Cervical Stenosis and Myelopathy

Cervical Stenosis and Myelopathy

Normal Anatomy

·  Spinal canal is the space in the vertebral column formed by the vertebrae

·  The spinal cord passes through this space

·  Intervertebral foramen is the lateral gap between two spinal vertebrae

·  The nerve roots pass through this space

Pathophysiology

·  Stenosis is a description rather than a diagnosis

·  Spinal stenosis refers to a narrowing of the vertebral canal or intervertebral foramen

·  it is most commonly caused by degenerative changes

·  Stenosis may result in myelopathy, an impaired function of the spinal cord caused by compression

·  Cervical stenosis leading to myelopathy is generally progressive and develops slowly.

·  Myelopathy caused by spondylosis is called cervical spondylotic myelopathy (CSM)

·  This is most prevalent at the C5-C6 level and rarely seen in the upper cervical segments (C3-C4)

Mechanism of injury

Stenosis

Insidious

·  Congenital/inherited

·  Idiopathic (hereditary)

·  Achondroplastic

·  Acquired Stenosis

·  Infection

·  Tumours

·  Foreign Bodies

·  Disc Protrusion

·  Ligamentous Hypertrophy

·  Osteophyte formation

·  Facet joint Hypertophy

·  Spondylolisthesis

Traumatic

·  Fractures

·  Upper Cervical Instability

Myelopathy

Insidious

·  Stenosis causes

·  Rheumatoid Arthritis

Traumatic

·  Fractures

·  Ligament Rupture (Upper Cervical Instability)

Examination

Subjective

Stenosis

·  Presentation will depend on associated pathology

·  Insidious onset

·  Progressive worsening of symptoms

·  Aggravating by positions that reduce space (extension, rotation)

Myelopathy

·  Upper and/or lower limb pain, weakness, sensation, reflex changes

·  Clumsiness

·  Neuropathic pain

·  Gradually worsening symptoms

·  Bladder or bowel dysfunction

·  Difficulty walking for long distances

·  Reduced fine motor skills and co ordination

·  Insidious onset of symptoms

·  Neck pain may or may not be present

·  Falls

Objective

Stenosis

·  Presentation will depend on associated pathology

·  Pain with movements that close space

Myelopathy

·  Hyper reflexia in the upper or lower extremities

·  Increased Tone

·  Pathological reflexes positive Hoffmans and/or Babinski sign

·  Upper and/or lower quarter sensation loss (bilateral or quadrilateral)

·  Bilateral or quadrilateral weakness

·  Poor co-ordination and fine motor skills

·  Gait Instability

Differential Diagnosis

Subjective Findings / Tone / Motor / Co ordination / Reflexes / Sensory
Myelopathy / Arm and leg feel twitchy, jerky, clumsy, heavy, and stiff.
Scraping toes on the floor. / Arm and leg weakness, heavy, stiff, tight. / Dropping things, knocking over things, unable to do up fasteners. / Arm and leg feel twitchy, jerky, clumsy / Arm and leg feel numb dead, tingly, cold.
Characteristic patterns of pain in upper limb and lower limb
Radiculopathy / Arm feels clumsy heavy or stiff, heavy or dead.
No change in legs. / Arm feels weak, heavy.
No change in legs. / Dropping things, knocking over things, unable to do up fasteners.
No change in legs / Arm feels slow, heavy.
No change in legs / Arm feels numb, dead, tingly cold.
No change in legs.
Pain in one or two upper limb dermatomes but no associated pain in the lower limb.
Objective Findings / Tone / Motor / Co ordination / Reflexes / Sensory
Myelopathy / Reduced extensor tone in the UL, increased flexor tone in the UL. Opposite pattern in the LL. / Reduced in the extensors of the upper limb, increased in the flexors of the UL. Opposite pattern in the LL. / Reduced in the UL and LL / Increased in the flexors of the UL. Opposite pattern in the LL. Plantars upgoing/ Babinksi +ve / Characteristic patterns of sensation loss in UL and LL
Radiculopathy / Reduced for 1 or 2 UL myotomes. No change in the LL. / Reduced for 1 or 2 UL myotomes. No change in the LL. / Reduced in the UL no change in the LL / Reduced for 1 or 2 UL myotomes. No change in the LL. Plantars downgoing/ Babinksi –ve / Loss of sensation in 1 or 2 dermatomes. No change in the LL.

