Myelopathy is a term used to refer diseases that affect the spinal canal. Common causes of myelopathy are trauma to the spinal cord as a result of vertebral fracture or dislocation, herniated disc, osteoarthritis of the spine and tumors. Other causes include viral infections, immune reactions, and inadequate flow of blood through vessels of the spinal cord. It can occur at any age and in the neck and thoracic spine, the neck being more common.
The most common etiology in the spine however is cervical spondylotic myelopathy (CSM). CSM occurs in individuals aged above 55 years. Repeated trauma from activities such as carrying heavy loads or sports (gymnastics) increases the risk of CSM. The gradual wear and tear because of aging causes narrowing of the spinal canal that leads to compression of the spinal cord. This may cause symptoms such as:
- Pain and stiffness in the neck
- Loss of balance and coordination – difficulty in walking and performing simple tasks
- Tingling sensation and numbness
Your doctor may ask about your symptoms and examine your neck to look for any abnormal reflexes, numbness and atrophy of muscles. Some of the diagnostic tests such as X-rays, magnetic resonance imaging, and myelogram may be done to confirm the diagnosis. Myelogram is a special type of computed tomography (CT) scan in which a dye is injected prior to the scan in order to get a clearer outline of the spinal cord.
Nonsurgical methods provide temporary relief from the symptoms in some case. However, in many cases surgery is advised as non operative treatment will not reverse the compression most of the time. If you suffer from severe cord compression on imaging, demonstrates profound weakness in the arms or legs, or suffers from bowel or bladder incontinence, surgery is advised without a trial of non operative treatment modalities typically.
If non operative measures is tried, these options include:
- Soft Collars: Soft collars can be worn to allow the neck muscles to rest and restrict neck movements. This also helps in decreasing the pinching of nerve roots during movement
- Exercise: Simple exercises help to improve the strength and flexibility of your neck
- Nonsteroidal anti-inflammatory drugs (NSAIDs): Medications such as aspirin and ibuprofen can be taken to reduce swelling and pain
- Epidural steroid injections: Cortisone injections are given directly into the epidural space to decrease swelling as well as pain
Surgery of the spine is considered in case your symptoms do not alleviate with the conservative treatment methods. The main goal of surgery is to relieve cord compression. Sometimes a fusion will also be needed depending on your condition. The four common operations for CSM include:
Clinical Example 1
History: A 50 year old gentleman presents with a year history of difficulty using his left hand and clumsiness when walking. He has difficulty with buttoning his shirt and his handwriting has deteriorated over the years. He feels like he drops things easier. When he walks he feels like he is “drunk”.
Images: This is an example of his MRI which is usually ordered for patients who present similar to this man. The bottom arrow points to the normal part of the spine. The gray stripe running from the top to the bottom of the image is the spinal cord. Around the spinal cord is spinal fluid (the white area on the left and right of the spinal cord). In the area pointed by the upper arrow, the spinal cord is deformed and the white area around the spinal cord has disappeared. This represents spinal cord compression.
In a cross section of the spine, the left MRI image shows a normal level. The arrow points to the normal spinal fluid (white area) surrounding the spinal cord. On the right is a compressed area. As you can see, the spinal cord is not oval anymore. The shape has changed. Also the amount of spinal fluid has decreased.
Surgery: This gentleman had a laminoplasty procedure. Small plates and screws are used in the procedure to create more room for the compressed spinal cord (left image). On the right, a CT image represents what a laminoplasty procedure does. It creates more room for the spinal cord relieving the compression by cutting the bone and resetting it in a different position to create more room for the spinal cord.
Clinical Example 2
History: Patient is a 62 year old gentleman who has been suffering from inability to use his hands and unable to ambulate. His wife had been taking care of him for the past year as his functional abilities have declined. The past week prior to presentation, patient has been unable to stand to even change clothes and use the bathroom. He comes into the emergency room due to neck pain and his wife’s inability to take care of him.
Images: Unlike the prior case presentation, this patient has loss of the normal curvature of the spine. Because of this, patient is not a candidate for laminoplasty. Without a fusion, the likelihood of his drooping down is too high. Similar to the laminoplasty presention, there is similar cord compression although more levels are involved.
Surgery: In this case a laminectomy (decompression or relieving the spinal cord compression) and fusion (to keep the head from drooping down) was done. You can see the screws and plates in the vertebrae (bones of the spine) holding his head in a normal position.