Myelopathy

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Myelopathy
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Myelopathy describes any neurologic deficit related to the spinal cord. [1] The most common form of myelopathy in humans, cervical spondylotic myelopathy (CSM) , [2] [3] also called degenerative cervical myelopathy, [4] results from narrowing of the spinal canal (spinal stenosis) ultimately causing compression of the spinal cord. [5] 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.

Contents

In Asian populations, spinal cord compression often occurs due to a different, inflammatory process affecting the posterior longitudinal ligament.[ citation needed ]

Presentation

Clinical signs and symptoms depend on which spinal cord level (cervical, [6] thoracic, or lumbar) is affected and the extent (anterior, posterior, or lateral) of the pathology, and may include:[ citation needed ]

Diagnosis

Diagnosis of myelopathy

Myelopathy is primarily diagnosed by clinical exam findings. Because the term myelopathy describes a clinical syndrome that can be caused by many pathologies the differential diagnosis of myelopathy is extensive. [7] In some cases the onset of myelopathy is rapid, in others, such as CSM, the course may be insidious with symptoms developing slowly over a period of months. As a consequence, the diagnosis of CSM is often delayed. [8] As the disease is thought to be progressive, this may impact negatively on outcome.[ citation needed ]

Diagnosis of etiology

Once the clinical diagnosis myelopathy is established, the underlying cause must be investigated. Most commonly this involves medical imaging. The best way to visualize the spinal cord is magnetic resonance imaging (MRI). Apart from T1 and T2 MRI images, which are commonly used for routine diagnosis, more recently researchers are exploring quantitative MRI signals. [9] Further imaging modalities used for evaluating myelopathy include plain X-rays for detecting arthritic changes of the bones, and Computer Tomography, which is often used for pre-operative planning of surgical interventions for cervical spondylotic myelopathy. Angiography is used to examine blood vessels in suspected cases of vascular myelopathy.[ citation needed ]

The presence and severity of myelopathy can also be evaluated by means of transcranial magnetic stimulation (TMS), a neurophysiological method that allows the measurement of the time required for a neural impulse to cross the pyramidal tracts, starting from the cerebral cortex and ending at the anterior horn cells of the cervical, thoracic or lumbar spinal cord. This measurement is called Central Conduction Time (CCT). TMS can aid physicians to: [10]

TMS can also help in the differential diagnosis of different causes of pyramidal tract damage. [12]

Treatment

The treatment and prognosis of myelopathy depends on the underlying cause: myelopathy caused by infection requires medical treatment with pathogen specific antibiotics. Similarly, specific treatments exist for multiple sclerosis, which may also present with myelopathy. As outlined above, the most common form of myelopathy is secondary to degeneration of the cervical spine. Newer findings have challenged the existing controversy with respect to surgery [13] for cervical spondylotic myelopathy by demonstrating that patients benefit from surgery. [14]

See also

Related Research Articles

<span class="mw-page-title-main">Syringomyelia</span> Disorder in which a cyst forms in the spinal cord

Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. Often, syringomyelia is used as a generic term before an etiology is determined. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord. The damage may result in loss of feeling, paralysis, weakness, and stiffness in the back, shoulders, and extremities. Syringomyelia may also cause a loss of the ability to feel extremes of hot or cold, especially in the hands. It may also lead to a cape-like bilateral loss of pain and temperature sensation along the upper chest and arms. The combination of symptoms varies from one patient to another depending on the location of the syrinx within the spinal cord, as well as its extent.

<span class="mw-page-title-main">Transverse myelitis</span> Medical condition of the spinal cord

Transverse myelitis (TM) is a rare neurological condition wherein the spinal cord is inflamed. The adjective transverse implies that the spinal inflammation (myelitis) extends horizontally throughout the cross section of the spinal cord; the terms partial transverse myelitis and partial myelitis are sometimes used to specify inflammation that affects only part of the width of the spinal cord. TM is characterized by weakness and numbness of the limbs, deficits in sensation and motor skills, dysfunctional urethral and anal sphincter activities, and dysfunction of the autonomic nervous system that can lead to episodes of high blood pressure. Signs and symptoms vary according to the affected level of the spinal cord. The underlying cause of TM is unknown. The spinal cord inflammation seen in TM has been associated with various infections, immune system disorders, or damage to nerve fibers, by loss of myelin. As opposed to leukomyelitis which affects only the white matter, it affects the entire cross-section of the spinal cord. Decreased electrical conductivity in the nervous system can result.

