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Cervical Myelopathy

MRI showing cervical Myelopathy
Cervical Myelopathy

Cervical Myelopathy is affection of cervical spinal cord causing various neurological symptoms. This usually happens with chronic cervical spondylosis leading to progressive disc bulge, osteophyte formation and ligamentum flavum hypertrophy causing cervical spinal stenosis. It’s called Spondylotic Cervical Myelopathy. Some patients have narrowing of spinal canal since birth and are prone to develop these symptoms early (Congenital Spinal Stenosis). Ossification of ligaments of cervical spine is also common cause of cervical myelopathy. External pressure caused by spinal infection, fracture and tumor can also cause symptoms of cervical myelopathy. 

Symptoms of Cervical Myelopathy:

Cervical myelopathy will affect the neurological supply to both upper and lower extremities and part of the body below the level of cervical spinal cord compression.

  • Tingling, numbness, weakness in upper extremity.
  • Loss of grip and clumsiness of hand.
  • Loss of body balance.
  • Difficulty in walking, standing, sitting.
  • Loss of bladder-bowel control.
  • Spasticity in the extremities and body.

Diagnosis:

  1. Typical history and physical examination,
  2. MRI Scan: Main diagnostic tool which will show level and severity of pressure on spinal cord,
  3. X-rays: to rule out bone abnormalities and instability,
  4. CT Scan: A CT might be required to assess bone structure in detail, especially for patients suspected to be having ossified ligaments. Also, CT is recommended when MRI cannot be done (patients with heart pacemaker, ear cochlear implants, certain stainless steel orthopaedic implants),
  5. EMG-NCV: In cases where there is mismatch between MRI picture and patients symptoms. Also when other nerve related abnormalities need to be ruled out, e.g. diabetes, carpal tunnel syndrome, primary neuropathies and myopathies. EMG-NCV will give a baseline value for neurological condition against which recovery can be assessed in future.
  6. Blood Tests: Various blood tests might be required to rule out vitamin deficiency (B12), infection, and tumors.
  7. Other tests: Specific tests to confirm/ rule out infection and tumors might be required, if these conditions are suspected (CT guided biopsy, Histopathology, Culture and Sensitivity etc.)

Treatment:

Cervical Spinal stenosis is an irreversible pathology. Treatment for spinal stenosis is usually based on severity of patients symptoms and response to given treatment.

  1. Medical treatment: An initial course of pain killer medicines along with local application of pain relieving ointments are used to soothe pain. Other medications are given to make nerve more resistant to painful stimuli to reduce nerve related symptoms (radiculopathy, tingling, numbness). A spinal brace is given to eliminate excessive motion at painful spinal segment and to provide support to spine. Some amount of activity restriction is advisable to prevent worsening of symptoms.
  • Epidural Injection: Epidural injection can be tried to reduce radiculopathy symptoms. However, they don’t usually help with other symptoms as epidural injection doesn’t reverse spinal stenosis. Epidural injections cannot be given to patients with uncontrolled diabetes and patients on blood-thinner therapy for heart conditions.
  • Surgical Decompression of Spinal Cord: Patients who have severe symptoms to start with or those who don’t respond to above treatment with significant restriction of their day to day activities, usually need removal of pressure from spinal cord. This can be done in various ways-
  1. Anterior Cervical Spine Surgery: A minimally invasive procedure using a microscope to perform anterior cervical discectomy and/ or corpectomy with fusion done. This is done when pressure on spinal cord is primarily anterior.
  2. Posterior Cervical Spine Surgery: Patients with primary pressure on posterior aspect and multilevel compression are better benefited by a posterior surgery. A laminectomy with/ without fusion or laminoplasty can be done. Occasionally a targeted anterior procedure might be required in addition if there is associated anterior pressure and patient doesn’t recover completely after posterior only surgery.

Cervical myelopathy is a non-reversible condition which usually progresses. It is recommended to get the surgery done as soon as patient start having symptoms. Delaying surgery will lead to worsening of symptoms. These may not reverse completely even after the surgery due to permanent damage in spinal cord caused by long standing pressure.

A Thoracic Myelopathy will not affect upper extremities. However, part of the body below the level of compression will experience similar symptoms as in cervical myelopathy. This includes spasticity in legs, difficulty in standing and walking, and loss of bladder-bowel control. Ossification of ligaments is one of the main reason of thoracic myelopathy. This is more common in areas with fluorosis. Diagnosis and treatment protocols are similar to cervical myelopathy.