Background: The management of central cord syndrome (CCS) is controversial. There is a perception that CCS patients tend to improve without the need for surgical intervention. The purpose of this study was to compare the clinical improvements of patients with traumatic SCI, both with and without CCS. Methods: Nova Scotia Provincial Trauma Registry was retrospectively reviewed from 2005-2010. Improvement in the American Spinal Injury Association (ASIA) Impairment Scale (AIS) was determined after mean 5 months follow-up. Results: The study population comprised 96 cases with SCI, subdivided into cases with AIS grade A, non-CCS cases with AIS grades B-D and CCS cases. 88% of the non-CCS and 65% of the CCS patients underwent surgical decompression, with mean operative times being 71.6±137.8 and 102.9±144.6 post injury (p=0.45). The mean improvements in the mean ASIA motor scores for the three groups were 1.3±6.5 and 15.6±35.0 and 22.5±14.6 (p=0.004) respectively, with a statistically significant difference only between the CCS and AIS grade A groups (p<0.001). 20%, 54% and 10% of the patients respectively, underwent an improvement of ≥ one AIS grades (p=0.018, c2=8.0). Conclusions: This retrospective review investigates the natural history of CCS and explores the role of surgical intervention on optimizing patient outcome.