Cervical myelopathy occurs when the spinal cord is compressed. Spinal cord compression can cause neurologic symptoms – such as pain, numbness, or difficulty walking. Your spinal cord is the conduit that enables communication between your brain and body. The spinal cord begins at the base of the brain and ends at the first lumbar vertebra (L1). Below L1, the spinal cord becomes the cauda equina; a bundle of lumbar and sacral nerves.
Anatomy of Cervical Myelopathy
Your spine is made up of 24 bones, called vertebrae, that are stacked on top of one another.
The seven small vertebrae that begin at the base of the skull and form the neck comprise the cervical spine.
Other parts of your spine include
Spinal cord and nerves. The spinal cord extends from the skull to your lower back and travels through the middle part of each stacked vertebra, called the central canal. Nerves branch out from the spinal cord through openings in the vertebrae (foramen) and carry messages between the brain and muscles.
Intervertebral disks. In between your vertebrae are flexible intervertebral disks. They act as shock absorbers when you walk or run.
Intervertebral disks are flat and round and about a half inch thick. They are made up of two components:
- Annulus fibrosus. This is the tough, flexible outer ring of the disk.
- Nucleus pulposus. This is the soft, jelly-like center of the disk.
- More common in adults age 50 and older
- Most often affects the cervical spine (neck)
- Less common in the thoracic spine (mid back)
- Sometimes affects the low back (eg, severe lumbar spinal stenosis)
- Usually a gradual and progressive disorder
- Can develop quickly (eg, trauma, injury)
Below is a lateral MRI of a patient’s cervical spine. The red arrow points to areas where the spinal cord is compressed—cervical myelopathy.
Symptoms of Cervical Myelopathy
- Neck pain and stiffness
- Find yourself dropping things
- Hand clumsiness (eg, buttoning a shirt)
- Balance problems
- Difficulty walking
- Tingling or numbness in the arms, fingers, or hands
- Weakness in the muscles of the arms, shoulders, or hands. You may have trouble grasping and holding on to items.
- Imbalance and other coordination problems. You may have trouble walking or you may fall down. With myelopathy, there is no sensation of spinning, or “vertigo.” Rather, your head and eyes feel steady, but your body feels unable to follow through with what you are trying to do.
- Loss of fine motor skills. You may have difficulty with handwriting, buttoning your clothes, picking up coins, or feeding yourself.
- Pain or stiffness in the neck
There are many different causes of myelopathy; several are listed below.
- Cervical kyphosis
- Cyst or tumor
- Degenerative spondylosis (spinal arthritis)
- Epidural abscess, infection
- Herniated disc
- Inflammatory diseases (eg, Rheumatoid Arthritis)
- Osteophytes (bone spurs)
- Spinal Stenosis
- Vertebral body abnormality
Diagnosis of Cervical Myelopathy
The neurological exam is non-invasive and evaluates your sensory and motor functions. Sensory functions are related to your senses, such as sight, hearing, eye movement, and touch. Motor functions are related to your gait (how you walk), balance, coordination, reflexes, the range of motion, and muscle movement.
After discussing your medical history and general health, your doctor will ask you about your symptoms. He or she will conduct a thorough examination of your neck, shoulders, arms, hands, and legs, looking for:
- Changes in reflexes—including the presence of hyperreflexia, a condition in which reflexes are exaggerated or overactive
- Numbness and weakness in the arms, hands, and fingers
- Trouble walking, loss of balance, or weakness in the legs
- Atrophy—a condition in which muscles deteriorate and shrink in size
The diagnosis of CSM is primarily based on the clinical signs found on physical examination and is supported by imaging findings. According to Cook et al, selected combinations of the following clinical findings are effective in ruling out and ruling in cervical spine myelopathy. Combinations of three of five or four of five of these tests enable the post-test probability of the condition to 94–99%:
- gait deviation
- +ve Hoffmann’s test
- inverted supinator sign
- +ve Babinski test
- age 45 years or older
Other clinical examination tests often used for myelopathy include
- Spurling’s test
- Distraction test
- +ve clonus/Babinski/Hoffman’s
- Hyperreflexic biceps
- Hyperreflexia quadriceps
- Hyperreflexia achilles
- Pain constancy
- L’hermitte’s sign
- Romberg test
Although these tests exhibit moderate to substantial reliability among skilled clinicians, they demonstrate low sensitivity and are not appropriate for ruling out myelopathy. One method used to improve the diagnostic accuracy of clinical testing is combining tests into clusters. These often overcome the inherent weakness of stand-alone tests.
