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10-28-2012, 05:17 PM
Cervical Disc Disorder with Myelopathy
![[Image: hern_dis.jpg]](http://www.mdguidelines.com/images/Illustrations/hern_dis.jpg)
Myelopathy is an inclusive term referring to any disease of the spinal canal. The cervical region specifies the neck region of the spine. The following are examples of myelopathy: carcinomatous myelopathy (spinal cord degeneration associated with cancer); compressive myelopathy (spinal cord changes from the pressure of hematomas or masses); and radiation myelopathy (spinal cord destruction from radiation sources such as x-ray therapy). When the spinal cord destruction is caused as a complication of disease, the specific myelopathy signifies that origin; for example, diabetic myelopathy.
Cervical disc disorder with myelopathy can result from either a herniation of a cervical disc or spinal cord compression by spinal stenosis. A cervical disc (intervertebral disc) is a cushion-like structure found between the cervical spinal bones (vertebrae C2 through C7) that run from the base of the skull to shoulder level. Discs are composed of a gel-like inner material (nucleus pulposus) encased in a ring of tough, fibrous outer material (annulus fibrosis); intervertebral discs absorb shock and allow movement of the spine. Disc displacement (herniation) occurs when the nucleus pulposus and/or the annulus protrudes abnormally into the spinal canal. Most often, a disc herniation presses on an exiting spinal nerve, causing dysfunction in a nerve root (radiculopathy). Less commonly, the spinal cord can become compressed by a herniated or bulging disc alone, or in combination with degenerative changes (cervical spondylosis) or with a narrow spinal canal (spinal stenosis).
Cervical disc herniation with myelopathy is less common than cervical disc herniation without myelopathy. Although both disorders cause neck pain and disturbances in arm sensation and strength, myelopathy is a more critical problem involving neurological disturbances in the legs and possible impairment of bowel and/or bladder control.
Individuals with cervical disc disorder and myelopathy show signs and symptoms of myelopathy, with or without radiculopathy. Symptoms of the latter typically include pain radiating into the arm or chest with finger numbness and motor weakness. Blood supply to the brainstem and posterior fossa brain structures can also be affected by vertebral artery compression from spondylosis and may include dizziness, syncope, blurred vision, ringing in the ears (tinnitus), and pain behind the eyes. Like radiculopathy or arm symptoms, these brain stem symptoms may coexist with the symptoms of spinal cord compression that define myelopathy.
Discs normally begin the degeneration process by at least the third decade of life; by the fifth decade of life, most individuals exhibit degenerative changes (Windsor). Nevertheless, many individuals have no symptoms, and over the years these degenerative changes can slowly narrow the spinal canal until myelopathy occurs.
Myelopathy can also begin suddenly in the aftermath of a massive cervical disc rupture. Individuals who develop very rare acute cervical disc herniation with myelopathy as a result of injury often participate in sports that place a vertical load on the cervical spine, such as soccer, football, wrestling, ice hockey, diving, rugby, and trampolining.
Risk: Individuals in their twenties who participate in sports and those between 60 and 70 years of age are at greater risk for degeneration of the cervical spine resulting in cervical disc syndrome with myelopathy (Windsor). Displaced cervical discs occur equally as often in men as in women (Furman), but cervical spondylosis begins earlier in men. Radiologic findings show that 90% of men over age 50 and 90% of women older than age 60 have degenerative changes in the cervical spine (Al-Shatoury).
Incidence and Prevalence: One in five visits to an orthopedic practice is for cervical discogenic pain (Windsor). Eight percent of all herniated discs occur in the cervical region of the spine. Cervical spondylotic myelopathy is the most frequent cause of spinal cord dysfunction in individuals older than 55 years in the US and worldwide (Al-Shatoury).
Degeneration of cervical intervertebral discs accounts for 36% of all spinal intervertebral disc disease, second only to lumbar disc disease, which accounts for 62% of all spinal intervertebral disc disease (Windsor).
Source: Medical Disability Advisor
History: Individuals may report clumsiness or difficulty using the hands and legs. Subtle disturbances in gait, with gradual deterioration, may be reported. Bowel or bladder control problems may be reported, as well as sexual dysfunction. The symptoms may present in different ways. There may be a central spinal cord syndrome, and individuals may have weakness in the arms, even greater weakness in the legs, and depressed arm reflexes corresponding to the level of compression. A history of neck and arm pain and pins-and-needles sensations or paresthesias (radiculopathy) may be reported.
