Cervical Myelopathy
Cervical Myelopathy
Cervical Myelopathy
Cervical Myelopathy
Cervical myelopathy is a condition caused by narrowing of the Congenital. Myelopathy due to congenital stenosis does not
spinal canal leading to cord dysfunction.1 The most common have a specific underlying lesion. It is caused by a canal diameter
causes are congenital stenosis and degenerative stenosis which is narrower from birth. It is often not symptomatic until
caused by spondylosis (degenerative osteoarthritis).2 When it secondary degeneration further narrows the canal.
is caused by spondylosis it is commonly referred to as cervical
spondylotic myelopathy (CSM). Rheumatoid arthritis (RA) is Spondylosis. CSM is the result of degenerative changes which
a common condition affecting around 1% of the population. develop with age, including ligamentum flavum hypertrophy or
Around 90% of patients with RA have cervical spine involvement buckling, facet joint hypertrophy, disc protrusion and posterior
with between 11% and 58% of these patients having neurological spondylotic ridges. One or all of these changes contribute to
involvement.3,4 Many of these patients have cervical myelopathy. an overall reduction in canal diameter which may result in
Whatever the underlying disease process, the compression cord compression. Spondylolisthesis usually occurs in the
is usually progressive and will often require surgical intervention lower cervical spine. It is caused by arthrosis of the facet joints
to prevent further disability. Many patients experience combined with disc degeneration leading to instability.7
significant improvement in symptoms after surgery, so operative
intervention should be considered for almost all patients. Post traumatic myelopathy. Trauma may induce myelopathy
or precipitate symptoms of an underlying stenosis of the spinal
Epidemiology canal. Smaller diameter canals have an increased chance of
Cervical myelopathy is more common in men and tends to neurological injury in trauma.8
present earlier than in women. Radiologically, the condition is
present in 13% of men in the third decade and almost 100% of Ossification of the posterior longitudinal ligament (OPLL). This
men over the age of 70. In women the disease presents later, is a common feature in patients with cervical myelopathy with up
with 5% showing radiographic changes in the fourth decade to 25% being affected. It is particularly common in patients from
going up to 96% in women over the age of 70.5 Changes are the far east. It is seen on imaging as areas of ossification behind
more common in patients with RA where 85% of those with the vertebral bodies. The extent is best defined by CT.9
moderate to severe disease will have x-ray changes.6
When patients with cervical myelopathy present in the third or Myelopathy due to tumour expansion. Intraspinal tumours
fourth decade of life it is usually secondary to congenital stenosis. are a relatively uncommon cause of cervical myelopathy but
If it presents later in life, degenerative spondylosis is usually must always be considered given the potentially catastrophic
the underlying cause. Patients who have a congenitally narrow consequences of the diagnosis being missed. Tumours may
canal are predisposed to the effects of spondylotic changes originate in the spinal cord (intramedullary tumours) or compress
earlier, as there is less space in the canal to accommodate the from outside (extramedullary tumours). Metastatic deposits are
compressing lesions. usually slow growing with gradual onset of symptoms.
to lead to a syndrome of spasticity and loss of proprioception in X-ray. Plain x-ray is the initial imaging modality of choice.
the legs. These patients often have gait disturbance and suffer Anteroposterior (AP) and lateral views should be requested.
multiple falls. Multilevel disease is common causing a mixture of These will show spondylolisthesis, fusion and osteophytes
symptoms. clearly. Absolute measurements of the canal size are not reliable
from x-ray. However, Pavlov’s ratio can be used as a guide to
Common presenting complains are: indicate narrowing. It is worked out as the AP diameter of the
• Heavy feeling in the legs spinal canal divided by the AP diameter of the vertebral body.
• Poor exercise tolerance Where instability is suspected to be the cause of symptoms
• Radiculopathy (especially in RA) flexion and extension views of the cervical
• Poor fine motor skills spine will show abnormal motion (Figure 1).
• L’Hermitte’s phenomenon - intermittent electric shock MRI. MRI gives a detailed three-dimensional image of the cervical
sensations in the limbs, exacerbated by neck flexion spinal cord and any compression present. It has been key in
• Numbness and tingling in the limbs recent years in diagnosing the condition early. The advantages of
MRI are that it involves no radiation and gives excellent imaging
Late in the disease where compression is severe, if surgical of the disc and nerves including intrinsic changes in the cord
decompression is not performed the symptoms progress to and nerve roots (Figure 2). The extent of panus in patients with
sphincter dysfunction and quadriparesis. CSM is the most RA is also well demonstrated. In recent years new techniques
common cause of acquired spastic paraparesis in adults. have become more prevalent which reduce the impact of artifact
caused by instrumentation.
