Myelopathy is the clinical scenario of spinal cord compression causing upper motor neuron (UMN) neurologic dysfunction such as trouble walking, increased reflexes and spasticity, muscle weakness and/or numbness. The natural progression of this condition is usually a slow, gradual deterioration, although some patients present with a rapid decline of physical function and/or paralysis.
How are spinal stenosis and myelopathy diagnosed?
The condition of cervical spinal stenosis and myelopathy is not uncommon, and clinicians must be aware of its possibility when evaluating patients with neck problems. It can be complicated when the symptoms or physical findings are atypical. Some patients may only complain of neck pain without overt neurologic abnormalities. All patients with significant arthritis seen on plain X-rays should be considered for additional studies such as MRI to evaluate the extent of spinal canal compromise. It is important for the clinician to conduct a thorough history and clinical examination prior to formulating a diagnosis so as not to misdiagnose this condition. Imaging studies and occasionally laboratory tests must be used to clarify the diagnosis.
What are the treatment options?
The treatment of cervical spinal stenosis often depends on the severity of a patient’s symptoms and the severity of neurologic compression. Patients with mild or moderate stenosis may respond initially to conservative treatments. Conservative treatments may consist of oral anti-inflammatory medications and pain medications. Muscle relaxant medications should be used for severe pain and muscle spasms and only for short duration in elderly patients. Complications secondary to medications are more common in the elderly, and all medications should be closely monitored by the prescribing physician. Physical therapy and modalities may also be utilized with caution, primarily to improve a patient’s strength, endurance and level of function. Manipulation should not be utilized. Epidural steroid injections may provide short-term improvement of pain symptoms.
When a patient has severe spinal stenosis and myelopathy, or a patient with mild or moderate stenosis has not benefited from conservative modalities, surgical intervention is considered. Patients with severe spinal cord compression and/or severe myelopathy with weakness are candidates for surgery. The goal of surgery is to remove the compression from the spinal cord, to improve a patient’s pain and level of function, and to prevent further deterioration of function and worsening pain. If the majority of pressure is coming from osteophytes in the front of the spine, then an anterior corpectomy with strut graft and fusion may be considered. If the majority of the compression is occurring in the back part of the spinal cord, then a laminectomy or laminaplasty may be performed. Occasionally, patients with severe, multiple level stenosis will require both front and back of the neck surgery to adequately decompress and stabilize the spine. Generally, a cervical spinal fusion will always be required and recommended in addition to the decompression component. Spinal instrumentation may also be utilized to impart immediate stability and increase the rate of bone healing and mending. Careful preoperative evaluation and delicate perioperative and postoperative management is particularly important to ensure success and avoid complications.