Cervical spondylotic myelopathy

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Cervical spondylotic myelopathy
Other namesSpondylotic radiculomyelopathy
Specialty Neurology

Cervical Spondylotic Myelopathy (CSM) is a disorder characterised by the age-related deterioration of the cervical spinal cord. [1] Referred to be a range of different but related terms, a global consensus process selected Degenerative Cervical Myelopathy as the new overarching disease term. [2] It is a neurological disorder related to the spinal cord and nerve roots. [3] The severity of CSM is most commonly associated with factors including age, location and extent of spinal cord compression.

Contents

Incidence of CSM increases with age, where spinal cord compression is bound to be present people aged 55 or above. [4]

Pain, numbness, issues with balance and coordination are symptoms widely representative of most common cases of CSM. [5] It primarily results from spinal cord compression due to the degenerative changes in the cervical region of the spine. [6] A wide range of tests and medical care are available to help diagnose and treat CSM, respectively, due to the relatively high incidence of CSM.

Signs and symptoms

Numerous CSM symptoms are present which primarily vary according to the relative location and extent of the spinal cord compression. Most common symptoms are: [7]

Pain in the neck, arms and legs are characterised by the inflammation in the respective regions of nerve root compressions. [7] It is common for CSM patients to experience a sudden onset of a concentrated, sharp and burning sensation in the affected area. [8] This pain is accompanied by loss of sensation or a tingling sensation in the limbs; observable characteristics associated with the inability to grasp objects or walk properly. [7] Damage to the spinal cords and nerve roots typically result in muscle weakness in regions concerning both upper and lower limbs. This results in lack of cohesiveness in movement coordination of the arms and legs. Compression at the superior cervical region can lead to compensatory compression at inferior levels (for example, the lumbar spine) and affect control over bowel or bladder function. [4] The severity of such symptoms tend to progress over time and occur more frequently amongst older patients. [5]

CSM symptoms can be unilateral or bilateral, depending on the lateral regions where compression of the spinal cord and nerve roots occur. [9] If left untreated, CSM can lead to long-term or permanent damage to the spinal cord and nerve roots. [5]

Causes

The general cause of CSM is the compression of the spinal cord and related nerve roots as a result of the deterioration of the spinal column. The narrowing of the spinal canal due to the inability of the disc to structurally support the vertebrae results in compression. [10] As the disc continues to lose its elasticity from progressive wear and tear, spinal cord compression increases.

Daily activity

As an age-related disorder, the severity of CSM increases with age. Although, further degeneration can be accelerated via daily practices including poor posture or sedentary behaviours. Prolonged poor posture can misalign the spinal column to apply uneven distribution of weight on the spinal cord and nerve roots. [10] Absence of physical activity also contributes to exacerbating CSM symptoms, as lack of exercise and muscular strength cannot provide adequate support to the spine.

Medical conditions

Spinal arthritis [11] – most commonly osteoarthritis – is the inflammation of superior and inferior facet joints within the spine. This leads to the formation of Osteophytes [11] which grow around the joints. This contributes to narrowing the spinal canal and compressing the spinal cord in the corresponding region.

Herniated disk due to tearing of the spinal disk over time, causes the disk to protrude and exert pressure on surrounding spinal nerve tissue. Consequent compression on the spinal cord at the cervical region causes CSM. [12]

Osteoporosis is the weakening of the bones due to progressive decrease in bone density. [13] In older patients, the low bone density of the spine is unable to support the weight of the body. This gives rise to CSM via vertebral compression fractures [14] promoting further compression of the spinal cord and nerve roots.

