History

Fact Explanation
Chronic pain Bony outgrowths occur due to degeneration of cervical vertebral discs; this causes stenosis of the spinal canal. Chronic pain may be due to several mechanisms: compression of the radicular arteries causing ischemia to the spinal cord, compression of spinal cord segments and stenosis of spinal foramina that impinge upon the nerve roots. [1]
Regional anesthesia Cervical cord compressive myelopathy due to bony spurs that reduce the saggital diameter of the spinal canal.[1,2]
Loss of hand dexterity A disabling symptom, that may impair the patient's Activities of Daily Living (ADL). This may be due to cervical cord compression, where it causes spasticity and a upper motor type of paralysis. Alternatively, narrowing of the spinal foramina may compress the nerve roots, causing a lower motor type flaccid paralysis. Involvement of C8 spinal segment/ nerve root can cause a finger drop.[1,3]
Lower extremity weakness This may be the only or the most prominent symptom in some patients. Occurs due to compression of the spinal cord in the cervical region. [2]
Spastic quadriparesis Upper motor neuron lesion of bilateral upper and lower limbs may occur if the stenosis occurs at a high cervical cord level. Compression of the cord causing myelopathy, may even occur due to tumors of the cervical vertebrae. [4]
Cerebellar ataxia Will occur due to compression of the cerebellar tracts in the spinal cord. [2,5]
More common in the elderly population As the vertebral disc cartilage ages, it loses some of it water content. As a result of this the shock absorbing quality of the cartilage diminishes. Subsequent tears occur in the annulus of the cartilage that heal with formation of scar tissue that is weak and unable to cushion the vertebral facets joints. This leads to osteoarthritis of the facet joints and resultant bony spur formation that causes stenosis of the spinal canal or foramina.
References
  1. KOBAYASHI S. Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis. World J Orthop [online] 2014 Apr 18, 5(2):134-145 [viewed 22 May 2014] Available from: doi:10.5312/wjo.v5.i2.134
  2. AKHAVAN-SIGARI R., ROHDE V., ALAID A.. Cervical Spinal Canal Stenosis and Central Disc Herniation C3/4 in a Man with Primary Complaint of Thigh Pain. J Neurol Surg Rep [online] 2013 July, 74(02):101-104 [viewed 22 May 2014] Available from: doi:10.1055/s-0033-1349202
  3. KODA MASAO, FURUYA TAKEO, ROKKAKU TOMOYUKI, YAMAZAKI MASASHI, MURAKAMI MASAZUMI, TAKAHASHI KAZUHISA, MANNOJI CHIKATO. Drop finger as an adjacent segment disease after cervical expansive laminoplasty. Neurol India [online] 2013 December [viewed 22 May 2014] Available from: doi:10.4103/0028-3886.125399
  4. ER UYGUR, ŞIMşEK SERKAN, YIğITKANLı KAZıM, ADABAğ AYSEGüL, KARS HAMIT ZAFER. Myelopathy and Quadriparesis due to Spinal Cord Compression of C1 Laminar Osteochondroma. Asian Spine J [online] 2012 December [viewed 22 May 2014] Available from: doi:10.4184/asj.2012.6.1.66
  5. HEFFEZ DAN S., ROSS RUTH E., SHADE-ZELDOW YVONNE, KOSTAS KONSTANTINOS, MORRISSEY MARY, ELIAS DEAN A., SHEPARD ALAN. Treatment of cervical myelopathy in patients with the fibromyalgia syndrome: outcomes and implications. Eur Spine J [online] December, 16(9):1423-1433 [viewed 22 May 2014] Available from: doi:10.1007/s00586-007-0366-2

