Cervical Spondylotic Myelopathy SIEMIONOW SPINE SURGERY Kris Siemionow, MD

SIEMIONOW SPINE SURGERY 
Kris Siemionow, MD
Chicago, Illinois
Cervical Spondylotic Myelopathy
Correspondence should be addressed to:
K. B. Siemionow, M.D.
Assistant Professor of Orthopaedics and Neurosurgery
University of Illinois, Chicago
Email: [email protected]
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Dr. Krzysztof (Kris) B. Siemionow MD is Assistant Professor of
Orthopaedics and Neurosurgery at the University of Illinois in
Chicago. Dr. Siemionow completed fellowships in Spine Surgery and
he specializes in the surgical management of spinal conditions
affecting the neck, spine, and back in adults, children, and
adolescents. Dr. Siemionow is Board Certified by the American Board
of Orthopaedic Surgery.
Dr. Siemionow completed a residency in Orthopaedic Surgery at the
Cleveland Clinic in Cleveland, Ohio, ranked one of the top hospitals
in the nation by US News. While in Cleveland, Dr. Siemionow
completed a combined orthopedic/neurosurgical spine fellowship at
the Cleveland Clinic Spine Institute. After completing residency, Dr.
Siemionow and his family moved to Chicago. In Chicago, Dr.
Siemionow completed fellowship training in Adult Spine Surgery at
Rush University Medical Center and a Pediatric Spine Fellowship at
the Shriners Hospital for Children.
Dr. Siemionow participates in an annual spine surgery mission to
Uganda, East Africa, where he treats both children and adults
suffering from spinal trauma, scoliosis, tumors, and infection.
Dr. Siemionow has published numerous scientific articles pertaining
to spine surgery and basic science spine research. He was awarded
an NIH grant to study, “ The effects of inflammation on glial fibrillary
acidic protein expression in satellite cells of the dorsal root ganglion.”
Some of his current research is focused on the aging spine, the
effects of less invasive surgical techniques, and robotic spine
surgery.
Dr. Siemionow has been awarded several patents for developing
devices and technologies used in nerve and spine surgery. Currently
he is working on applications for terahertz electromagnetic waves
with scientists at Case Western Reserve University.
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Cervical Spondylotic Myelopathy
Introduction
You might have been diagnosed with cervical spondylotic myelopathy or CSM by your
doctor. What is CSM? Cervical spondylotic myelopathy is a slowly progressive process
resulting from age related spinal degeneration that can lead to significant functional
disability and, in some cases, paralysis. It is now well established, that CSM is the result
of a reduction in the space available for the spinal cord in the spinal canal. This causes
pressure on the spinal cord itself and results in damage to the blood supply, nerves, and
the nerve cells that form the spinal cord. [1, 2]. CSM is the most common type of spinal
cord dysfunction affecting individuals over 55 years of age[2-4]. The most common
reason for the reduction in spinal cord diameter is age related degeneration of the spinal
joints and discs. These joints wear out just like other joints in the body and form bone
spurs, the discs decrease in height and bulge. With time, the combination of these factors
results in narrowing of the passage for the spinal cord.
Without definitive surgical treatment, progressive deterioration is common. Conservative
treatment is generally ineffective, and surgical intervention remains the most reliable and
predictable method to halt further neurologic deterioration.
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MRI of the cervical spine. The arrows are showing spinal cord compression caused
by degenerative changes. In this case the discs are collapsed and bulging and the
ligaments are thick and buckled.
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History
The natural history of cervical myelopathy is best summarized as a gradual, progressive
worsening of symptoms and decline in functional status. The most common pattern is a
stepwise progression of symptoms followed by periods of stable or worsening function
and in rare instances, improvement[5, 6]. In a review of 120 patients, Clarke and
Robinson identified a slow pattern of stepwise decline in function with intervals of stable
neurologic function in 50% of patients, and a rapid pattern with stable intervals in 25% of
patients[6]. In contrast, 20% of patients had a slow, continuous progression of symptoms
without a stable period, while 5% were found to have a rapid deterioration of neurologic
function. Lees and Turner similarly defined stepwise neurological dysfunction with
quiescent intervals.[5] The authors additionally demonstrated that patients with long
standing disease (>10 years) were more likely to be severely disabled than those earlier in
the disease process.
