Edit concept Question Editor Create issue ticket

Cervical Myelopathy

Cervical myelopathy is a clinical syndrome that involves the disruption of neuronal impulses from the brain through the spinal cord, at the level of the cervical spine. Due to the location of the signal interruption, the patient may experience symptoms related to the arms, hands, legs, bowel and bladder functions.


Presentation

Cervical myelopathy may lead to a multitude of symptoms which pertain to many regions of the body, including the arms, hands, feet, bowel and bladder. Motor function and sensory stimuli may be impaired. It is common for the diagnosis to be delayed, since the symptoms experienced by the patients are neither specific, nor pathognomonic.

The fashion in which the symptoms present is also variable: it is possible for the disease to be diagnosed within a week from the onset of the symptoms and also possible for decades to pass, before significant symptomatology is present in order to reach a diagnosis [6]. The rate of development is also not specific, even for the very same individual; periods of time with minimal progression are interchanged with periods of time when the symptoms deteriorate with increased speed. It is practically no specific way to predict the character of the symptoms' progression, even though older patients experience a generally more rapid symptomatology deterioration rate.

Common symptoms arising from cervical myelopathy include the following:

  • Loss of balance
  • Lack of coordination and/or dexterity
  • Weakness
  • Numb extremities
  • Paralysis
  • Pain, usually to the neck. It may be accompanied by headaches or pain radiating to the shoulder region, to the arms or hands [7].
  • Inability to control the hands

Neurological symptoms may also be present, such as the Babinski sign, clonic jerks, hyperflexia or bowel and bladder dysfunction. Simultaneously, the arms and hands may be atrophic.

