Cervical Stenosis and Myelopathy
Cervical Stenosis and Myelopathy : A users guide to medical decisions and treatments
What is cervical myelopathy and stenosis?
The cervical spine (neck) is a series of complex connected bones called cervical vertebrae. The bone structure protects the spinal canal and the nerves that exit the neck to control the head, shoulders, arms and even your gastrointestinal tract. The numerous connections via muscles, ligaments, tendons, discs, and muscles between the vertebrae provide support, stability and movement.
With age, the intervertebral discs become less spongy and lose water which reduces their overall height. This will lead to a reduced disc space as well as a bulging of the disc into the spinal canal area. When the disc loses its height, the muscles and ligaments around the disc will thicken and enlarge as a protective measure. These changes are common over the age of 50 and are generally referred to as a “cervical spondylosis” and “cervical stenosis”.
Cervical stenosis can occur slowly over decades or it can progress rather quickly. When this thickening occurs, in addition to the bulging and or herniation of the disc, the spinal cord will become impinged. This in turn, affects the function of the nerves. Impingement causes altered activity of the nerve by decreasing its conduction potential. It will also result in symptoms such as numbness, weakness, pain and referral traveling down the arm and into the hand. Cervical stenosis is the occurrence of the narrowing of the spinal canal due to osseous changes (changes in bone structure) while myelopothy refers to the injury of the spinal cord.
What are the symptoms?
Stenosis does not necessarily cause symptoms. Stenosis, bulging and herniation’s of the cervical disc are only symptomatic if a nerve is compressed. Harvard University conducted a research study which showed that 50% of people who have herniation’s are asymptomatic. If symptoms do occur, they usually result in myelopathy or radiculopathy (numbness and weakness in the upper extremity.
Roughly half of patients with myelopathy have pain in their neck and arms. Most have symptoms of arm and leg dysfunction depending on where the spinal cord is injured (remember, the cord travels down the body. One can have an injury high in the neck which produces symptoms in the lower body). Arm symptoms may include weakness, stiffness, or clumsiness in the hands (we call them the dropsies). You may experience not being able to hold tings in your hands, button your shirt, or remove the lid from a jelly jar. Urinary urgency is also common. Bladder and bowel incontinence may also be present.
How is it diagnosed?
As with any diagnostic procedure, the patients’ history is 99% of the diagnosis. The physical exam and radiology confirms the diagnosis and comprise the other 1 %. There are a lot of questions involved, a detailed medical history, a review of all bodily systems, and an orthopedic and neurological exam. Some of the findings that indicate stenosis are radiculopathy in the upper and lower extremities, increased reflexes in the knee and ankles with decreased reflexes in the arms. Many times there are changes in your gait cycles (the way you walk) such as clumsiness or loss of balance. There is also a loss of sensitivity in the hands and feet in terms positional change and fine motor movement like buttoning a shirt.
Other findings may include clonus (rapid beating of an appendage triggered by certain positions indicating spinal cord impingement), extension of the big toe with a foot stroke (Babinski reflex) or contracture of the thumb and index finder after flipping the middle finger (Hoffmans’s sign). These are all indicators of spinal cord dysfunction. Range of motion and flexibility are also compromised although it is not a definitive symptom as we all get a little stiff as we get older.
Electrical studies can also be performed; however, I usually do not prescribe them as they only indicate that impingement is present and do not tell us where the impingement occurs.
What treatments are available?
There are many treatments available for myelopathy and stenosis; however, which direction you pursue depends on who your primary care or gateway physician is. As a chiropractic physician, my philosophy is conservative management first, injections second and when all else fails, surgery is the final option. This, of course, depends on the severity of the case and the case history.
In mild cases of stenosis with or without myelopathy, non-operative conservative management should be the first choice. Since chiropractic physicians are experts in the musculoskeletal system, it is my opinion that a chiropractor should be your first line of defense. After the exams, depending upon the results of the exams, chiropractors can relieve spinal stiffness and increase flexibility and stabilize the spine. From there, physical therapy is usually prescribed to build strength and endurance in the cervical structure once the impingement is relieved. If the pain is constant and not responding to conservative management, medicinal intervention is commonly prescribed in terms of corticosteroids and NSAIDS. I do want to make one things abundantly clear…..corticosteroids and NSAIDS will help the inflammation and also help relieve the pain, however, they do very little to address the structural problems that led to your condition. Pain is the last symptom to arrive and the first to leave. Just because you are not in pain does not necessarily mean that your problems are solved.
In more serious cases, spinal decompression may be in order. There are several ways to decompress a spine. The conservative approach is through spinal decompression in which you are placed on a decompression apparatus which causes mechanical traction of the neck in order to bring water into the disc and relieve the compression. I do this on a daily basis and have fantastic results with it. If conservative decompression fails, you may need surgical intervention.
Surgical intervention can include several different procedures. You will want to talk to a neurosurgeon for these recommendations as they are experts in this field. Surgical options include anterior decompression and fusion where the disc and bone material causing the impingement or compression is removed from the front of the spine. Posterior decompression is another option which does the same thing but from the back of the neck. Some patients will need braces placed in the neck while others only need bone grafts. Laminectomies are also an option in which the part of the bone compressing the nerve is removed.
Medication and Pain Management
Medication used to treat cervical myelopathy is meant to reduce spasms, relieve pain, and give the patient relief. Again, symptomatic care is great for symptoms, but you need to get to the root cause of your pain. Your doctor may prescribe several different classes of medications for you. These may include corticosteroids, muscle relaxants, injections, or narcotics. Some of these meds will also present certain side effects such as drowsiness, constipation, addiction, felling “high”, gastrointestinal distress, ulcers, and bleeding. You will want to discuss which option is best for you with your medical professional.
Misconceptions of Stenosis and Myelopathy
Many times I will get new patients with myelopathy and stenosis. One of the first things we do is get them on a rehabilitation program. Many patients think that doing nothing is the best thing for them in order to restrict further damage. This is the wrong approach. Decreased activity reduces flexibility, strength and cardiovascular endurance. A physical therapy exercise rehabilitation program will begin with stretching to restore flexibility in a tight neck, trunk and arms. The exercises will be performed frequently throughout the day to preserve or increase the flexibility. Cardiovascular exercise is commonly recommended for endurance and strength. Improved blood supply will also help decrease your symptoms. Everyday activities will become easier the more flexible a spine becomes.
What about vitamins?
I always prescribe vitamins and supplements for my patients. The more therapies you can put into a body, the faster the result. Simple things like multivitamins for overall health, omega three fatty acids for inflammation and B vitamins for nervous system health go a long way. There are also a plethora of good supplements out there for disc nutrition and joint health as well. You will want to consult your health professional for these recommendations.
Cervical stenosis and myelopathy are common pathologies that we see in the medical and health profession every day. There are many options to choose from in terms of treatment. As a health professional, I always promote conservative management first as it is the least invasive way to get you back to health and wellness.