Cervical Myelopathy

Original Editor - Bridgit A Finley.

Top Contributors - Laura Ritchie, Rachael Lowe, Bridgit A Finley, Stefanie Van De Vijver, Kim Jackson, Admin, Evan Thomas, Vidya Acharya, Loes Verspecht, Lise Buelens, Dale Boren, Manisha Shrestha, Bram Van Laer, Lucinda hampton, Simisola Ajeyalemi, Scott Cornish, WikiSysop, Karen Wilson, Timothy Assi, Jess Bell, Olajumoke Ogunleye, Aminat Abolade, Naomi O'Reilly, Habibu Salisu Badamasi, Ilke Joukes and Kai A. Sigel

Definition/Description[edit | edit source]

Cervical myelopathy is the result of spinal cord compression in the cervical spine. Any space occupying lesion within the cervical spine with the potential to compress the spinal cord can result in this degenerative disease of the spinal cord. [1] [2]Cervical compression in myelopathy is predominantly due to pressure on the anterior spinal cord with ischaemia and to deformation of the cord by anterior herniated discs, spondylitic spurs or an ossified posterior longitudinal ligament. [3]Human histological studies revealed degeneration of the anterior horns, cavity formation, and demyelination in the severely compressed spinal cord. The spontaneous course of myelopathy is characterized either by long periods of stable disability followed by episodes of deterioration or a linear progressive course. The presentation of a cervical myelopathy varies in accordance to the severity of the spinal cord compression, and it's location.[4]

Clinically Relevant Anatomy
[edit | edit source]

There are seven cervical vertebrae and eight cervical nerve roots.[5] [2] The spinal cord is the extension of the central nervous system outside the cranium. It is encased by the vertebral column and begins at the foramen magnum. [6] The spinal cord is an extremely vital part of the central nervous system, and even a small injury to it can lead to severe disability. [7]
A complex system of ligaments serves to stabilize and protect the cervical spine. For example, the ligamentum flavum that extends from the anterior surface of the cephalic vertebra to the posterior surface of the caudal vertebra and connects to the ventral aspect of the facet joint capsules. A ligament that is also often involved in this condition is the posterior longitudinal ligament. It is situated within the vertebral canal, and extends along the posterior surfaces of the bodies of the vertebræ, from the body of the axis, where it is continuous with the membrana tectoria, to the sacrum.[7]

Cervical Vertebra
Ligamentum Flavum


Chronic cervical degeneration is the most common cause of progressive spinal cord and nerve root compression. Spondylotic changes can result in stenosis of the spinal canal, lateral recess, and foramina.  Spinal canal stenosis can lead to myelopathy, whereas the latter two can lead to radiculopathy.

Cervical spine myelopathy resulting from sagittal narrowing of the spinal canal and compression of the spinal cord is present in 90% of individuals by the seventh decade of life[8]

Although the exact prevalence is unknown cervical, spine myelopathy is recognized as the most common form of spinal cord dysfunction in individuals over the age of 55[8]


Epidemiology /Etiology[edit | edit source]

Cervical spondylotic myelopathy is the most common disorder of the spinal cord in persons older than 55 years of age. [5] [9] [10] Radiologic spondylotic changes increase with patient age; 90% of asymptomatic persons older than 70 years have some form of degenerative change in the cervical spine. Both sexes are affected equally. Cervical spondylosis usually starts earlier in men (50 years) than in women (60 years). It causes hospitalization at a rate of 4.04 per 100,000 person-years.[5] [11] 

The causes of cervical myelopathy can be divided into different categories:
• Static factors: A narrowing of the spinal canal size can result from disc degeneration, spondylosis, stenosis, osteophyte formation at the level of facet joints, segmental ossification of the posterior longitudinal ligament and yellow ligament hypertrophy, calcification or ossification. Patients with a congenitally narrow spinal canal (<13mm) have a higher risk for the development of symptomatic cervical myelopathy. [4] [11] [12]
• Dynamic factors: due to mechanical abnormalities of the cervical spine or instability. [4]
• Vascular and cellular factors: Spinal cord ischemia affects oligodendrocytes, which results in demyelination exhibiting features of chronic degenerative disorders. Also glutamatergic toxicity, cell injury and apoptosis may occur. [4]