Spinal tumors can be classified into primary tumours or metastatic tumours which originate from or disseminate to the site of compression, respectively. As the tumours surrounding the spinal column grow in size, the spinal canal is narrowed and therefore results in pressure to be exerted directly on the spinal cord and nerve roots. [15]

Diagnosis

A patient presenting with signs of CSM must see a doctor to perform a wide variety of diagnostic tests. Physical examination is used to determine the severity of the disease by examining the extent of observable CSM symptoms. [7] [16] The severity of CSM symptoms indicates of the amount of pressure the cervical spine is under. Physical examination involves flexibility of the neck, strength and reflexes of limb muscles, gait patterns, etc. [12]

Imaging studies may be used to understand the fundamental cause of the CSM symptoms. This includes: [12] [17]

Prevention

By nature of the CSM as an age-related degenerative condition, there are ways to minimise or delay the onset of CSM, but averting CSM completely can be difficult. [19] Risks of this condition may be reduced by:

Treatment

The fundamental principle behind treating CSM lies in decompressing the pressure put on the spinal cord and nerve roots. Although, the treatment options vary depending on the severity and duration of CSM symptoms as determined by a medical professional.

Non-surgical treatments

Physical therapy

Physical therapy is an appropriate treatment option for mild to moderate stages of CSM to help enhance muscle strength. [7] Stronger core stability helps correct posture which releases intraspinal pressure exerted on the spinal cord and therefore reduces CSM-related pain.

Medications

Upper and lower limb pain caused by inflammation at the corresponding nerve roots can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or steroid injections. [7] CSM medications include: [21] [22]

Other medications including acetaminophen, oral corticosteroids, and muscle relaxants are used in conjunction with NSAIDS to address both pain and inflammation. [17]

Soft cervical collar

A ring-shaped cushion that is secured around the neck with velcro. This is a form of a cast that restricts neck movement and relaxes the neck muscles in daily activities. Usage must be controlled as prolonged usage may permanently weaken the neck muscles. [17]

Injection therapy

Injection of steroids and anaesthetics into the affected area of interest is devised for achieving short-term benefits with treating the disease. [12]

  • Cervical epidural block – neck or arm discomfort due to disc herniation in respective regions of the cervical spine may be addressed by injection into the epidural space adjacent to the protective covering of the spinal cord
  • Cervical facet joint block – minor injections at the joints of the affected regions of the cervical spine
  • Media branch block and radio-frequency ablation – diagnosis and alleviation of pain from specific medial branches of the spinal nerve upon administering anaesthetics in the cervical region of interest to locate the area for treatment. A non-curative radio-frequency ablation treatment is applied to damage the nerves causing the pain in the joints with the use of sound waves.

Surgical treatments

Surgical decompression

Surgery is often involved in severe cases of CSM to manually relieve the pressure exerted on the spinal cord and related nerve roots. [23] Laminectomy is a common surgical procedure for spinal decompression, wherein a part of the vertebrae is excised to alleviate compression on the spinal cord. [7] [24]

Related Research Articles

<span class="mw-page-title-main">Tetraplegia</span> Paralysis of all four limbs and torso

Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis. The paralysis may be flaccid or spastic. A loss of sensory function can present as an impairment or complete inability to sense light touch, pressure, heat, pinprick/pain, and proprioception. In these types of spinal cord injury, it is common to have a loss of both sensation and motor control.

<span class="mw-page-title-main">Lumbar spinal stenosis</span> Medical condition of the spine

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. Lumbar spinal stenosis can cause pain in the low back or buttocks, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control.

<span class="mw-page-title-main">Cervical spine disorder</span> Medical condition

Cervical spine disorders are illnesses that affect the cervical spine, which is made up of the upper first seven vertebrae, encasing and shielding the spinal cord. This fragment of the spine starts from the region above the shoulder blades and ends by supporting and connecting the skull.

<span class="mw-page-title-main">Spondylosis</span> Degeneration of the vertebral column

Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints. If severe, it may cause pressure on the spinal cord or nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

Myelopathy describes any neurologic deficit related to the spinal cord. The most common form of myelopathy in humans, cervical spondylotic myelopathy (CSM), also called degenerative cervical myelopathy, results from narrowing of the spinal canal ultimately causing compression of the spinal cord. When due to trauma, myelopathy is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular myelopathy.

