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Cervical Stenosis / Cervical Myelopathy
Causes, Symptoms, Diagnosis and Treatment of Cervical Stenosis /
Cervical Mylopathy
Cervical stenosis refers to a lack of sufficient room for the spinal cord in the neck.
Pressure on the spinal cord or on the blood vessels of the spinal cord can result in a syndrome known as cervical myelopathy. Additionally, continual mild trauma from stenosis can result in myelopathy. Cervical myelopathy is a form of spinal cord injury that has a fairly classic clinical appearance. Cervical stenosis can be seen without signs or symptoms of cervical myelopathy, in fact some degree of cervical stenosis is common in elderly patients.
Causes
Some of the more common causes are congenital spinal stenosis (a narrowing of the spinal canal that has been present since birth), bone spurs (sometimes called cervical spondylosis), cervical disc herniation and thickening of the various ligaments of the cervical spine. Amongst the more unusual causes of cervical myelopathy are amyotrophic lateral sclerosis (ALS, Lou Gerhig’s disease), multiple sclerosis, Chiari I malformation, syringomyelia (fluid within the spinal cord), blood clot, infection and tumor. This is only a partial list.
Symptoms
Pain is a rare component of cervical myelopathy though it may be present in cervical stenosis due to pressure on nerve roots. The same process that causes spinal stenosis may result in stenosis of the openings in the spine where the nerves exit. Trouble using the hands due to weakness may be seen. Difficulty walking due to spasticity is not uncommon. Urinary troubles, in particular a feeling of urgency is also common.
Diagnosis
As always, a careful history and physical examination are the first steps in diagnosis. There many possible causes of cervical myelopathy, most of which will be distinguished by the history, physical examination and other testing. Although plain x-rays of the cervical spine may show evidence of spondylosis and stenosis, MRI imaging is much better. MRI shows the cause of the pressure on the spinal cord. It also shows whether or not spinal cord injury or atrophy is present. Occasionally, cervical myelogram and post-myelogram CT scans are used. The post-myelogram CT scan my help define the bone structures somewhat better than the MRI. Generally, however, the MRI is the study of choice. Electrical testing in the form of somatosensory evoked response (or potential) testing may be ordered. This test measures how signals are conducted through the spinal cord.
Treatment
In deciding how best to treat cervical stenosis/myelopathy it is necessary to understand the natural history of the problem. It has been said that in many cases, that once the signs and symptoms of cervical myelopathy are present that they may remain stable. Of course, they may also progress and it is generally felt that decompression has a better effect when signs and symptoms are mild. Although the majority of patients will improve with surgical decompression, a significant number will not enjoy any benefit and a few may worsen.
There are two main approaches to surgical decompression of cervical stenosis. Anterior (from the front) and posterior (from the back). The anterior approach is best for problems involving discs and bone spurs (which are located in front of the spinal cord and not approachable from the back). The number of levels to be treated is decided by the surgeon. Anterior surgery will almost always involve fusion with bone. In many cases, metal plates and screws will be used.
The posterior approach will be considered when there is generalized stenosis of the cervical spinal canal or sometimes when there are three or more levels involved. The surgeon will decide the specific operation. It is important to note that when evidence of spinal cord injury or atrophy is present, the outcome may not be as good as when these problems are absent. This does not mean that surgery should be avoided. Surgery may help to prevent the problem from becoming more severe.