What is myelopathy?

We speak of myelopathy when the nerve tissue in the spinal cord of the cervical or thoracic spine is affected or damaged. The word myelopathy is composed of the ancient Greek components "myelon" for spinal cord and "pathos" for disease or injury. Inside the spine, there is the spinal canal in which the spinal cord runs until the lower spine where there are the nerve fibers. Between the vertebral bodies, nerves leave the spinal canal and continue into the arms or legs. If there is a constant or massive pressure on the spinal cord, caused by disc herniation, spinal canal stenosis, tumors or reduced blood flow, then the spinal cord tissue loses its vitality and leads, in the long term, to the damage and death of the nervous tissue with loss of function. Since the central nervous system (CNS) in this area cannot regenerate or multiply, the consequences remain permanent or worsen.

Depending on the cause of spinal cord affection, there could be different forms, in fact the localization (whether in the cervical or thoracic spine) of the myelopathy determines its symptoms.

Frequency of occurrence - men are twice as likely to be affected by myelopathy than women

Degenerative changes in the cervical spine are most likely to affect middle-aged and older-aged people. Interesting news: In a Japanese study, 1,155 patients underwent cervical myelopathy in a district of 2.26 million people. Most patients were in their 6th or 7th decade. In 30% of the cases there was spinal stenosis.

There are several causes for myelopathy

Of course, you want - and should - know what causes myelopathy.

Here are the answers. Basically, the damage to the spinal cord can be caused by various mechanisms. If the spinal canal is narrowed too much, it can lead to significant deficits on the arms and legs, with disruption of fine motor skills, sensation, gross force, and gait pattern. Partial or complete paraplegia can be caused by a not dilated spinal canal.

How do we get myelopathy? Damage to the nerve tissue of the spinal cord can be caused by acute traumatic experiences such as accidents. But herniated discs, spinal canal stenosis, tumors and cysts can also be the cause. Also inflammation and disturbances in the blood supply can also cause myelopathy. The different causes trigger different variants of myelopathy.

There are three different forms of myelopathy:

  1. Compression Myelopathy: It can arise from tumors, spinal and meningeal metastases, posttraumatic condition, after a vertebral fracture, traumatic and nontraumatic bleeding, contusion, after herniated discs, by spinal stenosis and spondylosis (wear).
     
  2. Vascular Myelopathy: Reduced blood flow leads also to damage the nerve cells in the spinal cord. Circulatory disorders occur in vascular malformations or vasoconstriction (stenosis). An acute blood loss can also lead to an undersupply of the spinal cord (shock symptoms).
     
  3. Radiation Myelopathy: You have probably heard of radiation damage. In fact, radiotherapy can damage the spinal cord.

Myelopathy - when symptoms develop insidiously

Myelopathy is characterized by various symptoms which usually develop gradually. They depend primarily on the region of the myelopathy. In the case of spinal cord compression, symptoms are usually painless and can appear after years, delaying then the diagnosis itself. First signs may be discomfort in the hands or soles of the feet, and uncertainties when walking in the dark. For all forms of myelopathy, the damaged spinal cord segments can no longer function properly in the nervous system, leading to neurological deficits.
 
Some patients complain of pain in the neck with radiation, numbness or loss of strength in the arms. Pain is not as important as neurological disorders when we talk about myelopathy. Also typical is the falling asleep of the arms or hands while sleeping at night. Initial symptoms may be increasing stiffness in the neck with pain when turning the head around. Damage to the spinal cord can also be accompanied by pain that radiates to the legs, causing gait insecurity and loss of control over the bladder or bowel. Be very careful if your motor disabilities in your hands increase, if your calligraphy becomes square or "thin" and if objects fall from your hands. These can be symptoms caused by myelopathy as well as the inability to button up a shirt. Cervical myelopathy has a progressive course. At the onset of the disease mild motor (gait disturbances) and sensory loss of function of the upper and/or lower extremities can be perceived. Atrophy of hand muscles and of the arm with weakness is often seen. Unilateral compression can lead to sensory disturbances and increasing motor failures (Brown-Séquard syndrome).

When myelopathy affects the thoracic spine, symptoms are similar to those resulting from cervical myelopathy. The symptoms occur insidiously and result from the loss of function of the affected spinal cord areas. Characteristic features are weakness and stiffness in the legs, difficulty in breathing, atrophy of muscles, sensory disorders, gait disturbances, sensory disturbances, paralysis, bladder, bowel disorders and by men disturbances in erection.

Vascular myelopathy manifests itself in different functional failures, depending on the affected vessels. Patients complain of weakness, numbness, motor skills disorders, bladder emptying problems, balance and sexual disorders, and stiffness of the muscles. In the advanced stage, tissue atrophy and difficulty in breathing can also be a consequence.

Myelopathy makes the diagnosis difficult for the doctor

Basically, two things must be said about diagnostics:

  1. An accurate diagnosis is a prerequisite for suitable therapy.
  2. The sooner a diagnosis can be made, the sooner a disease is detected, the better the prognosis for a complete recovery can be made. That's obvious, and you may have experienced it yourself. Motto: Quickly recognized - quickly banned!

Myelopathy, on the other hand, makes the diagnosis difficult for the doctor - and there is a reason: There is no specific early detection mark, in other words: The disease process in myelopathy is often creeping and not very visible so that a diagnosis is often made only with advanced disease. In addition to the disease itself, this is the perfidious thing about myelopathy.