<span class="mw-page-title-main">Degenerative disc disease</span> Medical condition

Degenerative disc disease (DDD) is a medical condition typically brought on by the normal aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with or without symptoms, but is typically identified once symptoms arise. The root cause is thought to be loss of soluble proteins within the fluid contained in the disc with resultant reduction of the oncotic pressure, which in turn causes loss of fluid volume. Normal downward forces cause the affected disc to lose height, and the distance between vertebrae is reduced. The anulus fibrosus, the tough outer layers of a disc, also weakens. This loss of height causes laxity of the longitudinal ligaments, which may allow anterior, posterior, or lateral shifting of the vertebral bodies, causing facet joint malalignment and arthritis; scoliosis; cervical hyperlordosis; thoracic hyperkyphosis; lumbar hyperlordosis; narrowing of the space available for the spinal tract within the vertebra ; or narrowing of the space through which a spinal nerve exits with resultant inflammation and impingement of a spinal nerve, causing a radiculopathy.

In medicine, a stinger, also called a burner or nerve pinch injury, is a neurological injury suffered by athletes, mostly in high-contact sports such as ice hockey, rugby, American football, and wrestling. The spine injury is characterized by a shooting or stinging pain that travels down one arm, followed by numbness and weakness in the parts of the arms, including the biceps, deltoid, and spinati muscles. Many athletes in contact sports have suffered stingers, but they are often unreported to medical professionals.

Wobbler disease is a catchall term referring to several possible malformations of the cervical vertebrae that cause an unsteady (wobbly) gait and weakness in dogs and horses. A number of different conditions of the cervical (neck) spinal column cause similar clinical signs. These conditions may include malformation of the vertebrae, intervertebral disc protrusion, and disease of the interspinal ligaments, ligamenta flava, and articular facets of the vertebrae. Wobbler disease is also known as cervical vertebral instability (CVI), cervical spondylomyelopathy (CSM), and cervical vertebral malformation (CVM). In dogs, the disease is most common in large breeds, especially Great Danes and Doberman Pinschers. In horses, it is not linked to a particular breed, though it is most often seen in tall, race-bred horses of Thoroughbred or Standardbred ancestry. It is most likely inherited to at least some extent in dogs and horses.

<span class="mw-page-title-main">Spinal cord compression</span> Medical condition

Spinal cord compression is a form of myelopathy in which the spinal cord is compressed. Causes can be bone fragments from a vertebral fracture, a tumor, abscess, ruptured intervertebral disc or other lesion.

<span class="mw-page-title-main">Spinal disc herniation</span> Injury to the connective tissue between spinal vertebrae

A spinal disc herniation is an injury to the intervertebral disc between two spinal vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatment may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.

<span class="mw-page-title-main">Anterior cervical discectomy and fusion</span> Surgical procedure

Anterior cervical discectomy and fusion (ACDF) is a surgical procedure to treat nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy, followed by inter-vertebral fusion to stabilize the corresponding vertebrae. This procedure is used when other non-surgical treatments have failed.

<span class="mw-page-title-main">Cervical spinal stenosis</span> Medical condition

Cervical spinal stenosis is a bone disease involving the narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration, but may also be congenital. Treatment is frequently surgical.

<span class="mw-page-title-main">Central cord syndrome</span> Human spinal cord disorder

Central cord syndrome (CCS) is the most common form of cervical spinal cord injury (SCI). It is characterized by loss of power and sensation in arms and hands. It usually results from trauma which causes damage to the neck, leading to major injury to the central corticospinal tract of the spinal cord. CCS most frequently occurs among older persons with cervical spondylosis, however, it also may occur in younger individuals.

<span class="mw-page-title-main">Neurogenic claudication</span> Medical condition

Neurogenic claudication (NC), also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis (LSS) and describes intermittent leg pain from impingement of the nerves emanating from the spinal cord. Neurogenic means that the problem originates within the nervous system. Claudication, from the Latin word for to limp, refers to painful cramping or weakness in the legs. NC should therefore be distinguished from vascular claudication, which stems from a circulatory problem rather than a neural one.