Causes
The cause of cervical myelopathy is often multifactorial, but can be categorized
into mechanical and vascular etiologies. [7]. Spinal cord compression can arise from birth
defects, progressive degenerative changes, acute cervical disc herniation, hardening of
ligaments (OPLL) or cervical deformity (kyphosis/translation).
Congenital(present at birth), or developmental canal stenosis may be an
underlying contributor to many, but not all, patients with symptomatic disease. A
congenitally narrow canal provides less space than a normally open canal to
accommodate for compressing strucutres or deformity.
Progressive cervical degeneration (spondylosis), a common cause of CSM,
contributes to compression by progressive cervical disc disease, degeneration of the
facet( small joints located in the back of the spinal column) joints, degeneration of the
joints of Luschka or uncinate joints(located outside of the disc), formation of bone spurs
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(ostephytes), and thickening or infolding of the ligaments (like ligamentum flavum)[8, 9].
Additionally, compression can arise from other structures such as acute disc herniations
or ligament calcification. All of these compressive structures act as a space-occupying
mass within the fixed volume of the cervical spinal canal.
Cross section through spinal column of a cadaver demonstrating bone
spurs(white arrow) and ligament thickening and buckling(black arrow).
These changes contribute to spinal cord compression.
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Cervical deformities such subaxial subluxation, seen in rheumatoid disease, can
contribute to CSM by further diminishing the spinal canal volume. Deformities such as
cervical kyphosis may result in a mechanical stretch to the spinal cord and subsequent
CSM symptoms. These mechanical factors may be worsened by neck motion resulting in
repetitive trauma to the cervical cord.
In addition to pure mechanical effects on the spinal cord, CSM symptoms may also be
due to spinal cord ischemia(lack of sufficient blood flow). These ischemic changes are
likely secondary to direct compression or direct spinal cord stretch and may lead to
further nerve cell injury.[10]
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They may account for the stepwise progression of symptoms seen in patients with
otherwise stable radiographic findings. Maintenance of spinal cord blood flow, possibly
through collateral circulation, may explain how some patients remain asymptomatic
despite significant cord compression or deformation.
Clinical Presentation
Due to its wide spectrum of causes, this degenerative process results in various clinical
presentations. In the early stages, neck pain is a common complaint, with cervical
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radiculopathy(pain radiating down the arm) and myelopathy seen in more advanced
disease. Some patients report neck pain as a significant component of their symptoms,
while others have little or no such symptoms[11]. Numbness or paresthesias in the hands,
that is often associated with a loss of hand coordination, is another common complaint.
This may be manifested as an inability to distinguish items such as coins in ones pocket,
or an inability to perform delicate tasks such as tying shoes or buttoning a shirt[4].
Complaints of difficulty with writing, or an unexplained change in handwriting are also
common[8]. Patients may report that they cannot tell the temperature of water, although
they can tell that their hand is submersed[12].
Patients may complain of arm pain, which is most commonly travels down one of the
arms (radiculopathy). [11]. Concomitant radiculopathy is one of the most common
presenting symptoms and may be seen in more than 40% of patients with CSM [13,
14].10,18. The same degenerative changes that contribute to central stenosis and result in
spinal cord compression, such as a bone spur or herniated disc, may impinge on the
neural foramen causing nerve root compression and the resultant radiculopathy. The
presence of a concomitant radiculopathy can influence both treatment decision making as
well as surgical planning.
Problems with walking are very common and are often one of the first signs of
spinal cord compression. Gait disturbance such as a loss of balance or unsteadiness when
walking are the most common lower extremity complaints reported by patients with CSM
and myelopathy should be considered in the differential diagnosis of a patient with a
history of multiple, unexplained falls [14, 15]. Hip muscle weakness can be profound in
these patients and may contribute to difficulty with getting out of a chair[8]. Additionally,
a number of patients with CSM may present with primary complaints of low back and leg
pain symptoms, often due to associated lumbar nerve compression. Although the
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frequency of symptomatic lumbar nerve compression is unknown, the incidence of
anatomic stenosis has been reported to be 5 to 25% of patients.[16, 17].
