Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Cervical Disc Disorder with Myelopathy


Related Terms

  • Cervical Radiculopathy
  • Cervical Spondylosis
  • Cervical Spondylotic Myelopathy
  • Degenerative Disc Disease

Differential Diagnosis

Specialists

  • Anesthesiologist
  • Neurologist
  • Neurosurgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Factors Influencing Duration

The length of disability depends on the severity and duration of spinal cord compression, the severity of persistent sensory and motor problems, the presence of absence of incontinence, whether surgery was performed, and, if so, whether a fusion was included, which requires time for the fusion to occur. Length of disability will also depend on whether nonsurgical treatment regimens are followed, the age and health status of the individual, and the individual's response to treatment.

Duration also depends on how much neck extension is necessary when performing work that calls for the arms to be elevated above shoulder level. Even with improvement after treatment, persistent myelopathy is usually incompatible with heavy work.

Medical Codes

ICD-9-CM:
721.1 - Cervical Spondylosis with Myelopathy; Anterior Spinal Artery Compression Syndrome; Spondylogenic Compression of Cervical Spinal Cord; Vertebral Artery Compression Syndrome
722.4 - Cervical Disc Degeneration
722.7 - Intervertebral Disc Disorder with Myelopathy
722.70 - Intervertebral Disc Disorder with Myelopathy, Unspecified region
722.71 - Cervical Disc Disorder with Myelopathy
723.4 - Brachial Neuritis or Radiculitis NOS; Cervical Radiculitis; Radicular Syndrome of Upper Limbs
723.8 - Other Syndromes Affecting Cervical Region; Cervical Syndrome NEC; Klippels Disease; Occipital Neuralgia
723.9 - Unspecified Musculoskeletal Disorders and Symptoms Referable to Neck; Cervical (Region) Disorder NOS

Overview

© Reed Group
Myelopathy is an inclusive term referring to any disease of the spinal cord. For example, when due to trauma, it is known as spinal cord injury; when inflammatory, it is myelitis, and when vascular, it is labeled vascular myelopathy.
The cervical region specifies the neck region of the spine. The following are examples of myelopathy: carcinomatous myelopathy (spinal cord degeneration associated with cancer); compressive myelopathy (spinal cord changes from the pressure of hematomas or masses); and radiation myelopathy (spinal cord destruction from radiation sources such as x-ray therapy). When the spinal cord destruction is caused as a complication of disease, the specific myelopathy signifies that origin; for example, diabetic myelopathy.

Cervical disc disorder with myelopathy can result from either a herniation of a cervical disc or spinal cord compression by spinal stenosis. A cervical disc (intervertebral disc) is a cushion-like structure found between the cervical spinal bones (vertebrae C2 through C7) that run from the base of the skull to the upper back. Discs are composed of a gel-like inner material (nucleus pulposus) encased in a ring of tough, fibrous outer material (annulus fibrosis); intervertebral discs absorb shock and allow movement of the spine. Disc displacement (herniation) occurs when the nucleus pulposus and/or the annulus protrudes abnormally into the spinal canal. Most often, a disc herniation presses on an exiting spinal nerve, causing dysfunction in a nerve root (radiculopathy). Less commonly, the spinal cord can become compressed by a herniated or protruding disc alone, or in combination with degenerative bony changes (cervical spondylosis) or with a narrow spinal canal (spinal stenosis).

Cervical disc herniation with myelopathy is less common than cervical disc herniation without myelopathy. Although both disorders cause neck pain and disturbances in arm sensation and strength, myelopathy is a more critical problem, frequently also involving neurological disturbances in the legs and possible impairment of bowel and/or bladder control.

Individuals with cervical disc disorder and myelopathy show signs and symptoms of myelopathy, with or without radiculopathy. Symptoms of radiculopathy (nerve root dysfunction) typically include pain radiating into the arm or chest with arm and/or finger numbness and motor weakness in an arm.

Blood supply to the brainstem and posterior fossa brain structures can also be affected by vertebral artery compression from spondylosis and may include dizziness, syncope, blurred vision, ringing in the ears (tinnitus), and pain behind the eyes. Like radiculopathy or arm symptoms, these brain stem symptoms may coexist with the symptoms of spinal cord compression that define myelopathy.

