Cervical Myelopathy- Symptoms & Treatment

Last Updated on March 16, 2025

Cervical myelopathy is a neurological condition that occurs due to cervical spinal cord compression, most often due to secondary to degenera­tive changes within the cervical spine. Degenerative changes in the cervical spine are called cervical spondylosis. In advanced stages, cervical spondylosis can cause compression of the spinal cord and lead to neck stiffness, arm pain, numbness in the hands, and weakness of the hands and legs. This condition is also called cervical myelopathy.

Cervical myelopathy most commonly presents in older patients and the treatment often involves surgical decompression and stabilization as the condition is associated with step-wise progression.

Cervical myelopathy is the most common spinal cord disorder in persons more than 55 years of age. The overall prevalence in this population is unknown.

Relevant Anatomy

The cervical spine is formed by the first seven vertebrae which are named as C1 to C7 and make the neck region of the spine.

The normal cervical spine has a lordosis. That means it is curved with convexity on the anterior aspect. It ends when C7 joins with the first thoracic vertebra.

Vertebrae are the structural units of the spine. They are stacked together to form the entire vertebral column. Between each vertebra, are cushion-like structures called intervertebral discs which act as shock absorbers and also permit some movement.

Each vertebra contains a foramen which together form the vertebral canal.

The posterior longitudinal ligament marks the posterior end of the vertebral body. Any lesion of this would lead to compression on the anterior aspect of the cord.

Ligamentum flavum connects adjacent laminae of two vertebrae and can compress the cord from behind.

Cervical myelopathic changes occur after long-standing degenerative changes start compromising the canal space. Any preexisting deformity or condition that narrows the spinal canal makes it more likely.

The neural pathways are arranged in the cord in a way that motor pathways are anterior, sensory lateral, and proprioceptive lateral. The predominance of involvement tells about the part compressed.

Cause of Cervical Myelopathy

Cervical spondylosis is the most common cause of cervical myelopathy. The degenerative changes lead to cord compression and lead to neurologic deficit. Other conditions that may lead to long-standing compression of the cord may result in cervical myelopathy too. These are listed below.

• Cervical spondylosis: It is the most common cause of cervical myelopathy. The compression occurs due to degenerative changes like osteophytes, disc-osteophyte complex, degenerative spondylolisthesis, and yellow ligament (ligamentum flavum hypertrophy)
• Congenital Stenosis: Any stenosis causes a decrease in the space available for the cord. long-standing stenosis could lead to myelopathy. A degenerative process in the stenotic spine would lead to early symptoms of myelopathy.
• Ossification of the Posterior Longitudinal Ligament: The posterior longitudinal ligament is a ligamentous structure present posterior to the vertebral body and anterior to the cord throughout the vertebral canal. OPLL causes this to ossify and this causes spinal cord compression.
  symptoms usually begin when congenital narrowing combined with spondylotic degenerative changes in older patients.
• Space Occupying Lesion: Tumor, epidural abscess. tuberculoma etc may lead to compression of the spine and myelopathy.
• Cervical Trauma: Apart from casing acute cervical cord injury, the trauma can lead to alignment and degenerative changes leading to compression.
• Spine deformity: A deformity like kyphosis can put compressive forces on the spinal cord.

Pathophysiology of Cervical Myelopathy

Neurologic injury in cervical myelopathy can occur due to

• Direct compression from
  • Osteophyte overgrowth
  • Buckling of ligamentum flavum
• Dynamic compression during spinal movements
  • Due to cord stretching over ventral osteophyte ridges in flexion
  • Buckling of the ligamentum flavum during extension causes a reduction of space
• Spinal Cord Ischemia
  • The exact mechanism of ischemia is not understood but compression of the anterior spinal artery is proposed

Classification of Cervical Myelopathy

Nurick’s, Ranawat and JOA classifications are most commonly used for cervical myelopathy.

 Nurick Classification

Nurick classification is based in gait and ambulatory functions.

• Grade 0: Root symptoms only or normal
• Grade 1: Signs of cord compression, normal gait
• Grade 2: Gait difficulties but fully employed
• Grade 3: Gait difficulties prevent employment, walks unassisted
• Grade 4: Unable to walk without assistance
• Grade 5: Wheelchair or bedbound

Ranawat Classification

• Class I- Pain, no neurologic deficit
• Class II- Subjective weakness, hyperreflexia, dysesthesias
• Class IIIA – Objective weakness, long tract signs, ambulatory
• Class IIIB- Objective weakness, long tract signs, non-ambulatory

JOA Classification

Hukuda et.al introduced the Japanese Orthopedic Association (JOA) Scale for cervical myelopathy in 1985. It consisted s of 17 points that measured the sensorimotor status of the upper limb, lower limb, and bladder sphincter.

Later, Benzel et al modified this scale to a 20-point scale.  It is a widely used scoring system for cervical myelopathy.

Clinical Presentation of Cervical Myelopathy

There would be a history of longstanding cervical spondylosis. The myelopathy is suspected when neurologic symptoms appear.

Presentation of cervical myelopathy ranges from having subtle findings such as clumsiness of hand functions or balance difficulties to incontinence and complete paralysis.

