Cervical spondylosis with myelopathy: Painful and sometimes paralyzing

Author(s):Ann M. Harrington Henwood, RN, RN, CNS

Often mistaken for arthritis, this disorder causes decreased height of intervertebral discs in the neck.

With the continued “graying” of America, healthcare professionals are caring for more elderly patients than ever. Part of the natural aging process is cervical spondylosis, a progressive degenerative spine condition. In this disorder, vertebral bodies in the neck enlarge through osteophyte (bone spur) formation, while intervertebral discs in the neck become dehydrated, stiff, and calcified, leading to decreased disc height. This combination of processes causes stenosis of the cervical canal, resulting in spinal cord compression.

Nearly everyone who lives long enough will develop cervical spondylosis, but relatively few people will be treated for it. The condition is the most common cause of cervical spinal-cord dysfunction after age 55. Treatment depends on symptoms, which can vary from none to mild to severe, such as quadriparesis (weakness of all four limbs).

Cervical spondylosis is thought to be underdiagnosed because to a large extent its signs and symptoms are expected in the elderly. Persons with the disorder may be told they have arthritis. However, spondylosis does not involve synovial joint inflammation. Rather, it’s a complex process of intervertebral disc changes and osteophyte formation and usually includes loss of lordosis in the cervical spine. Neural elements in the cervical spinal canal are crowded and may become mildly to severely compressed.

Assessment

Magnetic resonance imaging, computed tomography, or X-rays reveal cervical spondylosis in up to 95% of persons older than age 65. Yet most people with the condition lack signs and symptoms. When these do arise, the most common are neck pain and manifestations of radiculopathy (nerve root irritation or compression resulting in upper extremity symptoms) or myelopathy (spinal cord dysfunction cord resulting in neurologic deficits).

Radiculopathy may cause pain, weakness, or paresthesias varying from mild to severe. Patients describe the pain a deep aching or stabbing pain down the arm. It occurs in a dermatomal distribution and usually affects both arms. Paresthesia may cause numbness, tingling, or a pinprick sensation.

Myelopathy may result in little or no dysfunction—or severe dysfunction, with any of the following:

  • gait disturbance
  • difficulty with fine motor coordination
  • clumsiness of the hands
  • spasticity of the lower extremities
  • motor weakness of all extremities
  • urinary and bowel dysfunction.

Cervical symptoms usually are mechanical in nature, worsening with activity and easing with rest. Patients describe them as deep and agonizing. The pain may be so severe that patients are reluctant to turn their head to speak. They may grasp the back of the neck to demonstrate the location. In some cases, pain radiates into the head, causing cervicogenic headaches.

Signs and symptoms of cervical spondylosis usually have an insidious onset, and patients notice a slow progressive decline. (See the box below.)

On physical examination, you may find some or many of the following:

  • clonus or spasticity of the lower extremities
  • sensory changes (light touch, pinprick sensation, or temperature dysfunction)
  • generalized weakness throughout muscle groups, especially in the extremities
  • poor or pathologic tandem gait
  • atrophy of the hand’s thenar prominence (the fleshy fat pad just superior to the thumb on the ventral portion of the hand)
  • positive L’Hermitte’s sign (shock-like sensations down the spine or arms with rapid neck flexion or extension).
  • In an otherwise asymptomatic patient, hyperreflexia, a positive Babinski test, and a positive Hoffman’s sign (hand contraction in response to tapping on distal finger joints) are early signs of cervical spondylosis. But some patients may have only mild symptoms—or none at all—despite MRIs showing severe cervical spondylosis with spinal-cord compression.

Diagnosis

  • Cervical spondylosis is diagnosed from radiologic tests, which may include cervical X-rays, computed tomography scans, magnetic resonance imaging (MRI) scans, and myelography. The condition can be diagnosed from characteristic MRI and X-ray findings, which typically reveal loss of disc height, osteophyte formation, foraminal stenosis, subluxations, and loss of lordosis or kyphosis.

