Cervical Myelopathy

Cervical myelopathy refers to damage to the spinal cord in the neck region – it may also be categorised as Degenerative Cervical Myelopathy (DCM) or Cervical Spondylotic Myelopathy (CSM), both of which are associated with spinal degeneration as a result of ageing and the wear and tear cycle. Cervical myelopathy is a relatively rare condition and understanding of it remains somewhat limited; the time course of the disorder is usually long, and neurological symptoms often mimic those of other disorders such as carpal tunnel, making a diagnosis more difficult to establish.

The Cervical Spine

The cervical spine begins at the base of the skull, it is made up of seven cervical vertebrae, classified as C1 to C7, which connect to the thoracic spine at T1. It is the most flexible region of the spine, providing a great deal of mobility to the skull, as well as supporting its weight. This complex and intricate structure is formed of vertebrae, intervertebral discs, muscles, ligaments and tendons to protect the delicate spinal cord. 

The spinal cord is formed of a long cylinder of nerves, which along with the brain, make up part of the Central Nervous System (CNS). The CNS transmits electrochemical signals between the brain and the body, it is protected by the skull in the head and housed in a protective casing of vertebrae, ligaments and other soft tissues as it extends from the brainstem to the 1st lumbar vertebrae in the lower back. The spinal cord lies within the spinal canal, like the brain, this is covered by a protective layer of three connective tissues known as the meninges, the space between the outer and middle layers of the meninges is filled with cerebrospinal fluid (CSF) – a transparent liquid which serves to cushion and protect the spinal cord.

Pressure induced damage to the spinal cord, can disrupt the relay of signals travelling to and from the brain, resulting in dysfunction and neurological deficits.

What Causes Cervical Myelopathy?

Damage to the spine may occur for a number of reasons, when this causes compression or injury to the cervical spinal cord, it is referred to as cervical myelopathy. This may be a result of either trauma, infection or disease, or as a result of degenerative changes to the spinal structure.

The higher up the spine, injury or degeneration occurs, the more serious the potential outcome will be – injuries at the very top of the cervical spine between the C1 and C2 (Atlas and Axis) levels, are rare, but can be fatal.

Degenerative Changes

Degeneration can occur at any point along the spine, the cervical region however, is particularly prone to degenerative changes due to its mobility and function (supporting the weight of the head). Degeneration becomes increasingly common as we age, and may not present with any symptoms, in some cases however, degenerative changes can become more severe and cause compression or irritation to the spinal cord.

The following degenerative changes may be associated with cervical myelopathy:

Cervical Spondylosis

Spondylosis describes the collective name for a number of degenerative spinal conditions – a type of wear and tear arthritis which may occur at any point along the spine including the neck. Extensive cervical spondylosis can result in cervical myelopathy.

Spinal Stenosis

The narrowing of the spinal vertebrae, caused by degenerative changes or injury can put pressure on the spinal cord.

Ligament Changes

Changes to the ligaments and joints in the cervical spine often occur due to the onset of osteoarthritis, putting pressure on the spinal cord – osteoarthritis can cause an inflammatory reaction in the affected bones, cartilages and ligaments, this in turn can provoke hypertrophy, ossification or calcification of the ligaments causing them to squeeze against the spinal canal and in some cases compress the cord itself.

Disc Herniation

As part of the ageing process, the intervertebral discs begin to lose moisture and elasticity, leaving them prone to herniation and a subsequent extrusion of disc material into the cervical spine, exerting pressure on the spinal cord.

Formation of Osteophytes

Osteoarthritis can prompt the formation of osteophytes (bony spurs) in response to wear and tear damage to the vertebrae. Osteophytes may grow in the spinal canal putting pressure on the spinal cord – they usually form as a result of degenerative disc disease which causes the cervical discs to dry out and in some cases collapse, allowing the vertebrae to come in contact with one another.

Trauma

Direct trauma to the cervical spine is often due to sudden injury such as a vehicle collision, fall or deliberate blow, causing fracturing of the vertebrae or ligament injury, and possible compression of the spinal cord.

Damage to the cervical spinal cord as a result of direct trauma often has severe life threatening or life altering consequences, such as paralysis of the legs, torso and arms. It may also provoke the inability to breathe without assistance, impaired speech, lack of bladder and bowel control, leaving the individual in such as physical state that assistance may be required for a number of daily activities, and in more severe cases 24 hour a day personal care.

Spinal Tumours

Abnormal growths in the form of cysts, tumours or bone metastasis can form in and around the spinal canal, compressing the spinal cord.

Other Causes

Myelopathy may also be the result of a number of other infectious, inflammatory, neoplastic or vascular conditions, but these are all much less common.

Symptoms

Cervical myelopathy provoked by degenerative changes can result in the onset of a number of symptoms which may vary greatly in severity, depending on the extent of the compression to the spinal cord. The reaction of the spinal cord to compression can also vary from person to person. Possible symptoms of cervical myelopathy include the following:

  • Headaches/dizziness
  • Difficulty using the hands
  • Pain, cramps, weakness or numbness in the arms, hands and legs
  • Paralysis
  • Poor coordination
  • Fatigue
  • Imbalance/gait problems
  • Loss of bladder/bowel control
  • Radiculopathy, damage to a nerve roots as they exit the spinal cord may cause shooting pains, numbness or weakness in the muscle group controlled by the effected nerve

Diagnosis

In order to establish an accurate diagnosis, it is important to distinguish this condition from any other neurological disease or infection.

A full history of all symptoms, including a detailed background of the individual’s general health and occupation etc. with a neurological examination to assess reflexes, sensation and muscle strength will all be helpful, imaging however, will play a crucial role in successful diagnosis.

MRI Scan – An essential component of diagnostic testing for cervical myelopathy, the MRI scan provides detailed images of the spinal cord and its surrounding structures – highlighting the relation of any pathology to the spinal cord.

CT Scans with Myelogram – A CT scan offers detailed cross-sectional projection of the bony structures, this can be combined with a myelogram (an injection of contrast dye used to highlight the spinal cord) to provide a detailed image.

X Ray – Any changes to the vertebrae, including the formation of osteophytes or fractured vertebrae will be illustrated by X Ray.

Electromyogram – nerve conduction studies can determine how well electrochemical signals travel to and from the brain.

Any patient with suspected cervical myelopathy should be referred immediately to a specialist neurologist, a delay in diagnosis can lead to permanent functional disability.

Treatment

The progressive nature of this disorder and the permanent damage it can cause, mean that treatment must be administered as soon as possible.

Decompression Surgery

Surgery is often considered in the treatment of cervical myelopathy in order to relieve the spinal cord compression– although surgery carries with it a number of associated risks, in many cases doing nothing is more of a risk in itself, as spinal cord compression if left alone, can progress to paralysis. A consultation with the surgeon will establish whether or not the disease will benefit from surgical treatment.

Pain relief medication or steroid injections may provide temporary relief for the symptoms of this disorder but will not alter the course of the disease.

Pain Management

Cervical myelopathy is a life changing disorder, causing a wide range of symptoms often severely disrupting everyday routines and activities. Coping with chronic pain and life altering symptoms can be extremely difficult, resulting in feelings of anxiety, depression and isolation. The pain management clinic offers a multidisciplinary team of surgeons, pain management consultants, physiotherapists, psychologists and other health care professionals to provide patients with an individualised treatment plan.

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