Discs normally begin the degeneration process by at least the third decade of life; by the fifth decade of life, most individuals exhibit degenerative changes (Windsor). Nevertheless, many individuals have no symptoms, and over the years these degenerative changes can slowly narrow the spinal canal until myelopathy occurs.

Myelopathy can also begin suddenly in the aftermath of a massive cervical disc rupture. Individuals who develop very rare acute cervical disc herniation with myelopathy as a result of injury often participate in sports that place a vertical load on the cervical spine, such as soccer, football, wrestling, ice hockey, diving, rugby, and trampolining.

Incidence and Prevalence: One in five visits to an orthopedic practice is for cervical discogenic pain (Windsor). Eight percent of all herniated discs occur in the cervical region of the spine. Cervical spondylotic myelopathy is the most frequent cause of spinal cord dysfunction in individuals older than 55 years in the US and worldwide (Al-Shatoury).

Degeneration of cervical intervertebral discs accounts for 36% of all spinal intervertebral disc disease, second only to lumbar disc disease, which accounts for 62% of all spinal intervertebral disc disease (Windsor).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Individuals in their twenties who participate in sports and those between 60 and 70 years of age are at greater risk for degeneration of the cervical spine resulting in cervical disc syndrome with myelopathy (Windsor). Displaced cervical discs occur equally as often in men as in women (Furman), but cervical spondylosis begins earlier in men. Radiologic findings show that 90% of men over age 50 and 90% of women older than age 60 have degenerative changes in the cervical spine (Al-Shatoury).

Source: Medical Disability Advisor



Diagnosis

History: The history depends on the underlying cause for the myelopathy. Individuals may report clumsiness or difficulty using the hands and legs. Subtle disturbances in gait, with gradual deterioration, may be reported. Bowel or bladder control problems may be reported, as well as sexual dysfunction. The symptoms may present in different ways. There may be a central spinal cord syndrome, and individuals may have weakness in the arms, even greater weakness in the legs, and depressed arm reflexes corresponding to the level of compression. A history of neck and arm pain and pins-and-needles sensations or paresthesias (radiculopathy) may be reported.

Physical exam: The key symptoms of myelopathy are impaired function of limbs. There may be bowel and/or bladder control impairment. Myelopathy affecting the lower limbs results in an altered gait, hyperreflexia, and perhaps weakness in the lower limbs. The knee and ankle muscle stretch reflexes are greater than normal, and pathologic reflexes like the Babinski response may be present. There may be impaired sensation in the lower limbs and/or the area around the genitals and anus (perineum). Similarly, myelopathy affecting the upper limbs results in upper limb weakness and incoordination, hyperactive reflexes, and altered upper limb sensation.

Loss of sensation may be noted in the distribution of an exiting cervical nerve, most commonly the sixth or seventh cervical root. While myelopathy produces muscle weakness and hyperactive reflexes, radiculopathy produces muscle weakness and loss of the reflex corresponding to the nerve being compressed. Symptoms usually occur on the same side as the disc herniation.

Neck pain may be aggravated by bending the head backward or rotating to the affected side. Spurling’s maneuver involves extending and rotating the neck to see if radicular arm pain is produced.

With spondylosis, physical signs may be more diffuse, because those degenerative changes usually occur at more than one level in the cervical spine. There may be some restriction in neck motion from spondylosis, especially during neck extension. Muscle atrophy in the forearms can be seen in long-standing cases. Loss of sensory and motor function below the level of spinal cord compression may be evident.

Tests: Plain x-rays of the cervical spine are taken, including flexion and extension films to detect instability in the spine. An MRI detects spinal cord compression. If the MRI shows increased signal in the spinal cord at the level of cord compression (gliosis or myelomalacia), it may suggest a poor prognosis for recovery of spinal cord function, even with decompressive surgery. Specialists in neurology or physical medicine and rehabilitation usually perform electromyography (EMG) if individual presents with a history and physical examination suggestive of potential cervical radiculopathy, but an EMG is of limited value in evaluating myelopathy. Somatosensory evoked potentials can evaluate myelopathy but are less commonly needed. Urodynamic studies may be used to assess bladder incontinence.