Mechanism of Injury / Pathological Process
[edit | edit source]

The onset is insidious and gradual, which is related to degenerative changes in the cervical spine anatomy. Osteophytic overgrowth, thickening of the ligamentum flavum (dorsally) and of the posterior longitudinal ligament can compress the spinal cord.  The intervertebral discs dry out resulting in loss of disc height, which increases compression of the vertebral end plates and osteophytic spurs develop at the margins of the end plates.  The degenerative changes encroach on the spinal cord and cause compression.

According to Cook et al[8] cord compression may occur from:

  1. osteophytes secondary to degeneration of intervertebral joints
  2. stiffening of connective tissues, such as the ligamentum flavum at the dorsal aspect of the spinal canal, which can impinge on the cord by "buckling" when the spine is extended
  3. degeneration of the intervertebral discs together with subsequesnt bony chnages
  4. other connective tissue changes

The cord compression is thought to be a combination of static compression and intermittent dynamic compression from cervical motion (flexion/extension).

Clinical Presentation[edit | edit source]

Cervical spondylotic myelopathy can cause a variety of signs and symptoms.  The onset is insidious, which typically becomes apparent in persons aged 50-60 years.  About half of patients with cervical myelopathy have pain in their neck, scapular area, or arms. Most have symptoms of arm and leg dysfunction.  Arm symptoms may include weakness, numbness (nonspecific/dermatomal) or clumsiness in the hands. Leg symptoms may include weakness, difficulty walking, and/or frequent falls.  In later cases, bladder and bowel incontinence can occur.  The first signs are often increased knee and ankle reflexes.  A myelopathy is an upper motor neuron lesion and the patients may present with spasticity, hyperreflexia, clonus, Babinski and Hoffman's sign.  

Sex  Both sexes are affected equally.  Cervical spondylosis usually starts earlier in men (50 years) than in women (60 years).

Age  40-60 years old.  Radiologic spondylotic changes increase with patient age; 90% of asymptomatic persons older than 70 years have some form of degenerative change in the cervical spine.

File:Cervical Osteophytes.jpg
Osteophytes with Cord Compression
Cervical Spondylosis

Common Symptoms[edit | edit source]

  • Distal weakness
  • Decreased ROM in the cervical spine, especially extension.
  • Clumsy or weak hands
  • Pain in shoulder or arms
  • Unsteady or clumsy gait
  • Increased reflexes in the lower extremities and in the upper extremities below the level of the lesion.
  • Numbness and parasthesia in one or both hands
  • Radiculopathic signs

Differential Diagnosis[edit | edit source]

• Adhesive Capsulitis
• Brown-Sequard Syndrome
• Carpal Tunnel Syndrome
• Central Cord Syndrome
• Cervical Disc Disease
• Cervical Myofascial Pain
• Cervical Sprain and Strain
• Chronic Pain Syndrome
• Diabetic Neuropathy
• Multiple Sclerosis
• Myofascial Pain
• Neoplastic Brachial Plexopathy
• Osteoporosis and Spinal Cord Injury
• Radiation-Induced Brachial Plexopathy
• Rheumatoid Arthritis
• Traumatic Brachial Plexopathy
• Tumors

Diagnostic Procedures[edit | edit source]

A detailed and thorough neurologic examination is the current standard to diagnose the presence of cervical myelopathy. A magnetic resonance image (MRI) is considered the best imaging method for confirming the presence of cervical stenosis, cord compression, or myelomalacia, elements germane to cervical spine myelopathy. An MRI is most useful because the tool expresses the amount of compression placed on the spinal cord, and demonstrates relatively high levels of sensitivity and specificity. [5] [13] Anterior-posterior width reduction, cross-sectional evidence of cord compression, obliteration of the subarachnoid space and signal intensity changes to the cord found on MR imaging are considered the most appropriate parameters for confirmation of a spinal cord compression myelopathy. [5] Moore than half of patients with cervical spine myelopathy show intramedullary high signal intensity on T2-weighted imaging, mainly in the spinal gray matter. [14] MRI of the cervical spine can not only identify spinal canal stenosis, but can also rule out spinal cord tumors.

