1. Cervical Stenosis and Myelopathy

2. Normal Anatomy

3. 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)

4. 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

6. 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

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

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

9. 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

10. 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

11. 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

12. Special Tests
Hoffmans (upper limb Babinski)
Babinski
Romberg

13. 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

14. 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

15. General Management
Analgesia
Gabapentin
Activity modification

16. 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

17. 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

18. 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