Clinical Case Cervical Spondylotic Myelopathy
Overview
Cervical spondylotic myelopathy (CSM) is a condition characterized by the compression of the spinal cord, resulting from the narrowing of the spinal canal and degenerative changes.
This compression, which can be caused by factors related to development or dynamic factors, leads to the onset of CSM. CSM presents with typical signs such as pain in the neck and radiating pain, along with sensations of numbness and tingling, muscle weakness, and spasms in the upper limbs.
Additionally, CSM can give rise to notable neurological issues like impaired walking and dysfunction of the bladder. To ensure optimal treatment for patients, it is crucial to have a comprehensive understanding of the causes and progression of CSM.
Causes
CSM is typically caused by age-related degenerative changes in the spinal canal. While it is more common in older adults, a study aims to explore the characteristics of CSM in young adults under 30, as this population is rarely affected.
In a study reported by literature, a very small percentage (0.27%) of CSM patients under 30 years old were analyzed. They were mostly male and engaged in high daily activities that placed stress on their necks. Radiographs showed congenitally narrowed spinal canals and positive findings for dynamic spinal movements.
Participating in sports activities, particularly contact sports like American football and rugby, is a significant contributor to spinal injuries among young individuals.
This study focused on patients who engaged in high daily activities related to sports or occupations, resulting in ongoing strain on their necks. Unlike cases with sudden onset symptoms, the patients in this study experienced a gradual development of symptoms over time.
This suggests that the consistent occurrence of mild daily injuries and traumas may play a role in the progression of degenerative spinal changes and the occurrence of subclinical neurological damage.
CSM risk is associated with congenitally narrowed cervical spinal canal stenosis. Measuring the sagittal spinal canal diameter on radiographs is a common method, and a diameter of 12 mm or less indicates a high risk of CSM development.
Symptoms of CSM
The symptoms of CSM can vary widely and may develop slowly over time. Common symptoms include:
- Neck pain and stiffness: Although not always present, neck discomfort is often one of the first signs of CSM.
- Radiculopathy: This refers to symptoms like pain, numbness, and tingling that radiate from the neck into the shoulders, arms, and hands.
- Myelopathy: This term describes symptoms due to spinal cord compression, including:
- Weakness in the arms and legs: Patients may notice difficulty with fine motor skills, such as buttoning a shirt or writing. Walking may become unsteady or more effortful.
- Numbness and tingling: Sensory disturbances in the hands and feet are common.
- Gait and balance problems: As the spinal cord compression progresses, patients may experience difficulty walking, frequent falls, and a feeling of instability.
- Bladder and bowel dysfunction: In severe cases, there can be issues with urinary incontinence or bowel control.
Diagnosis
MRI scans revealed disc degeneration, spinal cord compression, and abnormal signal changes. The sagittal alignment of the cervical spine showed two common types, associated with different patterns of spinal cord compression and damage. These findings suggest that high daily activities and congenital canal stenosis can contribute to the development of symptomatic CSM in young adults.
The Torg-Pavlov ratio is another indicator, and all patients in the study had a ratio <0.8, indicating a predisposition to congenital canal stenosis. While women have a higher prevalence of this condition, men engaged in high daily activities can experience spinal cord compression in the presence of congenital canal stenosis.
Dynamic canal stenosis, also referred to as the “pincer mechanism,” is an added risk factor for CSM. The study revealed that the majority of patients displayed positive indications of dynamic canal stenosis, suggesting that individuals with congenital canal stenosis and active daily routines may experience an intensified compression of the spinal cord.
The use of absolute radiographic measurements to assess cervical spine instability and canal stenosis is a topic of debate. However, there are suggested criteria for evaluating the space available for the spinal cord at the C1 level.
For patients who meet the radiographic criteria for instability and stenosis, it is advisable to undergo further MRI evaluation to support a comprehensive diagnosis of myelopathy involving multiple disciplines.
Magnetic resonance imaging (MRI) is a valuable diagnostic tool for examining intervertebral disc and spinal cord conditions. The study observed degeneration in all discs at the affected level, along with the presence of spinal cord compression, deformity, and intramedullary abnormal signal lesions.
These findings suggest that the combination of high daily activities, degenerative instability, and congenital canal stenosis can contribute to spinal cord compression and damage, potentially resulting in the development of symptomatic CSM.
The objective of this study was to examine the sagittal alignment of the cervical spine in young adult patients to identify radiographic and biomechanical characteristics of cervical spondylotic myelopathy (CSM).
The most frequently observed alignment was the “reverse-sigmoid” type, which exhibited single-level spinal cord compression and positive indications of decreased neutral foramen (DNF) or posterior vertebral slip. On the other hand, alignments such as “lordosis” or “straight” demonstrated multi-level spinal cord compression and altered biomechanics.
Therefore, it is crucial to closely monitor young male athletes and workers with pre-existing sagittal malalignment and congenital canal stenosis for the development of dynamic canal stenosis and spinal cord damage.