Arm Pain
  • CLINICAL FEATURES: A patient with arm pain and numbness was referred by a neurosurgeon for nonsurgical consult. He had a large C5-6 disk herniation with no signs or symptoms of myelopathy.[ncbi.nlm.nih.gov]
  • STUDY DESIGN: A case of cervical myelopathy with a severe nape and upper arm pain caused by anomalous bilateral vertebral arteries is reported.[ncbi.nlm.nih.gov]
  • Japanese Orthopaedic Association score (JOA score) and visual analog scale of neck pain, upper arm pain and numbness were evaluated before surgery, and at scheduled time points after surgery.[ncbi.nlm.nih.gov]
  • Cervical Myelopathy A disc prolapse generally causes compression of a nerve causing cervical radiculopathy (arm pain, numbness, pins and needles, and weakness). However, a cervical disc prolapse can also compress the spinal cord in the neck.[langdonspine.com]
Turkish
  • Copyright 2017 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.[ncbi.nlm.nih.gov]
Neck Pain
  • This is a case report of a 67-year-old man who presented with neck pain with progressive myelopathy. Neurologic examination demonstrated a cervical myelopathy with muscle weakness and sensory disturbance of both extremities.[ncbi.nlm.nih.gov]
  • Visual analog scale of neck pain was 0/10 in all 3 patients at follow-up. No patients showed evidence of spinal instability after surgery.[ncbi.nlm.nih.gov]
  • SUMMARY OF BACKGROUND DATA: Cervical muscle alterations have been reported in patients with chronic neck pain, but the assessment of cervical muscle morphology has been overlooked in patients with DCM.[ncbi.nlm.nih.gov]
  • The Japanese Orthopedic Association scoring system (JOA score), axial neck pain, and radiological findings were analyzed.[ncbi.nlm.nih.gov]
  • There was no significant difference found postoperatively between LF and EL groups in terms of postoperative JOA (P 0.39), VAS neck pain (P 0.93), postoperative CCI (P 0.32) and Nurich grade (P 0.42).[ncbi.nlm.nih.gov]
Cervical Osteoarthritis
  • Cervical osteoarthritis and abnormal alignment is called cervical spondylosis . When the spinal canal is narrowed and the spinal cord is being compressed, it leads to dysfunction of the nerves of the spinal cord.[my-spine.com]
Hyperreflexia
  • BACKGROUND: Gait dysfunction associated with spasticity and hyperreflexia is a primary symptom in patients with compression of cervical spinal cord.[ncbi.nlm.nih.gov]
  • Abstract Diabetes may affect the typical physical findings associated with cervical spondylotic myelopathy, as coexisting diabetic neuropathy may dampen expected hyperreflexia and also produce non-dermatomal extremity numbness.[ncbi.nlm.nih.gov]
  • Symptoms and Signs Cord compression commonly causes gradual spastic paresis, paresthesias, or both in the hands and feet and may cause hyperreflexia. Neurologic deficits may be asymmetric, nonsegmental, and aggravated by cough or Valsalva maneuvers.[merckmanuals.com]
  • On physical examination upper motor neuron signs are present including hyperreflexia, clonus, spasticity, Lhermitte’s phenomenon, up-going plantar response, and Hoffmann’s sign [ 4 ].[aclr.com.es]
  • […] shoulder Numbness or paresthesia in the upper extremities Sensory changes in the lower extremities Motor weakness in the extremities Gait difficulties ("spastic gait," hesitant and jerky) Myelopathic or "upper motor neuron" findings such as spasticity, hyperreflexia[emoryhealthcare.org]
Clonus
  • […] or paresthesia in the upper extremities Sensory changes in the lower extremities Motor weakness in the extremities Gait difficulties ("spastic gait," hesitant and jerky) Myelopathic or "upper motor neuron" findings such as spasticity, hyperreflexia, clonus[emoryhealthcare.org]
  • Thus these medical signs will become pathological: Increased tension in the leg muscles (Hyperreflexia) Accentuated reflexes of the knee and ankle Forced extension of the ankle may cause the foot to beat up and down rapidly (clonus) Stimulating the sole[dr-bertagnoli.com]
  • […] both the upper and lower extremities is often present (foraminal stenosis or peripheral neuropathy may result in absent reflexes) The inverted radial reflex (finger flexion instead of a brachioradialis reflex) Positive Babinski and Hoffman reflexes Clonus[tristate-ortho.com]
  • Physical examination revealed hyperreflexia of all right-sided deep-tendon reflexes and sustained clonus of the right ankle.[consultant360.com]
  • CSM is that it will involve the axial skeleton and skip the head and face. 9 Clark suggested that sensory findings usually include preservation of touch, loss of pain and temperature, loss of proprioception and vibration below the level of lesion. 2 Clonus[dynamicchiropractic.com]
Long Tract Signs
  • This case highlights the need to look for long tract signs of physical exam to explore possible causes of cervical myelopathy to account for weakness in the legs, which cannot be accounted by the low back alone.[aclr.com.es]
  • […] extremities; - Brown-Séquard syndrome : - ipsilateral motor deficits with contralateral sensory deficits - may be the least advanced form of the disease; - Brachialgia and cord syndrome: radicular pain in the upper extremity along with motor and/or sensory long-tract[wheelessonline.com]
  • When the stenosis and myelopathy is severe, most patients will develop long tract signs (UMN) consisting of a wide-based gait, balance difficulties, and weakness.[uscspine.com]
Spastic Paraplegia
  • Other conditions like primary spinal cord tumors, syringomyelia, metastatic tumors, subacute combined degeneration of the spinal cord (vitamin B12 deficiency), hereditary spastic paraplegia, normal pressure hydrocephalus, and spinal cord infarction can[boneandspine.com]
Lower Motor Neurone Lesion
  • CONCLUSIONS: When there is diagnostic ambiguity between the upper and lower motor neuron lesions in VAD, motor-evoked potential study can be helpful to diagnose peripheral neurological complication of VAD.[ncbi.nlm.nih.gov]
Urinary Retention
  • Other studies have found that 20% of their patients with degenerative myelopathy over age 65 had bladder dysfunction, mostly associated with urinary retention.[necksolutions.com]
  • - Discussion: - characterized by weakness (upper lower extremity); - ataxic broad based suffling gait, sensory changes; - rarely urinary retention; - anatomy of compression: - anterior cord compression ---- protruding disc or posterior osteophytes ; -[wheelessonline.com]

Workup

Cervical myelopathy is diagnosed according to the patient's medical history, physical examination and radiographic depiction, which is expected to reveal changes consistent with the condition.