Physical exam: The key symptoms of myelopathy are impaired function of limbs. There may be bowel and/or bladder control impairment. Myelopathy affecting the lower limbs results in an altered gait, hyperreflexia, and perhaps weakness in the lower limbs. The knee and ankle muscle stretch reflexes are greater than normal, and pathologic reflexes like the Babinski response may be present. There may be impaired sensation in the lower limbs and/or the area around the genitals and anus (perineum). Similarly, myelopathy affecting the upper limbs results in upper limb weakness and incoordination, hyperactive reflexes, and altered upper limb sensation.
Loss of sensation may be noted in the distribution of an exiting cervical nerve, most commonly at the sixth or seventh cervical root. While myelopathy produces muscle weakness and hyperactive reflexes, radiculopathy produces muscle weakness and loss of the reflex corresponding to the nerve being compressed. Symptoms usually occur on the same side as the disc herniation.
Neck pain may be aggravated by bending the head backward or rotating to the affected side. Spurlings maneuver involves extending and rotating the neck to see if radicular arm pain is produced.
With spondylosis, physical signs may be more diffuse, because those degenerative changes usually occur at more than one level in the cervical spine. There may be some restriction in neck motion from spondylosis, especially during neck extension. Muscle atrophy in the forearms can be seen in long-standing cases. Loss of sensory and motor function below the level of spinal cord compression may be evident.
Tests: Plain x-rays of the cervical spine are taken, including flexion and extension films to detect instability in the spine. An MRI detects spinal cord compression. If the MRI shows increased signal in the spinal cord at the level of cord compression (gliosis), it may suggest a poor prognosis for recovery of spinal cord function, even with decompressive surgery. Specialists in neurology or physical medicine and rehabilitation usually perform electromyography (EMG) if individual presents with a history and physical examination suggestive of potential cervical radiculopathy, but an EMG is of limited value in evaluating myelopathy. Somatosensory evoked potentials can evaluate myelopathy but are less commonly needed. Urodynamic studies may be used to assess bladder incontinence.
Source: Medical Disability Advisor
Source: Medical Disability Advisor
Source: Medical Disability Advisor
Nonsurgical <sup></sup> Specialist Cervical Disc Disorder with Myelopathy Physical or Occupational Therapist Up to 24 visits within 12 weeks Surgical Specialist Cervical Disc Disorder with Myelopathy Physical or Occupational Therapist Up to 24 visits within 12 weeks
Source: Medical Disability Advisor
Source: Medical Disability Advisor
If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.
Regarding diagnosis:
Regarding treatment:
Regarding prognosis:
Myelopathy is an inclusive term referring to any disease of the spinal canal. The cervical region specifies the neck region of the spine. The following are examples of myelopathy: carcinomatous myelopathy (spinal cord degeneration associated with cancer); compressive myelopathy (spinal cord changes from the pressure of hematomas or masses); and radiation myelopathy (spinal cord destruction from radiation sources such as x-ray therapy). When the spinal cord destruction is caused as a complication of disease, the specific myelopathy signifies that origin; for example, diabetic myelopathy.
Cervical disc disorder with myelopathy can result from either a herniation of a cervical disc or spinal cord compression by spinal stenosis. A cervical disc (intervertebral disc) is a cushion-like structure found between the cervical spinal bones (vertebrae C2 through C7) that run from the base of the skull to shoulder level. Discs are composed of a gel-like inner material (nucleus pulposus) encased in a ring of tough, fibrous outer material (annulus fibrosis); intervertebral discs absorb shock and allow movement of the spine. Disc displacement (herniation) occurs when the nucleus pulposus and/or the annulus protrudes abnormally into the spinal canal. Most often, a disc herniation presses on an exiting spinal nerve, causing dysfunction in a nerve root (radiculopathy). Less commonly, the spinal cord can become compressed by a herniated or bulging disc alone, or in combination with degenerative changes (cervical spondylosis) or with a narrow spinal canal (spinal stenosis).
Cervical disc herniation with myelopathy is less common than cervical disc herniation without myelopathy. Although both disorders cause neck pain and disturbances in arm sensation and strength, myelopathy is a more critical problem involving neurological disturbances in the legs and possible impairment of bowel and/or bladder control.
Individuals with cervical disc disorder and myelopathy show signs and symptoms of myelopathy, with or without radiculopathy. Symptoms of the latter typically include pain radiating into the arm or chest with finger numbness and motor weakness. Blood supply to the brainstem and posterior fossa brain structures can also be affected by vertebral artery compression from spondylosis and may include dizziness, syncope, blurred vision, ringing in the ears (tinnitus), and pain behind the eyes. Like radiculopathy or arm symptoms, these brain stem symptoms may coexist with the symptoms of spinal cord compression that define myelopathy.
