Cervical Stenosis and Myelopathy

Normal Anatomy

Pathophysiology Spinal Stenosis Myelopathy Description rather than a diagnosis narrowing of the vertebral canal, lateral recess or intervertebral foramen commonly caused by degenerative changes May result in myelopathy Myelopathy impaired function of the spinal cord caused by compression generally progressive and develops slowly Myelopathy caused by spondylosis is called cervical spondylotic myelopathy (CSM) most prevalent at the C5-C6 level rarely seen in the upper cervical segments (C3-C4)

Cervical Spondylotic Myelopathy Result of degenerative changes ligamentum flavum hypertrophy or buckling, facet joint hypertrophy disc protrusion posterior spondylotic ridges overall reduction in canal diameter cord compression

Mechanism Of Injury- Stenosis Insidious Congenital/Inherited Idiopathic (hereditary) Achondroplastic Acquired Stenosis Infection Tumours Foreign Bodies Disc Protusion Ligamentous Hypertrophy Osteophyte formation Facet joint Hypertophy Spondylolisthesis Traumatic Fractures Upper Cervical Instability

Mechanism Of Injury- Myelopathy Insidious Stenosis causes Rheumatoid Arthritis Trauma Fractures Ligament Rupture (Upper Cervical Instability)

Subjective - Stenosis Stenosis Presentation will depend on associated pathology Insidious onset Progressive worsening of symptoms Aggravating by positions that reduce space (extension, rotation)

Subjective - Myelopathy Upper and/or lower limb pain, weakness, sensation changes Clumsiness Neuropathic pain Gradually worsening symptoms Bladder or bowel dysfunction Difficulty walking for long distances Reduced fine motor skills and co ordination Falls Insidious onset of pain Neck pain may or may not be present

Objective Stenosis Presentation will depend on associated pathology Pain with movements that close space Myelopathy Upper and/or lower quarter sensation loss (bilateral or quadrilateral) Bilateral or quadrilateral weakness Pathological reflexes Poor co ordination and fine motor skills Increased and Decrease Tone

Objective Stenosis Presentation will depend on associated pathology ie myelopathy Myelopathy Hyper reflexia in the upper or lower extremities Hypertonia Positive Hoffmans and/or Babinski sign Sensory changes Weakness Decreased dexterity Gait instability

Special Tests Hoffmans (upper limb Babinski) Babinski Romberg

Further Investigation MRI (angled sagittal) CT with Myelogram (dye injected to highlight the nerves) Sagittal T2-weighted magnetic resonance imaging of the cervical spine, which demonstrated moderately severe spinal stenosis at the C3–C4, C5–C6, and C6–C7 levels, with less severe spinal stenosis at the C4–C5 level

Axial T2 weighted MRI (A) and CT myelograph (B) at C4-C5 level showing an ossified mass on the right with bony protrusion into the canal

General Management Analgesia Gabapentin Activity modification

Conservative – Management - Myelopathy Immediate onwards referral If diagnostics have already been completed and conservative management suggested, monitor symptoms closely, if they worsen surgical intervention may be indicated. Myelopathy may develop rapidly and delays in surgical intervention may result in poor outcome. Heat/Ice Traction

Conservative - Management - Stenosis Manage the underlying pathology Pain Relief NSAID’s, Ice, Massage Restore Normal ROM Tx, Cx and Shoulders Soft tissue techniques and joint mobilisations Restore Normal Neurodynamics Soft tissue techniques, joint mobilisations, nerve sliders Restore Normal Muscular Activation Scapular stabilisers, deep cervical extensors, deep cervical flexors

Surgical - Management Decompress the cervical spinal canal and achieve an arthodesis of the treated levels. This can be achieved in the following ways: Posterior approach Laminectomy Laminoplasty Anterior approach Discectomy and interbody fusion Corpectomy and fusion