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Cervical Spine Stenosis

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Other Names

  • Cervical Spinal Stenosis
  • Cervical Spondylotic Myelopathy (CSM)
  • Cervical canal stenosis
  • Spear Tacklers Spine
  • Spear Tackler's Spine

Background

  • This page describes stenosis of the cervical spinal canal

Epidemiology

  • Peak age of cervical myelopathy is between 50 and 60 years of age[1]
  • By age 65, 95% of men and 70% of women have degenerative changes of the cervical spine[2]
  • Up to 26% of MRI-detected cervical spine lesions are asymptomatic in older men[3]

Pathophysiology

  • Represents a spectrum of illness from asymptomatic to Cervical Myelopathy
    • Narrowing of the spinal canal is a predictive risk factor for developing an myelopathy[4]
  • In the cervical spine, segments C5-6 and C6-7 are often affected (need citation)
  • Spear Tacklers Spine refers to canal stenosis due to repetitive microtrauma and improper tackling techniques

Etiology

  • Typically due to repetitive microtrauma resulting in
    • Facet arthropathy and hypertrophy
    • Ligamentous hypertrophy, especially ligamenta flava
    • Degenerative disc disease and degeneration
    • Ventral spondylophyte formation
  • May also be due to congenitally narrowed spinal canal exacerbated by pathological factors

Pathoanatomy

  • Vertebral bodies of C1-C7
    • Provide enough space for the spinal cord, which takes up between 50-75% of available space

Associated Injuries


Risk Factors


Differential Diagnosis


Clinical Features

  • General: Physical Exam Neck
  • History
    • Although patients may be asymptomatic, most report progressive and insidous onset of neck pain
    • Symptoms typically develop slowly and and may be painless
    • Neurologic deterioration can be rapid and occurs in phases[5]
    • Patients also can experience pain and paresthesia in the head, neck, and shoulder
  • Physical Exam
    • Early symptoms usually involve abnormal sensation of hands, abnormal gait, deficiency in fine more skills
    • In later stages, spasticity, hyperreflexia, pyramidal tract symptoms may be seen
  • Special Tests
    • Lhermittes Sign: Radicular/ electric shock-like symptoms with neck flexion (by exam OR history)
    • Hoffman Sign: Tapping middle finger causes reflexive contraction of thumb, index finger

Evaluation

  • Diagnostic Imaging Criteria
    • normal AP diameter is ~17 mm
    • relative stenosis 10-13 mm
    • absolute stenosis <10 mm
    • Intervertebral disk space diameter of 8 mm or smaller has a PPD of 84%m LR+ 15.6 for the prediction of SCI (need citation)
  • Normal canal width tapers as it descends
    • C1: 23 mm
    • C2: 20 mm
    • C3-C6: 17 mm
    • C7: 15 mm

Radiographs

  • Standard cervical spine radiographs
  • May be normal or demonstrate nonspecific degenerative changes
  • Flexion-extension films may be useful to assess for instability

CT

  • Useful to evaluate for osseus changes
  • Ideally combined for CT Myelogram

MRI

  • Diagnostic imaging modality of choice
  • Can detect stenosis as well as other causes
  • Can identify signal enhancement in the cord (radiographic evidence of myelopathy)

EMG/NCS

  • Helpful to support diagnosis of myelopathy

Classification

  • N/A

Management

Prognosis

  • One study compared conservative to nonoperative management[6]
    • In this study, surgical patients had improved functional status and overall pain compared to conservatively managed patients
  • Another study failed to find any difference between surgical and conservative management[7]
  • Schroeder et al: 10 athletes with a known diagnosis drafted into the NFL[8]
    • None of these athletes sustained a SCI in the NFL

