Cervical myelopathy guidelines

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Cervical myelopathy is a condition where the spinal cord gets compressed in the neck.

While the this can occur as a result of a herniated disc alone, it is usually in combination with osteoarthritis affecting the spine (cervical spondylosis) or a developmentally narrow spinal canal (spinal stenosis).

Cervical spondylotic myelopathy (CSM) is the most common spinal cord disorder in persons past the age of 55. Spondylosis refers to degenerative changes that occur in the spine, including osteoarthritis affecting the uncovertebral joints (the joints in the posterior portion of the spine), intervertebral discs, ligaments, and connective tissue of the cervical vertebrae.

With age, the intervertebral discs dry out causing loss of disc height. This process puts greater stress on the articular cartilage of the uncovertebral joints. Osteophytes (bony spurs) develop at the margins of the vertebrae. In addition to osteophytes, the ligamentum flavum (the long ligament that extends the entire length of the spine) stiffens and buckles into the spinal cord. In the typical scenario, osteophytic overgrowth in front accompanied by the buckling of the ligamentum flavum in back can cause direct compression of the spinal cord resulting in myelopathy. Symptoms are believed to develop when the spinal cord has been compressed by at least 30 percent.

CSM will generally cause these symptoms: neck stiffness; unilateral or bilateral aching; neck, arm and shoulder pain; and stiffness or clumsiness while walking .

CSM usually develops insidiously. In the early stages of CSM, complaints of neck stiffness are common because of the presence of advanced cervical spondylosis. Other common complaints include crepitus (a feeling as if there's sand in the neck) with movement; stabbing arm pain; a dull "achy" feeling in the arm; and numbness or tingling in the hands.

Pain caused by a pinched nerve is called "radiculopathy." Some patients will exhibit signs and symptoms of radiculopathy and myelopathy.

The major symptom of CSM is weakness or stiffness in the legs. Patients with CSM may also present with unsteadiness of gait. Weakness or clumsiness of the hands in conjunction with weakness in the legs is also characteristic of CSM. Symptoms may be asymmetric.

A clumsiness while using the hands and legs is often present. Bowel or bladder control problems are often reported, as is sexual dysfunction.

A Brown-Sequard syndrome may be seen. This will cause one-sided spinal cord dysfunction, withweakness on one side and loss of sensation on the opposite side.

The physical and neurologic examination is often fruitful. Flexion of the neck may cause an "electric shock-like" sensation down the center of the back, referred to as Lhermitte's sign. Atrophy of the hands may be present.

Loss of vibratory sense or proprioception in the extremities (especially the feet) can occur.

A characteristic physical finding of CSM is hyperreflexia (reflexes very brisk). Ankle clonus and Babinski's sign (pathologic extension of the great toe with stroking of the foot) in the feet may be seen. Hoffmann's sign (a reflex contraction of the thumb and index finger after flicking the middle finger) is a subtle indicator of spinal cord dysfunction. A stiff or spastic gait is also characteristic of CSM in its later stages.

Hyperreflexia may be absent in CSM patients who have diabetes, causing a peripheral neuropathy.

Magnetic resonance imaging (MRI) of the cervical spine is the procedure of choice in patients with suspected CSM. In addition to giving an assessment of the degree of spinal canal stenosis, an MRI can identify spinal cord lesions that can also present with myelopathy (e.g., tumors).

Computed tomography (CT) may give a more accurate assessment of the amount of canal compromise because it is better than MRI for evaluating bone (osteophytes). Plain x-rays alone are of little use.

Electromyography is not that useful in most patients with CSM. It may help to exclude peripheral neuropathy. Somatosensory evoked potentials (SSEPs) provide a better assessment of spinal cord function than electromyography. However, SSEPs are nonspecific.

Other diagnoses to exclude...

Amyotrophic lateral sclerosis
Multiple sclerosis
Normal pressure hydrocephalus
Spinal cord infarction ( a clot shutting off blood supply to the spinal cord)
Transverse myelitis
Vitamin B12 deficiency

This condition is considered a neurosurgical emergency. Surgery is necessary if symptoms and signs progress, and is aimed at decompressing the spinal cord. If spondylosis is present, a cervical spinal fusion may also be done.

Conservative treatment is recommended only if the disease is not progressive. This includes a cervical collar to limit neck movement, physical therapy, and anti-inflammatory medication.

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