Clinical Case Cervical Spondylotic Myelopathy

Overview

Cervical spondylotic myelopathy (CSM) is a condition characterized by the compression of the spinal cord, resulting from the narrowing of the spinal canal and degenerative changes.

This compression, which can be caused by factors related to development or dynamic factors, leads to the onset of CSM. CSM presents with typical signs such as pain in the neck and radiating pain, along with sensations of numbness and tingling, muscle weakness, and spasms in the upper limbs.

Additionally, CSM can give rise to notable neurological issues like impaired walking and dysfunction of the bladder. To ensure optimal treatment for patients, it is crucial to have a comprehensive understanding of the causes and progression of CSM.

Causes

CSM is typically caused by age-related degenerative changes in the spinal canal. While it is more common in older adults, a study aims to explore the characteristics of CSM in young adults under 30, as this population is rarely affected.

In a study reported by literature, a very small percentage (0.27%) of CSM patients under 30 years old were analyzed. They were mostly male and engaged in high daily activities that placed stress on their necks. Radiographs showed congenitally narrowed spinal canals and positive findings for dynamic spinal movements.

Participating in sports activities, particularly contact sports like American football and rugby, is a significant contributor to spinal injuries among young individuals.

This study focused on patients who engaged in high daily activities related to sports or occupations, resulting in ongoing strain on their necks. Unlike cases with sudden onset symptoms, the patients in this study experienced a gradual development of symptoms over time.

This suggests that the consistent occurrence of mild daily injuries and traumas may play a role in the progression of degenerative spinal changes and the occurrence of subclinical neurological damage.

CSM risk is associated with congenitally narrowed cervical spinal canal stenosis. Measuring the sagittal spinal canal diameter on radiographs is a common method, and a diameter of 12 mm or less indicates a high risk of CSM development.

 

Symptoms of CSM

The symptoms of CSM can vary widely and may develop slowly over time. Common symptoms include:

• Neck pain and stiffness: Although not always present, neck discomfort is often one of the first signs of CSM.
• Radiculopathy: This refers to symptoms like pain, numbness, and tingling that radiate from the neck into the shoulders, arms, and hands.
• Myelopathy: This term describes symptoms due to spinal cord compression, including:
  • Weakness in the arms and legs: Patients may notice difficulty with fine motor skills, such as buttoning a shirt or writing. Walking may become unsteady or more effortful.
  • Numbness and tingling: Sensory disturbances in the hands and feet are common.
  • Gait and balance problems: As the spinal cord compression progresses, patients may experience difficulty walking, frequent falls, and a feeling of instability.
  • Bladder and bowel dysfunction: In severe cases, there can be issues with urinary incontinence or bowel control.

Diagnosis 

MRI scans revealed disc degeneration, spinal cord compression, and abnormal signal changes. The sagittal alignment of the cervical spine showed two common types, associated with different patterns of spinal cord compression and damage. These findings suggest that high daily activities and congenital canal stenosis can contribute to the development of symptomatic CSM in young adults.

The Torg-Pavlov ratio is another indicator, and all patients in the study had a ratio <0.8, indicating a predisposition to congenital canal stenosis. While women have a higher prevalence of this condition, men engaged in high daily activities can experience spinal cord compression in the presence of congenital canal stenosis.

Dynamic canal stenosis, also referred to as the “pincer mechanism,” is an added risk factor for CSM. The study revealed that the majority of patients displayed positive indications of dynamic canal stenosis, suggesting that individuals with congenital canal stenosis and active daily routines may experience an intensified compression of the spinal cord.

The use of absolute radiographic measurements to assess cervical spine instability and canal stenosis is a topic of debate. However, there are suggested criteria for evaluating the space available for the spinal cord at the C1 level.

For patients who meet the radiographic criteria for instability and stenosis, it is advisable to undergo further MRI evaluation to support a comprehensive diagnosis of myelopathy involving multiple disciplines.

