Cervical Myelopathy  

Posted bythespinebookadminPosted inDegenerative, Topics

Background 

  • Neurologic impairment caused by cord compression 

Causes 

  • Spondylosis 
  • Congenital stenosis 
  • OPLL 
  • Tumour 
  • Epidural abscess 
  • Trauma 
  • Kyphosis 
  • Associated 
    • Tandem stenosis in 20% 

DDx 

  • Stroke 
  • Multiple Sclerosis 
    • Autoimmune, female, age 30 
    • MRI brain and spine – other lesions 
    • Vision loss, brainstem – cranial neve including Diplopia, cerebellar, spinal cord 
  • Amyotrophic Lateral Sclerosis 
    • Anterior horn of SC – UMN and LMN 
    • Tongue fasciulations 
    • EMG – widespread deinnervation and fibrillation 
  • Brain tumour 
  • Syringomyelia 
  • Intoxication 

Presentation 

  • Symptoms 
    • Axial neck pain 
    • Non dermatomal parasthesia 
    • Weakness clumsiness 
    • Gait instability* most important predictor 
    • Urinary retention 
  • Physical Exam 
    • Motor 
      • Weakness, LE is worse 
    • Finger escape (spontaneous abducts due to intrinsic weakness) 
    • Grip and Release – normal is 20 times in 10 
    • UMN 
      • Hyperreflexia (absent if radicular disease) 
      • Inverted radial 
      • Hoffmann’s – snap distal phalanx of middle finger -> spontaneous flexion of other fingers 
      • Sustained clonus >3 beats (100% sensitivity) 
      • Babinski – +ve with great toe extension 
    • Gait 
      • Toe to heel – difficulty 
      • Romberg – arms out, eyes closed -> loss of balance with posterior column dysfunctiton (late bad finding) 
    • L’Hermittte sign – flexion leads tot electric shock sensations into extrermities 
  • Sensory  
    • Proprioception dysfunction – dorsal column 
    • Decreased pain sensation  

Classification of Symptoms 

  • mJOA 
    • Upper motor 
      • 0 cant move hands 
      • 1 more hands no spoon 
      • 2 use spoon can’t button shirt 
      • 3 button shirt with great difficulty 
      • 4 button shirt with slight difficulty 
      • 5 normal 
    • Lower motor 
      • 0 No motor no sensory 
      • 1 sensory no motor 
      • 2 move legs cant walk 
      • 3 flat floor with cane 
      • 4 stairs with hand rail 
      • 5 stairs without hand rail but moderate unstable 
      • 6 mild instability but smooth walk 
      • 7 no dysfunction 
    • Upper sensory 
      • 0 no sensation 
      • 1 severe sensory 
      • 2 mild sensory 
      • 3 normal 
    • Bladder 
      • 0 inability to pee voluntarily 
      • 1 difficulty in urination 
      • 2 mild urination (frequency, hesitation) 
      • 3 normal micturition 
  • Mild 15-17, Moderate 12-14, Severe 0-11 

Imaging 

  • XR 
    • Flex ex views – IS THE KYPHOTIC DEFORMITY FIXED 
  • CTT 
  • MRI 
    • T2 myeolomalacia 
    • T1 changes is bad prognostic factor 
    • Compression raito 
      • Sagital: Transerse 
        • <4 is poor prognosis 
  • Key parameters 
    • Local kyphotic angle (13 is cutoff) 
    • K Line 
      • Center of cord a C2 to C7 
      • If most of cord is behind the K line – go from the front (drift back wont work) 

Management 

  • Non op – mild disease with minimal functional impairment 
    • PT – neck strengthening 
    • Non Opioid 
    • Hard collar slight flexion 
  • Operative 
    • PSDIF (K line is posterior, fixed Kyphosis <13) 
    • ACDF or Anterior Corpectomy (K line is anterior, fixed Kyphosis >13) 
    • Front and Back – greater than 2 levels, K line anterior, Kyphosis >13 
    • Laminoplasty – less paraspinal atrorphy etc 
    • Arthrooplasty 
      • Equivalent outcomes in single and double levele disease 
      • Better in terms of reoperaiton rate 

Complications 

  • C5 palsy (equal in ACDF and PSIF patients) 
    • 5% 
    • Posterior migration of spinal cord while nerve root is tethered 
    • Immediately post op to weeks following surgery 
    • Prognosis – usually good 
  • HW failure 
    • 10% for 2 level anterior corpectomy 
  • Pseudathrosis 
    • 12% single 
    • 30% multilevel