Introduction

Cervical spondylosis is a degenerative condition affecting the cervical spine, essentially osteoarthritis of the cervical vertebral bodies. If the spinal canal is narrowed due to this process it can press on the spinal cord resulting in neurological dysfunction. Myelopathy is thought to occur in around 5-10% of patients who have cervical spondylosis.

Epidemiology

  • Incidence: 20.00 cases per 100,000 person-years
  • Peak incidence: 70+ years
  • Sex ratio: 1:1
Condition Relative
incidence
Cervical spondylitic myelopathy1
Transverse myelitis0.03
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Clinical features

Features
  • a variety of motor weakness, sensory loss and bladder/bowel dysfunction may be seen
  • neck pain
  • wide-based, ataxic or spastic gait
  • upper motor neuron weakness in the lower legs - increased reflexes, increased tone and upgoing plantars
  • bladder dysfunction e.g. urgency, retention

Investigations

An MRI of the cervical spine is the gold standard test where cervical myelopathy is suspected. It may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change.

Management

All patients with degenerative cervical myelopathy should be urgently referred for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery). This is due to the importance of early treatment. The timing of surgery is important, as any existing spinal cord damage can be permanent. Early treatment (within 6 months of diagnosis) offers the best chance of a full recovery but at present, most patients are presenting too late. In one study, patients averaged over 5 appointments before diagnosis, representing >2 years.

Currently, decompressive surgery is the only effective treatment. It has been shown to prevent disease progression. Close observation is an option for mild stable disease, but anything progressive or more severe requires surgery to prevent further deterioration. Physiotherapy should only be initiated by specialist services, as manipulation can cause more spinal cord damage.

Complications

Complications of surgery

Postoperatively, patients with cervical myelopathy require ongoing follow-up as pathology can 'recur' at adjacent spinal levels, which were not treated by the initial decompressive surgery. This is called adjacent segment disease. Furthermore, surgery can change spinal dynamics increasing the likelihood of other levels being affected. Patients sometimes develop mal-alignment of the spine, including kyphosis and spondylolisthesis, and this can also affect the spinal cord. All patients with recurrent symptoms should be evaluated urgently by specialist spinal services.