Source: Medical Disability Advisor



Treatment

As with diagnosis, the treatment is dependent on the underlying cause of the myelopathy. Although the treatment is often surgery, there is research to support conservative management for mild cases of this condition (Fouyas, "Surgery for Cervical"; Fouyas, "Cochrane Review on the Role"; Truumees).

Individuals with mild myelopathy can be treated conservatively, without surgery, if the condition is not progressive. The goals of treatment are to decrease pain, improve function, and prevent recurrence. A short period, perhaps 2 days, of rest may be helpful in reducing the intensity of the pain; rest must then be followed by mobilization. A soft cervical collar is sometimes briefly used at this time to limit neck movement and relieve pain in the neck.

The next phase of treatment involves physical therapy, primarily active exercise. Medication may be prescribed to relieve pain and may include anti-inflammatory medication, such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or narcotics. Muscle relaxants may also be given. Cervical epidural steroid injection(s) are often tried for the arm pain and weakness caused by associated radiculopathy, although evidence of effectiveness is lacking in the most recent systematic review (Armon). Cervical traction may be cautiously tried in therapy to see if it is helpful.

Surgery for the treatment of cervical disc disorder with myelopathy is considered when cervical radiculopathy or myelopathy or both are present with persistent radicular pain, motor weakness, progressive neurologic deficits, evidence of cord compression, and limited or no response to appropriate conservative treatment. In cases of cervical disc herniation with myelopathy, surgery is aimed at decompressing the spinal cord. Surgical treatment of cervical myelopathy most commonly entails anterior cervical discectomy and fusion (ACDF). This procedure involves removal of the herniated disc and fusion of the vertebrae to increase stability. The anterior procedure is the most direct approach and helps speed intervertebral fusion. Posterior discectomy (removal of the herniation) and foraminotomy are sometimes performed for radiculopathy, if a disc fragment can be more easily removed that way, but is not typically performed for myelopathy. Surgery may also be performed on the posterior bony wall of the cervical spine to enlarge the spinal canal (laminectomy or laminoplasty). A recent option is anterior discectomy with insertion of an artificial disc (artificial disc replacement) (Cepoiu-Martin).

Monitoring of neurological function after surgery is essential. Pain is usually controlled with oral analgesics, and the individual is discharged when ambulatory, usually the same day as the surgery or the next day. Light activities may be resumed after 6 weeks. Physical therapy is sometimes recommended, and future activity is not necessarily restricted. If a fusion has been performed, the surgeon may restrict heavier activities until the fusion is solid on radiographs, which may require 6 months of restrictions after surgery.

Source: Medical Disability Advisor



Prognosis

As with diagnosis, the prognosis is dependent on the underlying cause of the myelopathy. Conservative treatment may stop the progression of nerve damage but may not improve the individual's condition. Results are best if the history is short, fewer than 3 months. Complete reversal is rare if myelopathy has occurred (Al-Shatoury). Most surgical procedures are successful in decompressing the spinal cord and stabilizing the spine, with satisfactory results obtained in over 90% of individuals who undergo ACDF. Many of the individuals who develop myelopathy are older, and thus naturally were doing lighter work at the time they developed the myelopathy. The spinal cord function usually improves after surgery, but many times does not return to normal. The amount of residual neurologic deficit in the upper limbs (radiculopathy) and in the lower limbs (myelopathy) determines the function and work ability of the individual after surgery. Persisting neurologic deficit in all four limbs will preclude return to work in many jobs.

Spinal stability may be an issue if the spine is felt to be somewhat unstable after surgery. Safe activity levels have not been established for persons with an artificial disc replacement at one or two cervical levels.

The anterior cervical discectomy and fusion operation usually results in fusion and stability, and thus restrictions after this surgery are usually not required. Once fusion has occurred, the spine is stable, and following one level anterior fusion, 72% of National Football League players returned to professional football, which is much more physically demanding than almost any other job (Hsu). Thus neurologic deficit, and not spinal stability, is usually the determining factor in work ability and function.

