Cervical Spondylotic Myelopathy: A Common Cause of Spinal Cord Dysfunction in Older Persons

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WILLIAM F. YOUNG, M.D., Temple University Hospital, Philadelphia, Pennsylvania

Cervical Spondylotic Myelopathy:

A Common Cause of Spinal Cord Dysfunction in Older Persons part-2 TABLE 2
Diagnostic Criteria for Cervical Spondylotic Myelopathy Characteristic symptoms (leg stiffness, hand weakness)

Characteristic signs (hyperreflexia, atrophy of hands)

MRI or CT (showing spinal stenosis and cord compression as a result of osteophyte overgrowth, disc herniation, ligamentum hypertrophy)

MRI = magnetic resonance imaging; CT = computed tomography.

Amyotrophic lateral sclerosis (ALS) is another neurodegenerative disorder that can be confused with CSM. The absence of extremity sensory abnormalities on neurologic examination of a patient with myelopathy should alert the physician to the possibility of ALS. The presence of fasciculations on examination and a denervation pattern on electromyography serve as confirmatory evidence for ALS (Table 3).

Other conditions that can mimic CSM on presentation are primary spinal cord tumors, syringomyelia, extramedullary conditions (e.g., metastatic tumors), subacute combined degeneration of the spinal cord (vitamin B₁₂ deficiency), hereditary spastic paraplegia, normal pressure hydrocephalus and spinal cord infarction (Table 4).¹⁰ Most of these conditions can easily be distinguished from CSM based on characteristic MRI findings.

Treatment

Evaluating the efficacy of any particular treatment strategy for CSM is difficult because reports show that as many as 18 percent of patients with CSM will improve spontaneously, 40 percent will stabilize and approximately 40 percent will deteriorate if no treatment is given.¹⁹ Unfortunately, the current understanding of CSM does not allow physicians to predict the course of a patient. Also, the literature regarding various treatment strategies (surgical and nonsurgical) for CSM is flawed because of a lack of prospective controlled studies.

TABLE 3
Differential Diagnosis: CSM vs. ALS

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Feature	CSM	ALS
Age	Older than 55	Older than 55
MRI findings	Spondylosis	Spondylosis
Fasciculations	Absent	Present
Atrophy of arms	Present	Present
Atrophy of legs	Absent	Present
Denervation	Absent	Present

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CSM = cervical spondylotic myelopathy; ALS = amyotrophic lateral sclerosis; MRI = magnetic resonance imaging.

 

  TABLE 4
Conditions That Mimic Cervical Spondylotic Myelopathy on Presentation

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Amyotrophic lateral sclerosis

Extrinsic neoplasia (metastatic tumors)

Hereditary spastic paraplegia

Intrinsic neoplasia (tumors of spinal cord parenchyma)

Multiple sclerosis

Normal pressure hydrocephalus

Spinal cord infarction

Syringomyelia

Vitamin B₁₂ deficiency

Nonsurgical Treatment  OF NECK PAIN
In patients who are mildly affected by CSM, a "careful watching" approach can be taken. A variety of nonsurgical strategies have been used with variable success for the treatment of CSM. These include cervical traction, cervical immobilization (collar or neck brace), skull traction and physical therapy. Cervical immobilization is the most commonly used treatment in the United States. Some studies demonstrate the benefits of wearing a brace, while other studies show that immobilization does not improve the patient's condition.²⁰ It has also been reported that symptomatic patients may deteriorate neurologically during bracing, causing many to advocate earlier surgical intervention.^20,21 A nonsurgical approach is usually inadvisable.

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