Magnetic resonance imaging (MRI) is a valuable diagnostic tool for examining intervertebral disc and spinal cord conditions. The study observed degeneration in all discs at the affected level, along with the presence of spinal cord compression, deformity, and intramedullary abnormal signal lesions.

These findings suggest that the combination of high daily activities, degenerative instability, and congenital canal stenosis can contribute to spinal cord compression and damage, potentially resulting in the development of symptomatic CSM.

The objective of this study was to examine the sagittal alignment of the cervical spine in young adult patients to identify radiographic and biomechanical characteristics of cervical spondylotic myelopathy (CSM).

The most frequently observed alignment was the “reverse-sigmoid” type, which exhibited single-level spinal cord compression and positive indications of decreased neutral foramen (DNF) or posterior vertebral slip. On the other hand, alignments such as “lordosis” or “straight” demonstrated multi-level spinal cord compression and altered biomechanics.

Therefore, it is crucial to closely monitor young male athletes and workers with pre-existing sagittal malalignment and congenital canal stenosis for the development of dynamic canal stenosis and spinal cord damage.

It is important to exercise caution when interpreting the findings of this study for several reasons. Firstly, the true prevalence of CSM in patients under the age of 30, including those with mild symptoms treated in outpatient settings, remains uncertain as the study only included hospitalized patients.

Secondly, the small sample size restricts the statistical power and increases the likelihood of potential interpretation errors, despite utilizing appropriate statistical analysis methods.

Thirdly, the absence of a control group limits the ability to draw definitive conclusions. Furthermore, the retrospective nature of the study introduces limitations and potential biases related to participant selection.

However, the distinct characteristics observed in young adult patients with non-herniated, degenerative CSM underscore the need for future prospective cohort studies to gain a more comprehensive understanding of this condition.

Non-herniated, degenerative cervical spondylotic myelopathy (CSM) is rare in young adults under 30. However, it is more common in men with congenital canal stenosis and mild sagittal deformities.

High daily activities, such as sports or jobs that stress the neck, can accelerate disc degeneration and dynamic canal stenosis, leading to spinal cord compression and potential symptomatic myelopathy.

Treatment Options

Treatment depends on the severity of the condition:

• Conservative treatment: For mild cases, this may include physical therapy, pain management, and lifestyle modifications. However, close monitoring is necessary as the condition can progress.
• Surgical treatment: This is often recommended for moderate to severe cases to relieve spinal cord compression. There are different surgical approaches:
  • Anterior cervical discectomy and fusion (ACDF): Suitable for patients with compression in the front of the spine.
  • Posterior cervical decompression: Beneficial when multiple segments are involved or there’s compression from the back of the spine.

Each surgical approach has its risks and benefits, and the choice depends on individual patient factors, including the extent and location of spinal cord compression.

Post-Treatment Care

Post-surgery, patients typically undergo rehabilitation to regain strength and function. Recovery can vary, with some patients experiencing significant improvements in symptoms, while others may have lingering effects. Regular follow-ups are crucial to monitor recovery and manage any complications.

Recovery and Rehabilitation

Postoperative recovery from CSM surgery can vary based on the type of surgery performed and the individual patient’s condition. General guidelines for recovery include:

• Hospital Stay: Most patients stay in the hospital for a few days after surgery. During this time, they are monitored for any complications.
• Pain Management: Pain is managed with medications, and a gradual return to normal activities is encouraged.
• Physical Therapy: Rehabilitation exercises help restore neck mobility, strengthen muscles, and improve overall function. The therapist may also provide guidance on posture and ergonomic adjustments to prevent future problems.
• Follow-Up Appointments: Regular follow-ups with the surgeon are crucial to monitor healing and ensure that the spine is stable.

Conclusion

Cervical spondylotic myelopathy is a progressive condition caused by age-related changes in the cervical spine. Early detection and appropriate treatment are key to managing symptoms and preventing severe neurological deficits. If you experience persistent neck pain, numbness, or weakness in your limbs, consult a healthcare provider to explore potential causes and treatment options.