Cervical Myelopathy


Article Author:
Chester Donnally III
Andrew Hanna


Article Editor:
Christopher Odom


Editors In Chief:
Sisira Reddy
Joseph Nahas
Chokkalingam Siva


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
6/24/2019 1:41:46 PM

Introduction

Cervical myelopathy is a condition describing a compression at the cervical level of the spinal column resulting in spasticity (sustained muscle contractions), hyperreflexia, pathologic reflexes, digit/hand clumsiness, and/or gait disturbance. Classically it has an insidious onset progressing in a stepwise manner with functional decline. Without treatment, patients may progress toward significant paralysis and loss of function. Surgery is either anterior or posterior decompression of the tight area and likely fusion. A poor prognosis is associated with symptomatic duration of more than 18 months, increased cervical spine range of motion, and female gender.[1][2][3][4][5][4]

Etiology

While myelopathy is a term relating to the results from the compression of the spinal cord, stenosis is a term describing a narrowing of a normally patent canal. In the cervical spine, certain patients are more predisposed to myelopathy due to a congenitally narrowed spine cervical canal. Subsequent progression of stenosis or a cervical disc herniation will then more likely results in myelopathy at this level. Degenerative changes are usually at C5 and C6 or C6 and C7 due to the increased motion permitted at these levels. Additional contributors to canal narrowing are infolding of the ligamentum flavum, olisthesis, osteophytes, and facet hypertrophy. Myelopathy will develop in approximately 100% of patients with greater than 60% canal stenosis (of less than 6 mm disc cord space). Age is the most powerful predictor of perioperative morbidity and unfavorable neurologic recovery.

Epidemiology

Interestingly, when a patient with neck pain has radical symptoms following a muscle dermatome, he or she is more likely to improve from operative correction than those without radicular pain. It is more likely that this pain has a predictable source and origin if there is a particular myotome it follows. About 65% of patients that have both neck pain and the radicular symptoms will benefit from surgical decompression.

Asians are at increased risk of cervical myelopathy (1.9% to 4.3% of individuals older than 30 years) due to their increased prevalence of ossification of the posterior longitudinal ligament, which is a source of compression.

Pathophysiology

Cervical spondylotic myelopathy will frequently involve compression of the lateral corticospinal tracts resulting in (voluntary skeletal muscle control), and the spinocerebellar tracts (proprioception). Together, these deficits are responsible for the wide-based spastic gait with clumsy upper extremity function that is classic to cervical myelopathy. Additional commonly involved spinal cord regions are the spinothalamic tracts, which are responsible for contralateral pain and temperature sensation, the posterior columns, which are responsible for ipsilateral position and vibration sense, and the dorsal nerve root, which is responsible for dermatomal sensation.[6][7][8]

History and Physical

Patients presenting with myelopathy experience predominately upper extremity symptoms. These may include hand clumsiness, and a limited ability to perform fine motor tasks such as buttoning a shirt, combing hair, holding small objects, and differentiate coin sizes. Regarding lower extremity signs, patients will typically ambulate with a wide-based gait and weakness. Neck pain and radicular symptoms are also common. Additionally, physicians should examine for a Lhermitte sign (provocative positions that create an electric shock like sensation either down the back or into an extremity). Indicators of poor prognosis include bowel or bladder dysfunction, and general weakness.

Obtaining a history from the patient should focus on the timeline of pain, radiation of pain, and inciting events. A presentation of radiating pain correlates with canal stenosis. Radiating pain as the main issue has a much more predictable surgical outcome compared to a presentation of non-specific neck pain that likely is related to muscle fatigue and strain.

All physical examinations should include evaluation of the neurologic function of the arms, legs, bladder, and bowels. The key to a thorough exam is organization and patience. The clinician should evaluate not only strength but also sensation and reflexes. It is also important to examine the skin along the back and document the presence of tenderness to compression or any prior surgical scars.