Special Tests[edit | edit source]

Clinical examination tests often used for myelopathy include:

  • +Clonus
  • +Hoffman's Sign
  • Deep tendon reflexes
  • +Babinski sign
  • Hand withdrawl reflex
  • Suprapatellar quadriceps test
  • Inverted supinator sign

However, although these tests exhibit moderate to substantial reliability among skilled clinicians, they demonstrate low sensitivity and are not appropriate for ruling out myelopathy[8][15].  

According to Cook et al[15] Selected combinations of the following clinical findings are affective in ruling out and ruling in cervical spine myelopathy. Combinations of three of five or four of five of these tests enable post-test probability of the condition to 94–99%:

  1. gait deviation
  2. +Hoffmann’s test
  3. inverted supinator sign
  4. +Babinski test
  5. age >45 years 

Imaging[edit | edit source]

 Plain radiographs alone are of little use as an initial diagnostic procedure. MRI of the cervical spine can identify spinal canal stenosis, as well as rule out spinal cord tumors.  Radiographic cervical spinal cord compression and hyperintense T2 intraparenchymal signal abnormalities (MRI) correlate well with the presence of myelopathic findings on physical examination[16].

Outcome Measures[edit | edit source]

• Neck disability index http://www.physio-pedia.com/Neck_Disability_Index
• Neck pain and disability scale http://www.physio-pedia.com/Neck_Pain_and_Disability_Scale
• Nurick-score [17]
• Japanese-orthopaedic-association-score (JOA-Score) [17] [18] 
• Cooper-myelopathy-scale (CMS) [17]
• European-myelopathy-score (EMS) [17]

Management / Interventions
[edit | edit source]

Patients with cervical myelopathy that are treated with a conservative approach (anti-inflammatory medications, collar immobilization and physical therapy) may have some short term benefit in relief of painful symptoms.  Because the condition is degenerative and progressive, slow and continued progressive neurologic deterioration will occur.  

There is no consensus about the treatment of mild and moderate forms of cervical myelopathy(The Japanese Orthopaedic Association developed a scoring system for cervical myelopathy)[19]. Surgical treatment has no better results than conservative treatment over 2 years of follow-up[20]. Motor training programmes may improve arm and hand functioning at function and/or activity level in cervical spinal cord injured patients[21]. Surgery is needed in severe forms of progressive cervical myelopathy[22][23].

Physiotherapy has an important role before and after the surgery. In the pre-operative phase the physiotherapist will inform about the patients history and about the activity of daily living. The physiotherapist will inform the patient about the treatment and the expectations after the surgery. There are different tests to have an objective view on the abilities of the patient: distance of walking, Neck Pain and Disability Scale, Neck Disability Index and lung function.

Exercises to improve the mobility and the proprioception will be given to the patient. The patient starts unencumbered stabilisation exercises and then evolves to more active mobilisation exercises. During the day the patient is stimulated and helped to do daily life activities. The second day the intensity of the exercises increases and then evolve to standing and walking exercises. After a normal rehabilitation progress the patient can go home after nine day. At home the physiotherapy continues with active exercises. The physiotherapist has to make sure that the patient can continue his activity of daily living (ADL) and increases the intensity of it every day. After a normal rehabilitation there are no limitations to the adl-activities of the patient. Also important in the rehabilitation is to improve the posture[24]. Physiotherapy is important before the surgery to inform the patient and for the physiotherapist to get to know the patient and to set up a rehabilitation program. The main goal is to make the patient able to participate in society again without permanent restrictions due to the surgery.