Discs normally begin the degeneration process by at least the third decade of life; by the fifth decade of life, most individuals exhibit degenerative changes (Windsor). Nevertheless, many individuals have no symptoms, and over the years these degenerative changes can slowly narrow the spinal canal until myelopathy occurs.
Myelopathy can also begin suddenly in the aftermath of a massive cervical disc rupture. Individuals who develop very rare acute cervical disc herniation with myelopathy as a result of injury often participate in sports that place a vertical load on the cervical spine, such as soccer, football, wrestling, ice hockey, diving, rugby, and trampolining.
Risk: Individuals in their twenties who participate in sports and those between 60 and 70 years of age are at greater risk for degeneration of the cervical spine resulting in cervical disc syndrome with myelopathy (Windsor). Displaced cervical discs occur equally as often in men as in women (Furman), but cervical spondylosis begins earlier in men. Radiologic findings show that 90% of men over age 50 and 90% of women older than age 60 have degenerative changes in the cervical spine (Al-Shatoury).
Incidence and Prevalence: One in five visits to an orthopedic practice is for cervical discogenic pain (Windsor). Eight percent of all herniated discs occur in the cervical region of the spine. Cervical spondylotic myelopathy is the most frequent cause of spinal cord dysfunction in individuals older than 55 years in the US and worldwide (Al-Shatoury).
Degeneration of cervical intervertebral discs accounts for 36% of all spinal intervertebral disc disease, second only to lumbar disc disease, which accounts for 62% of all spinal intervertebral disc disease (Windsor).
Source: Medical Disability Advisor
History: Individuals may report clumsiness or difficulty using the hands and legs. Subtle disturbances in gait, with gradual deterioration, may be reported. Bowel or bladder control problems may be reported, as well as sexual dysfunction. The symptoms may present in different ways. There may be a central spinal cord syndrome, and individuals may have weakness in the arms, even greater weakness in the legs, and depressed arm reflexes corresponding to the level of compression. A history of neck and arm pain and pins-and-needles sensations or paresthesias (radiculopathy) may be reported.
Physical exam: The key symptoms of myelopathy are impaired function of limbs. There may be bowel and/or bladder control impairment. Myelopathy affecting the lower limbs results in an altered gait, hyperreflexia, and perhaps weakness in the lower limbs. The knee and ankle muscle stretch reflexes are greater than normal, and pathologic reflexes like the Babinski response may be present. There may be impaired sensation in the lower limbs and/or the area around the genitals and anus (perineum). Similarly, myelopathy affecting the upper limbs results in upper limb weakness and incoordination, hyperactive reflexes, and altered upper limb sensation.
Loss of sensation may be noted in the distribution of an exiting cervical nerve, most commonly at the sixth or seventh cervical root. While myelopathy produces muscle weakness and hyperactive reflexes, radiculopathy produces muscle weakness and loss of the reflex corresponding to the nerve being compressed. Symptoms usually occur on the same side as the disc herniation.
Neck pain may be aggravated by bending the head backward or rotating to the affected side. Spurlings maneuver involves extending and rotating the neck to see if radicular arm pain is produced.
With spondylosis, physical signs may be more diffuse, because those degenerative changes usually occur at more than one level in the cervical spine. There may be some restriction in neck motion from spondylosis, especially during neck extension. Muscle atrophy in the forearms can be seen in long-standing cases. Loss of sensory and motor function below the level of spinal cord compression may be evident.
Tests: Plain x-rays of the cervical spine are taken, including flexion and extension films to detect instability in the spine. An MRI detects spinal cord compression. If the MRI shows increased signal in the spinal cord at the level of cord compression (gliosis), it may suggest a poor prognosis for recovery of spinal cord function, even with decompressive surgery. Specialists in neurology or physical medicine and rehabilitation usually perform electromyography (EMG) if individual presents with a history and physical examination suggestive of potential cervical radiculopathy, but an EMG is of limited value in evaluating myelopathy. Somatosensory evoked potentials can evaluate myelopathy but are less commonly needed. Urodynamic studies may be used to assess bladder incontinence.
Source: Medical Disability Advisor
The majority of individuals can be treated conservatively, without surgery, if the condition is not progressive. The goals of treatment are to decrease pain, improve function, and prevent recurrence. A short period, perhaps 2 days, of rest may be helpful in reducing the intensity of the pain; rest must then be followed by mobilization. A soft cervical collar is sometimes briefly used at this time to limit neck movement and relieve pain in the neck.