Evaluation

The following should specifically be examined in cervical myelopathy patients:

  • Gait: Examine balance issues or spasticity issues
  • Reflex examinations for hyperreflexia: Biceps, brachioradialis, patellar, Achilles
  • Lhermitte sign: Neck flexion causes an electric shock-like (positive exam)
  • Hoffman sign: Examiner will extend the distal phalanx of the long finger (or flick the end of the digit) then rapidly release this digit- the patient will respond with a reflex flexion of the thumb and/or index finger.
  • Crossed radial reflex: Extension of both the biceps and wrist following a biceps reflex test
  • Inverted radial reflex: Extension of both wrist extension and finger flexion following tapping the brachioradialis
  • Finger escape sign: The patient is unable to hold the ulnar digits in extension and adduction.
  • Grip test: Failure to repetitive making a tight fist  

Imaging

  • X-ray: Paramount to all spine evaluations are radiographs AP and lateral of the spine. If possible, flexion and extension views will help determine ligamentous stability.
  • Torg ratio: Compares the diameter of cervical canal to the width of the cervical body, on the lateral view. Mid-posterior vertebral body to the nearest point on the lamina, divided by the width of the corresponding vertebral body. A ratio lower than 0.8 may indicate congenital stenosis (baseline narrowing).
  • MRI: Canal space of less than 10 mm indicates stenosis. Best to evaluate cord and disk space. Of note, up to 19% of asymptomatic patients have major cervical abnormalities which can be misleading. An MRI is imperative to evaluate spine pathologies. Compression and signal changes on T1 and T2 are indicative of myelopathy pathologies.

Treatment / Management

Non-surgical management should include anti-inflammatories, physical therapy, ultrasound modalities, and at times, corticosteroid injections, but these all supply temporary pain relief. What is clear is that once the symptomatology has started its progression, these short-term alternatives will not be a definitive treatment.[9][10][11][12]

In the setting of progression, surgical management should be highly considered. The goal of surgery is to increase the canal space which will lessen/eliminate the cord compression. It is now a general recommendation to surgically intervene earlier as opposed to a carefully waiting period. Regarding the surgical intervention, this can be done wither anterior or posterior.

For posterior, this approach should occur in lordosis deformities and when the pathology is occurring at the posterior aspect of the canal. One option is a laminectomy (ideally with preoperative lordosis greater than 10 degrees and absence of instability). Posterior approaches possibly have higher infection rates compared to anterior.

For anterior, this would be an Anterior Cervical Diskectomy and Fusion (ACDF). This can occur up to 3 disc levels. It is reported that 9% to 27% of patients will have a transient sore throat and dysphagia, usually resolving within 12 weeks. The most common neurologic complication is recurrent laryngeal nerve palsy in 3% patients.

Differential Diagnosis

Alternatives include:

  • Multiple Sclerosis
  • Guillain-Barre syndrome
  • Central Chord syndrome
  • Chiari malformation
  • Syrinx

Prognosis

An MRI can provide some guidance for clinicians and patients about the potential for improvement. Based on a systematic review of MRI findings by Tetreault et al. in 2013:

  • High-intensity changes on T2 and low intensity on T1: poorer recovery rate, worse motor symptom improvements
  • High ratio of T2 signal intensity between non-compressed and compressed (C7 through T1), was associated with a poorer JOA recovery rate.
  • More frequent high signal intensity on T2 predicts worse recovery

Pearls and Other Issues

  • Highly consider surgery if progression of symptoms, more than 6 months of issues, compression ratio (cord sagittal /transverse) less than 0.4, or on MRI the transverse area of the cord is less than 40 mm.
  • A consensus statement recommending surgical intervention once a diagnosis of cervical myelopathy has been made
  • Timeliness of intervention is critical. Patients with milder myelopathy and less than 6 months of symptoms have improved outcomes after surgery.

Enhancing Healthcare Team Outcomes

The diagnosis and management of cervical myelopathy is with an interprofessional team that consists of a nurse practitioner, neurologist, neurosurgeon, orthopedic surgeon, physiotherapist, and physiatrist. The treatment depends on symptoms and degree of spinal stenosis.

Non-surgical management should include anti-inflammatories, physical therapy, ultrasound modalities, and at times, corticosteroid injections, but these all supply temporary pain relief. What is clear is that once the symptomatology has started its progression, these short-term alternatives will not be a definitive treatment.

In the setting of progression, surgical management should be highly considered. The goal of surgery is to increase the canal space which will lessen/eliminate the cord compression. It is now a general recommendation to surgically intervene earlier as opposed to a carefully waiting period. Regarding the surgical intervention, this can be done wither anterior or posterior. 

The outcomes of these patients depend on the cause. Even though surgery is effective, it also has serious complications that can be life-threatening. For patients who obtain symptom relief with non-surgical treatment, the prognosis is good.[6]

 


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Cervical Myelopathy - Questions

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Which of the following symptoms is least likely to be seen with cervical myelopathy?