<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.

Spinal tumors are neoplasms located in either the vertebral column or the spinal cord. There are three main types of spinal tumors classified based on their location: extradural and intradural. Extradural tumors are located outside the dura mater lining and are most commonly metastatic. Intradural tumors are located inside the dura mater lining and are further subdivided into intramedullary and extramedullary tumors. Intradural-intramedullary tumors are located within the dura and spinal cord parenchyma, while intradural-extramedullary tumors are located within the dura but outside the spinal cord parenchyma. The most common presenting symptom of spinal tumors is nocturnal back pain. Other common symptoms include muscle weakness, sensory loss, and difficulty walking. Loss of bowel and bladder control may occur during the later stages of the disease.

<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.

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, 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 cushioning and connective tissue between 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 posture.

<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. 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">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.

Vascular myelopathy refers to an abnormality of the spinal cord in regard to its blood supply. The blood supply is complicated and supplied by two major vessel groups: the posterior spinal arteries and the anterior spinal arteries—of which the Artery of Adamkiewicz is the largest. Both the posterior and anterior spinal arteries run the entire length of the spinal cord and receive anastomotic (conjoined) vessels in many places. The anterior spinal artery has a less efficient supply of blood and is therefore more susceptible to vascular disease. Whilst atherosclerosis of spinal arteries is rare, necrosis in the anterior artery can be caused by disease in vessels originating from the segmental arteries such as atheroma or aortic dissection.

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

Myelomalacia is a pathological term referring to the softening of the spinal cord. Possible causes of myelomalacia include cervical myelopathy, hemorrhagic infarction, or acute injury, such as that caused by intervertebral disc extrusion.

Wartenberg's sign is a neurological sign consisting of involuntary abduction of the fifth (little) finger, caused by unopposed action of the extensor digiti minimi.

<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.

Spinal cord injury without radiographic abnormality (SCIWORA) is symptoms of a spinal cord injury (SCI) with no evidence of injury to the spinal column on X-rays or CT scan. Symptoms may include numbness, weakness, abnormal reflexes, or loss of bladder or bowel control. Neck or back pain is also common. Symptoms may be brief or persistent. Some do not develop symptoms until a few days after the injury.

<span class="mw-page-title-main">Monomelic amyotrophy</span> Medical condition

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. MMA 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 associated with MMA. MMA is not believed to be hereditary.

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

Cervicocranial syndrome or is a neurological illness. It is a combination of symptoms that are caused by an abnormality in the neck. The bones of the neck that are affected are cervical vertebrae. This syndrome can be identified by confirming cervical bone shifts, collapsed cervical bones or misalignment of the cervical bone leading to improper functioning of cervical spinal nerves.Greenberg Regenerative Medicine | Bryn Mawr, Pennsylvania 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.

Spinal cord stroke is a rare type of stroke with compromised blood flow to any region of spinal cord owing to occlusion or bleeding, leading to irreversible neuronal death. It can be classified into two types, ischaemia and haemorrhage, in which the former accounts for 86% of all cases, a pattern similar to cerebral stroke. The disease is either arisen spontaneously from aortic illnesses or postoperatively. It deprives patients of motor function or sensory function, and sometimes both. Infarction usually occurs in regions perfused by anterior spinal artery, which spans the anterior two-thirds of spinal cord. Preventions of the disease include decreasing the risk factors and maintaining enough spinal cord perfusion pressure during and after the operation. The process of diagnosing the ischemic and hemorrhagic spinal cord stroke includes applying different MRI protocols and CT scan. Treatments for spinal cord stroke are mainly determined by the symptoms and the causes of the disease. For example, antiplatelet and corticosteroids might be used to reduce the risk of blood clots in ischaemic spinal stroke patients, while rapid surgical decompression is applied to minimize neurological injuries in haemorrhagic spinal stroke patients instead. Patients may spend years for rehabilitation after the spinal cord stroke.

Cervical spondylotic myelopathy (CSM) is a disorder characterised by the age-related deterioration of the cervical spinal cord. Also called spondylotic radiculomyelopathy (SRM), it is a neurological disorder related to the spinal cord and nerve roots. The severity of CSM is most commonly associated with factors including age, location and extent of spinal cord compression.