The symptoms usually develop insidiously.

• Neck pain and stiffness
• Paraesthesias in both upper limbs
• weakness and clumsiness
• clumsiness or slowness with activities such as buttoning buttons or using keys (decreased dexterity of fine movements)
• Instability during walking**
  • Balancing issues
  • Weakness of lower limbs (considered to be the hallmark of cervical myelopathy)
• Retention of urine – appears late in the course

**Gait instability is a most important clinical predictor. Need for of assistive devices during walking  [cane, walker, or wheelchair] due to weakness or balance or necessity to use a handrail while negotiating stairs may be changes that would suggest progression of the myelopathy.

Physical examination in early cases may be normal, and motor weakness may be difficult to detect. Finding motor weakness in the lower limbs is considered more important. Patient might have upper motor neuron signs like spasticity and exaggerated reflexes.

The loss of pain and pinprick sensation indicates the involvement of sensory pathways.  The patient might have a loss of proprioception, which underlines the involvement of the dorsal column of the spinal cord. However, the loss of vibrational sense appears quite late. These occur in the advanced stages of the disease and often indicate a poorer prognosis.

Various tests and signs can help to elicit the weakness and spasticity.

• Finger Escape Sign: The patient extends and adducts the fingers. The small finger spontaneously abducts due to weakness of intrinsic muscles. Another version where the 4th and 5th digits abduct and flex spontaneously is also described.
• Grip and release: A normal person can make a fist and release about 20 times in 10 seconds. In the case of cervical myelopathy patients patients are often unable or struggling to complete the task.
• Increased Reflexes: Hyperreflexia is sign of upper motor neuron presentation. However, it may not be seen in concomitant neuropathy if present.
  • Inverted Supinator or radial reflex is produced when a strike tapping on the distal brachioradialis tendon leads to finger flexion instead of elbow flexion.
  • Sustained clonus– Sustained (more than 3) muscle contraction on stretching tendons. It has high specificity.
  • Hoffmann’s sign- Flexion and adduction of the thumb and flexion of the index finger when a distal phalanx of the middle finger is flicked
  • Babinski Test-  Extension of the great toe on stimulation of the sole. Normal test results in plantar flexion
• Balance and Steadiness of Gait
  • Patient is not able to perform toe to heel walk
  • Romberg test (Assesses dorsal column) asks the patient to stand with arms forward and closed eyes. Ability or inability is noted.

Imaging Studies

 X-rays

Recommended x-ray views are  AP, lateral, oblique, flexion, and extension views.

The x-rays show degenerative changes like reduced disc space, facet joint arthrosis, bone spurs, ossification of the posterior longitudinal ligament, and kyphosis of the cervical spine. Decreased canal diameter in the sagittal plane less than 13 mm leads to compression.

Look for cervical spine alignment, deformity, and any translation or compensatory subluxation above or below the spondylotic segment.

However, degenerative changes often do not correlate with symptoms. Moreover, the majority of elderly patients do have spondylotic changes in the cervical spine without myelopathy.

Flexion-extension radiographs should be done to assess dynamic compression.

MRI

MRI is the study of choice to evaluate the degree of spinal cord and nerve root compression.

Magnetic resonance imaging would reveal

• Disc herniations
• Facet joint hypertrophy
• Folding of the ligamentum flavum
• Cord edema
• Decreased the sagittal diameter of the cord

Magnetic resonance imaging of the cervical spine is the procedure of choice during the initial screening process of patients with suspected cervical myelopathy.

MRI can also identify intrinsic spinal cord lesions that can also present with myelopathy.

CT

CT would show the presence of bone spurs or any ossification of the posterior longitudinal ligament as a source of compression are best visualized on cervical CT scans and are important for operative planning.

CT may give a more accurate assessment of the amount of canal compromise because it is superior to MRI in evaluating bone.

CT myelography [Intrathecal injection of a contrast agent used in conjunction with CT] is used to assess cord compression especially a dynamic study for the visualization of contrast flow through the CSF in flexion, extension, and lateral bending. Since the advent of MRI, the use of myelography has decreased

Differential Diagnosis

It is important to ascertain the diagnosis before treatment is undertaken.  A study has reported up to 14% of patients who underwent surgery for cervical spondylotic myelopathy were later found to have other diagnoses.

Because cervical spondylosis is a universal finding in the elderly population, it is important to correlate cervical spondylotic changes with sensorimotor abnormalities identified on examination.

• Multiple sclerosis
• Amyotrophic lateral sclerosis
• Primary spinal cord tumors
• Syringomyelia
• Metastatic tumors,
• Subacute combined degeneration of the spinal cord (vitamin B12 deficiency)
• Hereditary spastic paraplegia
• Normal pressure hydrocephalus
• Spinal cord infarction
• Normal age-associated weakness

Treatment of Cervical Myelopathy

About 18 percent of patients with cervical spondylotic myelopathy are reported to improve spontaneously, 40 percent will stabilize and approximately 40 percent will deteriorate without treatment. The treatment varies with the severity of the disease, patient profile, and expectations.