Examination

Fact Explanation
Upper limb weakness Upper limb weakness can be of the upper motor neuron spastic type or of the lower motor neuron flaccid type. Spastic weakness occurs due to cord myelopathy caused by compression in the spinal canal. Flaccid weakness is due to compression of nerve roots as they travel out of the spinal foramina. [1]
Upper limb numbness, parasthesia Occurs due to spinal cord myelopathy. [2,3]
Upper limb spasticity Compression myelopathy of the upper motor neurons of the spinal cord. [1,2]
Exaggerated upper limb reflexes An upper motor neuron sign, that indicates compression myelopathy of the spinal cord. [1,2]
Spastic quadriplegia Compression myelopathy of the cervical spinal cord at a high level (C1, C2) can cause upper motor neuron spastic quadriparesis. [4]
Cerebellar ataxia A positive Romberg sign, impaired tandem walk, disdiadokokinesia and dysmetria are indicative of compression of the cerebellar tracts in cervical myelopathy. [2]
References
  1. KOBAYASHI S. Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis. World J Orthop [online] 2014 Apr 18, 5(2):134-145 [viewed 22 May 2014] Available from: doi:10.5312/wjo.v5.i2.134
  2. HEFFEZ DAN S., ROSS RUTH E., SHADE-ZELDOW YVONNE, KOSTAS KONSTANTINOS, MORRISSEY MARY, ELIAS DEAN A., SHEPARD ALAN. Treatment of cervical myelopathy in patients with the fibromyalgia syndrome: outcomes and implications. Eur Spine J [online] December, 16(9):1423-1433 [viewed 22 May 2014] Available from: doi:10.1007/s00586-007-0366-2
  3. GRüNINGER W, GRUSS P. Stenosis and movement of the cervical spine in cervical myelopathy. Spinal Cord [online] 1982 June, 20(3):121-130 [viewed 22 May 2014] Available from: doi:10.1038/sc.1982.24
  4. ER UYGUR, ŞIMşEK SERKAN, YIğITKANLı KAZıM, ADABAğ AYSEGüL, KARS HAMIT ZAFER. Myelopathy and Quadriparesis due to Spinal Cord Compression of C1 Laminar Osteochondroma. Asian Spine J [online] 2012 December [viewed 22 May 2014] Available from: doi:10.4184/asj.2012.6.1.66

Differential Diagnoses

Fact Explanation
Ankylosing spndylitis Ankylosing spondylitis is a chronic inflammatory arthritis, affecting the the axial skeleton that progresses to stiffness and progressive functional limitation and subsequent fusion of the vertebral bodies. Age of presentation is around the second to third decade of life, preponderance towards HLA-B27-positive white males. Other associated features are anterior uveitis, sacroilitis etc. [1]
Diffuse idiopathic skeletal hyperostosis (DISH) This is a non-inflammatory condition with pathological ossification of the anterolateral spinal ligaments and attachment sites of the tendons and ligaments. Cervical DISH causes chronic neck pain, dysphagia and sensation of foreign body in the throat. [2,3]
Dural abscess A rare entity. It results from the incomplete partition of epithelial ectoderm and neuroectoderm which can end anywhere along its tract within the spinal canal compartments and becomes a potential route for spread of infection. Spinal cord abscess may involve any part of the spinal cord but the thoraco-lumbar spine is the most frequent site. Clinical suspicion and radiological findings are essential for early diagnosis and treatment. [4]
Scoliosis Idiopathic scoliosis may sometimes cause neck pain, due to postural reasons. On examination the spinal scoliosis will be obvious. [5]
Peripheral vascular disease If the patient presents with intermittent claudication, there are two possibilities: neurogenic or vascular. Features in favor of neurogenic claudication are: pain when standing still, positive shopping cart sign, allevaiation of symptoms when sitting and predominant above knee symptoms. [6]
Psychogenic pain Malingering and other psychiatric conditions should be considered in a suggestive patient.
References
  1. GOUVEIA EB, ELMANN D, MORALES MS. Ankylosing spondylitis and uveitis: overview. Rev Bras Reumatol [online] 2012 Oct, 52(5):742-56 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23090374
  2. ESER OLCAY, KARAVELIOGLU ERGUN, BOYACI MEHMET GAZI, AYCICEK ABDULLAH. Diffuse Idiopathic Sceletal Hyperosteosis and Central Cord Syndrome After Minor Trauma: A Case Report. Ulus Travma Acil Cerrahi Derg [online] 2013 December, 19(1):73-76 [viewed 22 May 2014] Available from: doi:10.5505/tjtes.2013.81593
  3. BALAKUMAR KRISHNARASA , VIVEKANANDARAJAH , LUCINDA RIPOLL , EDWIN CHANG , ROBERT WETZ . Diffuse Idiopathic Skeletal Hyperostosis (DISH)—A Rare Etiology of Dysphagia. CMAMD [online] 2011 September [viewed 22 May 2014] Available from: doi:10.4137/CMAMD.S6949
  4. AL BARBARAWI M, KHRIESAT W, QUDSIEH S, QUDSIEH H, LOAI AA. Management of intramedullary spinal cord abscess: experience with four cases, pathophysiology and outcomes Eur Spine J [online] 2009 May, 18(5):710-717 [viewed 22 May 2014] Available from: doi:10.1007/s00586-009-0885-0
  5. RINSKY LA, GAMBLE JG. Adolescent Idiopathic Scoliosis West J Med [online] 1988 Feb, 148(2):182-191 [viewed 22 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1026057
  6. NADEAU M, ROSAS-ARELLANO MP, GURR KR, BAILEY SI, TAYLOR DC, GREWAL R, LAWLOR DK, BAILEY CS. The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation Can J Surg [online] 2013 Dec, 56(6):372-377 [viewed 23 May 2014] Available from: doi:10.1503/cjs.016512

