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Cervical Stenosis and Myelopathy M. J. Rosner
Spinal Canal 17;23;26;38;41;45;47;48;62;64;68;76;85;89;92
C1 22 mm (20 - 26 mm)C2 20 mm (18 - 23 mm)C3-7 18 mm (14 - 22 mm)
Sagittal Cord 26;31;48;61;76
C1 10.4 mm (7-11 mm)C2 9 mm (7-10 mm)C3-7 8.5 mm (6-9 mm)
Transverse Cord
10-14 mm 26;31;41;45;76;85;92
A-P Compression Ratio 31;36;92;92
About 0.6 in mid-cervical levelsIncreases to about .8-.9 at C1
Spinal Cord Area 26;45;76;92;93
26;45;92Reserve subarachnoid space 12;38
Vertebral Canal:Vertebral body ratio 23;41
< 0.9 defines congenital stenosis 59
Cord:Canal ratio 23
Neurologic Deficit
Degree of deficit poorly relates to radiographic change 32;62
Cord area 30-44 mm2 correlated with poor outcome 18
Cord increases with improvement 49
Canal of about 12 mm is probably associated with symptoms 57
Canal of about 15-16 mm usually asymptomatic 57
Etiology of deficitVascular 2;5;5;15;15;16;16;21;21;32;32;62;68;68
Venous compression 62
Arterial compression 51;62
Anterior spinal arteryArterial fibrosis 5;51
Vertebral artery 39;43;43;68;75;75;82;82
Connective tissue 62
Dural-arachnoid adhesions 15;16;21;84
Pia-arachnoid adhesions 15;16;21;62;84
ArachnoidDenticulate ligaments 11;39;62
Annulus fibrosis 46;63
Mechanical 2;47;62;68
Canal diameter (see above)Cord area A-P compression ratioHyperextension (see below)
Cervical Extension 2;3;7;13;20;27;35;40;50;57;62;63;66;68;68;69;74;83;87
Narrows A-P canal by 2-3 mmVertebra and lamina approximatePosterior longitudinal ligament redundant 1;62;74;83
Ligamentum flavum redundant and infolds 1-3;20;62;68;74;83
All ligaments hypertrophy with ageCord shortens by 2.5 cm from flexion to extension 1;42;45
Clinical Relevance
Central cord syndrome 7;74
Myelographic block in prone position 1;40
SCIWORA 3;7;24;25;34;65
Neuropraxia, commotio spinalis 73;86;87
“Stinger”
Common Occurrence
Motor Vehicle CrashesFalls & other traumaAll concussionsAnesthesia 1;30
Myelography 40;40;62
Surgical & Dental procedures 1;30;80
Occupations: Painting, welding, other
Congenital Cervical Stenosis: Does cord respond to decompression?
Congenital Cervical Stenosis
Compression is symmetricAppears normal to eyeballMeasurements define Stenosis & small cordCord expands when decompressed 71
Basic Rule of Spinal Cord: Lesion may be at, or anywhere above, the lowest level of clinical involvement by exam. Symptoms and signs may vary spatially and temporally and include: 4;6;46;49;53;77
PainMotorSensoryReflexAutonomic
Pain
May or may not be present 1;8;63;77
Axial PainHead/face 46
Atypical facial pain 46
Cluster Headaches 46
Neck pain 70% localize to neck 1;49;94
May be pain free 47
Interscapular pain (2787}Thoracolumbar 46;47;49;56;63;67;77
Flank/iliac crest 63
‘Spinal’ pain usually local and due to soft tissue involvement 63
Appendicular 44;46;49;70
Upper Extremity 49
Lower Extremity 46;47;49;56;63;67;77
Buttock 47
Thigh 47
Calves 63
Ankles 63
Burning, aching, dysesthetic, electric 1;8;46;47;63;77;86
Feeling of ‘tightness’ of feet, legs or hands 47
Lhermitte’s 1;46;47;53;63;67;77
Associated with tenderness to local palpation Interscapular 47
Radiculopathy 46;63
Usually superficial 46
Usually dermatomal 46
Primarily unilateral 46
Myelopathic 8;37;46
May be asymmetrical 37
Often worse with exertion 46
Worse at night 46;47
