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Cervical myelopathy

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Refers to compression on the cervical spinal cord.

The most common cause of the spinal cord dysfunction worldwide

Predominantly due to pressure on the anterior spinal cord with ischemia as a result of deformation of the cord by anterior herniated discs, spondylitic spurs, an ossified posterior longitudinal ligament or spinal stenosis.

Cervical myelopathy is the result of spinal cord compression in the cervical spine and is a common disorder in persons older than 55 years of age.

Any space occupying lesion within the cervical spine has the potential to compress the spinal cord can cause cervical myelopathy.

The course of myelopathy is characterized either by long periods of stable disability followed by episodes of deterioration or a linear progressive course.

Presents insidiously with clinical symptoms of gait instability, bladder dysfunction, weakness, and alteration of proprioception.
Neurological dysfunction results from spinal cord compression from cervical spine degenerative arthritis, resulting in axonal stretch associated injury and spinal cord ischemia.

The presentation varies in accordance to the severity of the spinal cord compression as well as its location.

There are seven cervical vertebrae and eight cervical nerve roots.

The cervical spinal cord is encased by the vertebral column and begins at the foramen magnum.

Ligaments serves to stabilize and protect the cervical spine.

The ligamentum flavum 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.

The posterior longitudinal ligament situated within the vertebral canal, originating from the body of the axis, where it is continuous with the membrana tectoria, and extends along the posterior surfaces of the bodies of the vertebrae until inserting into the sacrum.

Chronic cervical degeneration is the most common cause of progressive spinal cord and nerve root compression.

Cervical spondylotic changes can result in stenosis of the spinal canal, the lateral recess, and foramina.

Spinal canal stenosis can lead to myelopathy.

Spondylotic changes increase with patient age.

About 90% of asymptomatic persons older than 70 years have some form of degenerative change in the cervical spine.

Cervical spine myelopathy resulting from narrowing of the spinal canal and compression of the spinal cord is present in 90% of individuals by the seventh decade of life.

Both sexes are affected equally.

Cervical spondylosis usually starts earlier in men than in women 50 years and 60 year, respectively.

The static causes of cervical myelopathy include: narrowing of the spinal canal size that commonly results from degenerative changes in the cervical spine anatomy, such as 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.

Dynamic factors due to mechanical abnormalities of the cervical spine or instability include: vascular and cellular factors with spinal cord ischemia affecting oligodendrocytes, which results in demyelination, and glutamatergic toxicity, with cell injury and apoptosis.

Early symptoms of this condition are numb, clumsy, painful hands and impaired fine motor skills.

Diagnosis is primarily based on the clinical signs found on physical examination and is supported by imaging findings of cervical spondylosis with cord compression.

With a congenitally narrow spinal canal (<13mm), there is a higher risk for the development of symptomatic cervical myelopathy.

Mechanical abnormalities of the cervical spine or instability an lead to cervical myelopathy.

Spinal cord ischemia can affect oligodendrocytes, resulting in demyelination exhibiting features of chronic degenerative disorders.

Spinal cord ischemia may be associated with glutamate toxicity, cell injury and apoptosis may also occur.

Typically cervical myelopathy in persons aged 50-60 years is insidious in onset.

Due to a lack of pain the diagnosis is often delayed.

Patients may manifest symptoms of numbness, clumsy, painful hands, and disturbance of fine motor skills.

Common symptoms and signs include:

Distal weakness

Decreased range of motion in the cervical spine, especially extension.

Clumsy or weak hands.

Pain in shoulder or arms

Unsteady or clumsy gait.

Increased reflexes in the lower extremities and in the upper extremities below the

level of the lesion.

Numbness and parasthesia in one or both hands.

Radiculopathic signs.

The weakness and numbness occur in a non-dermatomal pattern.

With progression in spinal cord degeneration, 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 manifest.

Cervical myelopathy clinically may manifest neck pain, stiffness, decreased range of movement, shoulder and scapular pain, paresthesia in one or both arms or hands which are signs of radiculopathy,

Typically neurological signs of long-tract involvement such as exaggerated patellar and achilles tendon reflexes, pathological reflexes with clonus, or Babinski and Hoffman’s sign, spastic quadriplegia, and sensory loss and bladder-bowel disturbance may manifest.

Once diagnosed, cervical myelopathy reverting to normality never occurs and spontaneous temporary remission is uncommon.

In 75% of the patients with cervical myelopathy, worsening with neurological deterioration occurs, with 20% having slow steady progression, and 5% experience rapid onset and progression.

Diagnosis is confirmed by a complete neurological examination plus MRI.