In advanced cases of CSM, patients may have bladder or bowel impairment –
symptoms that are usually associated with a poor prognosis for recovery[18]. Urinary
symptoms vary and may consist of urinary frequency, urgency, incontinence, or urinary
retention. The incidence of these symptoms varies with 15 to 50% being reported in the
literature [19, 20]. Bladder dysfunction was demonstrated in 15% and bowel dysfunction
in 18% out of 269 patients with CSM[19]. In a clinical series involving CSM patients
older than age 55, 20% exhibited bladder dysfunction with urinary retention of varying
degrees[21, 22]. The “presence of neurogenic bladder was closely correlated with severe
leg symptoms”[23].
Other Causes Mimicking CSM
Diagnosing CSM is a challenge that requires a high degree of clinical suspicion. There
are other diseases that can mimic CSM. Complaints of difficulty with ambulating and
reduced hand dexterity should alert the examining physician to the possibility of an
underlying myelopathy. There are several other conditions that can mimic CSM on initial
presentation such as multiple sclerosis, ALS(Lou Gehrig’s disease), or polio among
others. [44, 45]. Most of these conditions can easily be distinguished from CSM based on
characteristic MRI findings which document spinal cord compression.
Treatment
If you were diagnosed with CSM then you need to consult a spine surgeon. Make
sure that your surgeon is board certified and has completed a fellowship in spine surgery.
Since CSM is a progressive problem, early surgical intervention is warranted in a patient
who presents with significant spinal cord compression and symptoms. In patients with
radiographic evidence of canal narrowing, with or without cord compromise, and only
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mild symptoms, such as neck stiffness and no radicular or myelopathic symptoms, initial
conservative management with close follow-up is appropriate and has shown equivalent
results to operative treatment.[46] Nonsurgical treatments for patients with mild
symptoms include cervical immobilization, pain medication, and physical therapy. There
is often apprehension associated with nonsurgical management , for both the patient and
the physician since it has been reported that symptomatic patients may deteriorate
neurologically during conservative treatment, causing many to advocate earlier surgical
intervention[47]. Many have also advocated surgical management in asymptomatic
patients to prevent spinal cord injury from minor trauma despite the lack of evidence to
support this recommendation. There is no strong clinical evidence (grade I, II, or III) to
support prophylactic spinal cord decompression and, therefore, asymptomatic patients are
best managed through serial clinical examination.
Surgical treatment for patients with moderate to severe symptoms is often
recommended. A number of treatment options exist – anterior decompression and fusion,
posterior laminectomy, posterior laminaplasty, posterior laminectomy and fusion, and
combined anterior and posterior procedures. Alignment of the spine, location of cord
compression (front vs back), flexibility of the spine, the presence of
deformity(angulation), the number of levels involved, and surgeon preference all
influence decision making. Deciding the approach, number of levels, fusion vs nonfusion techniques remain controversial, with little widespread agreement. Each has
demonstrated potential benefits and as well as risks. Overall, outcomes of surgical
decompression, among symptomatic patients, have been demonstrated to be superior to
nonoperative treatment in functional status, pain relief, and neurological status.[48]
Negative predictors of postoperative recovery include: poorer preoperative neurological
status, longer duration of symptoms, and advance patient age.[8]
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Summary
Cervical spondylotic myelopathy is a slowly progressive process resulting from
age related degenerative changes in the spine that can lead to significant functional
disability. Once myelopathic symptoms are present, most patients with will require
surgery to decompress the spinal cord and prevent further functional deterioration.
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References
1.
2.
.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Fehlings MG, S.G., A review of the pathophysiology of cervical spondylotic
myelopathy with insights for potential novel mechanisms drawn from traumatic
spinal cord injury. Spine 23:2730-2737, 1998.
WF:, Y., Cervical spondylotic myelopathy: a common cause of spinal cord
dysfunction in older persons. Am Fam Physician 62:1064-1070, 1073, 2000
Dillin W, B.R., Cuckler J, et al:, Cervical radiculopathy. A review. Spine 11:988991, 1986.
