Introduction
A case of cervical myelopathy with minimal symptoms is presented which in stark contrast to the typical An example of cervical spondylotic myelopathypresentation of cervical myelopathy. The resultant treatment and outcome also differ from traditional medical recommendations.
Literature review
Cervical myelopathy is a condition in which the spinal canal in the cervical spine is narrowed causing spinal cord compression (1). This most commonly occurs as a result of congenital stenosis or degenerative stenosis caused by spondylosis. Pathophysiology of cervical myelopathy is affected by static and dynamic factors. Static factors include the size of the spinal canal and spinal cord (2). The dynamic factors such as stretching the cord in flexion and shortening and fattening of the cord in extension can lead to further compression of the cord (3). The compression is usually progressive and occurs more frequently in men than women. While cervical myelopathy is a disease of the cervical spine, the presenting symptoms may affect both the upper and lower limbs. Symptoms include loss of balance, alteration of gait, poor coordination, diminished dexterity, weakness, numbness and paralysis. Pain is a common symptom but it may not always be present. In the advanced stages of the disease sphincter dysfunction and quadriparesis can occur. When examining a patient with cervical myelopathy one may note increased muscle tone, hyperreflexia, Babinski reflex, clonus, difficulty in tandem walking. Treatment of choice for moderate to advanced cervical myelopathy is surgical intervention although conservative treatment may be recommended for patients with mild cervical myelopathy (1)(4).
Clinical Examination
This 60 year old patient presents with mild neck pain and upper limb paraesthesias. Active cervical rotation was limited without pain. Upper and lower limb reflexes were increased bilaterally while the myotomes were normal. Hypoesthesia noted over C5 dermatome bilaterally. Spurlings, Lhermitte, Hoffman’s sign, Babinski and Romberg’s sign were within normal limits. No distal weakness was noted. Patient’s gait was normal.
Imaging
The patient had routine cervical spine x-rays which demonstrated mild spondylosis at C5/6. There was also moderate narrowing of the left C5/6 intervertebral foramen due to posterior osteophytes formation.
In stark contrast to the patient’s x-rays, symptoms and the clinical examination, the MRI shows severe spinal stenosis at level C5/6 as a result of central and paracentral disc osteophytes complex which impresses on the thecal sac. T2 hypertintense signal is demonstrated in keeping with myelopathic change at this level.
At level C6/7 there is moderate stenosis as a result of a central and paracentral disc osteophyte complex present with moderate stenosis. At this level myelopathic changes within the spinal cord are also noted.
Intervention
This patient had been treated with chiropractic care for low back pain prior to the onset of the symptoms related to cervical spinal stenosis. When he developed neck pain and upper limb paraesthesias he chose to continue with chiropractic care to resolve these symptoms while also consulting a local neurosurgeon for further investigation.
After seeing the MRI the neurosurgeon recommended immediate surgical intervention due to the extent of the myelopathic changes. I suggested that a second opinion from a local spinal orthopaedic surgeon be obtained. In addition to this second opinion, the patient decided to obtain another opinion in another country. Both of these opinions recommended a ‘wait and see’ approach with follow up investigations every three months. Other recommendations included wearing a soft collar brace when travelling and avoiding spinal manipulation.
Conservative management of this patient included manual traction, soft tissue therapy, posture correction and exercises. Adjustments An example of cervical spondylotic myelopathy(spinal manipulation) were performed at levels C3/4 and C5/6 prior to the MRI investigation. This was stopped after the MRI due to the possible risk of injury occurring from tension and possible ischemia of the cord during flexion and extension of the cervical spine as demonstrated by Breig (3). Manual traction was performed at thirty degrees of flexion with the hands of the practitioner placed around the occiput of the patient. Ten repetitions of twenty seconds each were performed at each session. Soft tissue therapy was used for the scalene, pectoralis minor, trapezius and rhomboid muscles to reduce stiffness in the cervical spine and to diminish the paraesthesias in the upper limb. The exercises prescribed and supervised by a biokineticist which is an exercise specialist in South Africa. The goal of the exercises was improving flexilibility and strength of the cervical musculature using isometric exercises while avoiding flexion and extension of the cervical spine.
The outcome of the treatment was favourable with reduced cervical spine pain, stiffness and hypoesthesia in the upper limbs after three treatments.
Conclusion
A case of cervical myelopathy as presented above may be more common in a chiropractic practice than previously realised. This may in part be due the lack of cervical myelopathy symptoms. While traditional medicine recommends surgery for moderate to severe cervical myelopathy, there is yet to be class I evidence to show that this approach is better that conservative treatment(4)(5). The possibility of chiropractic intervention with possible favourable outcomes can be considered depending on the severity of the patient’s symptoms.
Bibliography
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Dynamic changes of the spinal canal in patients with cervical spondylosis at flexion and extension using magnetic resonance imaging. Muhle C, Weinert D, Falliner A, Wiskirchen J, Metzner J, Baumer M, Brintman G Heller M. Investigative Radiology; 33(8):444-9.
Effects of mechanical stress on the spinal cord in cervical spondylosis. A study on fresh cadaver material. Breig A, Turnbull I. Hassler O. Journal o Neurosurgery. 1996 Jul; 25(1):45-56.
Conservative treatment of cervical spondylotic myelopathy. Yoshimatsu H, Negata K, Goto H, Sonoda K, Ando N, Imoto H, Mashima T, Takamiya Y. The Spine Journal. Jul-Aug; 1(4): 269-273.
Does nonoperative management play a role in the treatment of cervical spondylotic myelopathy. Matz PG. The Spine Journal. 2006 Nov-Dec; 6(Suppl 6):175S-181S.
Cervical spondylotic myelopathy: conservative versus surgical treatment after ten years. Kadanka Z, Bednarik J, Novotny O, Urbanek I, Dusek L. European Spine Journal. 2011 Sep; 20(9):1533-8.