The next phase of treatment involves physical therapy, primarily active exercise. Medication may be prescribed to relieve pain and may include anti-inflammatory medication, such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics. Muscle relaxants may also be given. Cervical epidural steroid injection(s) are often tried for the arm pain and weakness caused by associated radiculopathy, although evidence of effectiveness is lacking in the most recent systematic review (Armon). Cervical traction may be cautiously tried in therapy to see if it is helpful.
Surgery for the treatment of cervical disc disorder with myelopathy is considered when cervical radiculopathy or myelopathy or both are present with persistent radicular pain, motor weakness, progressive neurologic deficits, evidence of cord compression, and limited or no response to appropriate conservative treatment. In cases of cervical disc herniation, surgery is aimed at decompressing the spinal cord. Surgical treatment of cervical myelopathy most commonly entails anterior cervical discectomy and fusion (ACDF). This procedure involves removal of the herniated disc and fusion of the vertebrae to increase stability. The anterior procedure is the most direct approach and helps speed intervertebral fusion, but posterior disc herniation and foraminotomy is sometimes performed if a disc fragment can be more easily removed that way. Surgery may also be performed on the posterior bony wall of the cervical spine to enlarge the spinal canal (laminectomy or laminoplasty).
Monitoring of neurological function after surgery is essential. Pain is usually controlled with oral analgesics, and the individual is discharged when ambulatory, usually the same day as the surgery or the next day. Light activities may be resumed after 6 weeks. Physical therapy is usually recommended, and future activity is not necessarily restricted. If a fusion has been performed, the surgeon may restrict heavier activities until the fusion is solid on radiographs, which may require six months after surgery.
The next phase of treatment involves physical therapy, primarily active exercise. Medication may be prescribed to relieve pain and may include anti-inflammatory medication, such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics. Muscle relaxants may also be given. Cervical epidural steroid injection(s) are often tried for the arm pain and weakness caused by associated radiculopathy, although evidence of effectiveness is lacking in the most recent systematic review (Armon). Cervical traction may be cautiously tried in therapy to see if it is helpful.
Surgery for the treatment of cervical disc disorder with myelopathy is considered when cervical radiculopathy or myelopathy or both are present with persistent radicular pain, motor weakness, progressive neurologic deficits, evidence of cord compression, and limited or no response to appropriate conservative treatment. In cases of cervical disc herniation, surgery is aimed at decompressing the spinal cord. Surgical treatment of cervical myelopathy most commonly entails anterior cervical discectomy and fusion (ACDF). This procedure involves removal of the herniated disc and fusion of the vertebrae to increase stability. The anterior procedure is the most direct approach and helps speed intervertebral fusion, but posterior disc herniation and foraminotomy is sometimes performed if a disc fragment can be more easily removed that way. Surgery may also be performed on the posterior bony wall of the cervical spine to enlarge the spinal canal (laminectomy or laminoplasty).
Monitoring of neurological function after surgery is essential. Pain is usually controlled with oral analgesics, and the individual is discharged when ambulatory, usually the same day as the surgery or the next day. Light activities may be resumed after 6 weeks. Physical therapy is usually recommended, and future activity is not necessarily restricted. If a fusion has been performed, the surgeon may restrict heavier activities until the fusion is solid on radiographs, which may require six months after surgery.
Source: Medical Disability Advisor
Conservative treatment may stop the progression of nerve damage but may not improve the individual's condition. Results are best if the history is short, such as less than a few months. Complete reversal is rare if myelopathy has occurred (Al-Shatoury). Most surgical procedures are successful in decompressing the spinal cord and stabilizing the spine, with satisfactory results obtained in over 90% of individuals who undergo ACDF.
If surgery is performed, 50% of individuals may return to full employment and 40% to light employment, and 10% may remain disabled, even though improved.
If surgery is performed, 50% of individuals may return to full employment and 40% to light employment, and 10% may remain disabled, even though improved.
Source: Medical Disability Advisor
In individuals whose cervical disc disorders with myelopathy have been managed surgically, rehabilitation will focus on a postoperative protocol to be determined by the surgeon. Before rehabilitation begins, a careful assessment of the degree of central nervous system involvement is necessary. This should include signs of upper motor neuron involvement, such as tone irregularities, sensory, and motor changes (Boyce, Emery).
The primary goals of rehabilitation are to decrease pain, increase function, and to teach individuals how to manage their symptoms.