Management

Cervical spondylosis with myelopathy can be recognized early and treated either medically or surgically; waiting until later stages for treatment may make recovery less likely. If the condition progresses rapidly and causes loss of function, early treatment should be considered. Treatment may vary greatly depending on correlation of diagnostic findings with signs and symptoms. Referral for surgery depends on such factors as the degree of the patient’s neurologic dysfunction and provider preference.

Whether to use medical or surgical intervention is controversial. When surgery is recommended, the particular surgical approach may differ from one surgeon to the next. For a patient with early signs and symptoms of myelopathy, some clinicians may recommend surgery, whereas others may recommend conservative therapy first—a “watch and wait” approach to see if symptoms worsen. If symptoms persist or don’t improve to an acceptable degree with an observational or conservative approach, surgery may be recommended.

Medical management

In mildly to moderately symptomatic patients, medical management usually begins with medications and physical therapy. Muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs) or other analgesics commonly are used to treat cervical spondylosis and associated signs and symptoms. Anticonvulsants and antidepressant drugs may be given to treat neuropathic pain associated with spinal-cord and nerve-root compression.

Some physicians prescribe cervical collars to minimize injury in the event of a fall or other accident. Collars also may reduce pain by limiting motion and relieving the burden on supporting muscles. But their use can cause muscle atrophy and a decreased range of motion (ROM), ultimately leading to worse pain and contributing to worsening spondylosis.

After 6 to 12 weeks of conservative therapy, the patient should be able to determine if symptoms have improved, worsened, or stayed the same. If conservative therapy doesn’t help or if symptoms worsen during this interval, surgery may be recommended.

Surgery

The goal of surgery is to arrest symptom progression and if possible, restore lost function. Depending on diagnostic findings, correlation with the patient’s signs and symptoms, and the surgeon’s preference, one of several approaches may be used.

The ultimate surgical treatment is to take pressure off the neural elements by removing bone and decompressing the spinal cord. Once that occurs, the spinal elements and bone must be restabilized with a spinal fusion procedure.

For a patient with neurologic deficits associated with cervical spondylotic myelopathy, decompression is the goal of surgery. Decompression may take place using a ventral approach to the cervical spine (discectomy or corpectomy), a dorsal approach (laminectomy or osteotomy), or both. In most cases, the patient requires a procedure to restabilize and correct the deformity, called arthrodesis or fusion.

Not all spinal fusion procedures are the same. For an elderly patient with cervical spondylosis and myelopathy, the fusion is usually instrumented. To relieve spinal-cord compression, bone is removed at multiple levels and the spine is restabilized with instrumentation. Various devices may be used, including screws, rods, cages, cadaver bone, or an autograft (the patient’s own bone).

Preoperative and perioperative care

Discuss with patients what to expect before, during, and after surgery. Explain the potential risks, complications, and expected outcomes. Encourage patients to strive to be in the best physical condition possible. Inform them that they must obtain formal medical clearance for general anesthesia and surgery.

Instruct patients to stop taking anticoagulants (including NSAIDs and herbal preparations) and to stop smoking before surgery, as instructed by the surgeon. Urge them to make arrangements for help at home after discharge. In some cases, patients may undergo special preoperative testing, such as vocal evaluation before ventral surgery to check for impaired vocal cords and anesthesia evaluation for fiberoptic intubation in cases of severe spinal-cord compression.

Inform the patient that intraoperative care commonly includes administration of antibiotics and patient positioning. Usually a supine or prone position depending on the surgical approach, with careful attention to pressure points and genitalia.

Postoperative nursing care

Postoperative responsibilities include neurologic assessment, monitoring for procedure-related complications, pain management, incision care, mobilization, constipation prevention, and discharge education. Perform neurologic assessment at intervals ordered, focusing on extremity strength and movement. Compare results to preoperative findings and correlate them with the surgical procedure performed.

Monitor for complications, including incisional hematoma, cerebrospinal fluid leakage, and wound infection. Complications specific to ventral surgery include problems with airway patency, difficulty swallowing, and vocal hoarseness. After surgery using the dorsal approach, monitor the incision site and ensure proper drain management because of the large amount of drainage expected.