A plain radiograph of the cervical region of the spinal cord is expected to illustrate severe stenosis, which indicates augmented levels of pressure exerted on the organ, as well as osteophytes and subluxation. On the other hand, a magnetic resonance imaging scan (MRI) is an additional tool, that will help to further inspect the affected area, as it can depict the associated ligaments and invertebral discs; it can also help to rule out some etiologies, such as a tumor or syrinx [8]. T2-weighted hyperintensity at the precise location of the signal disruption has been associated with the severity of the condition and is co-evaluated from a prognostic point of view. T1 hypointensity is an indicator of possible ischemia, gliosis and osteomalacia: it is viewed as a poor prognostic factor [9] [10].

Staphylococcus Aureus
  • This 70-year-old woman initially presented with a methicillin-sensitive Staphylococcus aureus osteomyelitis involving the C-2 odontoid process.[ncbi.nlm.nih.gov]

Treatment

Cervical myelopathy is primarily characterized by increased levels of pressure to which the spinal cord is subjected to, due to an underlying pathology that causes compression of the organ. Therefore, every therapeutic regime aims at relieving the aforementioned pressure, so that neuronal signals, motor and sensory functions, can be restored.

Surgical intervention is the method of choice and is opted for in cases of mild to severe cervical myelopathy, or even in cases with minor stenotic changes that are in good general health and do not constitute high-risk surgical candidates. It is believed that these categories of patients benefit more from surgical therapy, in comparison with a conservative type of treatment. Techniques that are mainly used include the classic anterior cervical discectomy and fusion, performed in cases of anterior compression and the posterior laminectomy and fusion, reserved for patients affected by stenotic alienations caused by a pathology that is located on the posterior side of the spinal cord [11] [12].

Given that the majority of the patients who are diagnosed with cervical myelopathy are aged over 60 or 70 years old, comorbidities are often present; this reality implies that a considerable number of the patients do not constitute good surgical candidates. Conservative treatment can be the method of choice in this case, which involves regular sessions of physiotherapy, the use of a soft collar and lifestyle modifications, such as avoiding weight lifting or strenuous exercise.

Prognosis

Patients usually benefit greatly from surgical intervention, as the pressure exerted on the spinal cord is relieved and detrimental damage to the patient's functionality can be hindered. Nevertheless, surgery is often followed by complications, that depend on the typo of co-existent pathologies, especially given the fact that most patients who require surgical treatment are of a progressed age.

Etiology

Cervical myelopathy involves the narrowing of the spinal canal, which leads to the interruption of the neuronal signal that descends from the brain through the spinal cord or ascends from the periphery to the brain. A multitude of etiologies can account for such a condition; if it occurs at an age greater than 60 years old, it is usually attributed to degenerative spondylosis. Cases that are diagnosed at a younger age may be due to a congenital stenotic tendency of the cervical region of the spinal cord.

In general, any pathology that disrupts the regular transmission of the signals through the spinal cord and is localized to the area of the cervical spine can result in cervical myelopathy. Possible etiologies include:

  • Traumatization
  • Viral infections
  • Tumors, malignant or non-malignant
  • Autoimmune disorders
  • Inflammatory disorders

Epidemiology

Cervical myelopathy is a condition that displays a clear predilection for male patients, in comparison to female ones.

Specifically, it has been calculated that nearly 100% of the male patients and 96% of the female patients in their 70th decade are affected by cervical myelopathy [2]. Individuals affected by rheumatoid arthritis display radiographic findings consistent with cervical myelopathy at a rate of 85% [3].