<span class="mw-page-title-main">Laminoplasty</span>

Laminoplasty is an orthopaedic/neurosurgical surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The main purpose of this procedure is to provide relief to patients who may have symptoms of numbness, pain, or weakness in arm movement. The procedure involves cutting the lamina on both sides of the affected vertebrae and then "swinging" the freed flap of bone open thus relieving the pressure on the spinal cord. The spinous process may be removed to allow the lamina bone flap to be swung open. The bone flap is then propped open using small wedges or pieces of bone such that the enlarged spinal canal will remain in place.

<span class="mw-page-title-main">Facet syndrome</span> Medical condition

Facet syndrome is a syndrome in which the facet joints cause painful symptoms. In conjunction with degenerative disc disease, a distinct but functionally related condition, facet arthropathy is believed to be one of the most common causes of lower back pain.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

<span class="mw-page-title-main">Hirayama disease</span> Medical condition

Hirayama disease, also known as monomelic amyotrophy (MMA), is a rare motor neuron disease first described in 1959 in Japan. Its symptoms usually appear about two years after adolescent growth spurt and is significantly more common in males, with an average age of onset between 15 and 25 years. Hirayama disease is reported most frequently in Asia but has a global distribution. It is typically marked by insidious onset of muscle atrophy of an upper limb, which plateaus after two to five years from which it neither improves nor worsens. There is no pain or sensory loss. It is not believed to be hereditary.

<span class="mw-page-title-main">Cervicocranial syndrome</span> Medical condition

Cervicocranial syndrome or is a combination of symptoms that are caused by an abnormality in the cervical vertebrae leading to improper function of cervical spinal nerves. Cervicocranial syndrome is either congenital or acquired. Some examples of diseases that could result in cervicocranial syndrome are Chiari disease, Klippel-Feil malformation osteoarthritis, and trauma. Treatment options include neck braces, pain medication and surgery. The quality of life for individuals suffering from CCJ syndrome can improve through surgery.