Pain control is essential after spinal fusion surgery, which causes significant pain. Initially, most patients receive analgesics I.V., I.M, or by a patient-controlled analgesia (PCA) unit, and then transition to oral medications. As ordered, administer other drugs, which may include muscle relaxants and NSAIDs. For neuropathic pain, expect to give anticonvulsants and antidepressants. Other pain-management techniques may include heat or ice application and frequent position changes.

Postoperative ambulation and mobility are crucial to help control the patient’s pain and decrease the risk of complications associated with bed rest. Mobility can vary greatly and may depend on the level of preoperative mobility and procedure performed. Patients are at increased risk of constipation due to analgesics, anesthesia, and reduced mobility.

Incision care varies with the procedure. Keep the incision site clean and dry. If drains are present, know that output should decrease daily. Monitor for signs and symptoms of infection.

Be aware that a physical therapist should evaluate the patient the day after surgery. Occupational therapy should be ordered as needed; some patients have no postoperative upper-extremity deficits or symptoms. Cervical collar use depends on the surgeon’s preference and type of procedure performed. Some patients may require acute or subacute inpatient rehabilitation before discharge. Elderly patients should expect to need assistance at home for several weeks after surgery, even after discharge from a rehabilitation facility.

When providing discharge teaching, discuss limitations and restrictions set by the surgeon, such as permitted cervical-spine ROM, use of a cervical collar, driving, medication management, and return to activities of daily living. Instruct patients to report wound drainage, fever, or other signs or symptoms of infection, severe pain, or new neurologic decline or deficit. (For prognosis, see the box below.)

 

Going the nonsurgical route

A patient who’s mildly to moderately myelopathic with stable symptoms may opt not to have surgery unless symptoms become unstable and a downward neurologic decline resumes. Such a patient commonly asks, “What’s my risk for becoming paralyzed?” This question can’t be answered definitively. But it’s reasonable to tell patients they have a slightly higher risk of neurologic injury or compromise than persons without cervical spondylosis. (At the same time, you might want to remind them we’re all at risk for catastrophic injury each time we walk across the street or drive a car). Despite their slightly elevated risk, patients with stable mild to moderate symptoms should be able to live without severe restrictions and continue to engage in enjoyable activities without fearing a catastrophe.

Selected references

Harrop JS, Hanna A, Silva MT, Sharan A. Neurological manifestation of cervical spondylosis: An overview of signs, symptoms, and pathophysiology. Neurosurgery 2007;60(1, Supp 1 1): S14-20).

Matz PG, Pritchard PR, Hadley MN. Anterior cervical approach for the treatment to f cervical myelopathy. Neurosurgery. 2007;60(1 Supp 1):S64-70).

Mazanec D, Reddy A. Medical management of cervical spondylosis. Neurosurgery. 2007;60(1 Supp1- 1):S43-50.

Mummaneni PV, Haid RW, Rodts GE Jr. Combined ventral and dorsal surgery for myelopathy and myeloradiculopathy. Neurosurgery. 2007;60(1 Supp1 1):S82-89.

Shedid D, Benzel EC. Cervical spondylosis anatomy: Pathophysiology and biomechanics. Neurosurgery. 2007;60(1 Supp 1 1):S1-13.

Wiggins GC, Shaffrey CI. Dorsal surgery for myelopathy and myeloradiculopathy. Neurosurgery. 2007;60(1 Supp1 1):S71-81.

Ann M. Harrington Henwood is a Clinical Nurse Specialist at the Center for Spine Health at the Cleveland Clinic in Cleveland, Ohio.

30 COMMENTS

  1. I having a revision cervical laminectomy in September, 2019. I’m 77year old female. I cannot walk with out a crutch and have had a catheter since December, 2018. I kept telling my doctor and rheumatologist of my symptoms but they never listened to me.
    I Had my previous cervical laminectomy on December, 6th. I have only been given an Aston Vista collar to wear this last three weeks!
    One of the neurosurgeons, that I really have faith in, doesn’t think I should have this second operation, but he is in the minority.
    I’m really frightened and worried and wish to make a living will, as do not want to live if paralysed.