Examination findings MRI is not as good at identifying the extent of osteophytes and
Patients present with a number of clinical findings which are disc calcification so when these are suspected MRI should be
predominantly upper motor neuron signs. supplemented with CT.
• Weakness is more severe in the upper limbs.
• Gait is usually affected with an ataxic broad based gait. Table I.
• Hypertonia - increased resting muscle tone identified by European Myelopathy Score
passive movement.
• Hyperreflexia - exaggerated response to normal physiological Score Definition
reflexes.
• Ankle clonus - forced dorsiflexion at the ankle giving rise to Gait Function
sustained beats of clonus (more than three beats is considered 1 Unable to walk, wheelchair
pathological). 2 Walking of flat ground only with cane or aid
• Babinski sign - extension of the great toe on scratching of the 3 Climbing stairs only with aid
sole of the foot. 4 Gait clumsy, but no aid necessary
• Hoffman’s reflex - flicking of the terminal phalynx of the middle 5 Normal walking and climbing stairs
or ring finger causing concurrent flexion at the terminal phalynx Bladder and Bowel Function
of the thumb and index finger. 1 Retention, no control over bladder and/or bowel function
• Finger escape sign - the small finger spontaneously abducts 2 Inadequate micturition and urinary frequency
3 Normal bladder and bowel function
due to weak intrinsic muscles.
Hand Function
1 Handwriting and eating with knife and fork impossible
Classification
2 Handwriting and eating with knife and fork impaired
The most comprehensive classification system widely in use is 3 Handwriting, tying shoelaces or a tie clumsy
the ‘European Myelopathy Score’ (Table I). 4 Normal handwriting
The Nurick classification10 (Table II) is probably the most useful Proprioception and Coordination
classification to be used for stratifying the level of functional 1 Getting dressed only with aid
restriction in mobility, caused by cervical myelopathy. 2 Getting dressed clumsily and slowly
The Ranawat classification11 (Table III) is used to categorise 3 Getting dressed
patients who have rheumatoid myelopathy based on their history Paraesthesia / Pain
and examination findings. It can be used to predict recovery after 1 Invalidity due to pain
surgical intervention. 2 Endurable paraesthesia and pain
3 No paraesthesia and pain
Imaging
There are a number of ways that imaging can be used to Score of 17 to 18 - Normal function
diagnose the condition and help decide on a management plan. Score of 13 to 16 - Grade 1
Score of 9 to 12 - Grade 2
They are often used in combination to give a clear overall view Score of 5 to 8 - Grade 3
of the pathology.
Table II.
Nurick’s Functional Scale
Table III.
Ranawat Classification of Neurological Deficit
Fig. 2.
Class Level of Neurological Involvement
A stenotic segment between C4 and C6 on a T2 weighted
saggital reconstruction.
Class I No neural deficit
Class II Subjective weakness, dysaesthesia and
hyperreflexia
Class III A Objective weakness and long tract signs; patient
ambulatory
Class III B Objective weakness and long tract signs; patient
no longer ambulatory
Fig. 3.
A saggital section of a spondylotic c-spine with clear protrusion
of osteophyte into the canal.
Fig. 1.
Atlantoaxial subluxation in flexion.
CT. There are two main uses for CT scanning in the diagnosis of CT myelography requires a cervical or lumbar puncture
cervical myelopathy. There are some patients who are unable to and the introduction of contrast. Patients require inpatient
undergo MRI imaging, often because of an implanted cardiac monitoring for a period of time, as reactions to the contrast
device. For these patients a CT myelogram offers an imaging can present late. CT myelography has become rare in
option which is almost as sensitive as MRI.12 In general CT can practice now due to the widespread availability of MRI.
also give additional information on the presence of osteophytes
or other bony compressive lesions which are underestimated on
MRI scans (Figure 3).
