Cervical spondylosis with cervical myelopathy, commonly referred to as cervical spondylotic myelopathy (CSM), refers to impaired function of the spinal cord caused by degenerative changes of the discs and facet joints in the cervical spine (neck). This condition is the most common disorder causing dysfunction of the spinal cord (known as myelopathy) and results from compression of the spinal cord.
Most patients with this condition are over 50 years of age, but the age of onset is variable depending on the degree of congenital spinal canal narrowing.
The process that leads to spinal cord compression is a result of arthritis in the neck (also called cervical spondylosis or degenerative joint disease), which is incompletely understood and likely has a number of causes.
Factors That Lead to Cervical Spondylosis with Myelopathy
Factors that are thought to contribute to development of cervical spondylosis with myelopathy include:
Normal age-dependent changes of the intervertebral discs, most commonly manifested as cervical osteophytes (bone spurs) at the margins of the vertebrae.
- Arthritis in the neck leading to facet hypertrophy (enlargement of the facet joints).
- Thickening of the ligaments surrounding the spinal canal, especially the ligamentum flavum, which parallels loss of disc height.
- Translational mechanical instability resulting in subluxation (or partial dislocation) of the vertebral bodies.
- Congenitally small spinal canal, which renders the patient's spinal cord more susceptible to compression.
- Repetitive wear and/or trauma leading to degenerative changes affecting the disc spaces and vertebral endplates.
Patients with cervical spondylotic myelopathy often have some combination of the following symptoms:
- Weakness, numbness or clumsiness of the arms, hands, and/or fingers
- Altered walking ability perceived as poor balance, weakness, heaviness or numbness in the legs
- A painful, stiff neck
- Variable degrees of radicular arm pain (pain that radiates down the arm and possibly into the fingers).
Though cervical spondylotic myelopathy is painless in more than 50% of patients, when pain is present it may be described as a stabbing, burning sensation or a persistent dull ache radiating throughout the arms to the forearms, at times to the fingers, associated with "pins and needles" paresthesias extending into the fingers.
Patients often comment about dropping objects accidentally or having trouble fastening their clothes. If prolonged, there may be associated muscle wasting and overt loss of sensation to vibration, pinprick sensation, and pain and thermal sensation.
In addition, on examination, the doctor may notice increased resting tone of the arms and legs, focal weakness of muscles supplied by affected nerve roots, unsteadiness of gait, and abnormally brisk deep tendon reflexes.
Coordination may be affected as well, including impaired fine finger movement, as well as difficulty with coordinated walking, such as seen with reverse tandem gait. Neck flexion may induce electrical-like sensations running down the spine (referred to as Lhermitte's phenomenon). Sexual function may be adversely affected as well.
Both conservative (non-surgical) and surgical approaches are available to treat cervical spondylotic myelopathy.
Conservative (non-surgical) treatment is aimed at decreasing pain by reducing spinal cord and nerve root inflammation, as well as improving the patient's function and ability to perform daily activities.
Treatment generally consists of a combination of temporary immobilization of the neck, steroidal and/or non-steroidal anti-inflammatory medications (such as COX-2 inhibitors or ibuprofen), as well as physical therapy.
Depending on the specific MRI/CT myelogram findings, other potential treatment options include various forms of cervical traction and epidural steroid injections.
Patients with overt spinal cord compression resulting in spinal cord dysfunction (myelopathy) may be referred directly for consideration of surgery. Two common indications for having surgery include:
Symptoms failing to improve after 4 to 6 weeks of non-surgical management
- Progression of the symptoms in spite of non-surgical treatment
In the past, cervical laminectomy (removing the posterior aspects of the spinal canal) to decompress (relieve pressure on) the spinal cord has been the procedure of choice.
However, as previously described, the majority of the abnormal anatomy producing spinal cord compression is located anteriorly to (in front of) the spinal cord itself. This is only indirectly addressed by a cervical laminectomy, with a clear subset of patients either failing to benefit or even getting worse after a laminectomy. Therefore, depending on the patient's anatomy, many surgeons prefer anterior decompression of the spinal cord and nerve roots (in the front of the spine).
These procedures are referred to as anterior cervical decompression and fusion operations. The surgeon may also use instrumentation (plates and screws) to provide immediate internal support for the cervical spine, and to promote bone graft healing.
If you'd like to discuss this condition with one of our doctors, we would be more than happy to contact you. You don't need a primary care physician referral for us to see you.
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