Bernhardt M, H.R., Blume HW, et al: , Cervical spondylotic myelopathy. J Bone
Joint Surg Am 75:119-128, 1993.
Lees F, T.J., Natural history and prognosis of cervical spondylosis. BMJ
1963;2:1607-1610.
Clarke E, R.P., Cervical myelopathy: A complication of cervical spondylosis.
Brain 1956;79:483-510.
HH:, B., Cervical spondylosis and myelopathy. Instr Course Lect 44:81-97, 1995.
Bohlman HH, E.S., The pathophysiology of cervical spondylosis and myelopathy.
Spine 13(7):843-846, 1988.
L:, B., Adverse Mechanical Tension in the Central Nervous System (ed 2). New
York, NY, Wiley, 1978, p 264.
Baptiste, D.C. and M.G. Fehlings, Pathophysiology of cervical myelopathy. Spine
J, 2006. 6(6 Suppl): p. 190S-197S.
SE:, E., Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad
Orthop Surg 9(6):376-388, 2001.
Ono K, E.S., Fuji T, et al: , Myelopathy hand. New clinical signs of cervical cord
damage. J Bone Joint Surg Br 69(2):215-219, 1987.
Ferguson RJC, C.L., Cervical spondylotic myelopathy. Neurol Clin North Am
3:373-382, 1985.
CR:, C., Cervical spondylotic myelopathy: history and physical findings. Spine
13(7):847-849, 1988.
Rumi MN, Y.S., Cervical myelopathy history and physical examination. Semin
Spine Surg 16:234-240, 2004.
Epstein NE, E.J., Carras R, et al: , Coexisting cervical and lumbar spinal stenosis:
diagnosis and management. Neurosurgery 15:489-496, 1984.
Teng P, P.C., Combined cervical and lumbar spondylosis. Arch Neurol 10:298307, 1964.
Emery SE, B.H., Bolesta MJ, et al: , Anterior cervical decompression and
arthrodesis for the treatment of cervical spondylotic myelopathy: two to
seventeen-year follow-up. J Bone Joint Surg Am 69:21513
SIEMIONOW SPINE SURGERY
www.kbspine.com
219, 1987.
19.
Hukuda S, M.T., Ogata M, et al: , Operations for cervical spondylotic
myelopathy. J Bone Joint Surg Br 67:609-615, 1985.
20.
Lunsford LD, B.D., Zorub D: , Anterior surgery for cervical disc disease. Part 2.
J Neurosurg 53:12-19, 1980.
21.
Epstein N, E.J., Carras R. , Cervical spondylostenosis and related disorders in
patients over 65: Current managment and diagnosis techniques.
Orthotransactions 11:15, 1987.
22.
W., D., Clinical Syndromes in Cervical Myelopathy. Rothman-Simeone The Spine
5th edition. Philadelphia, Saunders Elsevier, 2006. pp 784-794. .
23.
Mochida K, S.K., Andou M., Urodynamic and electrophysiologic study of the
urinary disturbances caused by cervical myelopathy. J Spinal Disord. 1996
Apr;9(2):141-5.
24.
Newton HB, R.G., Lhermitte’s sign as a presenting symptom of primary spinal
cord tumor. J Neurooncol 29(2):183-188, 1996.
25.
Small JM, D.W., Watkins RG: , Clinical syndromes in cervical myelopathy, in:
Herkowitz H, Garfin SR, Balderson RA, et al (eds): The Spine (ed 4).
Philadelphia, PA, W.B. Saunders Co., 1999, pp 465-474.
26.
Dillin WH, W.R., Clinical syndromes in cervical myelopathy. Cervical disc
disease, in Rothman RH, Simeone FA (eds): The Spine (ed 3). Philadelphia, PA,
WB Saunders, 1992, pp 560-570.
27.
Houten J., E.T., Cervical Spondylotic Myelopathy and Radiculopathy: Natural
History and Clinical Presentation. The Cervical Spine. Editor Charles Clark. (4th
ed.). pp 735. Philadelphia 2005.
28.
Good DC, C.J., Wacaser L.: , “Numb, clumsy hands” and high cervical
spondylosis. Surg Neurol 22(3):285-291, 1984.
