesis 2], or [hypothesis 3].
-OR
+It is thought that Central Cord Syndrome  is the result of Compression of the spinothalamic and corticospinal tracts of the spinal cord, is caused by either<ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>.
+*Hyperextension injury.<ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
-[Pathogen name] is usually transmitted via the [transmission route] route to the human host.
+*Cervical spondylosis.<ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
+*Arterial ischemia to the spinal cord<ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
-OR
+*Central intraparenchymal spinal cord hematoma <ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
+*Isolated injury to the decussating CorticoSpinal tracts in the brain stem. <ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
-Following transmission/ingestion, the [pathogen] uses the [entry site] to invade the [cell name] cell.
-OR
-[Disease or malignancy name] arises from [cell name]s, which are [cell type] cells that are normally involved in [function of cells].
-OR
-The progression to [disease name] usually involves the [molecular pathway].
-OR
-The pathophysiology of [disease/malignancy] depends on the histological subtype.
 ==Causes==
-Disease name] may be caused by [cause1], [cause2], or [cause3].
+Central Cord Syndrome can be caused by
+*Trauma( MVA, Falls, Diving)<ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
-OR
+*Preexisting cervical spondylosis <ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
+*Ischemia<ref name="HarropSharan2006">{{cite journal|last1=Harrop|first1=James S.|last2=Sharan|first2=Ashwini|last3=Ratliff|first3=Jonathon|title=Central cord injury: pathophysiology, management, and outcomes|journal=The Spine Journal|volume=6|issue=6|year=2006|pages=S198–S206|issn=15299430|doi=10.1016/j.spinee.2006.04.006}}</ref>
-Common causes of [disease] include [cause1], [cause2], and [cause3].
-OR
-The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].
-OR
-The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click [[Pericarditis causes#Overview|here]].
-==Differentiating ((Page name)) from other Diseases==
-[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
-OR
+==Differentiating Central Cord Syndrome from other Diseases==
-[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].
+Central Cord Syndrome  must be differentiated from
+* Devic's Syndrome.<ref name="EpsteinHollingsworth2015">{{cite journal|last1=Epstein|first1=NancyE|last2=Hollingsworth|first2=Renee|title=Diagnosis and management of traumatic cervical central spinal cord injury: A review|journal=Surgical Neurology International|volume=6|issue=5|year=2015|pages=140|issn=2152-7806|doi=10.4103/2152-7806.156552}}</ref>
+* Primary Sjogren syndrome involving the Central Nervous System.<ref name="EpsteinHollingsworth2015">{{cite journal|last1=Epstein|first1=NancyE|last2=Hollingsworth|first2=Renee|title=Diagnosis and management of traumatic cervical central spinal cord injury: A review|journal=Surgical Neurology International|volume=6|issue=5|year=2015|pages=140|issn=2152-7806|doi=10.4103/2152-7806.156552}}</ref>
+* Multiple Sclerosis.<ref name="EpsteinHollingsworth2015">{{cite journal|last1=Epstein|first1=NancyE|last2=Hollingsworth|first2=Renee|title=Diagnosis and management of traumatic cervical central spinal cord injury: A review|journal=Surgical Neurology International|volume=6|issue=5|year=2015|pages=140|issn=2152-7806|doi=10.4103/2152-7806.156552}}</ref>
 ==Epidemiology and Demographics==