Sex distribution
Age distribution

Pathophysiology

Cervical myelopathy occurs when the spinal canal is compressed to a diameter of 13 millimeters, with the normal diameter being approximately 17 millimeters. Even though the basic pathophysiological mechanism that underlies cervical myelopathy is the compression of the spinal canal due to stenotic changes, each distinct pathology is followed by its own specific characteristics.

Disc herniation is a common cause of cervical myelopathy. As the inner portion of the vertebral disc herniates through the fibers, it occupies considerable space, leading to an elevated amount of pressure exerted to the spinal cord. On the other hand, a congenital type of stenosis implies that the patient is born with a narrower spinal canal at the cervical area, which inevitably leaves the spinal cord with less space than in other, healthy individuals. individuals born with congenital myelopathy usually experience no discomfort due to this degree of stenosis, but proceed to a symptomatic stage when degenerative spondylosis aggravates the narrowed part.

Acute traumatization may also lead to cervical myelopathy, either due to inflammation, direct damage or the development of a hematoma. In the same way, tumors that grow within the spine can directly damage the signal transmission, although this condition is relatively rare. The tumors that can compress the spinal cord may originate in the area within the spinal canal (intramedullary region) or outside the spinal canal (extramedullary region). Cases of ossification of the posterior longitudinal ligament can also lead to cervical spondylosis.

Lastly, spondylosis is one of the leading causes of cervical myelopathy, as it is a degenerative process that affects the cervical disc and then progresses to the endplates of the vertebral bodies. The latter receive a great deal of pressure and, as a result, osteophytes develop. The condition mentioned in the previous paragraph, ossification of the longitudinal ligament, can also partake in the pathogenesis of cervical spondylotic myelopathy [4] [5].

Prevention

Cervical myelopathy can unfortunately not be prevented.

Summary

Cervical myelopathy is a condition that affects the anatomy of the spine, with stenotic changes of the cervical region leading to the interruption of the neuronal signal and various associated neurological symptoms. The majority of the patients are diagnosed either with a congenital type of cervical stenosis or with a degenerative stenosis, induced by spondylosis. Except for these potential causes, cervical myelopathy may develop as a result of spinal stenosis caused by a tumor (intra- or extramedullary), viral infections, autoimmune disorders or traumatizations of the spinal canal at the height of the cervical spine.

Cervical myelopathy involves a plethora of symptoms; they are of neurological nature but their variety combined with the lack of a pathognomonic symptom or sign renders the disease prone to misdiagnosis or a delayed diagnosis. Sensory impairment affecting the hands or feet, gait abnormalities, weakness of the limbs or even paralysis are some of the symptoms associated with cervical myelopathy. Bowel and bladder dysfunction, as well as paresthetic phenomena may also be present. Diagnosis is achieved by acquiring a detailed medical history, a thorough clinical examination and imaging evaluation, including a plain radiograph and a magnetic resonance imaging scan of the cervical spine.

Cervical myelopathy requires early treatment in order to prevent permanent destructive damage to the spinal cord [1]. Surgical intervention is an option for patients who are good surgical candidates, whereas there are also conservative options for those whose co-morbidities constitute contraindications for a surgical intervention.

Patient Information

The spinal cord is a sensitive organ that is contained within the spinal canal. Its function is to host the nerves that travel from the brain to the periphery and send signals related to every possible function required by the organism. At the same time, the spinal cord also hosts ascending nerves, namely those that pick stimuli from the environment and transmit them to the brain for evaluation. the latter is referred to as sensory functions.

The spinal cord is sensitive to pressure alterations. Any condition or change that increases the amount of pressure exerted on the organ can lead to the disruption of the nerve signals that travel all the way up or down the spinal cord. This disorder is known as cervical myelopathy, when the factor that causes the signal interruption is located on the cervical region of the spinal cord.

