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Cervical Myelopathy

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Other Names

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

Background

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)

Pathophysiology

  • 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

Pathoanatomy

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

Associated Injuries


Risk Factors

  • Asian race

Differential Diagnosis


Clinical Features

  • General: Physical Exam Neck
  • 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
    • 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

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)

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

  • 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

See Also


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:
30 June 2021 16:15:04
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