Cervical Stenosis and Myelopathy M. J. Rosner

Spinal Canal 17;23;26;38;41;45;47;48;62;64;68;76;85;89;92

C1 22 mm (20 - 26 mm)C2 20 mm (18 - 23 mm)C3-7 18 mm (14 - 22 mm)

Sagittal Cord 26;31;48;61;76

C1 10.4 mm (7-11 mm)C2 9 mm (7-10 mm)C3-7 8.5 mm (6-9 mm)

Transverse Cord

10-14 mm 26;31;41;45;76;85;92

A-P Compression Ratio 31;36;92;92

About 0.6 in mid-cervical levelsIncreases to about .8-.9 at C1

Spinal Cord Area 26;45;76;92;93

26;45;92Reserve subarachnoid space 12;38

Vertebral Canal:Vertebral body ratio 23;41

< 0.9 defines congenital stenosis 59

Cord:Canal ratio 23

Neurologic Deficit

Degree of deficit poorly relates to radiographic change 32;62

Cord area 30-44 mm2 correlated with poor outcome 18

Cord increases with improvement 49

Canal of about 12 mm is probably associated with symptoms 57

Canal of about 15-16 mm usually asymptomatic 57

Etiology of deficitVascular 2;5;5;15;15;16;16;21;21;32;32;62;68;68

Venous compression 62

Arterial compression 51;62

Anterior spinal arteryArterial fibrosis 5;51

Vertebral artery 39;43;43;68;75;75;82;82

Connective tissue 62

Dural-arachnoid adhesions 15;16;21;84

Pia-arachnoid adhesions 15;16;21;62;84

ArachnoidDenticulate ligaments 11;39;62

Annulus fibrosis 46;63

Mechanical 2;47;62;68

Canal diameter (see above)Cord area A-P compression ratioHyperextension (see below)

Cervical Extension 2;3;7;13;20;27;35;40;50;57;62;63;66;68;68;69;74;83;87

Narrows A-P canal by 2-3 mmVertebra and lamina approximatePosterior longitudinal ligament redundant 1;62;74;83

Ligamentum flavum redundant and infolds 1-3;20;62;68;74;83

All ligaments hypertrophy with ageCord shortens by 2.5 cm from flexion to extension 1;42;45

Clinical Relevance

Central cord syndrome 7;74

Myelographic block in prone position 1;40

SCIWORA 3;7;24;25;34;65

Neuropraxia, commotio spinalis 73;86;87

“Stinger”

Common Occurrence

Motor Vehicle CrashesFalls & other traumaAll concussionsAnesthesia 1;30

Myelography 40;40;62

Surgical & Dental procedures 1;30;80

Occupations: Painting, welding, other

Congenital Cervical Stenosis: Does cord respond to decompression?

Congenital Cervical Stenosis

Compression is symmetricAppears normal to eyeballMeasurements define Stenosis & small cordCord expands when decompressed 71

Basic Rule of Spinal Cord: Lesion may be at, or anywhere above, the lowest level of clinical involvement by exam. Symptoms and signs may vary spatially and temporally and include: 4;6;46;49;53;77