Resources
[edit | edit source]

Dr. Pablo Pazmino, MD on Cervical Myelopathy

Mayo Clinic information on Spinal Stenosis

Wikipedia on Spinal Stenosis

In this video, Dr. Jeffrey Wang, a professor in the Department of Orthopaedic Surgery of UCLA, reviews Spinal Stenosis

[25]
[26]

Case Studies[edit | edit source]

57 Year-old male diagnosed with Cervical Myelopathy

Cervical Spondylotic Myelopathy in a Patient Presenting With Low Back Pain

Clinical Bottom Line[edit | edit source]

Cervical myelopathy is the result of spinal cord compression in the cervical spine and is the most common disorder of the spinal cord in persons older than 55 years of age. Cervical compression in myelopathy is predominantly due to pressure on the anterior spinal cord with ischaemia and to deformation of the cord by anterior herniated discs, spondylitic spurs or an ossified posterior longitudinal ligament. Early symptoms of this condition are ‘numb, clumsy, painful hands’ and disturbance of fine motor skill. The diagnosis of CSM is primarily based on the clinical signs found on physical examination and is supported by imaging findings of cervical spondylosis with cord compression. Once the disorder is diagnosed, complete remission to normality never occurs, and spontaneous remission to normal normality is uncommon. Exercises and techniques that may help relieve symptoms of cervical myelopathy include: cervical traction, manual therapy techniques, proprioceptive neuromuscular facilitation, cervical stabilization exercises and dynamic upper and lower limb exercises.

Recent Related Research (from Pubmed)[edit | edit source]

Failed to load RSS feed from http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=10SuWQ8ymABjulX7yzOMA4mM0Ok422wmPAwrVWPUMJAoZUZ9gK|charset=UTF-8|short|max=10: Error parsing XML for RSS

References[edit | edit source]

