Cervical Disc Disorder with Myelopathy

© Reed Group

Risk: 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).

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).

History: 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 at 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), 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.

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.

Although the treatment of choice for this condition is 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).