Special tests

·  Hoffmans

·  Babinski

·  Romberg

Further investigation

·  MRI (angled sagittal)

·  CT with Myelogram (dye injected to highlight the nerves)

Management

General

·  Analgesia

·  Gabapentin

·  Activity modification

Conservative

Stenosis

·  Manage the underlying pathology

·  Pain Relief

o  NSAID’s, Ice, Massage

·  Restore Normal ROM

o  Thoracic, Cervical and Shoulders

o  Soft tissue techniques and joint mobilisations

·  Restore Normal Neurodynamics

o  Soft tissue techniques, joint mobilisations, nerve sliders

·  Restore Normal Muscular Activation

o  Scapular stabilisers, deep cervical extensors, deep cervical flexors

Myelopathy

·  Refer onwards for further investigation immediately

·  If diagnostics have already been completed and conservative management suggested, monitor symptoms closely, if they worsen surgical intervention may be indicated

·  Myelopathy may develop rapidly and delays in surgical intervention may result in poor outcome

·  Heat/Ice

·  Traction

Surgical

The goal of surgical treatment is to decompress the cervical spinal canal and achieve an arthodesis of the treated levels. This can be achieved in the following ways:

Posterior approach

·  Laminectomy

·  Laminoplasty

Anterior approach

·  Discectomy and interbody fusion

·  Corpectomy and fusion

References

(Tavy et al., 1999, Almeida et al., 2013, Baptiste and Fehlings, 2006, Meyer et al., 2008, Rhee et al., 2013, Browder et al., 2004, Rumi and Yoon, 2004, Matz, 2006, Lebl et al., 2011, Todd, 2011, Singh et al., 2012, Kalsi-Ryan et al., 2013)

Almeida, G. P., Carneiro, K. K. and Marques, A. P. (2013) 'Manual therapy and therapeutic exercise in patient with symptomatic cervical spondylotic myelopathy: a case report', J Bodyw Mov Ther, 17(4), pp. 504-9.

Baptiste, D. C. and Fehlings, M. G. (2006) 'Pathophysiology of cervical myelopathy', Spine J, 6(6 Suppl), pp. 190s-197s.

Browder, D. A., Erhard, R. E. and Piva, S. R. (2004) 'Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series', J Orthop Sports Phys Ther, 34(11), pp. 701-12.

Kalsi-Ryan, S., Karadimas, S. K. and Fehlings, M. G. (2013) 'Cervical spondylotic myelopathy: the clinical phenomenon and the current pathobiology of an increasingly prevalent and devastating disorder', Neuroscientist, 19(4), pp. 409-21.

Lebl, D. R., Hughes, A., Cammisa Jr, F. P. and O’Leary, P. F. (2011) 'Cervical spondylotic myelopathy: pathophysiology, clinical presentation, and treatment', HSS journal, 7(2), pp. 170-178.

Matz, P. G. (2006) 'Does nonoperative management play a role in the treatment of cervical spondylotic myelopathy?', Spine J, 6(6 Suppl), pp. 175s-181s.

Meyer, F., Börm, W. and Thomé, C. (2008) 'Degenerative cervical spinal stenosis: current strategies in diagnosis and treatment', Deutsches Ärzteblatt International, 105(20), pp. 366.

Rhee, J. M., Shamji, M. F., Erwin, W. M., Bransford, R. J., Yoon, S. T., Smith, J. S., Kim, H. J., Ely, C. G., Dettori, J. R., Patel, A. A. and Kalsi-Ryan, S. (2013) 'Nonoperative management of cervical myelopathy: a systematic review', Spine (Phila Pa 1976), 38(22 Suppl 1), pp. S55-67.

Rumi, M. N. and Yoon, S. T. 'Cervical myelopathy history and physical examination'. Seminars in Spine Surgery: Elsevier, 234-240.

Singh, A., Tetreault, L., Fehlings, M. G., Fischer, D. J. and Skelly, A. C. (2012) 'Risk factors for development of cervical spondylotic myelopathy: Results of a systematic review', Evidence-based spine-care journal, 3(3), pp. 35.

Tavy, D. L., Franssen, H., Keunen, R. W., Wattendorff, A. R., Hekster, R. E. and Van Huffelen, A. C. (1999) 'Motor and somatosensory evoked potentials in asymptomatic spondylotic cord compression', Muscle Nerve, 22(5), pp. 628-34.

Todd, A. G. (2011) 'Cervical spine: degenerative conditions', Current Reviews in Musculoskeletal Medicine, 4(4), pp. 168-174.

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