Burning 46;47
Usually bilateral 46;47;63
Feeling of ‘tightness’ 47
Feeling of ‘stiffness’ 63
Legs about to ‘collapse’ 47;63
Mechanical Back signs usually absent 46;47
Feeling of ‘coldness’ of limb—hands or feet 63
Chest/cardiac 1;46
NeurogenicOccurs in anesthetic regions post-cord injury 14;60
Pain may be due to lost of descending nociceptive inhibition 54;55
MotorNormal Exam 47
Numb, clumsy hands 53;77;94
Intrinsic atrophy 49;77;79;91;94
C8, T1 ‘Radiculopathy’ by EMG 79
CTS 77
Arm--Leg--Leg—arm progression 48
Hip girdle weakness 1;46;47;77;94
Foot drop(s)Any spinal cord syndrome 49;53
Stiffness, spasticity 63;77
Drop attacks 63
Sensory 49
Normal Exam 46;47
Any modalityPin, touch, temperature 1;77
Proprioception, vibration 77
May include face 46
May be dissociated 77;85
Usually bilateral 77
Usually asymmetrical 77;94
Often non-dermatomal 94
Stocking-glove 77;94
Non-cervical sensory level 77
Peripheral neuropathy
IQ test
ReflexesUsually increased 1;49
May be hypoactive 46
Combination 46
May be normal 46;47;77
Inverted reflexes 1
Babinski about 50% 49;77
Hoffman about 15% 22;49;77
Autonomic Changes 1;6;46;52;90
Facial 46
Flushing 46
Lacrimation 46
Sweating 46
Pupillary change 46
Bladder >10-50% 49;63;78
Incontinence unusual 6
Frequency, nocturia common 63
Hesitancy occasional 1;63
Bowel 63
May be precipitous 63
Retention/constipation 63
Sympathetic: FrequentHorner’sRaynaud’s phenomenonRSD
Mimics 1;46;46;53;94
Carpal Tunnel Syndrome 77
Cluster Headaches 46
Multiple SclerosisGuillian-BarreAxonal neuropathyPost-polio syndromeBrachial Plexitis Syringomyelia 85
CFS-CFIDS/FibromyalgiaMany others
Synergistic‘Double crush’ 88
CTS, Ulnar palsy 77
Peripheral neuropathyNormal pressure hydrocephalusNeoplasia Vertebral atheroma 46
Vertebral Insufficiency 46
MS, others
Diagnosis: Often difficult 46;47
Slowly, variably progressive 77
Symptoms attributed to other conditions:‘…my prostate.’‘...since my babies.’‘...my arthritis.’No single syndromeNon-quantitative radiology
Red FlagOnset after surgery, trauma, hyperextension of neckHx CTS, ACF other spinal surgery with little changePrior history of neck or upper extremity numbness, paralysisHx of brachial plexitis
Numb, clumsy handsHip girdle weaknessFeet burn, other sx at nightUrinary frequency, urgency, nocturia with above
DiagnosisHistory, Physical 46;47
MR: Static, dynamic, quantitativePlain filmsCT/myelogramElectrical: best for concomitant diseaseHyperextension associated with onset 22
Suspicious but open mind
Conservative TreatmentSymptomaticTry to identify hyperextension or flexion & limit neck movement (?collar)PT: Posture
Posterior neck/shoulder girdle Abdominal musculature Balance
Surgical Treatment
Adequate decompression 81
Posterior Cervical Laminectomy 19;28;29;33;81
Expansile laminoplasty 58
Anterior Cervical Fusion(s)Multilevel Corpectomy 72
Cervical lordosis key 9;10
May require combination aboveMay have to consider posterior fossa
Conclusion: The narrow spinal canal is capable of compromising any or all spinal cord function(s) to virtually any degree and any combination and, rarely, in near isolation. Because of the dynamic changes of the spinal canal with movement and other events, the compromise may be variable producing intermittent, variable symptoms and signs
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