Investigations - for Diagnosis

Fact Explanation
Spinal radiographs Anterior and lateral cervical spine X-Rays are an initial investigation, routinely indicated if cervical spinal trauma is suspected in the secondary survey of the ATLS protocol. In patients with chronic pain, imaging is not necessary if there is no neurological deficit and there is no suspicion of an underlying medical condition. [1]
CT myelogram CT scan is performed after intra thecal administration of contrast media by a lumbar puncture. Less favored when compared to MRI due to radiation exposure and invasive nature of contrast administration. [1,2,3]
MRI MRI is usually preferred over CT for the investigation of neck and back pain in the elderly as it causes less radiation exposure and has better soft-tissue visualization. Enables direct evaluation of the spinal cord with calculation of four parameters: Pavlov's ratio, sagittal diameter, spinal cord area, and spinal canal area. This gives an objective assessment of the degree of spinal canal stenosis. [1,2]
Nerve conduction studies Nerve conduction studies of the peripheral nerves are useful in differentiating compression myelopathy from other causes of neuropathy. [4]
References
  1. TAYLOR JA, BUSSIèRES A. Diagnostic imaging for spinal disorders in the elderly: a narrative review Chiropr Man Therap [online] :16 [viewed 23 May 2014] Available from: doi:10.1186/2045-709X-20-16
  2. SONG KJ, CHOI BW, KIM SJ, KIM GH, KIM YS, SONG JH. The Relationship between Spinal Stenosis and Neurological Outcome in Traumatic Cervical Spine Injury: An Analysis using Pavlov's Ratio, Spinal Cord Area, and Spinal Canal Area Clin Orthop Surg [online] 2009 Mar, 1(1):11-18 [viewed 23 May 2014] Available from: doi:10.4055/cios.2009.1.1.11
  3. OGURA H, MIYAMOTO K, FUKUTA S, NAGANAWA T, SHIMIZU K. Comparison of Magnetic Resonance Imaging and Computed Tomography-Myelography for Quantitative Evaluation of Lumbar Intracanalar Cross-Section Yonsei Med J [online] 2011 Jan 1, 52(1):137-144 [viewed 23 May 2014] Available from: doi:10.3349/ymj.2011.52.1.137
  4. ADAMOVA B, VOHANKA S, DUSEK L. Dynamic electrophysiological examination in patients with lumbar spinal stenosis: Is it useful in clinical practice? Eur Spine J [online] 2005 Apr, 14(3):269-276 [viewed 23 May 2014] Available from: doi:10.1007/s00586-004-0738-9