It is important to exercise caution when interpreting the findings of this study for several reasons. Firstly, the true prevalence of CSM in patients under the age of 30, including those with mild symptoms treated in outpatient settings, remains uncertain as the study only included hospitalized patients.
Secondly, the small sample size restricts the statistical power and increases the likelihood of potential interpretation errors, despite utilizing appropriate statistical analysis methods.
Thirdly, the absence of a control group limits the ability to draw definitive conclusions. Furthermore, the retrospective nature of the study introduces limitations and potential biases related to participant selection.
However, the distinct characteristics observed in young adult patients with non-herniated, degenerative CSM underscore the need for future prospective cohort studies to gain a more comprehensive understanding of this condition.
Non-herniated, degenerative cervical spondylotic myelopathy (CSM) is rare in young adults under 30. However, it is more common in men with congenital canal stenosis and mild sagittal deformities.
High daily activities, such as sports or jobs that stress the neck, can accelerate disc degeneration and dynamic canal stenosis, leading to spinal cord compression and potential symptomatic myelopathy.
Treatment Options
Treatment depends on the severity of the condition:
- Conservative treatment: For mild cases, this may include physical therapy, pain management, and lifestyle modifications. However, close monitoring is necessary as the condition can progress.
- Surgical treatment: This is often recommended for moderate to severe cases to relieve spinal cord compression. There are different surgical approaches:
- Anterior cervical discectomy and fusion (ACDF): Suitable for patients with compression in the front of the spine.
- Posterior cervical decompression: Beneficial when multiple segments are involved or there’s compression from the back of the spine.
Each surgical approach has its risks and benefits, and the choice depends on individual patient factors, including the extent and location of spinal cord compression.
Post-Treatment Care
Post-surgery, patients typically undergo rehabilitation to regain strength and function. Recovery can vary, with some patients experiencing significant improvements in symptoms, while others may have lingering effects. Regular follow-ups are crucial to monitor recovery and manage any complications.
Recovery and Rehabilitation
Postoperative recovery from CSM surgery can vary based on the type of surgery performed and the individual patient’s condition. General guidelines for recovery include:
- Hospital Stay: Most patients stay in the hospital for a few days after surgery. During this time, they are monitored for any complications.
- Pain Management: Pain is managed with medications, and a gradual return to normal activities is encouraged.
- Physical Therapy: Rehabilitation exercises help restore neck mobility, strengthen muscles, and improve overall function. The therapist may also provide guidance on posture and ergonomic adjustments to prevent future problems.
- Follow-Up Appointments: Regular follow-ups with the surgeon are crucial to monitor healing and ensure that the spine is stable.
Conclusion
Cervical spondylotic myelopathy is a progressive condition caused by age-related changes in the cervical spine. Early detection and appropriate treatment are key to managing symptoms and preventing severe neurological deficits. If you experience persistent neck pain, numbness, or weakness in your limbs, consult a healthcare provider to explore potential causes and treatment options.
Do you have more questions?
What are the early signs of cervical spondylotic myelopathy?
Early signs of cervical spondylotic myelopathy (CSM) often include neck pain, stiffness, and subtle changes such as tingling or numbness in the arms and hands. Patients may also experience slight balance issues or difficulty with fine motor tasks, such as buttoning a shirt or writing.
How quickly does cervical spondylotic myelopathy progress?
The progression of CSM varies widely among individuals. Some may experience a rapid decline in function, while others may have a slow, insidious onset of symptoms over many years. Regular monitoring and early intervention are key to managing the disease effectively.
Can lifestyle changes help manage cervical spondylotic myelopathy?
Yes, lifestyle changes can play a significant role in managing CSM. Maintaining good posture, using ergonomic tools, avoiding heavy lifting, and engaging in regular low-impact exercises can help alleviate symptoms and potentially slow the progression of the condition.
Are there any non-invasive treatments for cervical spondylotic myelopathy?
Non-invasive treatments for CSM include physical therapy to strengthen neck muscles and improve flexibility, pain management with medications such as NSAIDs or muscle relaxants, and lifestyle modifications like improving posture and using cervical collars to support the neck.
When is surgery necessary for cervical spondylotic myelopathy?
Surgery is typically considered necessary for CSM when symptoms are moderate to severe, when there is significant spinal cord compression visible on imaging studies, or when non-surgical treatments fail to provide adequate relief. Surgery aims to decompress the spinal cord and stabilize the spine.
What are the risks associated with surgery for cervical spondylotic myelopathy?
As with any surgical procedure, there are risks associated with surgery for CSM. These can include infection, bleeding, nerve damage, spinal cord injury, complications from anesthesia, and the potential need for further surgeries. However, for many patients, the benefits of surgery outweigh these risks.
How successful is surgery for cervical spondylotic myelopathy?
Surgery for CSM is generally successful, with many patients experiencing significant relief from symptoms. The extent of recovery can vary depending on the severity and duration of spinal cord compression prior to surgery, as well as the patient’s overall health.
Can cervical spondylotic myelopathy recur after surgery?