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Which ethnicity is at a higher risk for cervical myelopathy due to ossification of the posterior longitudinal ligament?



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Which classification system for cervical myelopathy is based on just lower extremity presentations?



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Following anterior decompression and fusion (ACDF) for cervical myelopathy, which transient muscle weakness is most common?



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A 67-year-old male presents as he has been noting progressing difficultly combing his hair, putting in contacts, and buttoning his shirt. On exam, his hand function shows a strong grip. When told to hold his left-hand fingers in an extended and adducted position, his ring and small fingers flex and abduct within 20 seconds. Additionally, with the middle phalanx for the long and middle finger held, the distal phalanx nail is flicked by the examiner and the thumb flexes at the IP joint. What is the next step in management?



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Cervical Myelopathy - References

References

Nagoshi N,Tsuji O,Okada E,Fujita N,Yagi M,Tsuji T,Nakamura M,Matsumoto M,Watanabe K, Clinical indicators of surgical outcomes after cervical single open-door laminoplasty assessed by the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire. Spinal cord. 2019 Feb 21;     [PubMed]
Nakajima H,Uchida K,Taguchi T,Yamashita T,Tominaga T,Tanaka M,Yamagata M,Kaito T,Ushida T, Multicenter cross-sectional study of the clinical features and types of treatment of spinal cord-related pain syndrome. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. 2019 Feb 15;     [PubMed]
Nagoshi N,Iwanami A,Isogai N,Ishikawa M,Nojiri K,Tsuji T,Daimon K,Takeuchi A,Tsuji O,Okada E,Fujita N,Yagi M,Watanabe K,Nakamura M,Matsumoto M,Ishii K,Yamane J, Does Posterior Cervical Decompression Conducted by Junior Surgeons Affect Clinical Outcomes in the Treatment of Cervical Spondylotic Myelopathy? Results From a Multicenter Study. Global spine journal. 2019 Feb;     [PubMed]
Zakaria HM,Bazydlo M,Schultz L,Pahuta MA,Schwalb JM,Park P,Aleem I,Nerenz DR,Chang V, Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative. Journal of neurosurgery. Spine. 2019 Feb 15;     [PubMed]
Zhang L,Chen J,Cao C,Zhang YZ,Shi LF,Zhai JS,Huang T,Li XC, Anterior versus posterior approach for the therapy of multilevel cervical spondylotic myelopathy: a meta-analysis and systematic review. Archives of orthopaedic and trauma surgery. 2019 Feb 9;     [PubMed]
Hitchon PW,Woodroffe RR,Noeller JA,Helland L,Hramakova N,Nourski KV, Anterior and Posterior Approaches for Cervical Myelopathy: Clinical and Radiographic Outcomes. Spine. 2019 Jan 29;     [PubMed]
Grelat M,Gimenez C,Madkouri R, Cervical Cord Compression by Exostosis. The Journal of orthopaedic and sports physical therapy. 2019 Feb;     [PubMed]
Heary RF,MacDowall A,Agarwal N, Cervical spondylotic myelopathy: A two decade experience. The journal of spinal cord medicine. 2018 Jul 26;     [PubMed]
Park MK,Lee SJ,Kim SB,Lee KW,Lee HJ,Han EY,Kim BR, The effect of positive changes during intraoperative monitoring of the functional improvement in patients with cervical compressive myelopathy. Clinical interventions in aging. 2018;     [PubMed]
Acaroğlu E,Nordin M,Randhawa K,Chou R,Côté P,Mmopelwa T,Haldeman S, The Global Spine Care Initiative: a summary of guidelines on invasive interventions for the management of persistent and disabling spinal pain in low- and middle-income communities. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2018 Sep;     [PubMed]
Fehlings MG,Kwon BK,Tetreault LA, Guidelines for the Management of Degenerative Cervical Myelopathy and Spinal Cord Injury: An Introduction to a Focus Issue. Global spine journal. 2017 Sep;     [PubMed]
Donnally CJ 3rd,Butler AJ,Rush AJ 3rd,Bondar KJ,Wang MY,Eismont FJ, The most influential publications in cervical myelopathy. Journal of spine surgery (Hong Kong). 2018 Dec;     [PubMed]

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