Cervical Myelopathy
1. Introduction
Cervical myelopathy refers to compression of the spinal cord as it passes through the neck (3). In our necks, there are seven bones called vertebrae (also known as the cervical vertebrae). These vertebrae are separated by an intervertebral disc, a circular disc of a tough, durable substance known as cartilage. The vertebrae and discs between them throughout the spine make up the spinal column, which in addition to enabling movement, also serves to protect the spinal cord (4). Each level of the spinal column has a pair of exiting nerve roots (right and left) which supply muscles, skin, and organs. The spinal cord and peripheral nerves are important structures, and any injury or irritation of these structures can cause symptoms such as pain, weakness and altered sensation (1).
Cervical myelopathy is a condition where compression is placed on the spinal cord, usually due to age-associated changes of the vertebrae and/or intervertebral discs. In many people these age-associated changes do not cause pain or any alteration in nerve function (2). However, in some cases a narrowing of the spinal canal causes compression on the spinal cord and or/exiting nerve roots leading to pain, weakness, and loss of function (5).
Frequently Asked Questions
Cervical myelopathy refers to compression of the spinal cord at neck level (3). This compression can be due to trauma, or a structural congenital (7), or degenerative change (2), in the neck bones and/or intervertebral disc.
- It is very rare and estimated to affect approximately less than 2-5% of the population (1).
- Yes, because it affects the spinal cord, any symptoms related to this potential diagnosis require urgent assessment (8,14).
- Cervical myelopathy can be progressive meaning symptoms may get worse over time thus early detection is key to manage this condition safely (7).
- Whilst a long list of potential symptoms is associated with myelopathy not all patients are affected in the same way (2).
- Many people who demonstrate changes on MRI scans are pain-free and can carry out normal daily activities as normal (2).
- Myelopathy is a condition that is usually associated with the effects of the ageing process; therefore, it is more likely to affect those who are over the age of 70 (1, 10).
- Symptoms typically come on gradually and may be diagnosed as early as aged 50 years (7).
- If there has been trauma to the neck symptoms can come on more suddenly and affect a younger population (6,7).
- Common symptoms of myelopathy include:
- Reduced range of movement in the neck and upper limbs (4).
- Muscle weakness in the arms or legs (5,6).
- Changes to grip strength and/or dexterity of the hands and fingers (5,6).
- Changes in sensation of the arms or legs, such as pins and needles or numbness (1,6,9).
- Changes to walking, such as unsteadiness or falls (6).
Once a diagnosis has been confirmed, there are several things you may be able to do to help manage your symptoms (16-19):
- Exercises to maintain or improve range of movement in your neck and strengthen muscles around your neck, shoulder and back.
- Posture awareness and correction, alongside taking regular breaks from sitting.
- Certain medications may be prescribed by your doctor to help reduce pain and any symptoms associated with nerve irritation such as pins and needles.
- Cervical myelopathy is most commonly a progressive condition that may deteriorate over time (1, 7, 10).
- However, the rate and extent of deterioration varies significantly, and this can be helped greatly by physiotherapy (16-18).
- In traumatic, or extreme degenerative cases surgical management may be indicated, although reported recovery rates and reduction in symptoms post-surgery are variable (12,13).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
The severity of cervical myelopathy varies depending on the location and extent of spinal cord compression. However, some of the more commonly reported symptoms include (6):
- Reduced range of movement of the neck, particularly looking up to the sky (extension).
- Clumsiness or a loss of dexterity in the hands (such as difficulty picking up coins, doing up buttons, dressing).
- Pain that radiates into both shoulders, and down both arms.
- Changes to your walking, such as catching your foot or unsteadiness.
- Numbness or pins and needles in the arms, or hands.
- Muscle weakness in the shoulders, arms or legs potentially leading to falls or a loss of grip strength.
3. Causes
A narrowing of the spinal canal which protects the spinal cord commonly results from degenerative changes in the anatomy of the neck (7). These are often normal, associated changes to the height(s) of the discs, a decrease in the size of the central canal of the spinal cord, and the presence of bony spurs that develop where one vertebra meets another (known as osteophytes).
It is important to note here that these changes often do not match well with pain or loss of function (2). Compression of the spinal cord can cause changes in the way(s) nerve signals are transmitted to the skin and muscles (9). This can lead to symptoms such as weakness, altered sensation, and in advanced cases, more obvious muscle wasting and functional deterioration (4).
In very extreme cases, the level of compression on the spinal cord can lead to complete loss of function in the upper or lower limbs requiring emergency attention (6).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing cervical myelopathy. It does not mean everyone with these risk factors will develop symptoms.