If surgery is performed, 50% of individuals may return to full employment and 40% to light employment, and 10% may remain disabled, even though somewhat improved.

Source: Medical Disability Advisor



Rehabilitation

In individuals whose cervical disc disorders with myelopathy have been managed surgically, rehabilitation will focus on a postoperative protocol to be determined by the surgeon. Before rehabilitation begins, a careful assessment of the degree of central nervous system involvement is necessary. This should include signs of upper motor neuron involvement, such as tone irregularities, sensory, and motor changes (Boyce, Emery).

The primary goals of rehabilitation are to decrease pain, increase function, and to teach individuals how to manage their symptoms.

The first goal in treating cervical disc disorder with myelopathy is to decrease symptoms. In combination with pharmacological management, modalities such as heat and cold can be used (Braddom). While managing pain, individuals may be instructed in gentle exercises of the neck and other involved body parts. As a result of the variability in individual response, the treating practitioner must pay careful attention to tolerance to treatment. Initial exercises may include neck isometrics, stretching, and gentle range of motion. Postural training should be initiated as soon as tolerated by the individual (Yoshimatsu).

Once range of motion is restored, therapy should progress to strengthening and stabilization exercises of the neck, shoulders, and trunk. If there is lower extremity involvement, gait training, stretching, and strengthening exercises are indicated for the lower extremity and trunk. In addition to undergoing supervised rehabilitation, the individual should be instructed in a home exercise program to be practiced daily and continued independently after the completion of rehabilitation. Individuals should also be instructed in how to care for and protect the neck.

An ergonomic evaluation can provide information regarding the avoidance or modification of activities and work positions that could aggravate symptoms. Psychological intervention, such as cognitive and behavioral pain management, may be indicated to support the individual and identify associated factors that may be contributing to the pain.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistCervical Disc Disorder with Myelopathy
Physical or Occupational TherapistUp to 24 visits within 12 weeks
Surgical
SpecialistCervical Disc Disorder with Myelopathy
Physical or Occupational TherapistUp to 24 visits within 12 weeks
Note on Nonsurgical Guidelines: Lengthy physician observation is necessary to track the progression of this condition.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Permanent spinal cord damage can occur, which may be so severe as to result in paralysis (paraplegia) of the affected lower limbs. Permanent loss of bowel and/or bladder control may occur. Chronic pain-induced depression may occur in some individuals.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work may need to be modified to allow for weakness in the arms and/or legs, decreased dexterity, and an abnormal gait. Overhead work requiring neck extension should be avoided. Hard physical labor may be severely limited or impossible. Work modifications may be temporary or permanent, depending on the individual's response to treatment. Ongoing physical therapy early after diagnosis or surgery may require regular time away from work.

Accommodations: Individuals with cervical myelopathy are usually at least middle-aged, and residual neurologic deficit and co-morbidities frequently preclude doing heavy or very heavy work. Employers who can transfer these individuals into sedentary or light work may be successful in returning these individuals to the workplace.

Source: Medical Disability Advisor



Maximum Medical Improvement

For cases managed with surgery and without complications, MMI is usually reached by 6 months after surgery.

Additional slow neurologic recovery may still occur, but because of time, not because of treatment (and therefore does not qualify as "MMI").

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Does the individual have a past history of prior episodes of cervical radiculopathy? Has the individual had prior neck surgery?
  • Does individual have documented persisting sensory and motor impairments, or incontinence?
  • Is the gait abnormal?
  • Is more than one cervical level involved? If “yes”, heavy work is less likely to be tolerated.
  • In the case of disc herniation, did a precipitating compensable event occur? Is a lawyer potentially advising against return to work because of pending litigation?
  • Was diagnosis of cervical disc disorder with myelopathy confirmed by MRI and/or myelography? Did MRI show increased signal in the spinal cord (gliosis or myelomalacia if present suggests incomplete spinal cord function recovery, even with surgical treatment).
  • Has imaging after surgery shown the expected result (fusion has occurred, disc replacement is in ideal position, etc.)?
  • Is there a co-morbid significant low back disorder also present?