MRI is considered the best imaging method for confirming the presence of spinal canal stenosis, cord compression, myelomalacia, or spinal cord tumor.

MRI demonstrates the amount of compression on the spinal cord and has a relatively high level of sensitivity and specificity.

MRI can demonstrate anterior-posterior width reduction, evidence of cord compression, obliteration of the subarachnoid space and signal intensity changes to the cord to confirm of a spinal cord compression myelopathy.

Plain X-rays alone are of little use as an initial diagnostic procedure.

Patients frequently show intramedullary high signal intensity on T2-weighted MR imaging, mainly in the spinal gray matter.

MRI hyperintense T2 intraparenchymal signal abnormalities correlate well with the presence of myelopathic findings on physical examination with cervical spinal cord compression

The diagnosis of cervical myelopathy is primarily based on the clinical signs found on physical examination and is supported by imaging findings.

Combinations of three of five or four of five of clinical findings enable diagnosing the condition 94–99% of the time:

gait deviation

Positive Hoffmann’s test

inverted supinator sign

Positive Babinski test

age 45 years or older

Other clinical examination findings often include:

Spurling’s test

Distraction test

Positive clonus/Babinski/Hoffman’s reflexes

Hyp2242eflexic biceps

Hyp2242eflexic quadriceps

Hyp2242eflexic achilles

L’hermitte’s sign

Positive Romberg test

These tests demonstrate low sensitivity and are not appropriate for ruling out myelopathy.

To improve the diagnostic accuracy of clinical testing, combining tests is necessary.

Differential diagnosis of cervical myelopathy:

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

Spinal Cord Injury

Radiation-Induced Brachial Plexopathy

Rheumatoid Arthritis

Traumatic Brachial Plexopathy

Tumors

For mild and moderate forms of cervical myelopathy, surgical treatment has no better results than conservative treatment over two years of follow-up.

The conservative approach with anti-inflammatory medication and physical therapy may result some short term benefit in relief of pain.

With 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 pain may also be helped with surgery.

Surgery is to decompress the spinal cord, usually with fusion and his frequently perform for severe and progressive symptoms.
More than 112,400 cervical spine operations are performed in the US annually.
 US hospital charges for cervical surgery exceeds $2 billion per year.
Surgical practice is a ventral or dorsal decompression type fusion.

When myelopathy is caused by spinal cord tumors, surgical treatment is likewise indicated.

Better surgical outcomes associated with:

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

Surgical goals for cervical myelopathy is decompression of the spinal cord.

Surgical techniques include: multi-level discectomies, corpectomies with or without instrumented fusion, laminectomy with or without instrumented fusion or laminoplasty.

Surgical results: 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

Studies suggest no difference between the surgery and conservative treatments, but there is little of evidence that conservative treatment halts or reverses its progression.

The goals of physiotherapy are:

pain relief

to improve function

to prevent neurological deterioration

to reverse or improve neurological deficits

Symptomatic treatments include:

Cervical traction and manipulation of the thoracic spine: useful for the reduction of pain and disability.

Cervical traction can be combined with other treatments like electrotherapy and exercises.

Manual therapy techniques:

Exercises

Cervical stabilization exercises

Dynamic upper and lower limb exercises.

Proprioceptive neuromuscular facilitation: for the upper and lower limbs.

Motor training programs.

Mobility and proprioception exercises

Aerobic exercises

Balance training

Core stability exercises

The natural course of myelopathy is characterised either by long periods of stable disability followed by episodes of deterioration or a linear progressive course.

Its presentation varies in accordance to the severity of the spinal cord compression as well as its location.

A complex system of ligaments serves to stabilize and protect the cervical spine.

The ligamentum flavum 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.

The posterior longitudinal ligament. It is situated within the vertebral canal, originating from the body of the axis, where it is continuous with the membrana tectoria, and extends along the posterior surfaces of the bodies of the vertebrae until inserting into the sacrum.

Cervical myelopathy is the most common disorder of the spinal cord in persons older than 55 years of age.

Radiologic spondylotic changes increase with patient age.

About 90% of asymptomatic persons older than 70 years have some form of degenerative change in the cervical spine.

By the seventh decade of life, 90% of individuals who have

sagittal narrowing of the spinal canal and compression of the spinal cord have cervical myelopathy.

Cervical myelopathy affects both sexes equally.

Cervical spondylosis usually starts at 50 years in men.

Cervical spondylosis usually starts at 60 years in women..

Cervical myelopathy causes hospitalization at a rate of 4.04 per 100,000 person-years.

Symptoms usually develop slowly, and the lack of pain, indicates there may be an interval of years between the onset of disease and first treatment.

