Timothy Lapp MD MSc FRCPC, April 3, 2019

Cervical Spondylotic Myelopathy

How to diagnose the most common form of spinal cord injury

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Disclosure

❖ Speaker Honoraria and Educational grants within last 2 years from Allergan (Botox)

Objectives

❖ Identify patients with possible spinal cord compression as a result of cervical spondylotic compression

❖ Choose appropriate investigations for cervical spondylotic myelopathy

❖ Select suitable neurospecialist consultant

CSM Background

❖ Definition - “cervical spinal cord compression as a result of degenerative changes to the components of the spine”

❖ Diagnosis - requires a single symptom, single physical sign, and MRI abnormality

❖ Delay - mean time to diagnosis is 2.2 yrs and 5.2 physician visits (all types)

Case 1. Ms C.R.❖ 01/2019 - 49 yr RH restauranteur with left shoulder “hot

steel rod” pain for 5 mo, left radial hand numbness and paresthesae, influenced by neck and shoulder movements

❖ PMHx - nil

❖ Meds - Pregabalin 50mg bid

❖ P/E - normal gait, MSR 2+ x 4 limbs, Neg Babinskis, Neg Hoffman’s, No spasticity or clonus, Neg L wrist Tinels/Phalens, Normal Cervical spine ROM, Neg Spurling’s, no limb weakness/atrophy

Case 2. Ms A.D.❖ 52 yr old from remote community

❖ 12/2017 - referred by walk-in MD, 3 mo history of bilat upper limb numbness and paresthesae. Also c/o of more recent similar symptoms from trunk to toes, difficulty walking, no bladder or bowel changes, no other neuro symptoms, cervical extension causes electrical sensations down her spine

❖ PMHx - hypertension, previous cocaine user, smoker

❖ Meds - HCTZ, Amlodipine, Ramipril, K+

❖ P/E - no ataxia, hyper-reflexic all limbs, Babinskis negative, Hoffmans positive bilat, no spasticity or clonus, negative Tinels and Phalens

Case 3. Mr G.A.❖ 52 yr old baker

❖ 06/2012 - neck pain and progressive left radial arm pain and paresthesae, incoordination of right arm and leg, urinary incontinence once

❖ PMHx -Lumbar decompression 2010

❖ Meds - Tramadol, Lactulose, Imovane

❖ 07/2012 P/E - spastic R leg monoplegic gait, , weak L C6 myotome, R hand intrinsic weakness, MSR 4+ (except bilat biceps), Positive bilat Hoffman’s, R lower limb spasticity MAS 3, sustained clonus R ankle and non sustained clonus L ankle, Negative Babinskis, sensation normal x4 modalities, Cranial Nerves normal, no fasciculations

Symptoms

❖ ataxia

❖ sensory complaints - upper > lower limbs

❖ weakness/incoordination

❖ falls

❖ neck pain / headache

❖ bowel / bladder (rare)

Physical Signs❖ ataxia (Rhomberg / Tandem Gait)

❖ limited cervical ROM❖ muscle weakness - upper > lower limb

(central cord syndrome)

❖ hand weakness (digit abductors, grip)❖ spasticity ❖ Babinski / Hoffman

❖ hyper-reflexia❖ clonus

❖ L’Hermitte sign❖ diminished vibration / proprioception❖ possible cervical radicular signs (atrophy,

hyporeflexia, sensory loss)

Imaging

❖ Xrays

❖ Computed Tomography

❖MRI❖ diffusion tensor imaging?

❖ magnetic resonance spectroscopy?

Electrodiagnosis

❖ NCS/EMG may help identify cervical/lumbar radiculopathy, and/or peripheral nerve entrapments, polyneuropathy

❖ Somatosensory Evoked Potentials are non-specific and usefulness is undetermined

Etiology❖ Degenerative Changes

(Spondylosis) :❖ vertebral bodies❖ invertebrate discs❖ uncovertebral and facet joints❖ ligamentous hypertrophy /

ossification❖ congenitally narrow canal❖ previous trauma / fusion

Who/Where/When

❖ men > women (2.7:1)

❖ >55 yrs old (CSM > traumatic SCI)

