Cervical Myelopathy

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Databases Searched: Pubmed, Web of Knowledge, PEDro
Keywords: Cervical myelopathy, Physical Therapy, Treatment, Management, Cervical Stenosis, CSM, Differential diagnosis

Definition/Description

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. [3,11] 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. [20] 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. [1]

Clinically Relevant Anatomy

There are seven cervical vertebrae and eight cervical nerve roots. [5,11] 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. [2] 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. [4]
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. [4]

Epidemiology /Etiology

Cervical spondylotic myelopathy is the most common disorder of the spinal cord in persons older than 55 years of age. [5,7,9] 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. [5,10]

Zhang et al. divided the cause of cervical myelopathy into different categories [12]:
• 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. [1,10,15]
• Dynamic factors: due to mechanical abnormalities of the cervical spine or instability.[1]
• 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.[1]

Characteristics/Clinical Presentation

Cervical myelopathy can cause a variety of signs and symptoms. Spinal cord symptoms caused by cervical spondylosis are divided into two groups: long-tract and segmental symptoms. Early symptoms of this condition are ‘numb, clumsy, painful hands’ and disturbance of fine motor skills [1]. As spinal cord degeneration progresses, lower motor neuron findings in the upper extremities, such as loss of strength, atrophy of the interosseous muscles and difficulty in fine finger movements, may present. Additional clinical findings may include: neck stiffness (decreased ROM, especially extension), shoulder pain, paresthesia in one or both arms or hands, signs of radiculopathy, Babinski and Hoffman's sign, ataxia and dexterity loss. [5,6,21] Typical neurological signs of long-tract involvement are exaggerated tendon reflexes (knee and ankle), presence of pathological reflexes, spastic quadriplegia, sensory loss and bladder-bowel disturbance. [15]
Once the disorder is diagnosed, complete remission to normality never occurs, and spontaneous remission to normal normality is uncommon. In 75% of the patients, episodic worsening with neurological deterioration occured, 20% had slow steady progression, whereas 5% had rapid onset progression. [1]

Differential Diagnosis

• 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

A detailed and thorough neurologic examination is the current standard to diagnose the presence of cervical myelopathy. A magnetic resonance image 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. [5,6] 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.[8] MRI of the cervical spine can not only identify spinal canal stenosis, but can also rule out spinal cord tumors.

Outcome Measures

• 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 [13]
• Japanese-orthopaedic-association-score (JOA-Score) [13,14]
• Cooper-myelopathy-scale (CMS) [13]
• European-myelopathy-score (EMS) [13]

Examination

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. [7] According to Cook et al. selected combinations of the following clinical findings are affective in 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% [5]:
1. gait deviation
2. positive Hoffmann’s test
3. inverted supinator sign
4. positive Babinski test
5. age >45 years
Other clinical examination tests often used for myelopathy include [5,7]:
• Spurling’s test http://www.physio-pedia.com/Spurling's_Test
• Distraction test
• Positive clonus
• Hyper-reflexia biceps
• Hyper-reflexia quadriceps
• Hyper-reflexia achilles
• Pain constancy
• L’hermitte’s sign
• Romberg test http://www.physio-pedia.com/Romberg_Test
However, although these tests exhibit moderate to substantial reliability among skilled clinicians, they demonstrate low sensitivity and are not appropriate for ruling out myelopathy. One method used to improve the diagnostic accuracy of clinical testing is combining tests into clusters. These often overcome the inherent weakness of stand alone tests. [5]

Medical Management

When myelopathy is caused by factors of a progressive nature, such as spinal cord tumors, surgical treatment is indicated. [15] People who have progressive neurologic changes (such as weakness, numbness, or falling) with signs of severe spinal cord compression or spinal cord swelling are candidates for surgery. Patients with severe or disabling pain may also be helped with surgery.[12]

People who experience better surgical outcomes often have these characteristics:
• The symptom of an electrical sensation that runs down the back and into the limbs
• Younger age
• Shorter duration of symptoms
• Single rather than multiple areas of involvement
• Larger areas available for the cord

The principal aim of surgery for cervical myelopathy is the decompression of the spinal cord. The surgical techniques include multilevel discectomies or corpectomies with or without instrumented fusion, laminectomy with or without instrumented fusion or laminoplasty. [1] Surgical decompression is generally considered if the symptoms affect daily life, but early surgical intervention is thought to be more effective. Therefore, early detection may be the key to minimize postoperative sequelae. [8]

Final outcomes from the surgery vary. Typically, one-third of patients improve, one-third stay the same, and one-third continue to worsen over time, with respect to their pre-surgical symptoms.[9,12]

Physical Therapy Management

There is no consensus about the treatment of mild and moderate forms of cervical myelopathy. Surgical treatment has no better results than conservative treatment over 2 years of follow-up. Patients with cervical myelopathy that are treated with a conservative approach (anti-inflammatory medication and physical therapy) may have some short term benefit in relief of painful symptoms.

In general, the goals of the treatment are: [1]
• relieve pain
• improve functional limitations
• prevent neurological deterioration
• reverse or improve neurological deficits

Cervical myelopathy can be treated symptomatically. Possible forms of therapy are:
• Cervical traction and manipulation of the thoracic spine: useful for the reduction of pain scores and level of disability in patients with mild cervical myelopathy. Other signs and symptoms, such as weakness, headache, dizziness, and hypoesthesia, are positively affected. [18]
http://www.youtube.com/watch?v=ouoQd6PPJcI
https://www.youtube.com/watch?v=Rj4Y5JGNPZs
• Manual therapy techniques: employed to reduce the neck pain with natural apophyseal glides and sustained natural apophyseal glides for cervical extension and rotation. [12]
http://www.physiopedia.com/Manual_Therapy_and_Exercise_for_Neck_Pain:_Clinical_Treatment_Tool-kit
• Cervical stabilization exercises: when there is anteroposterior instability of the vertebral bodies of a degenerative nature, vertebral segment stabilization of the cervical spine can be performed with a pressure biofeedback unit (PBU), performing 10 repetitions sustained for 10s, beginning with 22mmHg with the intention to progress to 30mmHg. [12]
http://www.physio-pedia.com/Deep_Neck_Flexor_Stabilisation_Protocol
• Dynamic upper and lower limb exercises (flexion and extension) with the use of the PBU on the neck.[12]
• Proprioceptive neuromuscular facilitation: for the upper and lower limbs.[12]
• Improving the posture
• Motor training programmes: may improve arm and hand functioning at function and/or activity level in cervical spinal cord injured patients
• Mobility and proprioception exercises
• Aerobic exercises: treadmill,... [12]
• Balance training: standing on one leg with eyes open and evolving to eyes closed; standing on a stable platform and evolving to an unstable platform with a rocker board [12]
• Core stability exercices [12]
• Hydrotherapie [12].

Key Research

Cook et al., Clustered clinical findings for diagnosis of cervical spine myelopathy,2010, Journal of manual and manipulative therapy

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