Myelopathy Symptoms, Causes, and Treatments

Myelopathy describes any neurologic deficit related to the spinal cord. When due to trauma, it is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. A disease that is vascular in nature is known as vascular myelopathy. The most common form of myelopathy in humans, cervical spondylotic myelopathy (CSM), also called degenerative cervical myelopathy is caused by arthritic changes (spondylosis) of the cervical spine, which result in a narrowing of the spinal canal (spinal stenosis) ultimately causing compression of the spinal cord. In Asian populations, spinal cord compression often occurs due to a different, inflammatory process affecting the posterior longitudinal ligament.

What is myelopathy?

Myelopathy is an injury to the spinal cord due to severe compression that may result from trauma, congenital stenosis, degenerative disease, or disc herniation. The spinal cord is a group of nerves housed inside the spine that runs almost its entire length. When any portion of the spinal cord becomes compressed or constricted, the resulting symptoms are known as myelopathy.

Types of Myelopathy

Myelopathy can occur in any area of the spine and has a different name depending on where in the spine it appears.

Cervical Myelopathy

Cervical myelopathy occurs in the neck and is the most common form. Neck pain is one of the symptoms of cervical myelopathy, but not all patients experience it.

Thoracic Myelopathy

Thoracic myelopathy occurs in the middle region of the spine. The spinal cord in this area typically gets compressed due to bulging or herniated discs, bone spurs, or spinal trauma.

Lumbar Myelopathy

Lumbar myelopathy is a rare condition because, in most people, the spinal cord ends in the top section of the lumbar spine. However, if the spinal cord is low-lying or tethered, it can be affected by lumbar myelopathy.

Myelopathy Symptoms

Clinical signs and symptoms depend on which spinal cord level (cervical, thoracic, or lumbar) is affected and the extent (anterior, posterior, or lateral) of the pathology, and may include:

• Upper motor neuron signs—weakness, spasticity, clumsiness, altered tonus, hyperreflexia, and pathological reflexes, including Hoffmann’s sign and inverted plantar reflex,
• Lower motor neuron signs—weakness, clumsiness in the muscle group innervated at the level of spinal cord compromise, muscle atrophy, hyporeflexia, muscle hypotonicity or flaccidity, fasciculations,
• Sensory deficits, and
• Bowel/bladder symptoms and sexual dysfunction.

Causes of Myelopathy

As you age, inflammation, arthritic illness, bone spurs, and the flattening of the spinal discs between the vertebrae can put pressure on the spinal cord and the nerve roots. Myelopathy typically develops slowly as a result of the gradual degeneration of the spine (spondylosis), but it can also take an acute form or stem from a spine deformity present at birth.

• Common causes of myelopathy are degenerative spinal conditions, such as spinal stenosis, and a narrowing of the bony passageways of the spine through which the spinal cord and nerve roots travel.
• Central disc herniations can also result in compression of the spinal cord, leading to the development of myelopathy.
• Autoimmune disorders, such as rheumatoid arthritis in the spine, can also lead to degenerative changes in the vertebrae that result in spinal cord compression and myelopathy.
• Hernias, cysts, hematomas, and spinal tumors, including bone cancer, may also press on the spinal cord and lead to myelopathy.
• Acute myelopathy can develop quickly as a result of a spinal injury, spinal infection, inflammatory disease, radiation therapy, or neurological disorders.

Myelopathy Diagnosis

Diagnosis of myelopathy

It is primarily diagnosed by clinical exam findings. Because the term myelopathy describes a clinical syndrome that can be caused by many pathologies the differential diagnosis is extensive. In some cases the onset of myelopathy is rapid, in others, such as CSM, the course may be insidious with symptoms developing slowly over a period of months. As a consequence, the diagnosis of CSM is often delayed. As the disease is thought to be progressive, this may impact negatively on the outcome.

Diagnosis of etiology

Once the clinical diagnosis of myelopathy is established, the underlying cause must be investigated. Most commonly this involves medical imaging. The best way to visualize the spinal cord is magnetic resonance imaging (MRI). Apart from T1 and T2 MRI images, which are commonly used for routine diagnosis, more recently researchers are exploring quantitative MRI signals. Further imaging modalities used for evaluating myelopathy include plain X-rays for detecting arthritic changes of the bones, and Computer Tomography, which is often used for pre-operative planning of surgical interventions for cervical spondylotic myelopathy. Angiography is used to examine blood vessels in suspected cases of vascular myelopathy.

The presence and severity can also be evaluated by means of transcranial magnetic stimulation (TMS), a neurophysiological method that allows the measurement of the time required for a neural impulse to cross the pyramidal tracts, starting from the cerebral cortex and ending at the anterior horn cells of the cervical, thoracic or lumbar spinal cord. This measurement is called Central Conduction Time (CCT). TMS can aid physicians to:

• Determine whether myelopathy exists
• Identify the level of the spinal cord where myelopathy is located. This is especially useful in cases where more than two lesions may be responsible for the clinical symptoms and signs, such as in patients with two or more cervical disc hernias
• Follow-up the progression of myelopathy in time, for example before and after cervical spine surgery

TMS can also help in the differential diagnosis of different causes of pyramidal tract damage.

Myelopathy Treatment

The treatment depends on the causes. However, in some cases, the cause may be irreversible, so the treatment may only go as far as helping you relieve the symptoms or slowing down the further progression of this disorder.

Nonsurgical Myelopathy Treatment

Nonsurgical treatment may include:

• Bracing,
• Physical therapy, and
• Medication.

These treatments can be used for mild myelopathy and are aimed at reducing pain and helping you return to your daily activities.

Nonsurgical treatment does not remove the compression. Your symptoms will progress — usually gradually, but sometimes acutely, in some instances. If you notice the progression of your symptoms, talk to your doctor as soon as possible. Some of the progression can be irreversible even with treatment, which is why it’s important to stop any progression when identified in the mild stages.

Surgical Myelopathy Treatment

Spinal decompression surgery is a common treatment to relieve pressure on the spinal cord. Surgery can also be used to remove bone spurs or herniated discs if they are found to be the cause of myelopathy.

For advanced myelopathy caused by stenosis, your doctor may recommend a surgical procedure to increase the channel space of your spinal cord (laminoplasty). This is a motion-sparing procedure, which means your spinal cord retains flexibility at the site of the compression. For various reasons, some patients may not be candidates for a laminoplasty. An alternative is decompression and spinal fusion which can be done anteriorly (from the front) or posteriorly (from the back). During spinal fusion, vertebrae are fused to eliminate motion in the affected segment of the spine.

Minimally invasive spine surgery may offer relief with a lower risk for complications and a potentially faster recovery than conventional open surgery procedures.

While you’re awaiting surgery, a combination of exercise, lifestyle changes, hot and cold treatments, injections, or oral medication can help you control any pain symptoms. It’s very important to take any medications exactly as your doctor prescribes them since many pain medicines and muscle relaxers can cause side effects, especially when used for a long time.

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