Cervical Myelopathy

Welcome to Vrije Universiteit Brussel's Evidence-based Practice project. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors

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, Karen Wilson, Timothy Assi, Jess Bell, Olajumoke Ogunleye, Aminat Abolade, Naomi O'Reilly, Habibu Salisu Badamasi, Ilke Joukes, Kai A. Sigel, Scott Cornish and WikiSysop  

Search Strategy

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

add text here related to physical examination and assessment

Medical Management

add text here

Physical Therapy Management

add text here

Key Research

add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Clinical Bottom Line

add text here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.