Early symptoms include numbness, clumsy, painful hands and disturbance of fine motor skills.

Weakness and numbness occur in a non-specific/non-dermatomal pattern.

With continued spinal cord degeneration, 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 be present.

Other signs of radiculopathy may include: neck pain and stiffness, decreased ROM, especially extension, shoulder and scapular pain, paresthesia in one or both arms or hands, Babinski and Hoffman’s sign, ataxia and dexterity loss.

Long-tract involvement are exaggerated tendon reflexes, presence of pathological reflexes, clonus, Babinski and Hoffman’s sign, spastic quadriplegia, sensory loss and bladder-bowel disturbance may occur.

Full recovery never occurs.

In 75% of the patients, episodic worsening with neurological deterioration occurs, 20% have slow steady progression, and 5% experience rapid onset and progression.

Common symptoms include:

Distal weakness

Decreased ROM in the cervical spine, especially extension.

Clumsy or weak hands

Pain in shoulder or arms

Unsteady or clumsy gait

Increased reflexes in the lower extremities and in the upper extremities below the level of the lesion.

Numbness and parasthesia in one or both hands

Radiculopathic signs

Diagnosis requires a thorough neurological examination plus MRI as standard evaluation.

A magnetic resonance image (MRI) is considered the best imaging method for confirming the presence of spinal canal stenosis, cord compression, myelomalacia, or spinal cord tumors.

MRI can indicate the amount of compression placed on the spinal cord and demonstrates relatively high levels of sensitivity and specificity.

MRI imaging can assay anterior-posterior width reduction, cross-sectional evidence of cord compression, obliteration of the subarachnoid space and signal intensity changes to the cord.

Patients with cervical spine myelopathy show intramedullary high signal intensity on T2-weighted imaging, mainly in the spinal gray matter in half the cases.

Cervical spinal cord compression and hyperintense T2 intraparenchymal signal abnormalities on MRI correlate well with the presence of myelopathic findings on physical examination.

The diagnosis is based on the clinical signs found on physical examination and is supported by imaging findings.

Combinations of three of five or four of five of the following tests describe probability of cervical myelopathy at 94–99%:

gait deviation

+ Hoffmann’s test

inverted supinator sign

+ Babinski test

age 45 years or older

Other clinical examination tests often used for myelopathy include:

Spurling’s test

Distraction test

+ clonus/Babinski/Hoffman’s

Hyp2242eflexic biceps

Hyp2242eflexic quadriceps

Hyp2242eflexic achilles

Pain constancy

L’hermitte’s sign

Romberg test

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

Spinal Cord Injury

Radiation-Induced Brachial Plexopathy

Rheumatoid Arthritis

Traumatic Brachial Plexopathy

Tumors

Management

No consensus exists for the treatment of mild and moderate forms of cervical myelopathy.

Patients treated with a conservative approach as anti-inflammatory agents and physical therapy, may have some short term benefit in relief of painful symptoms slow and continued progressive neurologic deterioration will occur.

Patients can be treated conservatively, as multiple studies have found no difference in long term outcomes between patients who received conservative or surgical treatment.

The goals of physiotherapy treatment are:

pain relief

to improve function

to prevent neurological deterioration

to reverse or improve neurological deficits

Cervical myelopathy can be treated symptomatically, with cervical traction and manipulation of the thoracic spine.

Cervical traction and manipulation may be useful for the reduction of pain scores and level of disability in patients with mild cervical myelopathy.

Cervical traction can be combined with other treatments like electrotherapy and exercises.

Manual therapy techniques can be used to reduce the neck pain.

Exercises for exercises for mechanical neck pain, with stretching, strengthening exercises, active range of motion exercises, home exercise programs.

Cervical stabilization exercises can be performed.

Dynamic upper and lower limb exercises.

Improve posture with education

Motor training programs.

Mobility and proprioception exercises.

Aerobic exercises.

Balance training

Core stability exercises

The only prognostic factor in which surgery can be generally recommended is with a circumferential spinal cord compression seen on an axial MRI.

With progressive neurologic changes with signs of severe spinal cord compression or spinal cord swelling are candidates for surgery.

Surgical outcomes are better in patients with the following:

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

Surgical techniques for decompression of the spinal cord include: multi-level discectomies or corpectomies with or without instrumented fusion, laminectomy with or without instrumented fusion or laminoplasty.

Outcomes from the surgery vary, with one-third of patients improving, one-third stay the same, and one-third continue to worsen over time, with respect to their pre-surgical symptoms.

There is little of evidence that conservative treatment halts or reverses its progression.

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