Regarding treatment:

  • Did individual's condition respond to conservative treatment?
  • Were medications (anti-inflammatory medications, narcotics, muscle relaxants) prescribed, and were they effective in relieving pain?
  • Did individual receive and comply with physical therapy?
  • Did individual adhere to a regimen of isometric exercise, aerobic training, and resistance training?
  • Is individual now a candidate for surgery? Based on what criteria?
  • Which surgical procedure was performed? Was neurological deficit corrected, improved, unimproved, or worse?
  • Would individual benefit from psychological counseling or enrollment in a chronic pain program?

Regarding prognosis:

  • Does the individual have persisting neurologic deficit that poses risks with return to work?
  • What are individual's physical limitations (capacity)? How severely do they affect function?
  • What is individual's health history? Are there co-morbidities that will affect "risk," "capacity," and "tolerance"?
  • What type of surgical procedure did individual undergo? Were multiple cervical levels involved?
  • Has individual experienced complications?

Source: Medical Disability Advisor



References

Cited

Al-Shatoury, Hassan A., et al. "Cervical Spondylosis." eMedicine. Eds. Francisco Talavera, et al. 18 Apr. 2012. Medscape. 11 Mar. 2013 <http://emedicine.com/pmr/topic27.htm>.

Armon, C., et al. "Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology." Neurology 68 (2007): 723-729.

Boyce, R. H., and J. C. Wang. "Evaluation of Neck Pain, Radiculopathy, and Myelopathy: Imaging, Conservative Treatment, and Surgical Indications." Instructional Course Lectures 52 (2003): 489-495. National Center for Biotechnology Information. National Library of Medicine. 19 Nov. 2004 <PMID: 12690875>.

Braddom, Randolph L. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia: W.B. Saunders, 2006.

Cepoiu-Martin , MC, et al. "Artificial Cervical Disc Arthroplasty." Spine 36 (25) (2011): E1623-E1633.

Emery, S. E. "Cervical Spondylotic Myelopathy: Diagnosis and Treatment." Journal of the American Academy of Orthopaedic Surgeons 9 6 (2001): 376-388. National Center for Biotechnology Information. National Library of Medicine. 19 Nov. 2004 <PMID: 11767723>.

Fouyas, I. P., et al. "Cochrane Review on the Role of Surgery in Cervical Spondylotic Radiculomyelopathy." Spine 27 7 (2002): 736-747. National Center for Biotechnology Information. National Library of Medicine. 19 Nov. 2004 <PMID: 11923667>.

Fouyas, I. P., et al. "Surgery for Cervical Radiculomyelopathy." Cochrane Database of Systematic Reviews 3 (2001): CD001466. National Center for Biotechnology Information. National Library of Medicine. 19 Nov. 2004 <PMID: 11686992>.

Furman, Michael B., et al. "Cervical Disc Disease." eMedicine. Eds. Everett C. Hills, et al. 12 Apr. 2012. Medscape. 11 Mar. 2013 <http://emedicine.com/pmr/topic25.htm>.

Hsu, W. K. , and . "Outcomes Following Nonoperative and Operative Treatment for Cervical Disc Herniations in National Football League Athletes." Spine 36 (10) (2011): 800-805.

Truumees, E., and H. N. Herkowitz. "Cervical Spondylotic Myelopathy and Radiculopathy." Instructional Course Lectures 49 (2000): 339-360. National Center for Biotechnology Information. National Library of Medicine. 19 Nov. 2004 <PMID: 10829188>.

Windsor, Robert E., et al. "Cervical Discogenic Pain Syndrome." eMedicine. Eds. Janos P. Ertl, et al. 14 Dec. 2011. Medscape. 11 Mar. 2013 <http://emedicine.com/sports/topic19.htm>.

Yoshimatsu, H., et al. "Conservative Treatment for Cervical Spondylotic Myelopathy. Prediction of Treatment Effects by Multivariate Analysis." European Spine Journal 1 4 (2001): 269-273. National Center for Biotechnology Information. National Library of Medicine. 19 Nov. 2004 <PMID: 14588331>.

Source: Medical Disability Advisor






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