Cervical Spondylotic Myelopathy

INTRODUCTION

Cervical spondylosis refers to a progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs. This process can lead to narrowing (stenosis) of the central spinal canal, ie, cervical spinal stenosis. If sufficiently severe, the cervical spinal cord is compressed, producing a syndrome of spinal cord dysfunction known as cervical spondylotic myelopathy. Myelopathy occurs in 5 to 10 percent of patients with symptomatic cervical spondylosis. Other clinical syndromes associated with cervical spondylosis include neck pain and cervical radiculopathy.

Cervical spondylotic myelopathy is the most common cause of myelopathy in adults over 55 years, causing progressive disability and impairing the quality of life.Cervical spondylotic myelopathy is the most common cause of myelopathy in older adults.

●Cervical spondylotic myelopathy results from a progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs and causing compression of the neural and vascular elements in the adjacent cord.

●There is no specific stereotyped presentation of cervical spondylotic myelopathy. Usually symptoms begin with an insidious onset of gait disturbance. Other common symptoms include sensory loss, and weakness and muscle atrophy in the hands, along with neck and arm pain. The examination usually reveals other myelopathic features.

●Cervical spondylotic myelopathy must be distinguished from amyotrophic lateral sclerosis (ALS) and other cervical cord disorders.

●The diagnosis of cervical spondylotic myelopathy is made by correlating the clinical features with findings of cervical spondylosis and cord compression seen on a neuroimaging study, usually magnetic resonance imaging (MRI).

●The clinical course and prognosis of cervical spondylotic myelopathy is not well characterized. Patients can deteriorate progressively or in a stepwise fashion with long periods of stability. Some patients may deteriorate abruptly in association with a minor neck injury.

●There are no large randomized trials on which to base treatment recommendations. For patients with mild, nondebilitating myelopathy we suggest surgical consultation for those at risk of neurologic deterioration (eg, active lifestyle, severe radiologic cord compression) (Grade 2C). Close neurologic follow-up should assess for deterioration when surgery is deferred. Conservative measures include intermittent neck immobilization, pain management, and restriction of high-risk or aggravating activities. For patients with more severe myelopathy or progressing deficits, we suggest surgical decompression (Grade 2C).

●Acute deterioration or an acute presentation with myelopathy in a patient with cervical spondylosis is a neurologic emergency. After confirmation of the diagnosis with MRI, patients should receive a surgical consultation. We suggest administration of intravenous methylprednisolone within eight hours of acute deterioration (Grade 2C). The standard dose is 30 mg/kg intravenous bolus, followed by an infusion of 5.4 mg/kg per hour for the first 23 hours.