❖ C5-C7

❖ average AP canal diameter 17mm / absolute stenosis <10mm

❖ heavy labourer

❖ genetic predisposition

❖ Down’s Syndrome

Static Risk Factors

❖ disc desiccation ❖ disc calcification❖ vertebral body end plate

osteophytosis❖ ligamentum flavum stiffens

Dynamic Risk Factors

❖ neck flexion - cord stretched/tethered against anterior canal wall osteophytes/discs

❖ neck hyperextension - canal narrows, compression posteriorly within canal from ligaments and posterior vertebral elements

Pathology

❖ Compression =

❖ neuroischemia/infarction

❖ oligodendrocyte apoptosis

❖ demyelination

❖ axonal degeneration

❖ anterior horn cell loss

Clinical Progression

❖ balance loss frequently first symptom

❖ motor symptoms progressive and less likely to recover than sensory symptoms

❖ insidious onset, but can be acute from fall with cervical hyper-extension

❖ can be benign clinical course with improvement, but complete recovery uncommon

Associated Conditions

❖ cervical radiculopathy (myeloradiculopathy)

❖ lumbar stenosis

❖ central cord syndrome (upper > lower limb weakness)

Differential Diagnosis❖ accurate diagnosis delayed by > 2yrs and 5 visits

❖ ALS

❖ MS

❖ spinal cord tumour (primary or metastatic)

❖ syrinx

❖ CNS infection/toxin/nutritional deficit

❖ movement disorder

❖ root/plexus/peripheral nerve insult

Natural History❖ uncertain

❖ no prospective controlled trials (surgery vs non-surgery)

❖ Lees and Turner, 1963, BMJ:

❖ less disability equates to better prognosis

❖ Kumar et al, 1999, Neurosurgery:

❖ 18% improve spontaneously

❖ 40% stabilize with no treatment

❖ 40% will deteriorate with no treatment

❖

Conservative Treatment

❖ analgesics - NSAID, neuropathic meds

❖ steroid???? (no evidence)

❖ avoid risky activities, cervical manipulations, traction

❖ soft collar for proprioceptive feedback

❖ hard collar in slight flexion for mild symptoms

Surgery❖ indicated for progressive neurological deterioration

❖ requires congruence of symptoms/signs/MRI

❖ increase canal size to reduce cord compression

❖ outcomes are unclear still, decompressing sooner is better than later.

❖ functional improvement and quality of life gains are likely

❖ anterior vs posterior approach?

❖ fusion?

❖ disc arthroplasty?

❖ minimally invasive techniques?

Anterior Approach

❖ C5-6-7 anterior discectomy, Lilian graft, and plating

Posterior Approach

❖ cervical laminectomy

Rehabilitation Post-CSM❖ mobility assessment +/- assistive

devices❖ gait training❖ fall risk management ❖ pain management❖ upper limb ADL assessment +/-

adaptive equipment❖ GU complications❖ pressure ulcer management ❖ post-op deterioration requires repeat

imaging to ensure adequate decompression

Case 1. Ms C.R. Outcome❖ 49 yr old restauranteur with L shoulder/arm pain

❖ MRI 12/18 - “C4-5 moderate broad based disc bulge, severe R and moderate L IVF narrowing, mild central canal stenosis, mild cord myelopathy / C5-6 severe R and minimal L IVF narrowing, mild central canal stenosis, no cord myelopathy”

❖ NCS 01/19 - normal median and ulnar results

❖ EMG 01/19 - abnormal L triceps study

Case 1. Ms C.R. Outcome

❖ Neurosurgical consultation 03/19

❖ symptoms improved in L arm

❖ off pregabalin

❖ MRI poorly visualized

❖ referred on to spine specialist given age (49 yrs) and potential for early myelopathy

Case 2. Ms A.D. Outcome❖ 52 yr old from remote community with upper and lower limb sensory

complaints and UMN signs

❖ MRI 12/17 - C5-6 broad based disc bulge with ligamentum flavum hypertrophy, spinal canal AP diameter is 6mm, T2 hyperintensity, moderate severe R IVF narrowing

❖ Xrays 01/17 with flexion/extension views - spondylosis, no instability, spinal canal 13mm in diameter in both flexion and extension