While surgery aims to decompress the spinal cord and stabilize the spine, there is always a possibility of recurrence. Factors such as ongoing degenerative changes in the spine or inadequate initial decompression can contribute to the recurrence of symptoms.
What kind of rehabilitation is required after surgery?
Rehabilitation after surgery for CSM typically involves physical therapy to improve neck mobility, strengthen muscles, and enhance overall function. This may include guided exercises, posture correction, and possibly occupational therapy to help with daily activities.
How long does recovery take after surgery for cervical spondylotic myelopathy?
Recovery time after surgery for CSM varies but generally ranges from several weeks to months. Most patients can return to normal activities within 3-6 months, depending on the type and extentof the surgery, the patient’s health, and adherence to rehabilitation protocols. Individual recovery can differ, and some patients might experience a quicker return to normal activities, while others might take longer to fully recover.
What are the potential complications if cervical spondylotic myelopathy is left untreated?
If left untreated, CSM can lead to severe and permanent spinal cord damage, resulting in significant neurological deficits such as chronic pain, pronounced muscle weakness, loss of sensation, and severe difficulty in walking or performing daily activities. In extreme cases, it can lead to paralysis or severe disability.
Are there alternative therapies for managing cervical spondylotic myelopathy?
Yes, alternative therapies such as acupuncture, chiropractic care, and yoga might provide some symptom relief for certain patients. However, these should complement, not replace, conventional medical treatments. It is crucial to discuss any alternative therapies with a healthcare provider to ensure they are safe and appropriate for the condition.
Can cervical spondylotic myelopathy affect other parts of the spine?
While CSM specifically affects the cervical spine, the degenerative processes causing it can also impact other parts of the spine, such as the thoracic or lumbar regions. This can lead to similar conditions, like lumbar spondylosis, which can cause lower back pain and nerve compression.
Is cervical spondylotic myelopathy hereditary?
There can be a genetic predisposition to developing spinal degenerative diseases, including CSM. However, environmental factors, lifestyle choices, and occupational hazards also significantly contribute to the condition’s development.
Can cervical spondylotic myelopathy be prevented?
While aging and genetic factors cannot be controlled, certain measures can help reduce the risk of developing CSM. These include maintaining a healthy weight, avoiding smoking, practicing good posture, using ergonomic furniture and tools, and engaging in regular exercise to strengthen the neck and back muscles.
How does cervical spondylotic myelopathy affect daily life?
CSM can significantly impact daily life by causing pain, stiffness, and neurological deficits. These symptoms can make it difficult to perform routine activities, affect work productivity, and reduce overall quality of life. In severe cases, it can lead to loss of independence and the need for assistance with daily tasks.
What is the difference between cervical spondylosis and cervical spondylotic myelopathy?
Cervical spondylosis refers to the general degenerative changes in the cervical spine, such as disc degeneration, bone spur formation, and ligament thickening. Cervical spondylotic myelopathy occurs when these changes compress the spinal cord, leading to neurological symptoms.
Can physical activity worsen cervical spondylotic myelopathy?
High-impact or strenuous physical activities that strain the neck can worsen CSM symptoms. It is essential to engage in low-impact exercises, such as swimming or walking, and follow medical advice on safe physical activities to avoid exacerbating the condition.
How is cervical spondylotic myelopathy different from a herniated disc?
A herniated disc occurs when the soft inner material of a disc bulges out through a tear in the outer layer, potentially compressing nearby nerves or the spinal cord. CSM involves broader degenerative changes that result in spinal cord compression from multiple sources, such as disc herniation, bone spurs, and ligament thickening.
Can cervical spondylotic myelopathy cause cognitive issues?
While CSM primarily affects motor and sensory functions, severe cases can indirectly impact cognitive function due to chronic pain, discomfort, and decreased quality of life, leading to issues like difficulty concentrating, memory problems, and emotional stress.
What role does age play in the development of cervical spondylotic myelopathy?
Age is a significant factor in developing CSM, as degenerative changes in the spine naturally occur with aging. Individuals over 50 are more likely to experience these changes, leading to an increased risk of spinal cord compression and CSM.
Can cervical spondylotic myelopathy be detected through routine check-ups?
CSM might not be detected during routine check-ups unless specific symptoms are reported. Detailed neurological examinations and imaging studies, such as MRI or CT scans, are necessary to diagnose CSM accurately.
What advancements are being made in the treatment of cervical spondylotic myelopathy?
Advances in CSM treatment include minimally invasive surgical techniques, improved imaging technology for early detection, and research into regenerative therapies aimed at repairing spinal cord damage and halting the progression of degenerative changes.
How does cervical spondylotic myelopathy impact mental health?
Chronic pain and disability from CSM can significantly affect mental health, leading to anxiety, depression, and decreased quality of life. Psychological support, counseling, and sometimes medications are necessary to help manage these mental health issues.
Is it safe to drive with cervical spondylotic myelopathy?
Driving can be challenging for individuals with severe CSM symptoms affecting coordination, strength, and reaction times. It is essential to consult with a healthcare provider to assess driving safety and, if necessary, make adjustments or consider alternatives to ensure safety.
I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.
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