  2. I am a 59 year old in Canada, just recently have acquired the symptoms of cervical spondylosis. I have pins and needles numbness in my left arm constantly. My doctor is against any surgery as it may not solve the issue. He prescribed a nerve pain pill called Gabapentin which I take daily. It seems to be helping with the pain and discomfort. I am able to sleep at night most nights. I was wondering if any of you have taken this drug or CBD oil to treat pain? CBD oil is commonly used today in Canada for a host of medical issues as treatment. (Aug. 2019)

  3. my dad had a lamenectomy two years ago he is pretty tough for his age (86) although now Finally after misdiagnoses the neck mri shows his priblem iscervial spondylosis myelopathy also severe spinal stenosis I an so confused as to what to do. The one sugeon said operate ans put metal bits in. Even tho he looks and acts 10 yrs younger over the past year ive seen him decline He is weak sick all the time in pain. he hs tryed injections and pills. his walking is getting worse. im so afraid that he will not make an operation i feel like i have to tell him what to do and im scared and confused!! can someone help me? thanks

  4. Hi had op on my lumber spine with fixation in 2015 after op for few months my symptoms improved slightly short lived started to go numb from waist down could not walk far had to sit down wherever I could until got some feeling back to carry on. Have severe pain in back radiating to the front effecting my bladder drink lots but rally pass much urine also piled weight on due to lack of exercise and all the jobs I used to do can’t do anymore.Had mri on my whole spine march this year got the result have now got cervical spondylitis myothape due to have op on 18th July ime absolutely petrified what the outcome will be the operation sounds horrific lots can go so wrong basically was told I would end up in wheelchair if I don’t have it done could still end up in one if I do plus a whole lot of other health problems. Really would like further advice before the op preferably taking someone with me I don’t remember all the surgeon said or take it in ime 70yr old lady live on my own would appreciate some advice regards Marion

  5. I began with neck problems when I was 40 years old. THAT is 25 years and 4 surgeries ago. Along with all but one failing. The worse due to a chiropractor grabbing my neck and twisting despite both WRITTEN warnings and me and my then 27 year old daughter SCREAMING at him not to touch my neck–as it had been fused just three months prior. He broke a screw off into a vertebrae and a plate was left buckled in my c-spine. A I already had damage in my T and lumbar regions-there was NO reason I would allow him to touch me. I did inform everyone that came into MY Optical Practice just how & why I was out of the office for so LONG=having all the hardware taken out–my neck rebuilt and new structural support back in. As of now—I have NO discs left at all in my entire spine–so the bone on bone is causing ever more spur development–soon to be a fusion. But never did I have anyone ignore me because I was only 40–my MRI’S and then Myelograms spoke for me. As for now–part of my spinal cord has flattened in the Cervical region. Yet the surgeons say they have a better chance at paralyzing me—than to help me. I have had 26 procedures to date. ENOUGH is enough. If they thought they could HELP & make some $$$,they would do so. I will never become some talking head for my husband to need to care for. That IS one thing I can spare this wonderful guy from.

  6. I looked info up and found this place to see if I could relate with others. I’m at my extreme wits end with these issues- it’s been 3 yrs since my 2nd cervical spine Surg. The 1st failed, the 2nd in 2016 a 4 level fusion both ant/post approach has left me with crippling pain, loss of range of motion, and a cascading amount of other new problems/ diagnosis. And the more I do, the worse it gets. Looking down to do any paperwork, computer, cooking, looking in my purse….makes the pain even more unbearable and it makes it hard to talk, breath, swallow…gives me constant headaches fro the occipital neuralgia, etc etc. I can’t take it anymore! I recently applied for disability and was denied because not severe enough!! I’m trying to do the Reconsideration forms and all I can do is cry from the pain from trying to fill out, make copies, etc. I’m almost done.i guess I don’t seem bad enough when you look at me but I’ve been in serious pain/ meds. Doctors don’t understand how bad, they just keep adding the problems to my records but can’t do anything but help with the pain. Thank you for listening. If you are wondering how I can write, have to prop up my iPad on table to eye level. Any advice for SSD would be helpful. Thanks, I was so happy and active before this😒

  7. I am 35 years old and I have all the things in my neck. My arms, back, and legs burn, I feel like I get pins and needles from my shoulders to the bottom of my feet. sometimes I feel as if I am going to fall over and now I am getting cluster headaches I don’t know what to do my dr. wants to keep giving me shots in the neck that don’t work. @35 I should not be feeling this bad.