- Congenital abnormalities – patients with a congenitally narrow spinal canal (<13mm) have a higher risk for the development of symptomatic cervical myelopathy (5).
- Increasing age – 90% of patients aged over the age of 70 have evidence of degenerative changes in the cervical spine, which may predispose to myelopathy (10).
- Gender – degenerative changes, which may predispose to myelopathy, tend to start earlier in men (averaged age 50) than women (average age 60) (7).
5. Prevalence
The prevalence of degenerative cervical myelopathy is poorly understood, in part because of the difficulties in diagnosis (1).
- It is estimated to affect less than 2-5% of the population (1).
- Cervical myelopathy is uncommon before the age of 40. Most patients are first diagnosed in their 50’s (7).
- The incidence of getting cervical myelopathy increases with age. Therefore, it is expected to become more prevalent with an ageing population (2).
- Studies on healthy volunteers have shown that 59% were found to have incidental cervical cord compression. However, only 2.3% of these presented with any symptoms (1).
6. Assessment & Diagnosis
An initial diagnosis of cervical myelopathy may be made by your physiotherapist asking you questions about your symptoms and performing a physical examination. However, a detailed neurological assessment alongside an MRI scan of your neck is currently the gold-standard method to diagnose cervical myelopathy (8). The clinical examination may entail an assessment of how you walk, the range of movement in your neck, the strength of the muscles in your arms and legs and other tests that check on the function of your nerves (such as testing your reflexes). You may be asked to complete one or two simple questionnaires eg: The Neck Disability Index; which help gather further information about your symptoms and how they may be affecting you to aid in diagnosis and monitoring of the condition.
7. Self-Management
Patients with degenerative cervical myelopathy that are treated with a conservative approach (such as pain-relieving medication and physiotherapy) may have some short-term benefit in relief of painful symptoms. However, because the condition is degenerative and progressive, symptoms may deteriorate over time although this depends on the severity and location of the compression. The goals of treatment are to therefore reduce pain, improve function and to create a long-term exercise plan to slow any future deterioration.
Strategies that may be recommended by your physiotherapist include:
- Exercise to improve the posture, range of movement and strength of your neck and upper limb muscles (16, 17).
- Advice, education and reassurance on the condition and advice as to when to seek help if symptoms deteriorate.
- Manual therapy (hands on treatment by a qualified physiotherapist) which can relieve pain and improve range of movement and function (16, 18).
8. Rehabilitation
Range of movement and exercises to strengthen the neck and upper limbs have been supported in research trials in patients with cervical myelopathy (19). The aim of exercise is to relive pain and improve function thus promoting independent management of the condition (16). Example programmes are presented below:
9. Cervical Myelopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This initial programme focuses on early, gentle movement of the neck and upper limbs. The aim is to improve range of movement and facilitate gentle pain relief so that everyday tasks involving your neck and upper limbs are easier to perform. This programme can be performed little and often throughout the day.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
Once your pain has settled to more manageable levels, you can progress to more challenging exercises that aim to strengthen the muscles around your shoulders, upper-mid back and neck. These may be performed once daily, or every other day, like you would if you were going to a gym or health club. These exercises aim to strengthen some of the muscles that support your neck, shoulders and mid-back to help offload the pain-sensitive structures contributing to your symptoms.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
The goal of the advanced rehabilitation plan is to continue to build further strength in the muscles around the neck, shoulders and mid-back and develop further control of your posture. These exercises, as they are more demanding, should be performed 3-4 times per week, to enable regular rest days.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and to establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
In people with severe cases, or where there are progressive neurologic changes (such as weakness, numbness or falling) surgery may be indicated. Patients with severe or disabling pain may also be helped with surgery (12, 13). The principal goal(s) of surgery for cervical myelopathy is to increase the space around the spinal cord (otherwise known as decompression). Surgical decompression is generally considered if the symptoms affect daily life, but early surgical intervention is thought to be more effective. Therefore, early detection of severe cases may be the key to minimise postoperative complications (14). Final outcomes from surgery vary. Typically, one-third of patients improve, one-third stay the same, and one-third continue to worsen over time, with respect to their pre-surgical symptoms (13, 15).
References
- Smith SS, Stewart ME, Davies BM, Kotter MRN. The Prevalence of Asymptomatic and Symptomatic Spinal Cord Compression on Magnetic Resonance Imaging: A Systematic Review and Meta-analysis. Global Spine Journal. June 2020. doi:10.1177/2192568220934496
- Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT, Kallmes DF, Jarvik JG. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. PMID: 25430861; PMCID: PMC4464797
- Kong LD, Meng LC, Wang LF, Shen Y, Wang P and Shang ZK. Evaluation of conservative treatment and timing of surgical intervention for mild forms of cervical spondylotic myelopathy. Exp Ther Med. 2013 Sep;6(3):852-856.