That is why it is particularly important in diagnostics to drive double-tracked: conversational and clinical examination. That is the reason why the doctor will ask you about the type of symptoms (loss of function, pain, bladder or rectal disorders) and about possibly known pre-existing conditions: ankylosing spondylitis, spondylarthrosis, trauma, osteoporosis, herniated disc, arterial circulatory disorders or radiotherapy.
 
It follows the neurological status with the examination of the gait pattern, the tests for pathological reflexes and sensory disturbances (anesthesia).

Then it comes to the use of diagnostic imaging, such as MRI (magnetic resonance imaging). Conventional X-rays can show good bone changes. Additional functional recordings should always be made to detect any instability.

Magnetic resonance imaging is the most important method of investigation to detect myelopathy. So this is THE method that should be chosen for the diagnosis. On the one hand, one can see structures compressing the spinal cord, such as a herniated disc or tumors. On the other hand, the MRI allows makes visible the distinction of damaged spinal cord regions from healthy neural tissue. Electrophysiological measurements (such as nerve conduction velocity, evoked potentials, etc.) provide important information about the spinal cord function.

Normally, the doctor will also conduct a laboratory examination of the blood to detect possible inflammation in the body.

There are different degrees of myelopathy - here's the European myelopathy score. Check your conditions:

 

The European Myelopathy Score (EMS):

A. Functions of the First Motor Neuron (Gait)

Points

Inability to walk, help needed

1

On flat ground only with walker/support

2

Climbing stairs only with walker/support

3

Unstable walk, gait pattern appearing plump

4

Normal gait

5

   

B. Functions of the First Motor Neuron and the Afferent System

Points

Overflow incontinence, no control

1

Problems of complete emptying and unstable frequency

2

Normal bladder and bowel function

3

   

C. Functions of the Second Motor Neuron

Points

Handwriting/eating with cutlery is not possible

1

Handwriting/eating with cutlery is limited

2

Handwriting/shoelace tying awkwardly

3

Normal handwriting/fine motor skills

4

   

D. Functions of the dorsal horn (Proprioception and Coordination)

Points

Dressing/undressing only with help

1

Dressing/undressing awkward and slow

2

Dressing/undressing normally

3

   

E. Posterior roots (segmental radicular paresthesia/pain)

points

Invalidating pain

1

Recoverable paraesthesia/pain

2

No paresthesia/pain

3

   

Sum: Division by score

 

Points

EMS degrees

5-8

Grade III

9-12

Grade II

13-16

Grade I

17-18

normal

The therapy includes physiotherapeutic measures

Conservative therapies are very limited but important as adjunctive therapy. Only at an early stage can mild pain be treated by medication. In case of intense pain, will be necessary a tailored-made therapy, in which anti-inflammatory and muscle-relaxing medications are included.

However, the actual causes of myelopathy can only be eliminated by microsurgery. The aim of a neurosurgical procedure is to remove or eradicate the causes in order to give to the spinal cord and the nerves more space. If there is a herniated disc, calcification (spondylosis), tumor, cyst, they will be removed with the help of a special microscope and micro-instruments. On the other hand, in the case of spinal canal stenosis microsurgery will be necessary to enlarge the spinal canal. In addition to the pressure relief or space creation for the neural structures there is usually a replacement of the disc with disc prosthesis or cages (placeholder). In some cases additional plating, dorsal stabilization or vertebral body replacement is necessary. Of course, subsequent physiotherapeutic measures are fundamental.

Back pain? Visit a specialist!

Listen to your body an visit your doctor. If you take it seriously - and you should, after all, it's about your health we are talking about - you should know and implement a few things. This includes: If you have long-time severe back pain in certain areas or even functional failures or abnormal sensations, then seek out immediately a specialist that should be a spine specialist, neurosurgeon or orthopedist.
 
If it comes to an operation, you should know that: in about 90 percent of all patients, there is an improvement. Of course, it is most evident when the disease is diagnosed with mild symptoms and operated on early. Since these state-of-the-art cervical spine operations are performed more gently and faster today, mobilization takes place the day after the operation. The head will be supported by a soft color for one to two weeks.

Also reassuring: at the surgically operated and immobilized height the disease does not occur again.

It is, of course, better to prevent the disease than any therapy. Here are some tips:

  • Avoid one-sided strains.
  • Avoid permanent malposition.
  • Move regularly.
  • Strengthen your back and abdominal muscles.
  • Seek the help of a physiotherapist even for mild ailments.
  • Avoid working with your neck bent for a long time, as well as pinching the phone between your head and shoulder.
  • When working on the screen, you should look as straight as possible.
Dr. med. Munther Sabarini

Author
Dr. med. Munther Sabarini
Specialist in Neurosurgery

Hans-Heinrich Reichelt

Co-author
Hans-Heinrich Reichelt
Chief Editor of Medizin für Menschen

The Avicenna Clinic in Berlin is always willing to help you

Since the year 2001, the Avicenna Clinic is based in Berlin. Our doctors have at least 25 years of international experience in their respective fields (neurosurgery, spinal surgery, anesthesia, and orthopedics).

If you have severe back pain, a herniated disc or a suspected herniation, please contact us using the following information:

Avicenna Clinic
Paulsborner Str. 2
10709 Berlin

Telephone: +49 30 236 08 30
Fax: +49 30 236 08 33 11
E-Mail: info@avicenna-klinik.de

You can call anytime, write an e-mail or fill out a callback form. Each patient then gets an appointment with a doctor of our clinic, who is a spine specialist (neurosurgeon). Based on MRI images (brought or made in our clinic) and on an in-depth examination, the doctor will discuss with you all the different therapy options or possibly surgery. You can also use our specialists only to obtain a (second) opinion.

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