Nonoperative

  • Indications
    • Cervical stenosis without myelopathy
    • Important to exclude findings of upper motor neuron dysfunction
    • Otherwise, no clear guidelines for operative vs nonoperative
  • Technique
    • Immobilize with Cervical Collar for unclear duration
    • Medication management including NSAIDS, Acetaminophen
    • Intermittent bed rest
    • Traction treatment (longitudinal extension of the cervical spine)
    • Physical Therapy to stabilize the cervicothoracic spine:
      • Strengthening the nuchal musculature
      • Strengthening the musculature of the upper quadrant
      • Strengthening the scapula
    • Avoidance of activities which stress the cervical spine

Operative

  • Indications
    • Myelopathy
    • Severe, refractory neck pain
  • Technique
    • Laminectomy
    • Spondylodesis
    • Corpectomy

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Safety of athletes with cervical spine stenosis who participate in sports remains unclear
    • This is particularly true in collision sports
  • Some have advocated that asymptomatic athletes with incidental diagnosis should be allowed to participate[9]
  • Others advocate that any athlete with transient neurological or sensory disturbance should consider not participating in contact sports[10]
  • Athletes should be counseled on the risks of participation in athletic activity before returning to play

Complications

  • Spinal Cord Injury
  • Cervical Cord Neurapraxia
    • 17/34 athletes with cervical cord neuropraxia were found to have cervical spine stenosis[11]
    • Others have reported up to 100% have some degree of cervical spine stenosis[12][13]

See Also


References


  1. Chiles BW, Leonard MA, Choudhri HF, Cooper PR. Cervical spondylotic myelopathy: patterns of neurological deficit and recovery after anterior cervical decompression. Neurosurgery. 1999;44:762–769
  2. Gore, Donald R. "Roentgenographic findings in the cervical spine in asymptomatic persons: a ten-year follow-up." Spine 26.22 (2001): 2463-2466.
  3. Teresi LM, Lufkin RB, Reicher MA, Moffit BJ, Vinuela FV, Wilson GM, et al. Asymptomatic degenerative disc disease and spondylosis of the cervical spine: MR imaging. Radiology. 1987;164:83–88
  4. Aebli N, Rüegg TB, Wicki AG, Petrou N, Krebs J: Predicting the risk and severity of acute spinal cord injury after a minor trauma to the cervical spine. Spine J 2013;13(6):597-604.
  5. Edwards CC, Riew KD, Anderson PA, Hilibrand AS, Vaccaro AF. Cervical myelopathy. Current diagnostic and treatment strategies. Spine J. 2003;3:68–81.
  6. Sampath, Prakash, et al. "Outcome of patients treated for cervical myelopathy: a prospective, multicenter study with independent clinical review." Spine 25.6 (2000): 670-676.
  7. Kadaňka, Z., et al. "Predictive factors for mild forms of spondylotic cervical myelopathy treated conservatively or surgically." European journal of neurology 12.1 (2005): 16-24.
  8. Schroeder GD, Lynch TS, Gibbs DB, et al. The impact of a cervical spine diagnosis on the careers of National Football League athletes. Spine (Phila Pa 1976) 2014;39(12):947-952
  9. 26. Kepler CK, Vaccaro AR: Injuries and abnormalities of the cervical spine and return to play criteria. Clin Sports Med 2012;31(3):499-508.
  10. Schroeder, Gregory D., and Alexander R. Vaccaro. "Cervical spine injuries in the athlete." Journal of the American Academy of Orthopaedic Surgeons 24.9 (2016): e122-e133.
  11. Torg JS, Pavlov H, Genuario SE, et al. Neurapraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg Am 1986;68(9):1354-1370.3782207
  12. Bailes JE: Experience with cervical stenosis and temporary paralysis in athletes. J Neurosurg Spine 2005;2(1):11-16.
  13. Brigham CD, Capo J: Cervical spinal cord contusion in professional athletes: A case series with implications for return to play. Spine (Phila Pa 1976) 2013;38(4):315-323.
Created by:
John Kiel on 17 June 2019 14:23:22
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Last edited:
17 November 2020 18:23:13
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