It is compression of the spinal cord in the cervical spine anteriorly due to disc prolapse, ossification/calcification of the posterior longitudinal ligament behind the vertebral bodies and posteriorly mainly due to ligamentous and bony hypertrophy. Mostly commences in middle age and progresses with time.
The spinal cord gets damaged progressively with time due to continued compression.
For a long time, radiological and silent damage may go on occurring without symptoms. Actually, the spinal cord goes on tolerating slow progressive damage without symptoms for a long time. However, due to compression on the spinal cord, the protective layer of CSF (cerebrospinal fluid) between the bony spine and the spinal cord is lost. Therefore, many patients present with sudden weakness or even total loss of power in all 4 limbs following a minor injury to the neck whereby the bony spine hits the spinal cord directly without the cushioning effect of CSF. This can be a catastrophic presentation because neurological recovery after spinal cord injury is always unpredictable despite surgery.
Therefore, it is imperative that patients undergo MRI of the cervical spine even with subtle symptoms to pick up significant spinal cord compression.
Subtle symptoms may include
Advanced symptoms
MRI would diagnose correctly the severity, length and location of compression and the extent of spinal cord damage.
Conservative if MRI does not show significant compression.
Surgery if the MRI shows significant compression. Surgery may be done from the front or the back of the neck or rarely both from the front and the back depending upon the length, location and severity of compression.
Surgery from the front of the neck is done through a small incision via which the surgeon reaches the front of the bony spine and thereafter under microscopic vision, removes all the bone and the discs compressing the spinal cord. After taking the pressure off the spinal cord, the surgeon replaces the gap in the bony spine by Titanium/PEEK cages which may be fixed by screws and or plates to the normal vertebral bodies above and below the gap created in the bony spine.
Surgery from the back of the neck is done through an incision in the midline. I prefer Expansive Open-Door Laminoplasty whereby the bony door at the back of the spinal cord is cut on one side and hinged open on the other side and a spacer is inserted in the opening to prevent the door from closing back. This increases the space inside the spinal canal for the spinal cord.
The patient has to wear a collar for some time following the surgery to avoid aggressive neck movements.
An aggressive exercise/physiotherapy regimen is crucial to maximizing recovery post-operatively and needs to start from post-operative day 1.
The first purpose of surgery is to prevent further neurological deterioration. Patients with no significant symptoms pre-operatively are near normal immediately post-operatively.
Recovery in patients who already have symptoms of spinal cord damage depends on extent of symptoms, extent of spinal cord damage on pre-operative MRI and precision of surgery. Recovery will happen slowly over many months and is maximized by an aggressive exercise/physiotherapy regimen. However, the extent and time-period of recovery is unpredictable. But it must be mentioned that many patients exhibit miraculous improvement over a few weeks/months. And therefore, it is never too late to try.
Advanced symptoms such as bowel/bladder involvement and gross weakness/paralysis with wasting or loss of muscle bulk are unlikely to reverse completely. Therefore, it is imperative that patients undergo identification and surgery for this problem before developing such advanced symptoms.
There are some medications for residual symptoms such as spasticity/heaviness of the legs, paraesthesias or abnormal sensations, burning sensations, nerve pain radiating along the arms or legs.
Though Cervical Compressive Myelopathy is best identified early and operated early before spinal cord damage, adequate and precise spinal cord decompression may lead to miraculous improvement in many patients with severe neurological symptoms.