- Neck disability index
- Neck pain and disability scale
- Japanese-orthopaedic-association-score (JOA-Score)
- Cooper-myelopathy-scale (CMS)
- European-myelopathy-score (EMS)
Differential Diagnosis of Cervical Myelopathy
- Adhesive Capsulitis
- Brown-Sequard Syndrome
- Carpal Tunnel Syndrome
- Central Cord Syndrome
- Cervical Disc Disease
- Cervical Myofascial Pain
- Cervical Sprain and Strain
- Chronic Pain Syndrome
- Diabetic Neuropathy
- Multiple Sclerosis
- Myofascial Pain
- Neoplastic Brachial Plexopathy
- Spinal Cord Injury
- Radiation-Induced Brachial Plexopathy
- Rheumatoid Arthritis
- Traumatic Brachial Plexopathy
Imaging test of Cervical Myelopathy
These provide images of dense structures, such as bone. An x-ray will show the alignment of the vertebrae in your neck.
Magnetic resonance imaging (MRI) scans
These studies create better images of the body’s soft tissues. An MRI can show spinal cord compression and help determine whether your symptoms are caused by damage to soft tissues—such as a bulging or herniated disk.
Computed tomography (CT) scans – More detailed that a plain x-ray, a CT scan can show narrowing of the spinal canal and can help your doctor determine whether you have developed bone spurs in your cervical spine.
Myelogram –This is a special type of CT scan. In this procedure, a contrast dye is injected into the spinal column to make the spinal cord and nerve roots show up more clearly.
Treatment of Cervical Myelopathy
Your spine specialist may recommend spine surgery. The goals of spine surgery to treat myelopathy are: (1) remove pressure from the spinal cord, (2) prevent symptoms from becoming worse, and (3) improve your condition.
In milder cases, initial treatment for CSM may be nonsurgical. The goal of nonsurgical treatment is to decrease pain and improve the patient’s ability to perform daily activities. Nonsurgical treatment options include:
Soft cervical collar – This is a padded ring that wraps around the neck and is held in place with velcro. Your doctor may advise you to wear a soft cervical collar to allow the muscles of the neck to rest and limit neck motion. A soft collar should only be worn for a short period of time since long-term wear may decrease the strength of the muscles in your neck.
Physical therapy management of Cervical Myelopathy
Patients can be treated conservatively. Kadaňka et al. found no difference in long term outcomes (2 years after the intervention) between a patient who received conservative or surgical treatment. Even after 10 years, there were no differences found between the surgery and conservative group.F ouyas et al also confirmed these findings. The only prognostic factor in which surgery can be generally recommended is with a circumferential spinal cord compression seen on an axial MRI.
The goals of physiotherapy treatment are
- pain relief
- to improve function
- to prevent neurological deterioration
- to reverse or improve neurological deficits
Cervical myelopathy can be treated symptomatically. Possible therapies include:
- Ice, heat, and other modalities – Your doctor may recommend careful use of ice, heat, massage, and other local therapies to help relieve symptoms. Applying a cold pack to the painful part of the back contracts inflamed muscle and relieves pain. This treatment helps a great deal when the disk has recently ruptured and swelling is at its greatest. A heating pad or warm pack helps with residual pain.