  8. One day I woke up tumbling as I got out of bed. I figured I wasn’t fully awake maybe? As the hours passed my symptoms worsen. I had a bad headache, fever and felt extremely tired and with imbalance as I walked. Long story short I ended up not able to move my legs nor arms and hands. I was paralyzed. (I’m only 38) I had no idea what was happening to me? I was hospitalized and had many tests, spinal tab and blood work but they didn’t find anything wrong with me. Finally I was told it was cervical myelopathy affecting disc c3c4c4. Symptoms have improved with rest, I’m able to walk with a walker but I’m so fearful for my future.

  9. I have cervical spondloysis myelopathy and my doctor said i need surgery I have pain all the time not sure about the surgery. But not sure about the surgery

  10. Hello my name is Espanola Gilliam . I had two surgeries for my c4-6. I was told.” I would get better, but that was a lie. I’m only 44yrs, and was injured at my job, and was diagnosed with Cervical spondylosis with severe stenosis. I also have myelomalacia. I tell you this..” the surgery didn’t not help”. My neck feels like electric shock, and unbearable pain rushing down my lower extremities including buttocks pain. Not to mention the numbness in both of my hands. Can’t tell if I’m touching hot, or cold water and holding anything in my hands is a very waist of time. I can’t sleep at night, because I can’t breathe. I pray you all take your time, because this pain everyday I don’t wish on my worse enemy.

  11. Cervical spondylosis is a serious issue, which mainly targets the aging people or it can be seen in few of the middle aged persons as well. Poor posture, degeneration, long sitting and unprincipled sleeping cause such problems.

  12. I had recent onset (2-3 months ago) of numbness and weakness in left hand. I had surgery for bilateral carpal tunnel last year. At that time, the nerve conduction study showed ulnar nerve slowing, but I really had no symptoms. Carpal tunnel sx was 100% effective. So when my numbness seemed to come on a bit rapidly I thought it was from the typical cause, the elbow. But further nerve conduction studies showed it was related to a cervical issue. MRI showed severe spinal cord compression at c4-5 & c5-6 w cord bruising. Neurosurgeon was so worried, he scheduled 2 level ACDF immediately. So, sx is tomorrow. I have a friend who waited a long time to get this done and now suffers from permanent cord atrophy. I am very anxious to say the least. I will try to remember to write again post-op.

  13. Age has nothing to do with spine issues. I was misdiagnosed for decades and refused MRI and proper treatment. I was told I was not old enough to have spine issues. I was misdiagnosed with fibromyalgia until my cervical collapsed internally and was slowly severing my spinal cord, I was bed ridden. It was discovered I have congenital spinal stenosis. My entire spine is collapsing, only 7 thoracic levels are not having issues. I had injections as a teen and major spine surgery at 30 and still dozens of doctors would not listen or help until I was 49 and looking at being a quad. There is serious age discrimination in medicine and age has nothing to do with sickness, disease, birth defects etc… I was 49 when spine collapsed and ,I had shrink about 2 inches and looked like a hunch back with pain down my arms and legs. The quackery in medicine is appalling and misdiagnosis is killing 200,000+ people a year.

  14. I have cervical pain and doctors prescribe medicin I am afraid to take since I suffer high blood pressure, high colesterol, etc., and such medicines are not appropriate for me. Is there a medicine for my pain safe enough?

  15. My cervical spinal stenosis is located c3 to c7. Arthritic doctor said no surgery unless I want to be paralyzed from the neck down. Exercise never helped. Had terrible head pain for 1 1/2 years. Finally found a head doctor who at least gave me a medicine that takes away the constant headaches. Know Know my situation is getting worse with numbness in right fingers and loss of voice now and again. I’m living life to the fullest as best I can. Who knows what tomorrow brings. Good luck all.

