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Myelopathy Associated with Cervical Spondylosis

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Myelopathy Associated with Cervical Spondylosis Myelopathy Associated with Etiology and Predisposing Factors The etiology of the degenerative Cervical Spondylosis: bony changes in cervical spondylosis that are associated with intervertebral diskogenic disease appears to be simi­ A Frequently lar to that of osteoarthritis in other parts of the body and the incidence increases with age. Recent or remote Unrecognized Disease head and neck trauma may be impor­ tant contributory factors because they tend to increase the rate of progression Donald i. Peterson, MD of the pathological process. Congenital Lloyd A. Dayes, MD abnormalities of the cervical spine Loma Linda, California increase the incidence of degenerative changes. If congenital fusion of verte­ brae is present, the most prominent changes occur at the intervertebral spaces adjacent to the fused vertebrae. Some degree of cervical spondylosis Cervical spondylosis or chronic diskogenic disease of the cervical can be demonstrated radiographically spine is a relatively common cause of myelopathy, but it is often in many people past the age of 40. 7 ’ 8 not recognized or is incorrectly diagnosed. The clinical presentation However, it usually is not associated may mimic several types of neurological disease including multiple with spinal cord pathology because sclerosis and amyotrophic lateral sclerosis. Even more frequently, there is adequate room for the cord in the spinal canal, even in the presence and especially early in the course of the disease, neurologic impair­ of prominent degenerative change, but ment is not recognized and the symptoms are thought to be due to myelopathy is especially likely to osteoarthritis. Early recognition of this condition is important since occur in patients with small spinal adequate treatment can prevent slowly progressive neurologic impair­ canals. ment. Knowledge of the pathophysiology of myelopathy due to cervical spondylosis and adequate radiographic evaluation will often Pathophysiology lead to treatment that can prevent progressive spinal cord damage. Cervical spondylosis consists of Cervical spondylosis with myelopathy is one of the most frequently degenerative changes in the interverte­ unrecognized and misdiagnosed, yet treatable, conditions affecting bral disks and vertebrae associated the nervous system. with changes in adjacent soft tissue (Figure 1). As the disk degenerates it becomes thinner and this causes some Cervical spondylosis is a degenera­ sive, irreversible damage to the spinal buckling and posterior bulging of the tive disease of the cervical spine which cord. This paper describes the annulus fibrosis and the posterior causes myelopathy if the degenerative mechanism of cord damage that may spinal ligament. There are bony process injures the spinal cord, or result from degenerative disease of changes in the margins of the vertebral radiculopathy, if nerve roots are the cervical spine and discusses the bodies adjacent to the degenerating damaged in the spinal canal or as they most important symptoms, signs, and disk. These changes consist chiefly of leave the spinal canal. When this condi­ radiographic criteria for diagnosis irregular bone proliferation causing tion presents with symptoms due to of myelopathy due to cervical formation of osteophytes, which may nerve root impairment, the correct spondylosis. project dorsolaterally into the verte­ diagnosis is usually suspected, but Although spinal cord damage from bral foramina, or posteriorly into the when cervical spine disease presents bone and soft tissue abnormality in spinal canal. These osseous changes chiefly as a myelopathy, it is often the cervical area has been recognized along with the posterior bulging of the unrecognized or incorrectly diagnosed. since antiquity,1 an awareness of the annulus fibrosus and posterior spinal For this reason, effective treatment frequency with which this condition ligament produce osseofibrous ridges, may be delayed, resulting in progres- causes neurological abnormality with sometimes referred to as transverse bar an understanding of its pathology and formation when seen on posterior- the radiographic criteria for diagnosis anterior views by myelography. These is relatively recent. The first complete projections into the spinal canal may description of the neurological.abnor­ decrease its diameter sufficiently to From the Neurology Section and the Sec­ tion of Neurosurgery, Loma Linda Univer­ malities due to cervical spondylosis damage the spinal cord by compres­ sity, School of Medicine, Loma Linda, was by Brain et al. Several other California. Requests for reprints should be sion or by interfering with its blood addressed to Dr. Donald I. Peterson, Neu­ investigators have contributed to