- Cervical traction and manipulation of the thoracic spine – useful for the reduction of pain scores and level of disability in patients with mild cervical myelopathy. Other signs and symptoms, such as weakness, headache, dizziness, and hypoesthesia, can also be positively affected. Cervical traction can be combined with other treatments like electrotherapy and exercises. Joghataei et al. reported a significant increase in grip strength after 10 weeks of this combined treatment
- Manual therapy techniques – used to reduce the neck pain with natural apophyseal glides and sustained natural apophyseal glides for cervical extension and rotation. Manipulation and mobilizations can be effective when they are combined with exercise therapy. When you use them without exercises, there is only poor evidence that it could be effective
- Exercises – the effects of exercise therapy specifically on cervical myelopathy have not been studied, but there is evidence for exercises for mechanical neck pain. For example: stretching, strengthening exercises, active range of motion exercises, home exercise programmes.
- Cervical stabilization exercises – when there is anteroposterior instability of the vertebral bodies of a degenerative nature, vertebral segment stabilization of the cervical spine can be performed with a pressure biofeedback unit (PBU),
- Dynamic upper and lower limb exercises – (flexion and extension) with the use of the PBU on the neck.
- Proprioceptive neuromuscular facilitation – for the upper and lower limbs.
- Improve posture
- Motor training programmes – may improve arm and hand functioning at a function and/or activity level in cervical spinal cord injured patients.
- Mobility and proprioception exercises
- Aerobic exercises
- Balance training – e.g. standing on one leg with eyes open and evolving to eyes closed; standing on a stable platform and evolving to an unstable platform with a rocker board
- Core stability exercises – In surgical cases, the physiotherapist still has an important role, both before and after the surgery. In the pre-operative phase, the physiotherapist needs to become thoroughly familiar with the patient’s history and about their activities of daily living that they are aiming to return to. The physiotherapist will inform the patient about the treatment program and the expectations after the surgery. There are different tests to develop a thorough picture of the patient’s baseline pre-operative status such as walking tolerance, Neck Pain and Disability Scale, the Neck Disability Index and lung function. Nomura et. al found that the maximum voluntary ventilation should significantly increase after surgery
- Continued Physical Activity – Though pain or weakness seem like good reasons to rest the neck, excessive bed-rest worsens the symptoms of a slipped disc in neck. Moving around too little allows muscles to grow weaker and prevents the body from healing. Periods of rest interspersed with periods of normal activity throughout the day keep the back muscles in shape.
- Physical Therapy – Physical therapists show slipped disc sufferers ways to move that do not cause pain. Occupational therapists teach skills that allow patients to return to a productive life.
- Nutrition – In order to restore the disc we also are going to need to include different substances in our diet. There are a lot of supplements on the market, of course. If you wish to try them, that’s fine. I personally don’t like them. I have tried one with glucosamine and chondroitin, but I didn’t feel any different. So, if you have the opportunity to take these with the food or from more natural sources, it will be great. You can find these substances in seafood and animal cartilages and by digesting them we ensure the building blocks for the connecting tissue for our joints and spine. Also, we will need more
- Omega 3 fatty acids – which can be supplied from cold pressed oils, fatty fish, flax seeds, chia and many more. Vitamins from the B group are very beneficial for people with herniated discs and all kinds of issues with the peripheral nervous system. Vitamins B1, B6 and B12 nourish the nerves and help them recover from the disk accident. Usually, doctors prescribe them as a part of the treatment, but it is worth mentioning anyway.
- A good massage – A massage is one of the natural methods of relieving pain. Individuals who get a massage weekly for several months stand a better chance of alleviating neck pain. A good massage provides a person with many health benefits that lessen neck pain. A massage triggers the release of endorphins. Endorphins aid in decreasing anxiety and relieving pain. They offer a relaxation effect by softening muscles that are injured preventing cramping.
- Undertaking yoga – Yoga is an applicable strategy for keeping the level of back pain at minimal levels. Taking yoga sessions often is very an effective method of dealing with neck pain. With yoga, there is a high likelihood of proper body functions. The use of pain prescriptions is also diminished. Patients suffering from neck pain related issues do not have to rely on these prescriptions to manage pain. Incorporating laughter in yoga is a good way of exercising. Yoga incorporates simple yet appropriate exercises that enhance the stretching of muscles. Laughter with yoga stimulates relieving of pain. It facilitates increased uptake of oxygen, little anxiety, and production of endorphins. All these variables play an essential role in diminishing neck pain.