  16. This is late April 2014. I have been through all the preop.stuff and I now waiting for an operation date. I am 59 years old and I retired last January and started feeling all the symtoms of spinal stenosis and had the M.R.I done and there it was three vertabraes sqeezing on my spinal cords also causing myelopathy. Did some internet hunting and found a wonderful neuro-surgeon at Toronto Western in Toronto Canada. His name is Dr. Taufik Valiante what a great and caring Doctor.

  17. I have had little to no voice for almost 2.5 years. I am experiencing severe neck pain and now pain going from my shoulder to my elbow on the right side. I have seen my primary physician, 2 ENT (going in September to my 3rd ENT), a neurologist, a pain management specialist, a physical therapist, orthopedic specialist and 2 speech pathologists. I have had tests after tests from MRI’s, brain scans, blood work, pain shots (which caused chemical meningitis).Has anyone else have these symptoms?

  18. I am on a count down to having this surery and am very scared bu the pain has got so
    Bad. I am sick of the twitching and the electrick shocks. My legs .arms and chest heart and now ji have head aches too. Life isn’t worth, living. My op is on the 30th and I would love sme feedback on what I can expect to improve. Thanks in advance. Ps I’m a 43 old mother dyNg to get out and about and get. A to work

  19. I have recently discovered that I have 4 discs pressing against the spinal column and my symtoms are extreme pain in the neck and pins and needles down the arm to the hand. I sometimes struggle to hold a pen and as I do many tile layout designs this is really bugging me. Doctor does not want to operate, my concern is would it not be better to operate now than wait until I am older and less able to handle surgery? Any suggestions out there?

  20. I too think I’m too young for this condition, yet here I am. The pain comes and goes, but when it comes, it is intense. I found quite a bit of relief from AminoActiv, which I rub directly on my neck. None of my doctors have suggested surgery.

  21. Pain has not improved. I saw ortho doctor for severe knee pain. He told my my myelopathy has now affected my tendons (tendinopathy). I am only 48 years old. I cannot believe something like this could happen at my age. Hopefully your father will have better results. My MRI does show a spinal cord lesion due to ischemia.

  22. Hi George
    My father has similar synptoms and we are assessing whether to go via surgical route. Did surgery help alleviate the pain in your case or in anyone’s case et all? Main concern for my father is inflammatory pain in back and limbs for last 5 years

  23. I had unexplained severe neck pain for years. Recently, I developed rapid progression of severe weakness and pain in arms & legs, unsteady gait, twitching and urinary hesitancy. MRI showed c5-c6 disk hernication with stenosis. Had surgery 5 weeks ago for cervical disk replacement. Arm and leg strength have improved, however I still have spasticity in arms and legs and significant pain. I fear chronic pain for the rest of my life. Please take neck pain seriously!

  24. I agree do not mess around with this problem! I had a tramatic fall 12 yrs ago beleive me when I say that I was told that it is just chronic pain I am living with on a daily basis even though I told doctors I temporarally lose feeling in my legs, pain can be anywhere at any given time, very debilitating I had 2 MRI done after the accident showed up in both cevrical & lumbar but finally a dr. gave me a diagnosis of this cevrical spondylosis joint w myelopethy just had my SSI hearing !!!

  25. Don`t mess around with this problem! If you feel the symptoms coming on, get it checked out immediately. I was diagnosed w/Cervical Spondylosis with Myelopathy about 4 years ago. I`m fused from C2 – C6 now. The pain , weakness & burning sucks. Nothing seems to help it except rest! Also, now I`m on SSDI & Medicare & only 53 years old.

  26. I have recently had a sudden attack of total weakness in all limbs.Thankfully temporary. I have C5 degenerative disc and narrowing to the spinal cord. Now I get general symptons but painfull neck.
    Neurologist says he is at a loss yet I have these symptons. Anyone else had same can help please?

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