an supply. These changes are usually rology Section, Loma Linda University, School of Medicine, Loma Linda, Calif increased understanding of this greatest at the 4th, 5th, and 6th 92354. condition.3’6 interspaces where the cervical spine is th e JOURNAL OF FAMILY PRACTICE, VOL. 4, NO. 2, 1977 233 blood supply. Wolf et al3 measured led to the conclusion by some investi­ the anterior-posterior diameter of the gators that cervical spondylosis is a cervical canal in 200 adults on films relatively benign condition because in taken with a 72-inch tube to film some cases there is no myelopathy, distance. The average sagittal diameter even though severe degenerative bone at levels of 4th, 5th, 6th, and 7th and disk changes are seen.13 Minor cervical vertebrae was 17 mm (range degenerative changes in a small spinal 12 to 22 mm) when measured from canal may cause severe myelopathy, the most posterior portion of the whereas severe bone and disk changes vertebral body to the most anterior in a large canal may be relatively portion of the spinous process at the asymptomatic. above levels. Payne and Spillane4 reported that Symptoms and Signs in patients with cervical spondylosis Symptoms and signs of cervical with myelopathy the canal diameter is spondylosis with myelopathy are smaller and averaged slightly greater usually those of upper motor neuron than 14 mm at the midpoint of the impairment of the lower extremities. Figure 1. Midsagittal section of cervi- These consist of varying degrees of cal spine and cord illustrating body of the 6th cervical vertebra, so degenerative bone and disk changes less space is available for the spinal stiffness, slowness, clumsiness, and causing spinal cord compression at cord. This measurement did not take incoordination of movement associ­ the Cg g interspace. There is thinning into account the decrease of diameter ated with hyperreflexia, spasticity, and of the disk with bulging of the of the spinal canal due to osseofibrous pathological reflexes. Sphincter annulus fibrosis, osteophyte forma­ tion, and vertebral subluxation caus­ ridges at the intervertebral spaces, impairment may occur in patients with ing decrease of spinal cord space. which further compromises the space more severe cord damage. Sensory for the spinal cord. Wolf et al suggest symptoms and signs may be present a sagittal diameter of the spinal canal but these are usually relatively minor most mobile during flexion and exten­ as projected on plain cervical spine compared with the motor system sion. As the disk deteriorates there is films of 10 mm or less at any point is abnormalities. Decrease of vibration decrease in height of the disk space likely to be associated with cord and position sense may occur. Impair­ with some associated loss of joint damage, whereas a minimum diameter ment of touch and pain sensation are stability, and this often results in mal­ of 13 mm or greater suggests that less frequently found. The upper alignment of the vertebral bodies, thus there is adequate space for the spinal extremities are often involved, but to a further decreasing the space available cord. These measurements (Figure 2) lesser degree than the lower extremi­ for the spinal cord. During flexion and are helpful in determining which pa­ ties. Symptoms in the upper extremi­ extension there may be considerable tients should have myelography but ties usually consist of some clumsiness anterior-posterior displacement (sub­ are not completely diagnostic in them­ and slowness of movements associated luxation) of one vertebra on another. selves because there may be consider­ with hyperactive reflexes. Tremor and These changes cause some thickening able encroachment on the space avail­ mild ataxia may be present. There may and indentation of the dura and there able for the spinal cord by soft tissue also be considerable loss of strength may be adhesions between the dura not visible on plain radiograms (Figure and muscle bulk. If the cervical nerve and the arachnoid. 2). For this reason the cord space may roots are involved, pain and paresthe­ Myelopathy may be exaggerated by be compromised even when the plain sias often occur in the upper extremi­ compromise of the radicular arteries films suggest that it is adequate. In ties and in some instances decrease of by foraminal stenosis produced by those patients with a spinal canal of sensation in the area supplied by the bony proliferation. This could render short anterior-posterior diameter, the involved nerve root. Often there is the cord marginally ischemic. decrease in size appears to be due to weakness and decrease of deep tendon The spinal cord within its shortened pedicles related to congeni­ reflexes due to lower motor neuron meningeal covering is well protected tal and growth factors which in most impairment at the level of the cervical by the bony spinal
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