A 50 year old man starts having neck pain and stiffness.
Then, develops numbness in his fingers, difficulty with buttons, or doing fine movements with
his fingers.
Next, is having difficulty walking and had some falls.
As the disease progress, he may develop incontinence of bowel and bladder.
These symptoms are typical of cervical myelopathy, a rare but serious condition known as cervical
spinal stenosis.
Today, I’ll explain what cervical myelopathy is and what are the most common causes.
I’ll talk about why it is so hard for doctors to suspect and diagnose it.
And then, I’ll tell you what the treatment options are.
So, let’s talk about cervical myelopathy today.
The spinal cord is located in this hole inside of the spine.
The spinal cord is very fragile and very important.
It contains all the neurons that control the muscles, bowels and bladder, and it also brings
sensations from the periphery to the brain.
If a person has a spinal cord injury at the neck they become quadriplegic, which means
they lose control of the muscles below that level and they also lose the sensations below
that level.
However, when there is a degenerative disease of the bones, like osteoarthritis, or thickening
of the ligaments around the spinal cord, the vertebral canal becomes narrowed, and it causes
a progressive compression of the spinal cord.
So, the neurons in that area will stop working and transmitting important information from
the brain to the organs and sensations from the periphery to the brain.
In spinal cord injury, the lesion is usually abrupt, like a car crash, diving and hitting
the neck, or a fall.
But in degenerative cervical myelopathy, the spinal cord compression is slow, and progressive,
and the symptoms appear slowly over many months or years.
The word myelopathy means that there is a lesion in the spinal cord.
The spinal cord contains neurons that are responsible for balance, and that is why the
person with cervical myelopathy will start having poor coordination, balance problems
and falls.
They start walking with the feet apart, that is to widen their base and improve their balance.
They also start losing the fine coordination of their fingers.
They say that they have difficulty doing the buttons of their shirt.
As I said, these symptoms are usually progressive over months or years, and they are non-specific.
So, some patients end up being diagnosed as carpal tunnel syndrome, and of course, they
do not improve after they have surgery to release the carpal tunnel.
There are reports in the scientific literature that it takes between 1 and 9 years for a
patient to have a proper diagnosis, and they see on average 5 consults before a diagnosis
is made.
BEFORE I CONTINUE, let me remind you that this video is not intended to provide medical
advice, it is for educational purposes only.
If you have a medical condition that requires treatment, please talk to your doctor to get
a treatment plan for you.
And if there is any emergency, please go to the nearest emergency department or call an
ambulance.
How do doctors make the diagnosis of cervical myelopathy?
The fist step is to do a proper neurological exam.
The doctor will observe the patient walking, and this is very typical wide base gate pattern.
Then, the doctor will examine the reflexes, and if the person has increased reflexes,
clonus and the presence of some abnormal reflexes in the hands and feet, that is very suggestive
of myelopathy.
The sensory examination may also demonstrate that the person has decreased sensations in
the hands and feet.
The next step is to order some imaging studies, the ideal is a magnetic resonance imaging,
or MRI.
But in some places, it may be a long waitlist to have an MRI, and in that case, a CT scan
may be ordered.
The MRI will show that the spinal cord is being compressed, like in this image here.
There might be one, two, three or more levels where the spinal cord is being compressed.
Sometimes, we see MRIs with compressions like this, but the patient does not have any symptom
and the neurological exam is normal.
Then, we just need to monitor but we don’t need to do any intervention.
Only when the person has progressive symptoms we need to send the patient to a consult with
a surgeon.
And the surgeon may decide to do a decompression surgery or procedure.
They will remove some parts of the bones and relieve the pressure on the spinal cord.
These surgical decompressions usually do not treat the pain, they are used to alleviate
the pressure on the spinal cord and avoid problems like muscle weakness, balance problems,
loss of sensation, and incontinence of bowels or bladder.
When people with cervical myelopathy come to me it is because they still have residual
neck pain and stiffness, even after they had a neck surgery to decompress the spinal cord.
I reassure them that the surgery was important to avoid further progression and complications.
The pain is usually from the soft tissues, like muscles and ligaments, or neuropathic
pain from the nerve compression and spinal cord compression.
When the pain is neuropathic, we need to treat with medications like antidepressants and
anticonvulsants.
Watch my other videos about amitriptyline, duloxetine, gabapentin and pregabalin.
We rarely use opioids because this type of pain is chronic and we don’t want to put
patients on long-term opioid therapy for many years.
I prepared a summary of this video that you can download it for FREE.
Just go to my website and download the document there.
The address is www.doctorAndreaFurlan.com/neck If you like this video so far, please give
a thumbs up here, and don’t forget to subscribe to this channel.
In most cases, the pain comes form the muscles around the neck.
The most common are the scalenes, upper trapezius, sternocleidomastoid, levator scapula and other
small muscles in the back of the neck.
We treat these as myofascial pain syndrome, and I have another video of exercises for
these muscles.
In some cases, the ongoing pain comes from the facet joints in the neck, and the person
will benefit from cortisone injection in these joints.
Because they are tiny joints, we need to use an x-ray or ultrasound to see if we are injecting
on the right spot.
Other interventions that are helpful to alleviate the pain from cervical spinal stenosis or
myelopathy include massage, application of heat, TENS, acupuncture and mind-body therapies.
Watch my other videos about these interventions.
If you know someone with cervical myelopathy, share this video with them.
There is a share button here.
I know many patients who are frustrated after surgery because they continue having pain
and the same symptoms as before.
They need to understand that the surgery was done to avoid further progression and more
compression.
Surgery is done to alleviate the pressure on the spinal cord, but it does not regenerate
the neurons that have been lost.
Surgery is not done to treat pain, but to avoid more damage to the spinal cord.
The pain from cervical myelopathy needs to be treated as a chronic pain condition, and
for this type of pain, I always tell my patients to use their toolbox of self-management.
So, don’t forget the 5M: movement, mind-body, manual, modalities and medications.
I hope you enjoyed this video.
Here are other videos from my channel that you can watch.
See you next time.
Goodbye!