Cervical myelopathy - clinical fact sheet and MCQ

Overview

Cervical myelopathy is a progressive neurological condition arising from compression of the spinal cord in the cervical spine. The most prevalent form, degenerative cervical myelopathy (DCM), results from age-related changes such as intervertebral disc degeneration, ligamentous hypertrophy or ossification, osteophyte formation, and congenital or acquired spinal canal stenosis. It is the leading cause of spinal cord dysfunction in adults worldwide. Though the onset is often insidious, the clinical course varies; some individuals experience a gradual stepwise decline, while others remain stable for prolonged periods. However, even patients who appear stable may experience sudden deterioration. Therefore, ongoing monitoring is essential.

The condition most commonly presents in men, and age of onset is typically late 50s to early 60s. It predominantly affects the C5-C6 level of the spinal cord, followed by C6-C7 and C4-C5. The pathophysiology includes both static compression and dynamic stress during cervical movement, which contribute to vascular insufficiency, inflammation, and neural tissue injury.

Diagnosis of cervical myelopathy

Diagnosing cervical myelopathy in primary care can be challenging due to its gradual onset and symptom overlap with other neurological conditions. A high index of suspicion is essential, particularly in people over 55 with persistent neurological symptoms.

1. Common symptoms:

• neck pain or stiffness

• unsteady gait or frequent falls

• upper extremity clumsiness or poor hand dexterity

• lower limb weakness or stiffness

• ascending paraesthesia

• bowel or bladder dysfunction in advanced cases

Physical signs:

• upper motor neurone signs: hyperreflexia, clonus, Babinski sign, Hoffmann’s sign, inverted brachioradialis reflex

• decreased range of motion in the cervical spine

• spasticity or muscle atrophy

• Romberg’s test and toe-heel walking difficulties may indicate proprioceptive deficits

2. Red flags that warrant urgent referral:

• age <20 or older age at symptom onset

• neurological signs in multiple myotomes or dermatomes

• constitutional symptoms (eg fever, weight loss)

• history of malignancy, infection, immunosuppression, or trauma

• lymphadenopathy or spinal tenderness on palpation

3. Differential diagnoses:

• multiple sclerosis (relapsing neurological deficits; often younger adults; variable presentation)

• motor neurone disease (mixed upper and lower motor signs; no sensory involvement)

• Parkinson’s disease (resting tremor, bradykinesia, rigidity; lack of sensory signs)

• peripheral neuropathies (distal symmetrical sensory loss; no upper motor signs)

• syringomyelia and central lesions (cape-like sensory loss; affects pain and temperature pathways)

Investigations

• MRI of the cervical spine is the gold standard for confirming spinal cord compression and associated signal changes

  • contrast is required only on suspicion of neoplastic or infectious processes

  • if MRI is contraindicated, consider CT myelography or plain radiographs (for assessing alignment or osteophytes)

Management of cervical myelopathy

Management decisions are based on symptom severity, imaging findings, and disease progression.

1. Primary care role:

• early recognition and timely referral

• education about the progressive nature of the condition

• management of comorbidities and patient expectations

2. When to refer:

• any suspicion of cervical myelopathy warrants prompt referral to spinal or orthopaedic services

• red flag features or rapidly progressive symptoms require urgent referral, ideally via direct discussion with the on-call spinal or orthopaedic registrar

3. Conservative management may be appropriate for:

• asymptomatic patients with radiographic compression but no clinical signs

• mildly symptomatic patients in a stable plateau phase, with careful monitoring every 6–12 months

• patients managed non-operatively should be closely monitored for any signs of progression, and surgical options should be revisited promptly if symptoms worsen, as early surgical intervention may offer better outcomes

4. Definitive treatment:

• surgical decompression (eg anterior cervical discectomy and fusion or posterior laminectomy) is indicated for moderate-to-severe cases, progressive disease, or if there is significant radiological cord compression

• surgery can halt or improve neurological decline; better outcomes are associated with younger age, shorter symptom duration, and fewer comorbidities

References

Lebl DR, Bono CM. Update on the diagnosis and management of cervical spondylotic myelopathy. J Am Acad Orthop Surg. 2015;23(11):648–660.

Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2001;9(6):376–388.

Kane SF, Abadie KV, Willson A. Degenerative cervical myelopathy: recognition and management. Am Fam Physician. 2020;102(12):740–750.

McCartney S, Baskerville R, Blagg S, McCartney D. Cervical radiculopathy and cervical myelopathy: diagnosis and management in primary care. Br J Gen Pract. 2018;68(666):44–46.

Badhiwala JH, Ahuja CS, Akbar MA, et al. Degenerative cervical myelopathy—update and future directions. Nat Rev Neurol. 2020;16(2):108-124.

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