Cervical myelopathy can arise due to many possible causes. Disc protrusion, degenerative processes that lead to a narrower spinal canal, tumors that compress from the inside or outside, viruses or autoimmune diseases can result in cervical myelopathy. Ligaments of the spinal cord can, as the age progresses, become calcified, therefore leading to abnormal amounts of pressure targeted on the organ. Disc herniation and degenerative stenosis (spondylosis) are amongst the most common causes of cervical myelopathy.

The cervical spine, since it is the top part of the spinal cord, hosts nerves that control the movement of the hands, feet and intestines; any nerve signal interruption can, as a result, cause symptoms that affect all these structures. For this reason, the symptomatology associated with cervical myelopathy is extremely diverse and there is no specific symptom that can direct the physician towards this specific diagnosis. Patients report a variety of symptoms, such as weakness of the arms, legs and hands, poor coordination, unbalanced gait and paresthesias (abnormal tingling or prickling sensations of the arms or legs). More severe symptoms include paralysis of the extremities or inability to control them, bowel and bladder incontinence. In general, the condition may develop extremely slowly, requiring up to 26 years in order to reach its peak and be diagnosed or it may be so aggressive, as to unfold over a period of a couple of weeks. Once the disorder is diagnosed, the rate of symptom progression also varies extremely even for the same individual: symptom progression may be minimal for some periods of time and rapid at other points.

The compression that the spinal cord is subjected to needs to be addressed, in order to prevent devastating and permanent damage to the spinal cord and an individual's functionality. Surgery is the preferred method when the condition is from moderate to severe, or in cases of patients who may experience minor symptoms but are in good health and can undergo surgery. Patients who are at a high risk of developing surgery-related complications are treated conservatively with physiotherapy, a soft collar and lifestyle modifications.

References

Article

  1. Baronand E, Young WF. Cervical spondylotic myelopathy: a brief review of its pathophysiology, clinical course, and diagnosis. Neurosurgery. 2007; 60: 35–41.
  2. Irvine DH, Foster JB, Newell DJ, Klukvin BN. Prevalence of cervical spondylosis in a general practice. Lancet.1965; 14: 1089-92.
  3. Bland JH. Rheumatoid arthritis of the cervical spine. J Rheumatol. 1974; 1: 319-42.
  4. Kumaresan S, Yoganandan N, Pintar FA, et al. Contribution of disc degeneration to osteophyte formation in the cervical spine: a biomechanical investigation. Journal of Orthopaedic. 2011; 19(5): 977–984.
  5. Hoff JT, Wilson CB. The pathophysiology of cervical spondylotic radiculopathy and myelopathy. Clinical Neurosurgery. 1977; 24:474–487.
  6. Brain WR, Northfield D, Wilkinson M. The neurolog-ical manifestations of cervical spondylosis. Brain. 1952; 75(2): 187–225.
  7. Vedantam K, Revanappa K, Rajshekhar V. Changes in the range of motion of the cervical spine and adjacent segments at 24 months after uninstrumented corpectomy for cervical spondylotic myelopathy. Acta Neurochirurgica. 2011; 153: 995–1001.
  8. Hsu W, Dorsi MJ, Witham TF. Surgical management of cervical spondylotic myelopathy. Neurosurgery Quarterly. 2009; 19: 302–307.
  9. Mehalic TF, Pezzuti RT, Applebaum BI. Magnetic resonance imaging and cervical spondylotic myelopathy. Neurosurgery. 1990; 26(2): 217–227.
  10. Okada Y, Ikata T, Yamada H. Magnetic resonance imaging study on the results of surgery for cervical compression myelopathy. Spine. 1993; 18: 2024–2029.
  11. Cloward RB. The anterior approach for removal of ruptured cervical disks. Journal of Neurosurgery. 1958; 15: 602–617.
  12. Smith GW, Robinson RA. The treatment of certain cervical-spine disorders by anterior removal of intervertebral disc and fusion. American Journal of Bone and Joint Surgery.1958; 40: 607–624.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-22 04:25