Cervical myelopathy

Cervical myelopathy is a type of myelopathy that is caused by axonal injury of the cervical spinal cord, either by direct compression or ischemic injury due to compression of the anterior spinal artery. The most common cause is cervical spondylotic myelopathy. Other etiologies include spinal trauma, neoplasms, epidural abscess, and autoimmune disorders. Onset can be acute, insidious, or progress in a stepwise fashion. Clinical features include neck pain and stiffness, impaired sensation in the hands and arms, weakness, poor manual dexterity, and gait instability. The diagnosis is confirmed by MRI. Treatment includes conservative management for mild disease without functional impairment or surgical decompression in acute or severe disease with functional impairment.

• Causes for compression of the spinal cord include:
  • Blunt or penetrating trauma (e.g., fracture, epidural hematoma)
  • Infection (e.g., abscess)
  • Radiation therapy
  • Autoimmune disorders (e.g., rheumatoid arthritis, neuromyelitis optica)
  • Neoplasms (e.g., meningiomas, nerve sheath tumors, metastases) or cysts (e.g., epidermoid cysts)
  • Ossification of the posterior longitudinal ligament (OPLL)
  • Congenital narrowing of the cervical spinal canal
  Degenerative diseases
  • Spinal stenosis
  • Ankylosing spondylitis
  • Discogenic myelopathy (central disc herniation)
  • Multiple sclerosis

References:^[1]

• Intramedullary or extramedullary (i.e., originating from within or outside the spinal cord) mass lesions compress the spinal cord and impair its perfusion; → mechanic and ischemic axonal injury → intramedullary edema → further narrowing of the medulla

References:^[2]

Features depend on the level of compression and the onset may be sudden (e.g., with trauma), step-wise, or slowly progressive (e.g., degenerative diseases)

• Neck, shoulder, upper limb, or lower limb pain (neck stiffness may be present)
• Signs and symptoms of lower motor neuron lesions at the level of the lesion; (e.g., weakness and atrophy in the arms and/or hands in lesions of the thoracic spine)
• Signs and symptoms of an upper motor neuron lesion below the level of the lesion; (e.g., abnormal spastic gait is often an early sign; hyperreflexia or a positive Babinski's sign may be present)
• Impaired sensation; (e.g., numbness; , impaired proprioception, ataxia)
• Impaired bladder and bowel control

Damage to the spinal cord and the nerve roots (radiculopathy) often occur simultaneously!

Pain is not commonly an early symptom. Therefore patients may not be diagnosed until myelopathy becomes severe!

References:^[1][3]

• MRI of the spine: : determines the site of narrowing of the medulla and the underlying pathology
• Myelography: (possibly with CT): when MRI is contraindicated (e.g., in patients with metal implants)

References:^[2][4]

• Subacute combined degeneration of the spinal cord
• Amyotrophic lateral sclerosis (Lou Gehrig's disease)
• Syringomyelia

References:^[4][5]

The differential diagnoses listed here are not exhaustive.

• Conservative treatment: (i.e., analgesia; , corticosteroid; therapy , bracing; , physiotherapy; ): indicated perioperatively; , for severe cases (e.g., degenerative cervical myelopathy ), and mild cases
• Decompression surgery: : typically indicated in acute or advanced cases

Acute cervical myelopathy with loss of bladder and bowel control is a neurological emergency that demands immediate surgical decompression!

References:^[3][5]