References

  1. ↑ "Myelopathy" at American Journal of Neuroradiology
  2. ↑ "The Science of CSM". Myelopathy.org: an online resource for cervical spondylotic myelopathy. Archived from the original on 2015-11-18. Retrieved 2015-11-05.
  3. ↑ Wu, Jau-Ching; Ko, Chin-Chu; Yen, Yu-Shu; Huang, Wen-Cheng; Chen, Yu-Chun; Liu, Laura; Tu, Tsung-Hsi; Lo, Su-Shun; Cheng, Henrich (2013-07-01). "Epidemiology of cervical spondylotic myelopathy and its risk of causing spinal cord injury: a national cohort study". Neurosurgical Focus. 35 (1): E10. doi: 10.3171/2013.4.FOCUS13122 . PMID   23815246.
  4. ↑ "AO Spine - Degenerative Cervical Myelopathy". AO Spine. AO Foundation. Retrieved 10 August 2022.
  5. ↑ Shedid, Daniel; Benzel, Edward C. (2007). "CERVICAL SPONDYLOSIS ANATOMY". Neurosurgery. 60 (SUPPLEMENT): S1–7–S1–13. doi:10.1227/01.neu.0000215430.86569.c4. PMID   17204889.
  6. ↑ Dr. Atkinson, Patty (March 27, 2013). "Cervical Myelopathy". Mayo Clinic News Network. Mayo Clinic. Retrieved 25 January 2017.
  7. ↑ Kim, Han Jo; Tetreault, Lindsay A.; Massicotte, Eric M.; Arnold, Paul M.; Skelly, Andrea C.; Brodt, Erika D.; Riew, K. Daniel (2013). "Differential Diagnosis for Cervical Spondylotic Myelopathy". Spine. 38 (22 Suppl 1): S78–S88. doi: 10.1097/brs.0b013e3182a7eb06 . PMID   23962997.
  8. ↑ Behrbalk, Eyal; Salame, Khalil; Regev, Gilad J.; Keynan, Ory; Boszczyk, Bronek; Lidar, Zvi (2013-07-01). "Delayed diagnosis of cervical spondylotic myelopathy by primary care physicians". Neurosurgical Focus. 35 (1): E1. doi:10.3171/2013.3.focus1374. PMID   23815245.
  9. ↑ Ellingson, Benjamin M.; Salamon, Noriko; Grinstead, John W.; Holly, Langston T. (2014). "Diffusion tensor imaging predicts functional impairment in mild-to-moderate cervical spondylotic myelopathy". The Spine Journal. 14 (11): 2589–2597. doi:10.1016/j.spinee.2014.02.027. PMC   4426500 . PMID   24561036.
  10. ↑ Chen R, Cros D, Curra A, Di Lazzaro V, Lefaucheur JP, Magistris MR, Mills K, Rösler KM, Triggs WJ, Ugawa Y, Ziemann U. The clinical diagnostic utility of transcranial magnetic stimulation: report of an IFCN committee. Clin Neurophysiol. 2008 Mar;119(3):504-32.
  11. ↑ Deftereos SN, et al. (April–June 2009). "Localisation of cervical spinal cord compression by TMS and MRI". Funct Neurol. 24 (2): 99–105. PMID   19775538.
  12. ↑ Chen R, Cros D, Curra A, et al. (March 2008). "The clinical diagnostic utility of transcranial magnetic stimulation: report of an IFCN committee". Clin Neurophysiol. 119 (3): 504–32. doi:10.1016/j.clinph.2007.10.014. PMID   18063409.
  13. ↑ Nikolaidis, Ioannis; Fouyas, Ioannis P; Sandercock, Peter AG; Statham, Patrick F (2010-01-20). "Surgery for cervical radiculopathy or myelopathy". Cochrane Database of Systematic Reviews (1): CD001466. doi:10.1002/14651858.cd001466.pub3. PMC   7084060 . PMID   20091520.
  14. ↑ Fehlings, Michael G.; Wilson, Jefferson R.; Kopjar, Branko; Yoon, Sangwook Tim; Arnold, Paul M.; Massicotte, Eric M.; Vaccaro, Alexander R.; Brodke, Darrel S.; Shaffrey, Christopher I. (2013-09-18). "Efficacy and Safety of Surgical Decompression in Patients with Cervical Spondylotic Myelopathy". The Journal of Bone and Joint Surgery. 95 (18): 1651–1658. doi:10.2106/JBJS.L.00589. ISSN   0021-9355. PMID   24048552. Archived from the original on 2015-11-13. Retrieved 2015-11-06.
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