Cervical Stenosis and Myelopathy
Complaints of Patients with Cervical Myelopathy:
Cervical canal stenosis usually manifests itself with complaints related to nerve root (radiculopathy) or spinal cord compression (myelopathy).
About approx. Half of them have neck or arm pain. In most of these patients, weakness and loss of function occur in the arms and legs.
Due to cervical myelopathy; Weakness in the arms and clumsiness in the hands, such as not being able to button a shirt, not being able to open and close a door handle, not being able to open a jar lid, are common complaints.
Complaints related to the legs manifest as difficulty in walking, weakness in the legs, and may progress to the inability to walk without assistance.
Cervical. Another complaint of patients with myelopathy is urinary incontinence. As the disease progresses, urinary and fecal incontinence and involuntary leakage may occur.
The progression of all these complaints over time may differ in each patient. In some patients, the progression of their complaints is rapid, while in others the progression is slow. In a group of patients, the progression stops after a certain point.
Examination Findings of Cervical Myelopathy
The first examination finding is usually increased upper and lower extremity reflexes. Different levels of neurological deficits can be detected. Early diagnosis is very important in this disease group. Progression of patients' complaints can be prevented with the treatment applied after early diagnosis. Diagnosing the disease begins with listening to the patient's complaints and asking questions in line with them. With the examination performed following this listening and questioning, some neurological deficits can be detected, which are: increased reflexes in the arms and legs (if there is radiculopathy, there may be a decrease in reflexes in the arms), gait disturbance (clumsy or unbalanced walking), loss of sensation in the hands and feet. In the examination, clonus (the foot continues to beat rapidly after bending towards the back), Babinski (when the bottom of the foot is scratched with a sharp object, the thumb bends towards the back of the foot while the other fingers open in a fan shape), Hoffman (the tip of the middle finger of the hand moves towards the palm). When quickly curled and released, the thumb and other fingers touch the palm. Pathological findings such as �straight movement) may be encountered. Detection of one or more of these findings is sufficient for the doctor to suspect cervical myelopathy.
Natural Course in Cervical Myelopathy
The clinic generally begins insidiously, the rate of progression varies, and complete recovery is rare after myelopathy develops. Worsening in attacks was observed in stable periods in 75% of the cases, slow progression in 20%, and sudden worsening in 5%. As myelopathy progresses, both lower extremities become weaker and spastic. There may be problems with sphincter control, incontinence is rare. In very advanced cases, support is required to walk. Movement is sometimes impossible, especially in elderly cases.
Diagnosis of Cervical Myelopathy
Direct x-rays of the neck may not provide sufficient information to confirm the diagnosis of cervical stenosis. Magnetic Resonance Imaging (MRI) is usually used to make this diagnosis. MRI shows the narrow cervical canal and compressed spinal cord in great detail. Computed Tomography (CT) can be used to better visualize the bone structures protruding into the cervical canal.
Image
A: Increased signal intensity in the T2-weighted sagittal MR image, B: Snake-eye appearance and significant spinal cord compression in the T2-weighted axial section.
Differential diagnosis of cervical myelopathy and other diseases can be made with electrophysiological tests that evaluate nerve conductions. Electromyography (EMG) and nerve conduction velocity studies are helpful methods in the differential diagnosis of cervical myelopathy and peripheral nerve diseases, especially peripheral nerve compression. Somatosensory evoked potentials (SEP) are tests performed by recording the stimulus given from the arm or leg from the brain, and a disruption in the transmission indicates spinal cord compression. This test is also helpful in the differential diagnosis of cervical myelopathy and other diseases.
Treatment Options in Cervical Stenosis
In cases with mild cervical stenosis, non-surgical methods may be the first choice in their treatment, whether there are signs of myelopathy or not. On the other hand, surgical treatment is generally recommended in case weakness and pain in the arms and legs increase and walking capacity decreases. The aim of surgical treatment is to repair the spinal cord and nerve root. It is the elimination of the pressure in the body (decompression). This goal can be achieved with different surgical techniques.
Surgeries performed from the front of the neck:
If the compression of the spinal cord is caused by the cervical disc, the body of the vertebrae and the ligaments in the front, these parts compressing the spinal cord are removed by surgery performed from the front of the neck and the spinal cord is relieved. Immobilization of that segment in order to strengthen the spine is called fusion. The bone graft that replaces the removed parts supports and strengthens this segment of the spine. Many surgeons may choose to attach a plate and screw system to that segment to further strengthen this established structure.
Surgeries performed from the back of the neck:
- Laminectomy; It involves removing the laminae and ligaments that compress the spinal cord from behind. In some cases, the surgeon may add fusion surgery to laminectomy to strengthen the spine.
Laminoplasty; It is based on the principle of widening the cervical canal by surgery performed from the back of the neck. In this operation, after removing some bone fragments, the spinal canal is widened by lifting the laminae like a door on the hinge support and preventing it from closing again.
After the surgery, patients must stay in the hospital for at least a few days. Many patients can begin to return to their daily activities 6-9 hours after the operation. The rehabilitation program that the patient should follow after the surgery is determined by the doctor.
Pain Management in Cervical Myelopathy
The purpose of medication use in cervical myelopathy is to relieve pain, muscle spasm and other symptoms. By recommending the use of one or more medications, the doctor tries to alleviate the patient's complaints and increase his functional capacity. Taking these medications more than necessary will not lead to faster recovery, but may cause unwanted drug side effects. If the patient has pain, the doctor may recommend the use of high-dose analgesics, non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. If the pain is much stronger and cannot be controlled with these medications, strong narcotic drugs (opioids) may be prescribed.
Other methods that can be applied for pain:
- Local to the area where the pain is triggered. anesthetic injection (sometimes steroids may be added to this). This injection is made directly into the painful muscle or soft tissue.
- Another trigger area injection is the facet joint injection.
- Cold or hot applications to the painful area can be used for analgesic purposes.
Prognosis< br /> Slightly more than half of the patients who undergo surgery show improvement compared to their preoperative condition.
The main purpose of surgery is to prevent deterioration.
Factors that negatively affect the prognosis: advanced age, serious neurological deficit, multi-level compression, long-term neurological Presence of deficit and narrowness of the anterior-posterior diameter of the canal, presence of signal changes within the spinal cord on MRI.
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