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Cervical Myelopathy

What is a Cervical Myelopathy?

A Cervical Myelopathy is a condition where the spinal cord in the neck is compressed. This often causes neurological problems which require treatment.

What is the difference between a Cervical Spondylotic Myelopathy and a Cervical Myelopathy?

A Cervical Spondylotic Myelopathy is a combination of severe, widespread degenerative spine disease (discs and spine joints) and spinal cord compression.

A Cervical Myelopathy is spinal cord compression which can be from any cause in the neck. The neck in general does not have to be severely degenerated. An example is a disc herniation at one disc of the spine, where the herniation is so large that it places pressure on the spinal cord.

What causes a Cervical Myelopathy?

Here are some of the common causes of a Cervical Myelopathy:

  1. Large Disc Herniations causing pressure on the spinal cord
  2. Trauma to the spine where either a disc or bone is pushed into the spinal cord.
  3. Bone spurs which are large enough to compress the spinal cord.
  4. An Infection of the spine where an abscess forms and compresses the spinal cord.
  5. Cancer of the spinal bones, spinal nerves or spinal cord itself.

What are some of the symptoms from a Cervical Myelopathy?

Here are some of the common symptoms:

  1. Unstable gait: in severe cases it can look like someone walks intoxicated
  2. Weakness in the arms or legs
  3. Weakness in the shoulder muscles
  4. Numbness and tingling in the arms or legs, specifically the hands
  5. Problems emptying the bladder
  6. Problems with controlling bowel movements
  7. Difficulty with task that require fine movements of the fingers (handwriting, knitting, buttoning a shirt, etc.)

How do Spine Specialists diagnose a Cervical Myelopathy?

Spine specialists use a patient history, a physical examination and specific spinal tests to make the diagnosis:

  1. History

The following questions can help make the diagnosis:

  • Do you have a difficult time walking? Has your gait changed?
  • Do you feel like you are having problems with your balance? Do you lose your balance if you are in a darker room? Do you stumble easily?
  • Do you have weakness in the arms or legs?
  • Do you have numbness or tingling in your arms or legs?
  • Has your handwriting changed?
  • Do you have trouble buttoning a shirt?
  • Do your shoulders feel weak?
  • Do you have trouble emptying your bladder?
  • Do you ever lose control over your bowels?

 

       2. Examination:

The spine specialist often examines the following:

  1. Gait testing
  2. Reflexes testing (SNE)
  3. Ankle clonus
  4. Strength testing (motor) of the arms and legs
  5. Sensation testing (sensory) of the arms and legs                     
  6. Babinski test
  7. Spurling’s test
  8. Lhermitt’s sign
  9. Valsalva test
  10. Hoffman’s Sign
  11. Rectal Examination

         3. Imaging

    1. X-Ray

X-Rays can be helpful to establish the basic anatomy of the neck. They can offer some information about the neck in general. The height of a disc can be seen, but not compression of a nerve or the spinal cord.

                 2. MRI

MRI information is critical when evaluating the compression of the spinal cord in a Cervical Myelopathy. It can show the spinal cord and spinal nerves in detail and can accurately assess how much compression of each exists. It can also determine if there is swelling present in the spinal cord (gliosis, myelomalacia). This can be a sign of impending damage or existing damage to the spinal cord.

The MRI can also show the exact causes of the spinal cord compression, whether related to a disc herniation or bone spurring for example.

                3. CT scan

Plain CT scans can show the bone anatomy of the cervical spine (neck) such as the Vertebrae and spine joints (facet joints) accurately. However they have the disadvantage of not being able to show the spinal nerves and spinal cord in detail.

               4. CT Myelograms

A CT Myelogram combines a CT Scan with an injection of dye into the spinal fluid. Since the spinal fluid bathes the spinal cord, the dye spreads around the spinal cord. A CT scan can then detect the dye and show if the spinal cord is compressed. However, typically this information is better seen on an MRI. However, there are instances where an MRI cannot be obtained or the spinal cord is obscured by the metal from a previous neck surgery. In these situations, the CT myelogram can be the best study to evaluate the spinal cord.

               5. Electromyogram (EMG) and Nerve Conduction Study (NCS)

An Electromyogram and Nerve Conduction Study (EMG/NCS) can evaluate the spinal nerves in the arms and legs. When the spinal cord is compressed, the signals to the spinal nerves are typically impaired. The EMG/NCS study can detect this and help with the diagnosis. However, typically the physical examination and the imaging studies such as the MRI scan are sufficient in making the diagnosis of a Cervical Myelopathy.

What treatments are available for a Cervical Myelopathy?

The treatment for a Cervical Myelopathy depends on the severity of the case. Surgery is reserved for severe conditions not responding to non-surgical care.

  1. Non-Surgical Care

A. Alternative Health Care

Alternative Health Care options may help with the pain from a Cervical Myelopathy, but are not likely to change the compression of the spinal cord and any neurological problems related to that. Acupuncture, Massage Therapy, and Meditation can be useful to help with the pain from this condition.

B. Chiropractic Care

Generally, spine manipulation is not recommended for conditions with Spinal Cord Compression, such as a Cervical Myelopathy. However, very gentle, non-manipulation treatments may have some benefit for pain.

C. Spine Exercises

Spine exercises can help prevent the loss of muscle mass from a Cervical Myelopathy. However, only gentle exercises are recommended due to the compression of the spinal cord. High impact exercises could potentially worsen this condition and are not recommended.

D. Physical Therapy

Traction can help with compressed spinal nerves, but not compression of the spinal cord. It is not commonly used for this condition, unless the patient is not a candidate for surgery and it is deemed safe by the Spine Surgeon.

Ultrasound and electrical stimulation can help with the muscle spasms common in this condition. Strengthening exercises can help maintain muscle strength, which can be otherwise lost.

E. Self Help Devices

A neck brace may be needed for a Cervical Myelopathy to protect the spinal cord from further injury. The brace can restricted a certain types of movements, such as significant forward bending of the neck, which could otherwise increase the pressure on the spinal cord. However, whether a neck brace is advised or necessary is the spine surgeon’s judgment. A very specific type of neck brace may need to be considered for this condition.

F. Medications

Here are some groups of medications which can help with the symptoms from a Cervical Myelopathy:

  1. Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
  2. Steroids
  3. Muscle Relaxants
  4. Pain Killers
  5. Nerve Pain Medications
  6. Antidepressants

G. Injections

Epidural steroid injections can help in some patients with the symptoms from a Cervical Myelopathy. However, with severe spinal cord compression, injections are usually not done out of fear that the injected fluid places more pressure on the spinal cord.

For milder cases of a Cervical Myelopathy or those where surgery cannot be offered, epidural injections can sometimes be used. However this should only be done if deemed safe and recommended by the Spine Surgeon.

Here are some the available injections:

Cervical Interlaminar Epidural Steroid Injection

Cervical Transforaminal Epidural Steroid Injection

 

2. Surgical Care

The decision for surgery usually takes some of the following factors into account:

  1. Severity of the symptoms, specifically neurological symptoms such as weakness in the arms and legs, gait problems, and problems with the bowels and bladder.
  2. Worsening of the symptoms
  3. Potential for irreversible damage to the spinal cord
  4. Severity of the spinal cord compression
  5. Overall health of the patient
  6. Risks versus benefits of the surgery

Here are some surgical options which are available for a Cervical Myelopathy:

  1. Anterior Cervical Discectomy and Fusion (ACDF)
  2. Cervical Laminectomy and Fusion
  3. Cervical Corpectomy