29.
Watson JC, B.W., Smith MM, et al: , Hyperactive pectoralis reflex as an
indicator of upper cervical spinal cord compression: report
of 15 cases. J Neurosurg 86(1):159-161, 1997.
30.
Shimizu T, S.H., Shirakura K., Scapulohumeral reflex (Shimizu). Its clinical
significance and testing maneuver. Spine. 1993 Nov;18(15):2182-90. .
31.
Law MD Jr, B.M., White AA 3rd: , Evaluation and management of cervical
spondylotic myelopathy. Instr Course Lect 44:99-110, 1995.
32.
Heller J., P.F., Gill S., Anatomy of the Cervical Spine. The Cervical Spine. Editor
Charles Clark. (4th ed.). pp 1-35. Philadelphia 2005.
33.
Rhee JM, H.T., Heflin J., Incidence of Physical Signs in Cervical Myelopathy: A
Prospective Controlled Study. Presented at the CSRS Annual Meeting in San
Francisco, CA. 2007.
34.
Matsunaga S, S.T., Taketomi E, et al: , The natural course of myelopathy caused
by ossification of the posterior longitudinal ligament in the cervical spine. Clin
Orthop Relat Res 305:168-177, 1994.
14
SIEMIONOW SPINE SURGERY
www.kbspine.com
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
Jr:, A.J., The clinical manifestations of spondylochondrosis (spondylosis) of the
cervical spine. Ann Surg 141:872-889, 1955.
Wilkinson HA, L.M., Ferris EJ:, Clinical-radiographic correlations in cervical
spondylosis. J Neurosurg 30:213-218, 1969.
Al-Mefty O, H.L., Middleton TH, et al: , Myelopathic cervical spondylotic lesions
demonstrated by magnetic resonance imaging. J Neurosurg 68:217-222, 1988.
Matsuda Y, M.K., Tada K, Yasuda A, Nakayama T, Murakami H, Matsuo M.,
Increased MR signal intensity due to cervical myelopathy. Analysis of 29 surgical
cases.J Neurosurg. 1991 Jun;74(6):887-92.
Boden SD, M.P., Davis DO, et al: , Abnormal magnetic resonance scans of the
cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint
Surg Am 72(8):1178-1184, 1990.
S, N., The pathogenesis of the spinal cord disorder associated with cervical
spondylosis. Brain, 1972;95: 87-100.
Naderi S, Ö.S., Pamir MN, Özek MM, Erzen C: , Cervical spondylotic
myelopathy: surgical results and factors affecting prognosis. Neurosurgery
43:43–50, 1998.
Benzel EC, L.J., Kesterson L, Hadden T., Cervical laminectomy and dentate
ligament section for cervical spondylotic myelopathy. J Spinal Disord. 1991
Sep;4(3):286-95.
Ranawat CS, O.L.P., Pellicci P, Tsairis P, Marchisello P, Dorr L., Cervical spine
fusion in rheumatoid arthritis. J Bone Joint Surg Am. 1979 Oct;61(7):1003-10.
Lapsiwala S., T.G., Myelopathy: Diagnosis and Differential Diagnosis. The
Cervical Spine. Editor Charles Clark. (4th ed.). pp 199-219. Philadelphia 2005.
WF., Y., Cervical spondylotic myelopathy: a common cause of spinal cord
dysfunction in older persons. Am Fam Physician. 2000 Sep 1;62(5):1064-70,
1073. Review.
Kadanka, Z., et al., Approaches to spondylotic cervical myelopathy: conservative
versus surgical results in a 3-year follow-up study. Spine, 2002. 27(20): p. 220510; discussion 2210-1.
AH., R., Myelopathy due to cervical spondylosis treated by collar immobilization.
Neurology 1966;16:951-4.
Sampath, P., et al., Outcome of patients treated for cervical myelopathy. A
prospective, multicenter study with independent clinical review. Spine, 2000.
25(6): p. 670-6.
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Figure Legend
Figure 1. Sagittal T2 weighted MRI showing compression of the spinal cord at C3-C4
with increased signal in the cord (arrow) indicative of myelomalacia.
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NOTES
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