Understanding Cervical Spinal Stenosis and Myelopathy
What is cervical stenosis? Myelopathy?
Stenosis simply means narrowing. Cervical stenosis refers to a narrowing of the spinal canal in the cervical spine or neck. The spinal canal is the hollow space in the center of the spine that contains the spinal cord and the nerve roots that exit between the vertebrae at each level.
When the spinal canal becomes so narrowed that the spinal cord is compressed, this can cause damage and dysfunction to the spinal cord, known as “myelopathy”. Myelopathy is differentiated from “radiculopathy” which refers to damage to the nerve roots that exit the spinal canal.
What is the cause?
Cervical spinal stenosis has many causes, but by far the most common cause is spondylosis or degeneration in the cervical spine.1 Similarly, degenerative cervical myelopathy is the most common cause of cervical spinal cord damage in adults over age 55.
Spondylosis occurs with aging and includes degenerative discs, spinal ligament hypertrophy, facet joint arthritis, and bone spurs, all of which encroach on the spinal cord and nerves within the spinal canal.2
Other, less common causes of cervical stenosis include trauma, tumors, and congenital narrowing of the cervical spinal canal.1
What are the symptoms?
Cervical spinal stenosis is common, though its true prevalence is not known. The natural history of stenosis is variable, but in the majority of cases, it does not progress to myelopathy.3 In fact, only 5-15% of patients with symptomatic cervical stenosis develop myelopathy.
Recognizing the warning signs of cervical myelopathy can help prevent permanent neurologic impairment. Neck pain is the most common symptom, but is very nonspecific, and the vast majority of people with neck pain do not have myelopathy. The most common early symptoms include pain in the neck, upper back, shoulder, and arm; numbness, tingling, and weakness in the arm or hands, loss of dexterity, decreased balance, and gait disturbance.4
These symptoms can lead to difficulty buttoning a shirt and frequent falls. Additional symptoms include bowel and bladder incontinence, retaining urine, and lower extremity weakness.
How is it diagnosed?
The diagnosis is made based on clinical history, exam, and imaging studies. A thorough neurologic exam is used to detect any signs of myelopathy, including hyperreflexia, weakness, sensory disturbance, and gait abnormality.
MRI of the cervical spine is the gold standard imaging study to evaluate for spinal stenosis and myelopathy; an area of increased signal within the spinal cord can reveal where there is damage.
In certain circumstances, electrodiagnostic testing can also be helpful in determining whether there is damage to the cervical nerve roots.
What are the treatment options?
The spectrum of treatment for cervical stenosis and myelopathy ranges from education and counseling on risks of progression for patients without spinal cord damage, to surgical decompression to relieve pressure on the spinal cord when there is myelopathy.
When surgery is not indicated, physical therapy can help alleviate pain and improve function with activities of daily living. In addition, treatments including cervical epidural injections and medications that treat nerve pain are often recommended if there is moderate to severe pain radiating to the arm.
According to AOSpine North America and the Cervical Spine Research Society, surgery is recommended for those with moderate to severe degenerative cervical myelopathy, or in situations where progressive weakness or bowel and bladder changes occur.
However, in the absence of neurologic signs and symptoms, surgery is not generally recommended, regardless of the degree of narrowing in the cervical spine.5 When surgery is not pursued, there should be a close follow-up of the neurological exam to assess for progressive deficits.
What if I have cervical stenosis, but no symptoms?
Asymptomatic cervical stenosis is very common, and studies in healthy volunteers have shown that incidental cervical cord compression can be detected in roughly 25-35% of individuals without symptoms.5 For these patients, surgery is not usually recommended.
Patients with asymptomatic cervical stenosis can continue to live their lives and enjoy their hobbies, but should avoid activities with high risk of fall and trauma to the neck such as heavy lifting, vigorous neck movement, and action sports. Another precaution is to adjust the headrest in vehicles to a position at the level of the head in vehicles to avoid whiplash.
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- Bohlman & Emery (1988). The pathophysiology of cervical spondylosis and myelopathy.
- Lebl et al (2011). Cervical spondylotic myelopathy: pathophysiology, clinical presentation, and treatment.
- Matz at al (2009). The natural history of cervical spondylotic myelopathy
- Fehlings et al (2017). A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy
- Smith et al (2021). The prevalence of asymptomatic and symptomatic spinal cord compression on magnetic resonance imaging: a systematic review and meta-analysis.