- Boos N and Aebi M (Eds). Spinal disorders: Fundamentals of Diagnosis and Treatment. Springer-Verlag Berlin Heidelberg. 2008.
- Cook C, Roman M, Stewart KM, Leithe LG, Isaacs R. Reliability and diagnostic accuracy of clinical special tests for myelopathy in patients seen for cervical dysfunction. J Orthop Sports Phys Ther. 2009 Mar;39(3):172-8. doi: 10.2519/jospt.2009.2938.
- Park SJ, Kim SB, Kim MK, Lee SH and Oh IH. Clinical features and surgical results of cervical myelopathy caused by soft disc herniation. Korean J Spine. 2013;10(3):138-143.
- Koakutsu T,Nakajo J, Morozumi N, Hoshikawa T, Ogawa S, and Ishii Y. Cervical myelopathy due to degenerative spondylolisthesis. Ups J Med Sci. 2011; 116(2): 129–132.
- Harrop, James S; Naroji, Swetha; Maltenfort, Mitchell; Anderson, D. Greg; Albert, Todd; Ratliff, John K; Ponnappan, Ravi K; Rihn, Jeffery A; Smith, Harvey E; Hilibrand, Alan; Sharan, Ashwini D; Vaccaro, Alexander. Cervical Myelopathy: A Clinical and Radiographic Evaluation and Correlation to Cervical Spondylotic Myelopathy. Spine 10 February 2010 [epub ahead of print]
- Cramer GD and Darby SA. Basic and Clinical Anatomy of the Spine, Spinal Cord, and ANS. 2nd Edition. Elsevier 2008.
- Kadanka Z, Bednarík J, Vohánka S, Vlach O, Stejskal L, Chaloupka R et al. Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study. Eur Spine J. 2000;9(6):538-44.
- Almeida GP, Carneiro KK and Marques AP. Manual therapy and therapeutic exercise in patient with symptomatic cervical spondylotic myelopathy: a case report. J Bodyw Mov Ther. 2013 Oct;17(4):504-9.
- Kadaňka, Zdeněk, et al. “Cervical spondylotic myelopathy: conservative versus surgical treatment after 10 years.” European Spine Journal 20.9 (2011): 1533-1538.
- Rhee, John M., et al. “Nonoperative management of cervical myelopathy: a systematic review.” Spine 38.22S (2013): S55-S67.
- Sato T, Horikoshi T, Watanabe A, Uchida M, Ishigame K, Araki T et al. Evaluation of cervical myelopathy using apparent diffusion coefficient measured by diffusion-weighted imaging. AJNR Am J Neuroradiol. 2012; 33(2):388-392
- Kadaňka, Z., et al. “Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study.” European Spine Journal 9.6 (2000): 538-544.
- Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Brontfort G, et al, Cervical Overview Group. Exercises for mechanical neck disorders. Cochrane Database Syst Rev 2005
- Annemie I. F. Spooren, Yvonne J. M. Janssen-Potten, Eric Kerckhofs and Henk A. M. Seelen. Outcome of motor training programmes on arm and hand functioning in patients with cervical spinal cord injury according to different levels of the icf: a systematic review. J Rehabil Med 2009; 41: 497–505
- Joghataei, Mohammad Taghi, Amir Massoud Arab, and Hossein Khaksar. “The effect of cervical traction combined with conventional therapy on grip strength on patients with cervical radiculopathy.” Clinical rehabilitation 18.8 (2004): 879-887.
- Fouyas, Ioannis P., Patrick FX Statham, and Peter AG Sandercock. “Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy.” Spine 27.7 (2002): 736-747.
Other Conditions in
Neck, Neurological, Orthopaedics, Pain
Whiplash Disorders
An injury which typically occurs following a road traffic collision, often affecting the soft tissues of the neck.
Thoracic Outlet Syndrome
A condition presenting with pain in the arm as a result of compression of structures around the neck/shoulder.
Neck Pain
Pain or discomfort in the neck and/or shoulder girdle, with or without pain referred to the arms.
Cervical Spinal Stenosis
Narrowing of the spaces through which the neck spinal nerves travel which can result in weakness, pain and reduced function.
Cervical Radiculopathy
Nerve pain originating from the neck and causing pain, altered sensation or weakness in the arm.
Cervical Disc Dysfunction
Disk/joint-related issues that can cause pain, weakness and altered sensation in the neck and arms.
Cervical Arterial Dysfunction
An umbrella term for rare vascular (blood vessles) problems of the neck.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Acute Torticollis
Sometimes referred to as “wry neck”, this is a condition causing muscle spasms and associated neck pain.