Cervical spondylosis with cervical myelopathy, commonly referred to as cervical spondylotic myelopathy (CSM), refers to impaired function of the spinal cord caused by degenerative changes of the discs and facet joints in the cervical spine (neck).
See Spondylosis: What It Actually Means
In severe cases, spondylosis can cause myelopathy, which is spinal cord compression that results in neurological deficits. Watch: Cervical Spondylosis with Myelopathy Animation
This condition is the most common disorder causing dysfunction of the spinal cord (known as myelopathy) and results from compression of the spinal cord.
Most patients with this condition are over 50 years of age, but the age of onset is variable depending on the degree of congenital spinal canal narrowing.
The process that leads to spinal cord compression is a result of arthritis in the neck (also called cervical spondylosis or degenerative joint disease), which is incompletely understood and likely has a number of causes.
See Cervical Osteoarthritis (Neck Arthritis)
Factors That Lead to Cervical Spondylosis with Myelopathy
Factors that are thought to contribute to development of cervical spondylosis with myelopathy include:
- Normal age-dependent changes of the intervertebral discs, most commonly manifested as cervical osteophytes (bone spurs) at the margins of the vertebrae
See Cervical Osteophytes: Symptoms and Diagnosis
- Arthritis in the neck leading to facet hypertrophy (enlargement of the facet joints)
- Thickening of the ligaments surrounding the spinal canal, especially the ligamentum flavum, which parallels loss of disc height
- Translational mechanical instability resulting in subluxation (or partial dislocation) of the vertebral bodies
See Subluxation and Chiropractic
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- Congenitally small spinal canal, which renders the patient's spinal cord more susceptible to compression
- Repetitive wear and/or trauma leading to degenerative changes affecting the disc spaces and vertebral endplates
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These changes in the cervical spine produce narrowing of the spinal canal itself, leading to thickening of the posterior longitudinal ligament and bone spur (osteophyte) formation compressing the spinal cord, most commonly at the C4-C7 levels. The end result is chronic compression of the spinal cord and nerve roots leading to impaired blood flow and neurological deficit resulting in frank damage within the spinal cord itself.
A related condition that is more commonly being appreciated is ossification of the posterior longitudinal ligament (OPLL) that can also lead to chronic spinal cord compression.
Cervical spondylosis is osteoarthritis of the cervical spine causing stenosis of the canal and sometimes cervical myelopathy due to encroachment of bony osteoarthritic growths (osteophytes) on the lower cervical spinal cord, sometimes with involvement of lower cervical nerve roots (radiculomyelopathy). Diagnosis is by MRI or CT.
Treatment may involve nonsteroidal anti-inflammatory drugs and a soft cervical collar or cervical laminectomy. Cord compression commonly causes gradual spastic paresis, paresthesias, or both in the hands and feet and may cause hyperreflexia. Neurologic deficits may be asymmetric,
nonsegmental, and aggravated by cough or Valsalva maneuvers. After trauma, people with cervical spondylosis may develop a central cord syndrome (see table Spinal Cord
Syndromes Spinal Cord Syndromes Eventually, muscle atrophy
and flaccid paresis may develop in the upper extremities at the level of the lesion, with spasticity below the level of the lesion. Nerve root compression commonly causes early radicular pain; later, there may be weakness, hyporeflexia, and muscle atrophy. MRI or CT Symptoms and Signs
Cervical spondylosis is suspected when characteristic neurologic deficits occur in patients who are older, have osteoarthritis, or have radicular pain at the C5 or C6 levels.
Diagnosis of cervical spondylosis is by MRI, CT, or CT myelography.
For cord involvement or refractory radiculopathy, cervical laminectomy
For radiculopathy only, nonsteroidal anti-inflammatory drugs (NSAIDs) and a soft cervical collar
If the cord is severely compressed, cervical laminectomy is usually needed; a posterior approach can relieve the compression but leaves anterior compressive osteophytes and may result in spinal instability and kyphosis. Thus, an anterior approach with spinal fusion is generally preferred.
Patients with only radiculopathy may try nonsurgical treatment with NSAIDs and a soft cervical collar; if this approach is ineffective, surgical decompression may be required. Indications for surgical decompression include
Intractable pain
Spinal cord compromise (eg, progressive weakness, bowel and bladder dysfunction)
Baclofen may help relieve spasticity.
Cervical spondylosis due to osteoarthritis, especially if the cervical canal is congenitally narrow, can lead to stenosis of the canal and development of osteophytes, which may compress the cord or nerve roots.
Cord compression commonly causes gradual spastic paresis and/or paresthesias in the hands and feet and may cause hyperreflexia, eventually resulting in muscle atrophy, with flaccid paresis in the upper extremities at the level of the compression, and spasticity below that level.
Nerve root compression commonly causes early radicular pain, sometimes followed by weakness, hyporeflexia, and muscle atrophy.
Diagnose using MRI or CT.
If the spinal cord is severely compressed, do a cervical laminectomy, usually with an anterior approach; for radiculopathy alone, try NSAIDs plus a soft cervical collar, but if this treatment is ineffective, consider surgical decompression.
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