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When daily activities like writing or holding a utensil become difficult, or you start to feel unsteady on your feet, don’t dismiss the symptoms. According to Ananth Eleswarapu, MD, an orthopedic spine surgeon with Montefiore Einstein, these could be signs of cervical myelopathy which can and should be treated. Approximately 20,000 people with symptoms of cervical myelopathy visit the hospital in the United States each year.
Myelopathy is a condition in which there is dysfunction of the spinal cord. It can result from many different things, including infection, tumors or compression of the spinal cord due to bones or disc herniations. Cervical myelopathy refers to dysfunction of the part of the spinal cord in the neck.
What Causes CSM?
Myelopathy can result from any condition that causes injury to the spinal cord. This includes viral infections, tumors autoimmune conditions (where the body’s immune system attacks the spinal cord, or compression of the spinal cord. It is important to find out what is causing the myelopathy to occur as the treatment will be different for each cause.
The most common cause of myelopathy is cervical spondylotic myelopathy (CSM)—this is when bone or soft tissue structures are pushing on the spinal cord. Almost all people will develop stenosis or compression of the spinal cord with age due to herniated discs, bone spurs, or overgrown ligaments. Only a small minority of people develop symptoms of myelopathy. We don't know why spinal cord compression causes no symptoms in most people and severe symptoms in a select few. Our spine team at Montefiore Einstein is engaged in research using multimodal artificial intelligence to try to understand what causes stenosis to become symptomatic. This may lead to novel, more targeted, or even preventive treatments in the future.
Signs and Symptoms
The spinal cord sends signals from your brain to the rest of your body to control movement and sensation. When the spinal cord is not working correctly, the first thing a patient will notice is difficulty with complex movements that require multiple muscles to work together in coordination. Think of tasks such as walking or tying shoelaces. We do these things so often we take them for granted. However, they require the brain to integrate information from our eyes and sensations from our skin and use it to coordinate the action of dozens of muscles in real time. All that information needs to pass through the spinal cord to get to the muscles. When the spinal cord is not working correctly, movements you do all the time can suddenly become difficult.
Myelopathy can be subtle at first, and patients may not attribute their symptoms immediately to a spine problem. A hairdresser might have trouble opening and closing scissors. Or a chef might fumble when cutting vegetables. Over time, the symptoms get more obvious.
In advanced cases, patients can have clumsiness of their hands and feet making it difficult to walk or feed themselves. They may have numbness that causes them to burn their hands on a hot stove without realizing it. In severe cases, even bowel and bladder function can be affected.
Diagnosis and Screening
The most important way in which myelopathy is diagnosed is by talking with patients. A doctor can ask questions about balance, dexterity, sensation and difficulty with daily tasks. We utilize the mJOA (modified Japanese Orthopedic Association) scale, which asks patients how much difficulty they have doing everyday things such as climbing stairs or buttoning a shirt. This assigns patients a score reflecting the severity of their disease. We can then follow it over time to see if it is getting better or worse.
There are physical exam findings, such as increased reflexes that are common in myelopathy. It should be stressed though that these physical exam findings correlate only loosely with patient symptoms. Treatment is guided by the severity of symptoms and not a physical exam.
Several imaging studies can help determine what is causing myelopathy. Upright X-rays can look for kyphosis or a tilted forward posture, which can put pressure on the spinal cord. CT or MRI can identify bone or soft tissue, respectively, which are putting pressure on the spinal cord.
Comprehensive On-Site Treatment Services
The course of symptoms in myelopathy is one of “stepwise decline”— that is, patients will have long periods of stable symptoms punctuated by brief intervals of rapid decline in function. Once the decline occurs, it is usually not reversible. That is why it is necessary to intervene early in the disease course, before this decline has occurred, to preserve as much function as possible.
Treatment for myelopathy involves addressing whatever is causing damage to the spinal cord. In the case of infections or tumors, the underlying disease is treated. For CSM, in which the spinal cord is being compressed, the treatment is surgery to decompress the cord. This can be done anteriorly, in which the spinal cord is accessed from the front of the neck, or posteriorly, in which the cord is accessed through an incision in the back of the neck. The decision of what type of surgery to perform is quite complex and best discussed with a doctor who knows the individual case well.
Generally speaking, patients will be in the hospital for 1-3 days post-surgery with an expected 3–6-month recovery period. Patients who have a loss of balance or dexterity before surgery can do rehab to try to regain those functions after surgery. Many patients will have pain with swallowing after surgery—this usually takes a few weeks to get better. There are rare risks of surgery including shoulder weakness and injury to the esophagus or blood vessels. Patients are, understandably, often nervous about undergoing spine surgery. In the modern era, however, cervical spine surgery is safe and routine. For patients with myelopathy, the risk of leaving the spinal cord compressed is usually far greater than the risk of having surgery.
Surgical Outcomes
The goal of surgery for myelopathy is to prevent spinal cord damage from getting worse. It is usually not possible to reverse spinal cord damage that has already occurred. This is why patients and doctors need to be aware of the symptoms of myelopathy and promptly seek evaluation by a specialist. In some cases, patients can have partial recovery of function after surgery. Having surgery early in the disease process before severe damage has occurred gives patients the best chance of recovering function.
For more information, visit Montefiore Einstein Comprehensive Orthopedic & Spine Center at montefiorenyack.org/orthopedic-spine. To schedule an appointment or consultation, call 845-358-1000.