- Adjusting sleeping position – A simple sleeping mistake can immensely contribute to neck pain. A poor sleeping position can cause stress and tension on the muscles contributing to neck pain. Altering one’s sleeping position and adopting a style that does not exert a lot of stress on the back is a recommended tactic. Nurturing sleeping habits such as assuming a reclining position, using wedge-shaped cushions and getting adjustable beds from reputable medical institutions are easy techniques to endorse. If a reclining position does not suit an individual, the other two techniques can be embraced.
- Heat therapy – Several considerations should be observed when using heat therapy. The right temperature ought to be set so as to ensure a patient does not face risks associated with too much exposure to heat. The key objective should be to ensure enough access to heat to the muscles to yield benefits for the patient. The adoption of heat therapy for easing neck pain is determined by the magnitude of pain a person is experiencing. In cases where relatively low back pain is encountered, short heat therapy sessions are recommended. On the other hand, if an individual is experiencing prolonged back pain, long heat therapy sessions are the most applicable.
- Taking hot baths – This is a form of heat therapy that aims at relieving neck pain. It guarantees permeation of heat into the muscles leading to reduced pain. Many individuals opt for this method since they believe it achieves competent results. Hot baths initiate a fast process of blood supply to stiff neck muscles. When this happens, the muscles relax and stretch leading to decreased pain. To avoid interference with one’s sleeping patterns, a hot bath should be taken several hours before retiring to bed.
- Aquatic therapy – This natural technique involves physical therapy in a pool. Individuals get the best out of this therapy by relying on the resistance of water. Consistency in undertaking this therapy is what ascertains getting back pain relief. Integrating aquatic therapy in an individual’s life for the better part of the week enhances the reduction of back pain quickly.
- Enlighten others – Individuals have the power to devise their own natural strategies that aid them in coping with back pain. The strategies can also be a good remedy for others going through similar circumstances. An individual can use social media platforms to equip others with important tips on how to keep back pain at bay. Further, becoming a member of associations that address back pain issues enables better communication of the knowledge gained from personal experience.
Medications of Cervical Myelopathy
In some cases, medications can help improve your symptoms.
- Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
- Antidepressants: A Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
- Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen, and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenoses, such as muscle spasms and damaged nerves.
- Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your back or neck. Steroids make inflammation go down. However, because of side effects, they are used sparingly.
- Anesthetics – Used with precision, an injection of a “nerve block” can stop the ain for a time.
- Muscle Relaxants – These medications provide relief from spinal muscle spasms.
- Skeletal muscle relaxers – may also be used. Their short term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side-effects.
- Neuropathic Agents: Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Antibiotic – to the management of bowel & bladders control and protect further infection. Infection causes should be treated with appropriate antibiotic therapy
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- Calcium & vitamin D3 – to improve bones health and healing fracture.
- Glucosamine & diacerine – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.
- Corticosteroid – to healing the nerve inflammation and clotted blood in the joints.
- Dietary supplement -to remove the general weakness & improved the health.
- Amitriptyline – If pain persists for more than a month, and has not responded to the above painkillers, your GP may prescribe a medicine called amitriptyline. Amitriptyline was originally designed to treat depression, but doctors have found that a small dose is also useful in treating nerve pain. You may experience some side effects when taking amitriptyline.
- Lesion debulking – is required for space-occupying lesions – eg, tumors, abscess.
- If surgery cannot be performed – radiotherapy may relieve cord compression caused by malignant disease.
- Radiation therapy and Chemotherapy – may have a role in treatment if the cauda equina syndrome is caused by a tumor.
- Support or brace – A pelvic belt can be used to stabilize a joint that is too loose until the inflammation and pain subside.