References

  1. ↑ Rubin M (2023-03-28). "Cervical Spondylosis and Spondylotic Cervical Myelopathy". MSD Manual. Retrieved 2023-03-28.
  2. ↑ Davies, Benjamin M.; Khan, Danyal Z.; Barzangi, Kara; Ali, Ahmad; Mowforth, Oliver D.; Nouri, Aria; Harrop, James S.; Aarabi, Bizhan; Rahimi-Movaghar, Vafa; Kurpad, Shekar N.; Guest, James D.; Tetreault, Lindsay; Kwon, Brian K.; Boerger, Timothy F.; Rodrigues-Pinto, Ricardo (March 2024). "We Choose to Call it 'Degenerative Cervical Myelopathy': Findings of AO Spine RECODE-DCM, an International and Multi-Stakeholder Partnership to Agree a Standard Unifying Term and Definition for a Disease". Global Spine Journal. 14 (2): 503–512. doi:10.1177/21925682221111780. ISSN   2192-5682. PMID   35769029.
  3. ↑ Yang D, Xu L, Hu Y, Xu W (June 2022). "Diagnosis and Treatment of Cervical Spondylotic Radiculopathy Using Selective Nerve Root Block (SNRB): Where are We Now?". Pain and Therapy. 11 (2): 341–357. doi:10.1007/s40122-022-00357-1. PMC   9098747 . PMID   35167060.
  4. 1 2 Singleton JM, Hefner M (2023). "Spinal Cord Compression". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID   32491536.
  5. 1 2 3 Tu J, Vargas Castillo J, Das A, Diwan AD (March 2021). "Degenerative Cervical Myelopathy: Insights into Its Pathobiology and Molecular Mechanisms". Journal of Clinical Medicine. 10 (6): 1214. doi: 10.3390/jcm10061214 . PMC   8001572 . PMID   33804008.
  6. ↑ Lebl DR, Hughes A, Cammisa FP, O'Leary PF (July 2011). "Cervical spondylotic myelopathy: pathophysiology, clinical presentation, and treatment". HSS Journal. 7 (2): 170–178. doi:10.1007/s11420-011-9208-1. PMC   3145857 . PMID   22754419.
  7. 1 2 3 4 5 6 7 8 "Cervical Spondylotic Myelopathy (CSM) - Spinal Cord Compression". OrthoInfo. American Academy of Orthopaedic Surgeons (AAOS). Retrieved 2023-03-28.
  8. ↑ "Pain Management After Spinal Cord Injury". UPMC | Life Changing Medicine. University of Pittsburgh Schools of the Health Sciences. Retrieved 2023-03-28.
  9. ↑ Simard JM, Popovich PG, Tsymbalyuk O, Gerzanich V (February 2012). "Spinal cord injury with unilateral versus bilateral primary hemorrhage--effects of glibenclamide". Experimental Neurology. Special Issue: NIH Replication Studies. 233 (2): 829–835. doi:10.1016/j.expneurol.2011.11.048. PMC   3272086 . PMID   22197047.
  10. 1 2 "Cervical Stenosis". Physiopedia. Retrieved 2023-03-28.
  11. 1 2 "Spinal Arthritis (Arthritis in the Back or Neck)". www.hopkinsmedicine.org. 2021-12-15. Retrieved 2023-03-28.
  12. 1 2 3 4 "Cervical Spondylosis: Symptoms, Causes, Treatments". Cleveland Clinic. Retrieved 2023-04-13.
  13. ↑ "Osteoporosis - Symptoms and causes". Mayo Clinic. Retrieved 2023-03-28.
  14. ↑ "Compression Fractures: Causes, Symptoms, Treatment & Prevention". Cleveland Clinic. Retrieved 2023-03-28.
  15. ↑ "Spinal cord tumor - Symptoms and causes". Mayo Clinic. Retrieved 2023-03-28.
  16. ↑ "Diagnostic Tests for Spinal Cord Injury". Shepherd Center. Retrieved 2023-03-28.
  17. 1 2 3 4 "Cervical Spondylosis (Arthritis of the Neck)". OrthoInfo. American Academy of Orthopaedic Surgeons (AAOS). Retrieved 2023-04-13.
  18. ↑ Syed MU, Khan Z, Zulfiqar A, Basham MA, Abdul Haseeb H, Azizullah S, et al. (September 2021). "Electrocardiographic Abnormalities in Patients With Spinal Cord Injury With Deranged Lipid Profile". Cureus. 13 (9): e18246. doi: 10.7759/cureus.18246 . PMC   8544921 . PMID   34722039.
  19. ↑ "Myelopathy: Symptoms, Causes and Treatments". Cleveland Clinic. Retrieved 2023-03-28.
  20. ↑ "Calcium, vitamin D, and your bones: MedlinePlus Medical Encyclopedia". Medline Plus. U.S. National Library of Medicine. Retrieved 2023-03-28.
  21. ↑ "Corticosteroids in the Treatment of Spinal Cord Injuries". Physiopedia. Retrieved 2023-03-28.
  22. ↑ Lambrechts MJ, Cook JL (April 2021). "Nonsteroidal Anti-Inflammatory Drugs and Their Neuroprotective Role After an Acute Spinal Cord Injury: A Systematic Review of Animal Models". Global Spine Journal. 11 (3): 365–377. doi:10.1177/2192568220901689. PMC   8013945 . PMID   32875860.
  23. ↑ Kopjar B, Bohm PE, Arnold JH, Fehlings MG, Tetreault LA, Arnold PM (August 2018). "Outcomes of Surgical Decompression in Patients With Very Severe Degenerative Cervical Myelopathy". Spine. 43 (16): 1102–1109. doi:10.1097/BRS.0000000000002602. PMC   6066419 . PMID   29462066.
  24. ↑ "Laminectomy". Mayo Clinic. Retrieved 2023-03-28.
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