Nonoperative Treatment

Nonoperative treatment of cervical myelopathy relies on observation, antiinflammatory drugs like NSAIDs, physical therapy, and lifestyle modifications. Nonoperative treatment is indicated in

• Mild disease without functional
• Patients who cannot undergo surgery for medical reasons
• patients who do not wish to get operated.

Soft Collars

Soft collars allow the muscles of the neck to rest and limit neck motion. Soft collars should only be worn for short periods of time because long-term wear can decrease the strength of neck muscles.

Exercise

Exercises improve neck strength and flexibility and may lessen discomfort. balance and gait training exercises should be done.

NSAIDs

Drugs like diclofenac and ibuprofen can reduce swelling and painful symptoms. Apart from this cervical traction, skull traction, and physical therapies are used.

Surgical Treatment

Symptomatic patients of cervical myelopathy who can be considered for surgery are

• 1-2 level involvement
• Significant functional impairment
• Not responding to medical treatment
• Progressive symptoms
• Bowel or bladder involvement
• Overt weakness

The operative treatment is effective to prevent a further decline in function, improvement in the current level of function might not be much. Following patients perform better with surgery.

• Younger age
• Shorter duration of symptoms
• Single rather than multiple areas of involvement

The primary goal of surgery in cervical myelopathy is to decompress the spinal cord, thus giving the neural elements more room and stabilization if required.

Various procedures  for cervical myelopathy are-

• Anterior cervical discectomy/corpectomy and fusion
• Anterior cervical discectomy/corpectomy and fusion
• Posterior laminectomy and fusion
• Combined anterior and posterior procedure
• Posterior laminoplasty
• Cervical disk arthroplasty

Anterior Cervical Discectomy and Fusion

In this, the neck is approached from the front. As the name suggests, the disc is removed and space is filled with bone graft. Cervical plates and screws are commonly used to help keep the bones in place till the actual fusion occurs.

This is the most often used procedure in most patients with single or two-level disease. It is indicated in

• Kyphotic deformity>10 degrees (kyphosis can be corrected anteriorly)
• Anterior pathology like ossification of posterior longitudinal ligament ossification.

The procedure is avoided in patients whose swallowing function is poor.

Anterior Cervical Corpectomy and Fusion

The vertebra is removed and replaced by a bone graft. It is indicated in extensive disease involving the posterior aspect of the vertebral body.

A combination of the two procedures may be performed.

Laminectomy

Using a posterior approach. bony arch (lamina), any bone spurs, and ligaments that are compressing the spinal cord are removed. Laminectomy relieves pressure on the spinal cord by providing extra space for it to drift backward.

Laminectomy ensures complete decompression of the spinal cord but makes the bones less stable.

Fusion with a bone graft and fixation with screws and rods may be added as laminectomy without fusion can cause kyphosis after the surgery.

Laminectomy and posterior fusion are indicated in

• Multilevel compression
• Minimal kyphosis (> 10 degrees of fixed kyphosis is a contraindication)

Laminectomy is ideal for people with very small spinal canals, and posterior soft tissue causing compression.

Combined Anterior and Posterior Surgery

This is indicated when 3 3-level corpectomy is done. It combines anterior plating with screws posteriorly to fix the spine. Without posterior stabilization anterior surgery alone would lead to failure.

Laminoplasty

It is a procedure that hinges the lamina open, without complete removal of the bone. The advantage of the procedure is that it preserves 30 to 50% of motion at the involved levels as fusion is not required.

Laminoplasty is usually performed from C3 to C7. There are many different techniques of laminoplasty like open door, French door etc. Each has its own set of advantages and disadvantages.
Overall, laminoplasty involves greater blood loss and post-operative neck pain.

Complications

• Surgical Infection
• Pseudoarthrosis
• Perioperative injuries
  • Recurrent laryngeal nerve injury
  • Vertebral artery injury
  •  Esophageal Injury – Dysphagia
  • C5 palsy
• Hardware failure and migration
• Postlaminectomy kyphosis
• Postoperative axial neck pain
• Epidural hematoma

References

• Morishita Y, Naito M, Hymanson H, Miyazaki M, Wu G, Wang JC. The relationship between the cervical spinal canal diameter and the pathological changes in the cervical spine. Eur Spine J. 2009 Jun;18(6):877-83. doi: 10.1007/s00586-009-0968-y. Epub 2009 Apr 9. [Link]
• Fehlings MG, Kwon BK, Tetreault LA. Guidelines for the Management of Degenerative Cervical Myelopathy and Spinal Cord Injury: An Introduction to a Focus Issue. Global Spine J. 2017 Sep;7(3 Suppl):6S-7S. [PMC Link]
• Heary RF, MacDowall A, Agarwal N. Cervical spondylotic myelopathy: A two decade experience. J Spinal Cord Med. 2018 Jul 26;42(4):1-9. [PubMed]
• Zhang L, Chen J, Cao C, Zhang YZ, Shi LF, Zhai JS, Huang T, Li XC. Anterior versus posterior approach for the therapy of multilevel cervical myelopathy: a meta-analysis and systematic review. Arch Orthop Trauma Surg. 2019 Jun;139(6):735-742.