The first goal in treating cervical disc disorder with myelopathy is to decrease symptoms. In combination with pharmacological management, modalities such as heat and cold can be used (Braddom). While managing pain, individuals may be instructed in gentle exercises of the neck and other involved body parts. As a result of the variability in individual response, the treating practitioner must pay careful attention to tolerance to treatment. Initial exercises may include neck isometrics, stretching, and gentle range of motion. Postural training should be initiated as soon as tolerated by the individual (Yoshimatsu).
Once range of motion is restored, therapy should progress to strengthening and stabilization exercises of the neck, shoulders, and trunk. If there is lower extremity involvement, gait training, stretching, and strengthening exercises are indicated for the lower extremity and trunk. In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation. Individuals should also be instructed in how to care for and protect the neck.
An ergonomic evaluation can provide information regarding the avoidance or modification of activities and work positions that could aggravate symptoms. Psychological intervention, such as cognitive and behavioral pain management may be indicated to support the individual and identify associated factors that may be contributing to the pain.
Although the treatment of choice for this condition is surgery, there is research to support conservative management for mild cases of this condition (Fouyas, "Surgery for Cervical"; Fouyas, "Cochrane Review on the Role"; Truumees).
The primary goals of rehabilitation are to decrease pain, increase function, and to teach individuals how to manage their symptoms.
The first goal in treating cervical disc disorder with myelopathy is to decrease symptoms. In combination with pharmacological management, modalities such as heat and cold can be used (Braddom). While managing pain, individuals may be instructed in gentle exercises of the neck and other involved body parts. As a result of the variability in individual response, the treating practitioner must pay careful attention to tolerance to treatment. Initial exercises may include neck isometrics, stretching, and gentle range of motion. Postural training should be initiated as soon as tolerated by the individual (Yoshimatsu).
Once range of motion is restored, therapy should progress to strengthening and stabilization exercises of the neck, shoulders, and trunk. If there is lower extremity involvement, gait training, stretching, and strengthening exercises are indicated for the lower extremity and trunk. In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation. Individuals should also be instructed in how to care for and protect the neck.
An ergonomic evaluation can provide information regarding the avoidance or modification of activities and work positions that could aggravate symptoms. Psychological intervention, such as cognitive and behavioral pain management may be indicated to support the individual and identify associated factors that may be contributing to the pain.
Although the treatment of choice for this condition is surgery, there is research to support conservative management for mild cases of this condition (Fouyas, "Surgery for Cervical"; Fouyas, "Cochrane Review on the Role"; Truumees).
FREQUENCY OF REHABILITATION VISITS
Nonsurgical <sup></sup> Specialist Cervical Disc Disorder with Myelopathy Physical or Occupational Therapist Up to 24 visits within 12 weeks Surgical Specialist Cervical Disc Disorder with Myelopathy Physical or Occupational Therapist Up to 24 visits within 12 weeks
<sup></sup> Note on Nonsurgical Guidelines: Lengthy physician observation is necessary to track the progression of this condition.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.
Source: Medical Disability Advisor
Source: Medical Disability Advisor
If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.
Regarding diagnosis:
- Does individual have accompanying sensory and motor impairments?
- Is the gait abnormal?
- Are individual's reflexes abnormal?
- Is bowel or bladder control abnormal?
- Is more than one cervical level involved?
- In the case of disc herniation, did a precipitating event occur?
- Was the onset of symptoms prolonged with no periods of recovery? What period of time passed between onset of symptoms and diagnosis?
- Was diagnosis of cervical disc disorder with myelopathy confirmed?
- Were myelography and CT or MRI done to confirm the diagnosis?
Regarding treatment:
- Did individual's condition respond to conservative treatment?
- Were medications (anti-inflammatory medications, narcotics, muscle relaxants) prescribed, and were they effective in relieving pain?
- Did individual receive and comply with physical therapy?
- Did individual adhere to a regimen of isometric exercise, aerobic training, and resistance training?
- Was individual a candidate for surgery? Based on what criteria?
- Which surgical procedure was performed? Was neurological deficit corrected, improved, unimproved, or worse?
- Would individual benefit from psychological counseling or enrollment in a chronic pain program?
Regarding prognosis:
- What are individual's physical limitations? How severely do they affect function?
- What is individual's health history?
- How soon after onset of symptoms did individual seek treatment?
- What type of surgical procedure did individual undergo? Were multiple cervical levels involved?
- Has individual experienced complications?
- Does individual have an underlying condition that may affect recovery, such as obesity, pregnancy, or any condition that significantly limits mobility?