- Joint injections – Numbing injections into the sacroiliac joint are used diagnostically to help identify the cause of them but are also useful in providing immediate pain relief. Typically, an anesthetic is injected along with an anti-inflammatory medication.
- Cervical epidural block – In this procedure, steroid and anesthetic medicine is injected into space next to the covering of the spinal cord (“epidural” space). This procedure is typically used for neck and/or arm pain that may be due to a cervical disk herniation, also known as radiculopathy or a “pinched nerve.”
- Cervical facet joint block – In this procedure, steroid and anesthetic medicine is injected into the capsule of the facet joint. The facet joints are situated at the back of the neck and stability and movement. Arthritis may be formed and will play a part to neck pain.
- Medial branch block and radiofrequency ablation – This procedure is usually done for some chronic neck pain It can be used for both diagnosis and treatment of a potentially painful joint.
Although people sometimes turn to chiropractic manipulation for neck and back pain, manipulation should never be used for spinal cord compression.
Other Treatment Options
- Other treatment options – may be useful in certain patients, depending on the underlying cause of the CES
- Weakness – Physiotherapy may be helpful if there is no inflammatory component such as that found in arachnoiditis where exercise might exacerbate the condition and cause flare-ups.
- Sensory Loss – Little conventional treatment exists for sensory loss in cauda Equina syndrome, although in conditions such as Multiple Sclerosis use of vitamin B complex is considered to have potential beneficial effects.
- Sore Feet – Loss of muscle tone and control over the movement of the foot may lead to foot pain. If foot drop is a notable issue, a brace to hold it in position may help. It is important; however, to attempt to maintain as much muscle tone as possible as well as the range of movement (ROM). Exercises might help.
- Sexual Dysfunction – Sexual dysfunction is very hard for people to talk about at times. It might be best to pursue advice from specialists. If no physical treatment is feasible for improving function, the person and their sexual partner might pursue counseling which might help to lessen the impact of this disability on not only the person affected but their partner.
- Depression – Depression is an understandable reaction to a form of debilitating illness. Antidepressant medication should be reserved for severe depression. Counseling and support are the preferred methods of managing depression. Sharing experiences may help people with Cauda equina syndrome to come to terms with the disabilities associated with Cauda Equina syndrome.
- Poor Circulation – Poor circulation is a common issue in Cauda Equina syndrome. The person’s feet may be cold and turn white, then red when re-warmed (also known as, ‘Raynaud’s syndrome,) as well as chilblains. Some medications exist that can be taken, yet it is most likely best to use general measures such as avoiding getting cold feet and foot massage with warm oil to help improve the person’s circulation. Avoid extremely hot baths after the feet have been cold because it will most likely cause chilblains.
- Postoperative care – includes addressing lifestyle issues (eg, obesity), and also physiotherapy and occupational therapy, depending on residual lower limb dysfunction.
- Prolotherapy – the practice of injecting solutions into joints (or other areas) to cause inflammation and thereby stimulate the body’s healing response – has not been found to be effective by itself, although it may be helpful when added to another therapy.
- Herbal medicines – as a whole, are poorly supported by evidence. The herbal treatments Devil’s claw and white willow may reduce the number of individuals reporting high levels of pain; however, for those taking pain relievers, this difference is not significant. Capsicum, in the form of either a gel or a plaster cast, has been found to reduce pain and increase function.
- Behavioral therapy – may be useful for chronic pain. There are several types available, including operant conditioning, which uses reinforcement to reduce undesirable behaviors and increase desirable behaviors;
- Cognitive behavioral therapy – which helps people identify and correct negative thinking and behavior; and respondent conditioning, which can modify an individual’s physiological response to pain. Medical providers may develop an integrated program of behavioral therapies. The evidence is inconclusive as to whether mindfulness-based stress reduction reduces chronic back pain intensity or associated disability, although it suggests that it may be useful in improving the acceptance of existing pain.
- Tentative evidence supports neuroreflexotherapy (NRT) – in which small pieces of metal are placed just under the skin of the ear and back, for non-specific low back pain
Surgery of Cervical Myelopathy
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