  1. ↑ Richard K. Root Clinical Infectious Diseases: A Practical Approach, 1999
  2. ↑ 2.0 2.1 Kong LD, Meng LC, Wang LF, Shen Y, Wang P and Shang ZK. Evaluation of conservative treatment and timing of surgical intervention for mild forms of cervical spondylotic myelopathy. Exp Ther Med. 2013 Sep;6(3):852-856.
  3. ↑ Dai L, Ni B, Yuan W and Jia L. Radiculopathy after laminectomy for cervical compression myelopathy. J Bone Joint Surg Br. 1998 Sep;80(5):846-9.
  4. ↑ 4.0 4.1 4.2 4.3 Boos N and Aebi M (Eds). Spinal disorders: Fundamentals of Diagnosis and Treatment. Springer-Verlag Berlin Heidelberg. 2008.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Cook C, Brown C, Isaacs R, Roman M, David S and Richardson W. Clustered clinical findings for diagnosis of cervical spine myelopathy. J Man Manip Ther. 2010 Dec; 18(4): 175–180.
  6. ↑ Cramer GD and Darby SA. Basic and Clinical Anatomy of the Spine, Spinal Cord, and ANS. 2nd Edition. Elsevier 2008.
  7. ↑ 7.0 7.1 Selzer ME and Dobkin BH. Spinal Cord Injury (American Academy of Neurology Quality of Life Series). Demos Medical Publishing (New York). 2008
  8. ↑ 8.0 8.1 8.2 8.3 Cook C, Roman M, Stewart KM, Leithe LG, Isaacs R. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction. J Orthop Sports Phys Ther. 2009 Mar;39(3):172-8. doi: 10.2519/jospt.2009.2938.
  9. ↑ Amenta PS, Ghobrial GM, Krespan K, Nguyen P, Ali M, Harrop JS. Cervical spondylotic myelopathy in the young adult: a review of the literature and clinical diagnostic criteria in an uncommon demographic. Clin Neurol Neurosurg. 2014. 120:68-72.
  10. ↑ Kadanka Z, Bednarík J, Vohánka S, Vlach O, Stejskal L, Chaloupka R et al. Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study. Eur Spine J. 2000;9(6):538-44.
  11. ↑ 11.0 11.1 Koakutsu T,Nakajo J, Morozumi N, Hoshikawa T, Ogawa S, and Ishii Y. Cervical myelopathy due to degenerative spondylolisthesis. Ups J Med Sci. 2011; 116(2): 129–132.
  12. ↑ Yonenobu K. Cervical radiculopathy and myelopathy: when and what can surgery contribute to treatment? Eur Spine J. 2000; 9(1): 1-7.
  13. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named Harrop
  14. ↑ Sato T, Horikoshi T, Watanabe A, Uchida M, Ishigame K, Araki T et al. Evaluation of cervical myelopathy using apparent diffusion coefficient measured by diffusion-weighted imaging. AJNR Am J Neuroradiol. 2012; 33(2):388-392.
  15. ↑ 15.0 15.1 Chad Cook, Christopher Brown, Robert Isaacs, Matthew Roman, Samuel Davis, and William Richardson. Clustered clinical findings for diagnosis of cervical spine myelopathy. J Man Manip Ther. 2010 December; 18(4): 175–180.
  16. ↑ Harrop, James S; Naroji, Swetha; Maltenfort, Mitchell; Anderson, D. Greg; Albert, Todd; Ratliff, John K; Ponnappan, Ravi K; Rihn, Jeffery A; Smith, Harvey E; Hilibrand, Alan; Sharan, Ashwini D; Vaccaro, Alexander. Cervical Myelopathy: A Clinical and Radiographic Evaluation and Correlation to Cervical Spondylotic Myelopathy. Spine 10 February 2010 [epub ahead of print]
  17. ↑ 17.0 17.1 17.2 17.3 Vitzthum H and Dalitz K. Analysis of five specific scores for cervical spondylogenic myelopathy. Eur Spine J. 2007; 16(12): 2096–2103.
  18. ↑ Tanaka N, Konno S, Takeshita K, Fukui M, Takahashi K, Chiba K et al. An outcome measure for patients with cervical myelopathy: the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ): an average score of healthy volunteers. J Orthop Sci. 2014 Jan;19(1):33-48.
  19. ↑ Yonenobu K, Abumi K, Taketomi E, Ueyama K. Interobserver and intraobserver reliability of the japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine(Phila Pa 1976). 2001 Sep 1;26(17):1890-4;discussion 1895
  20. ↑ Kadanka Z, Bednarík J, Vohánka S, Vlach O, Stejskal L, Chaloupka R, Filipovicová D, Surelová D, Adamová B, Novotný O, Nemec M, Smrcka V, Urbánek I. Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study. Eur Spine J (2000) 9 :538–544
  21. ↑ Annemie I. F. Spooren, Yvonne J. M. Janssen-Potten, Eric Kerckhofs and Henk A. M. Seelen .outcome of motor training programmes on arm and hand functioning in patients with cervical spinal cord injury according to different levels of the icf: a systematic review. J Rehabil Med 2009; 41: 497–505
  22. ↑ Massimo Leonardi, Norbert Boos , Degenerative disorders of the cervical spine
  23. ↑ 7 Law MD Jr, Bernhardt M, White AA 3rd.Cervical spondylotic myelopathy: a review of surgical indications and decision making. Yale J Biol Med. 1993 May-Jun;66(3):165-77.
  24. ↑ G. Aufdemkampe, J.B. Den Dekker, I. Van Ham, B.C.M. Smits-Engelsman, P. Vaes. Jaarboek fysiotherapie-kinesitherapie 2000. Bohn Stafleu Van Loghum, 275 p
  25. ↑ Stanford University. Imaging Patients with Myelopathy. Available from: http://www.youtube.com/watch?v=mJVEtq5GsJk[last accessed 09/03/13]
  26. ↑ The Gait Guys. A Gait Case of Combined Spinal Myelopathy and Trendelenburg Pathologies. Available from: http://www.youtube.com/watch?v=AYmzQL_NSeI[last accessed 09/03/13]|}
Retrieved from "https://www.physio-pedia.com/index.php?title=Cervical_Myelopathy&oldid=134263"