Conservative management
Conservative management may be considered in many cases, • Main site of cord compression
provided patients are closely followed up in clinic. Cervical • Whether compression comes from the front or the back
myelopathy is predominantly progressive and only a small • the number of levels involved
number of patients experience regression in their symptoms. • Bone quality
Some patients are medically co-morbid making surgery high risk. • Deformity (mainly kyphosis)
In these patients a trial of conservative management should • Instability (stepladder deformity in RA patients - multiple
certainly be considered. sequential levels of subluxation)
Non-operative management should involve regular analgesia. • Presence of fused segments
Gabapentin should be considered as an adjunct to simple • Patient wishes and expectations
analgesics for patients who have significant pain from radicular
symptoms. Posterior approach to the upper cervical spine
A soft collar may be used, especially when instability is The most common approach to the upper cervical spine is the
a significant cause of symptoms which is often the case in posterior approach. This enables the surgeon to insert screws
patients with RA. Physiotherapy may be of use in patients who into the occipital bone (Figure 4), the lateral masses of C1 or
can tolerate it which can involve traction, heat and ultrasound the pedicles, isthmus or lamina of C2. Insertion of screws in
therapy. Activity modification can be a useful way of limiting this area is not without risk, because of the proximity of the
factors which provoke symptoms. Extension of the cervical spine spinal cord and vertebral arteries. The vertebral arteries follow a
and restriction of heavy lifting can be particularly helpful. variable course in as many as 20% of patients. Wiring techniques
The use of epidural steroid injection is controversial. They according to Gallie15 or Brooks and Jenkins16 are used only
are primarily used in patients who have significant radicular as part of transarticular screw fixation according to Magerl17
symptoms. Their efficacy has been shown in some studies to the (Figure 5). The other frequently performed technique is lateral
similar to caudal epidural injection for radicular symptoms in the mass fixation of the C1 and pedicle fixation in C2 according to
lumbar spine.13 Goel and Harms.18 In cases where vascular anatomy does not
Patients who suffer a failure of at least three months allow for isthmus or pedicle screws, Wright introduced screws
conservative management should be considered for operative into the lamina of C2 with good success.19
intervention. Particularly if symptoms impair activities of daily
living surgical intervention should be considered. Any patient
who exhibits progressive neurological deficit should undergo
operative intervention unless the risk of surgery makes this
impossible. It should be made clear to the patient that the main
aim of operative intervention is to prevent progression of the
neurological symptoms and that recovery is unpredictable and
cannot be guaranteed.
Surgical management
The primary goal of any surgery is to restore the diameter of the
spinal canal such that compression of the spinal cord is relieved.
The choice of operation depends to a degree on the surgeon’s
experience with any particular procedure. However, the location
of stenosis and the vertebral body alignment will guide whether
an anterior or posterior approach is suitable.
Although controversial, there have been studies which show
that even when a patient is bedridden because of cervical
myelopathy, there is a benefit to operative intervention. One
study showed that in 55 patients with a Nurick score of 5
(chair bound or bedridden), two thirds improved one point after
decompression returning the patient to walking, albeit with
assistance.14
Surgical interventions can be divided into two anatomical
areas; the upper (C0-C2) and lower cervical spine (C3-C7) and Fig. 4.
two approaches; anterior and posterior. When considering A lateral x-ray of a patient who has undergone
approach, the decision making process has to consider a craniocervical fusion performed through the
number of factors: posterior approach.
Fig. 7.
A patient following C5 and C6 corpectomy and fusion
with a cage and plate.
through the posterior approach are laminectomy (with or without Combined approach to the cervical spine
instrumented fusion) and laminoplasty. In complex cases, especially with a combination of compression
Laminectomy extensively decompresses the spinal canal from both anterior and posterior structures associated with
allowing for decompression of the foramina when needed. instability, both approaches to the cervical spine have to be
Instrumentation is usually performed to prevent post- utilised (Figure 10). These cases may require extension down
laminectomy kyphosis and frequently to restore the normal to the upper thoracic spine or up high as the occiput. Patients
lordosis of the c-spine (Figure 8). The screws are inserted most have to be made aware of the significant functional restrictions
frequently into the lateral masses, they are bicortical and give resulting from these demanding procedures.
good stability. Pedicle screw fixation has been gaining popularity
recently, with the introduction of spinal navigation.
Fig. 8.
A patient who has undergone posterior decompression and
instrumented fusion of C2 - C5.
T. A. Coughlin BM BS BMedSci MRCS 10. Nurick S. The pathogenesis of spinal cord disorder associated with cervical
Z. Klezl MD PhD spondylosis. Brain 1972;95:87-100
11. Ranawat CS, O’Leary P, Pellicci P, et al. Cervical spine fusion in rheumatoid
Royal Derby Hospital arthritis. J Bone Joint Surg [Am] 1979;61-A:1003-10.
Uttoxeter Road
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DE22 3NE computed tomography in outpatients. J Comput Assist Tomogr 1987;10:817-21.
13. Lin EL, Lieu V, Halevi L, Shamie AN, Wang JC. Cervical steroid injections for
E-mail: zklezl@aospine.org
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