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Cervical Myelopathy

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Other Names

  • Cervical Cord Myelopathy (CCM)
  • Cervical Myelopathy
  • Degenerative Cervical Myelopathy

Background

History
Epidemiology

  • Cervical Myelopathy
    • Estimated to be between 4.1 to 60.5 per 100,000 people in North America[1]
  • Spinal Cord Injuries
    • Sports are responsible for about 8.9% of all spinal cord injuries[2]
    • 684 deaths in amateur/pro football 1945-1994, 17% related to cervical spine injury (need citation)

Introduction

General

  • Definition: compression at the cervical level of the spinal column
    • Resulting in neurological deficits including spasticity, hyperreflexia, digit/hand clumsiness, and/or gait disturbance
  • Degenerative cervical myelopathy can result from[3]
    • Static compression of the spinal cord
    • Spinal malalignment leading to altered cord tension and vascular supply
    • Repeated dynamic injury owing to segmental hypermobility.
  • Unstable spinal segements can lead to repetitive microtrauma
  • Most commonly affects lateral corticospinal tracts (motor), spinocerebellar tracts (proprioception)
  • Progression
    • Onset is most often insidious
    • Characterized by steplike deterioration, periods of stability
    • Rarely improves with nonoperative treatment

Etiology

  • Atraumatic, degenerative most common
    • Congenital or degenerative narrowing of the cervical spine and subsequent Cervical Spine Stenosis
    • Additional contributors Ligamentum flavum, olisthesis, osteophytes, and facet hypertrophy
    • Most commonly at C5-6, C6-7 (need citation)
    • Sometimes termed degenerative cervical spondylosis (CSM)
  • Less commonly
    • Trauma
    • Congenital stenosis
    • Epidural Abscess
    • Ossification Posterior Longitudinal Ligament
    • Cervical kyphosis

Anatomy of the Cervical Spine

  • Cervical Spine
  • Cervical canal cross sectional area[4]
    • 75% of canals in lower cervical spine
    • Less 50% at the level of C1

Associated Conditions


Risk Factors

  • Asian race

Differential Diagnosis


Clinical Features

History

  • Clarify timeline, inciting events,
  • Upper extremities predominantly affected
  • Clarify for subtle clues such as dropping items, having trouble writing, problems with balance
  • Ask about ambulation, urinary retention
  • Patient may endorse neck pain, stiffness

Physical Exam: Physical Exam Neck

  • Patient requires a thorough and detailed motor exam
  • Look for deficits in fine motor skills of hands
  • Gait exam may be wide based if lower extremity involved
  • Hyperreflexia

Special Tests


Evaluation

Radiographs

  • Standard Cervical Spine Radiographs
  • General findings, nonspecific
    • Degenerative changes of uncovertebral and facet joints
    • Osteophyte formation
    • Disc space narrowing
    • Decreased sagittal diameter
  • Torg ratio: Compares the diameter of cervical canal to the width of the cervical body
    • A ratio lower than 0.8 suggests stenosis
  • Flexion-Extension Radiographs
    • Look for instability, translation, subluxation

MRI

  • Gold standard imaging modality
  • Most useful to evaluate soft tissue structures including spinal cord
  • Canal space < 10mm indicates stenosis
    • Myelopathy will develop in nearly 100% of with greater than 60% canal stenosis (need citation)

CT

  • Complimnentary to MRI
  • Can use myelogram if MRI unavailable

EMG/NCS

  • High false negative rate
  • Can be useful to exclude other causes

Classification

Ferguson and Caplan Classification

  • Describes syndromes of myelopathy[5]
    • Medial syndrome: presents with long tract symptoms
    • Lateral syndrome: mostly radicular symptoms
    • Mixed medial and lateral syndrome
    • Vascular syndrome

Nurick Classification

  • Grade 0: Root symptoms only or normal
  • Grade 1: Signs of cord compression; normal gait
  • Grade 2: Gait difficulties but fully employed
  • Grade 3: Gait difficulties prevent employment, walks unassisted
  • Grade 4: Unable to walk without assistance
  • Grade 5: Wheelchair or bedbound

Ranawat Classification

  • Class I: Pain, no neurologic deficit
  • Class II: Subjective weakness, hyperreflexia, dyssthesias
  • Class IIIA: Objective weakness, long tract signs, ambulatory
  • Class IIIB: Objective weakness, long tract signs, non-ambulatory

Japanese Orthopaedic Association Classification

  • A point scoring system (17 total) based on function in the following categories
    • Upper extremity motor function
    • Lower extremity motor function
    • Sensory function
    • Bladder function
  • Has prognostic implications for follow up (need citation)

Management

Nonoperative

Operative

  • Indications
    • Disease progression
    • Refractory to conservative management
    • Significant impairment
    • Multi-level disease
  • Technique
    • Posterior approach
    • Anterior Cervical Diskectomy and Fusion (ACDF)
    • Laminectomy
    • Disk arthroplasty

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications and Prognosis

Complications

  • Recurrent CCN
    • Estimated to be up to 50% (need citation)
  • Surgical
  • Post op Infection
  • Pseudoarthrosis
  • Postoperative palsy in up to 4.6% of patients (need citation)
  • Recurrent laryngeal nerve injury
  • Hardweare failure
  • Chronic pain
  • Vertebral artery injury
  • Esophageal injury

Prognosis

  • Patients with radicular symptoms following a myotome more likely to benefit from surgical intervention (need citation)
    • Pain more likely to have a predictable point of origin amenable to surgery
  • Generally accepted that early surgical intervention leads to better outcomes
  • Radiographic prognosis
    • High intensity changes on T2, low intensity T1 associated with worse recovery (need citation)

See Also

Internal

External


References

  1. Michael G. Kaiser, R. H. (2018). Degenerative Cervical Myelopathy and Radiculopathy. Switzerland: Springer.
  2. Spinal cord injury facts and figures at a glance. J. Spinal Cord Med. 2010; 33: 439–40
  3. Nouri, Aria, et al. "Degenerative cervical myelopathy: epidemiology, genetics, and pathogenesis." Spine 40.12 (2015): E675-E693.
  4. Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine 1988; 13:831–7
  5. Rao, R. (2002). Neck Pain, Cervical Radiculopathy, and Cervical Myelopathy: Pathophysiology, Natural History, and Clinical Evaluation. The Journal of Bone & Joint Surgery, 1872-1881.
Created by:
John Kiel on 17 June 2019 14:21:44
Authors:
Last edited:
7 February 2024 22:30:14
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