PainMotorSensoryReflexAutonomic

Pain

May or may not be present 1;8;63;77

Axial PainHead/face 46

Atypical facial pain 46

Cluster Headaches 46

Neck pain 70% localize to neck 1;49;94

May be pain free 47

Interscapular pain (2787}Thoracolumbar 46;47;49;56;63;67;77

Flank/iliac crest 63

‘Spinal’ pain usually local and due to soft tissue involvement 63

Appendicular 44;46;49;70

Upper Extremity 49

Lower Extremity 46;47;49;56;63;67;77

Buttock 47

Thigh 47

Calves 63

Ankles 63

Burning, aching, dysesthetic, electric 1;8;46;47;63;77;86

Feeling of ‘tightness’ of feet, legs or hands 47

Lhermitte’s 1;46;47;53;63;67;77

Associated with tenderness to local palpation Interscapular 47

Radiculopathy 46;63

Usually superficial 46

Usually dermatomal 46

Primarily unilateral 46

Myelopathic 8;37;46

May be asymmetrical 37

Often worse with exertion 46

Worse at night 46;47

Burning 46;47

Usually bilateral 46;47;63

Feeling of ‘tightness’ 47

Feeling of ‘stiffness’ 63

Legs about to ‘collapse’ 47;63

Mechanical Back signs usually absent 46;47

Feeling of ‘coldness’ of limb—hands or feet 63

Chest/cardiac 1;46

NeurogenicOccurs in anesthetic regions post-cord injury 14;60

Pain may be due to lost of descending nociceptive inhibition 54;55

MotorNormal Exam 47

Numb, clumsy hands 53;77;94

Intrinsic atrophy 49;77;79;91;94

C8, T1 ‘Radiculopathy’ by EMG 79

CTS 77

Arm--Leg--Leg—arm progression 48

Hip girdle weakness 1;46;47;77;94

Foot drop(s)Any spinal cord syndrome 49;53

Stiffness, spasticity 63;77

Drop attacks 63

Sensory 49

Normal Exam 46;47

Any modalityPin, touch, temperature 1;77

Proprioception, vibration 77

May include face 46

May be dissociated 77;85

Usually bilateral 77

Usually asymmetrical 77;94

Often non-dermatomal 94

Stocking-glove 77;94

Non-cervical sensory level 77

Peripheral neuropathy

IQ test

ReflexesUsually increased 1;49

May be hypoactive 46

Combination 46

May be normal 46;47;77

Inverted reflexes 1

Babinski about 50% 49;77

Hoffman about 15% 22;49;77

Autonomic Changes 1;6;46;52;90

Facial 46

Flushing 46

Lacrimation 46

Sweating 46

Pupillary change 46

Bladder >10-50% 49;63;78

Incontinence unusual 6

Frequency, nocturia common 63

Hesitancy occasional 1;63

Bowel 63

May be precipitous 63

Retention/constipation 63

Sympathetic: FrequentHorner’sRaynaud’s phenomenonRSD

Mimics 1;46;46;53;94

Carpal Tunnel Syndrome 77

Cluster Headaches 46

Multiple SclerosisGuillian-BarreAxonal neuropathyPost-polio syndromeBrachial Plexitis Syringomyelia 85

CFS-CFIDS/FibromyalgiaMany others

Synergistic‘Double crush’ 88

CTS, Ulnar palsy 77

Peripheral neuropathyNormal pressure hydrocephalusNeoplasia Vertebral atheroma 46

Vertebral Insufficiency 46

MS, others

Diagnosis: Often difficult 46;47

Slowly, variably progressive 77

Symptoms attributed to other conditions:‘…my prostate.’‘...since my babies.’‘...my arthritis.’No single syndromeNon-quantitative radiology

Red FlagOnset after surgery, trauma, hyperextension of neckHx CTS, ACF other spinal surgery with little changePrior history of neck or upper extremity numbness, paralysisHx of brachial plexitis

Numb, clumsy handsHip girdle weaknessFeet burn, other sx at nightUrinary frequency, urgency, nocturia with above

DiagnosisHistory, Physical 46;47

MR: Static, dynamic, quantitativePlain filmsCT/myelogramElectrical: best for concomitant diseaseHyperextension associated with onset 22

Suspicious but open mind

Conservative TreatmentSymptomaticTry to identify hyperextension or flexion & limit neck movement (?collar)PT: Posture

Posterior neck/shoulder girdle Abdominal musculature Balance

Surgical Treatment

Adequate decompression 81

Posterior Cervical Laminectomy 19;28;29;33;81

Expansile laminoplasty 58

Anterior Cervical Fusion(s)Multilevel Corpectomy 72

Cervical lordosis key 9;10

May require combination aboveMay have to consider posterior fossa

Conclusion: The narrow spinal canal is capable of compromising any or all spinal cord function(s) to virtually any degree and any combination and, rarely, in near isolation. Because of the dynamic changes of the spinal canal with movement and other events, the compromise may be variable producing intermittent, variable symptoms and signs

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