Management - General Measures

Fact Explanation
Lifestyle modifications and home remedies Gives symptomatic relief from pain. Maybe appropriate for mild cervical spinal stenosis. Patients can avoid complications and potential risks of surgery. Advise to avoid hyper-extended or hyper-flexed positions, falls, intense exercise and any other dangerous activity. [1]
Pharmacological management of pain : Analgesics and muscle relaxants First line drugs are NSAIDs, these reduce inflammation and thereby reduce pain. Tri cyclic anti (TCA) depressants are also useful in the management of neuropathic pain. Oral opiods may be prescribed if other oral drugs prove ineffective, alternatively anti convulsants such as Gabapentin/ Carbamezapine are also useful in neuropathic pain due to their neural membrane stabilizing properties. Analgesics can be combined with muscle relaxants to improve pain relief.
Epidural steroid injections Methyl prednisolone and local anesthetic agents such as Bupivacaine can be administered epidurally. Administration at the site of maximal stenosis ensures that the highest concentration of steroid and anesthetic are delivered to the area of maximal nerve irritation, resulting in better pain management. [2]
References
  1. KONG LD, MENG LC, WANG LF, SHEN Y, WANG P, SHANG ZK. Evaluation of conservative treatment and timing of surgical intervention for mild forms of cervical spondylotic myelopathy Exp Ther Med [online] 2013 Sep, 6(3):852-856 [viewed 23 May 2014] Available from: doi:10.3892/etm.2013.1224
  2. MILBURN J, FREEMAN J, STEVEN A, ALTMEYER W, KAY D. Interlaminar Epidural Steroid Injection for Degenerative Lumbar Spinal Canal Stenosis: Does the Intervertebral Level of Performance Matter? Ochsner J [online] 2014, 14(1):62-66 [viewed 23 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963054

Management - Specific Treatments

Fact Explanation
Physical therapy Continuos cervical traction (Good Samaritan traction) can be applied; the patient's neck is placed in a slightly flexed position for up to 8 hours a day, for a two week period. [1]
Cervical laminectomy The most commonly performed surgery for cord myelopathy. Complications encountered are segmental instability and post laminectomy kyphosis. [2]
Cervical laminoplasty An alternative surgical option to laminectomy. Avoids possible complications of laminectomy such as spinal cord injury, post-op progression of cervical kyphosis and worsening of neurological deficit due to scar tissue. [2,3]
Interlaminar implant In severe cases of spinal stenosis, multi segmental laminectomy with posterior fixation may be indicated. In such instances titanium mesh implants with a bone graft can be used. [4]
Post operative rehabilitation and physical therapy A lengthy hospital stay should be expected following surgical intervention. Therefore it is important for these patients to resume their normal mobility and ADL, post operatively. Post-op physical therapy can be combined with pain management strategies to facilitate quick rehabilitation.
References
  1. KONG LD, MENG LC, WANG LF, SHEN Y, WANG P, SHANG ZK. Evaluation of conservative treatment and timing of surgical intervention for mild forms of cervical spondylotic myelopathy Exp Ther Med [online] 2013 Sep, 6(3):852-856 [viewed 23 May 2014] Available from: doi:10.3892/etm.2013.1224
  2. LAO LIFENG, ZHONG GUIBIN, LI XINFENG, QIAN LIE, LIU ZUDE. Laminoplasty versus laminectomy for multi-level cervical spondylotic myelopathy: a systematic review of the literature. Array [online] 2013 December [viewed 23 May 2014] Available from: doi:10.1186/1749-799X-8-45
  3. ITO M, NAGAHAMA K. Laminoplasty for Cervical Myelopathy Global Spine J [online] 2012 Sep, 2(3):187-194 [viewed 23 May 2014] Available from: doi:10.1055/s-0032-1315456
  4. GROB D, DAEHN S, MANNION AF. Titanium mesh cages (TMC) in spine surgery Eur Spine J [online] 2005 Apr, 14(3):211-221 [viewed 23 May 2014] Available from: doi:10.1007/s00586-004-0748-7