❖ CT 04/18 - C5-6 minor anterolisthesis, severe R facet arthropathy and IVF narrowing, diffuse central disc bulge and ligament hypertrophy better seen on MRI/C6-7 moderate bilat IVF narrowing, severe R facet arthropathy

Case 2. Ms A.D. Outcome❖ Neurosurgeon consultation 03/18 - nil progression (? new

clonus), wants CT and smoking cessation before surgery

❖ Neurosurgeon visit 06/18 - symptoms worse, still smoking, recommended to have C5-6-7 anterior discectomy and fusion with peek cages after not smoking for 3 mo., consider neuropathic pain meds

❖ Neurosurgeon visit 11/18 - quit smoking, symptoms about the same, using Gabapentin/Ibuprofen/Acetaminophen

❖ Surgery at next available date

Case 3. Mr G.A. Outcome

❖ 52 yr old baker with left arm pain and right sided motor complaints

❖ Xrays 06/12 - ?

❖ CT 07/12 - “disc space narrowing C3-4 and C4-C5; encroachment at R C3-4, L C4-5, bilat C5-6, bilat C6-7, minor compression of spinal canal C5-6”

❖ EMG 07/12 - L C6 radic

❖ MRI 08/12 - degenerative changes most marked at L C4-5 and R C5-6, C4-5 L paracentral osteochondral bar with L cord T2 hyperintensity, and C5-6 moderate concentric osteochondral bar with R cord T2 hyperintensity, “concerning for compressive myelopathy. Neurosurgical opinion recommended”

Case 3. Mr G.A. Outcome(s)❖ Neurosurgery 09/2012 - posterior approach with C4-C6 laminectomy and C3-6

instrumented fusion

❖ 10/15 - persistent bilateral upper limb sensory complaints R>L, but new bilateral lower trunk and limb pain, ambulatory only with a walker, no bladder and bowel incontinence. Ataxic, more hyper-reflexia, Babinski positive bilat (new), bilat leg spasticity (was only the R previously), lower limb and trunk sensory loss, Hoffman’s positive bilat. (same)

❖ MRI with contrast 11/15 - C6-7 focal enhancement of dorsal cord, previous successful decompression from C3-C6 (repeat study done at neurosurgeon’s request on 02/15 with same result)

❖ Neurosurgery 03/16 - anterior cervical decompression and fusion with iliac bone graft

❖ 11/18 - ambulatory with cane, spasticity bilat lower limbs (nil tx presently), neuropathic pain bilat lower limbs (pregabalin 150 mg bid), neurogenic bladder (sees urologist and on tamsulosin), neurogenic bowel (routine, dulcolax suppositories, lactulose)

Summary

❖ Maintain a high index of suspicion

❖ Diagnosis requires single symptom, single sign , MRI abnormality

❖ Know your UMN physical exam findings

❖ Refer to suitable neurospecialist

References❖ Young, FY, Cervical Spondylotic Myelopathy: A common cause of spinal cord dysfunction in older persons,

American Family Physician, Sept 2000

❖ Malcolm, GP, Surgical disorders of the cervical spine: Presentation and management of common disorders, Journal of Neurology, Neurosurgery, and Psychiatry, Vol 73, 2002

❖ Yang J. et al, Cervical Spondyotic Myelopathy. American Association of Physical Medicine and Rehabilitation Knowledge NOW website, Nov 2017

❖ Lees F, Turner J, Natural history and prognosis of cervical spondylosis, BMJ, 1963

❖ Kumar VG, Rea GL, Mervis LJ, McGergor JM, Cervical spondylotic myelopathy : Functional and radiographic long-term outcome after laminectomy and posterior fusion. Neurosurgery. 1999

❖ Fehlings MG et al, A global perspective on the outcomes of surgical decompression in patients with cervical spondylotic myelopathy: results from the prospective multi centre AOSpine international study on 479 patients. Spine. 2015

❖ Behrbalk E. et al, Delayed diagnosis of cervical spndylotic myelopathy by primary care physicians. Neurosurg Focus, 2013

❖ Haddas R. et al. Effect of cervical decompression surgery on gait in adult cervical spondylotic myelopathy patients. Spine Journal, 2017