Presentation of a clinical case A 54-year-old man has had a stiff neck for approximately 1 year. He complains of numbness in his fingers and difficulty buttoning his shirt, which he has not improved after surgery for carpal tunnel syndrome. Lately, he has experienced instability and started using a cane after falling. A neurologist identified hyperreflexia in his arms and legs. Magnetic resonance imaging (MRI) shows multilevel cervical spondylosis and herniated disc causing spinal cord compression. A diagnosis of degenerative cervical myelopathy (DCM) was made and he was referred to undergo spinal surgery for surgical decompression. |
| What is degenerative cervical myelopathy? |
DCM, formerly called cervical spondylotic myelopathy, involves dysfunction of the spinal cord due to compression at the cervical level. Patients report neurological symptoms such as pain and numbness in the extremities, poor coordination, imbalance, and bladder problems.
Due to its mobility, the cervical spine is particularly prone to degenerative changes such as disc herniation, ligamentous hypertrophy or ossification, and osteophyte formation. These changes are more common with age and are globally called spondylosis.
| How common is it? |
The epidemiology of DCM is poorly understood, in part due to difficulties in diagnosis. • The prevalence of surgically treated DCM is estimated at 1.6/100,000 inhabitants. The actual prevalence is likely to be much higher. • The incidence of DCM is expected to increase with an aging population. In most patients, the diagnosis is made after the age of 50; DCM is rare before age 40 • Studies in healthy volunteers have shown that incidental compression of the cervical cord is detected on MRI, and becomes more common with age. In a series of randomly selected volunteers aged 40 to 80 years, incidental compression of the cervical cord was detected on MRI in 59% of individuals (108/183; 31.6% in the fifth decade to 66.8 % in the eighth decade). Only 2 individuals reported related symptoms • A proportion of individuals with asymptomatic spinal cord compression will continue to develop DCM. The exact figure is unknown. The only prospective study to consider this (n = 199) found that 8% of people with asymptomatic spinal cord compression will develop DCM after 1 year, and 22% overall over the observation period (mean follow-up 44 months). Many patients with DCM remain undiagnosed. A small study of 66 hip fracture patients found that 18% had a prior clinical diagnosis suggestive of MCDD |
| Why is it not diagnosed? |
Diagnosis may be delayed by the lack of specificity and subtlety of the first manifestations, which overlap with other neurological conditions. Also contributing to the delay is incomplete neurological evaluation performed by professionals with little awareness of the disease. A study in Israel of medical records of 42 patients undergoing surgery for DCM found an average delay of 2.2 years from the onset of symptoms to definitive diagnosis.
On average, 5.2 ± 3.6 consultations were required until the diagnosis was made. 43% of these patients had symptoms of numbness and pain in their hands, but were initially diagnosed, and sometimes treated, for carpal tunnel syndrome.
The authors state that, in their clinical experience, the diagnosis of carpal tunnel syndrome, especially when diagnosed bilaterally, is often incorrect and the symptoms are caused by DCM.
| Importance of diagnostic delay |
Delay in treatment results in worse outcomes and permanent disability
Spinal cord compression results in progressive neurological deterioration and affects quality of life. If left untreated, it can lead to tetraplegia and wheelchair dependence. Surgical decompression can stop the progression of the disease, but the regenerative capacity of the spinal cord is limited and any damage is usually permanent.
Delay in treatment results in worse outcomes and permanent disability. Findings from the AOSpine series (746 patients with DCM) indicate that treatment performed within 6 months of symptom onset offers the best chance of recovery, but this time frame is some distance from the current average time it takes to do the treatment. diagnosis.
| How is it diagnosed? |
Early detection of DCM can be challenging. A high index of suspicion is advisable along with a comprehensive neurological examination.
| Signs and symptoms commonly reported in DCM |
>> Symptoms >> Signs • Motor |
| Research |
If DCM is suspected, an MRI of the cervical spine should be requested in order to detect spinal cord compression.
For patients with progressive disease and/or symptoms that substantially affect quality of life, emergency MRI should be indicated. In patients with mild symptoms, an MRI may be ordered without urgency. Note that the extent of spinal compression and signal changes in the spinal cord that appear on MRI do not correlate well with the severity of symptoms. Even mild compression can lead to serious illness.
Diagnostic pathways vary according to local services. In the United Kingdom, for example, many primary care doctors do not have direct access to MRIs and must refer the patient to a neurologist.
| How it is handeled? |
Often, spinal cord compression is an incidental finding and, at least initially, causes no symptoms. The patient can be reassured that drastic measures are not necessary at this stage, but they should be advised to promptly report any symptoms in the future.
The AOSpine group of surgeons advises that all patients with DCM be evaluated by a specialized surgeon (neurosurgeon or orthopedist). Guidelines based on the Japanese Orthopedic Association score classify patients by symptoms as mild or severe, depending on arm, leg and bladder function.
Surgery is recommended for patients with moderate or severe DCM and those with progressive disease. Patients with mild and stable DCM may receive symptomatic treatment (e.g., analgesics) and regular follow-up.
The AOSpine series showed that decompressive surgery can halt disease progression and significantly, although limited, restore function through a range of measures including pain relief and improvement in function and quality of life.
The optimal timing for surgery is debatable because disease progression is poorly understood. Preoperative physiotherapy should only be performed by specialists; Manipulation of the neck is strictly contraindicated as it could cause further damage.
It is not possible to predict the long-term outcome of surgery. Maximum recovery occurs around 6-12 months. Residual symptoms after this period are likely permanent and should be managed appropriately.
Functional deficits are common, and include falls and reduced mobility, incontinence, depression, sleep deficits, and self-care difficulties; Often the most problematic symptom is pain.
It is recommended that the patient be well informed that the pain is unlikely to resolve completely. Neuropathic and antispastic analgesic medication may be indicated for the treatment of pain. Early referral to specialized pain clinics is often helpful.
Ask patients to report any worsening or new appearance of symptoms or signs, as untreated levels of the cervical spine could cause further degeneration and cause spinal cord compression.
