In most conditions of the spine we advise patience. Cervical myelopathy is the most important exception. Here it is not a nerve root that is irritated, but the spinal cord itself that is under pressure — and the spinal cord recovers less well than a nerve. This page explains how the often quiet signs are recognised, how myelopathy differs from a herniated disc, and why an operation comes up for discussion earlier here.
Clumsy hands, an unsteady gait and hardly any neck pain: that is cervical myelopathy, and it is easily mistaken for getting older. The aim of every treatment is to prevent deterioration — what has been lost does not always come back.
What is it?
The spinal cord runs in the spinal canal of the cervical spine, the cable for everything that is moved and felt below the neck. Wear can narrow this canal: bulging discs, bony outgrowths on the vertebral bodies and joints, thickened ligaments, less often an ossification of the posterior longitudinal ligament or a slipping of a vertebra. If the spinal cord is put under such pressure that it loses its function, this is called cervical myelopathy — more precisely, degenerative or spondylotic cervical myelopathy. In adulthood it is the most common cause of a functional disorder of the spinal cord.
The difference from radiculopathy is fundamental. In a herniated disc of the cervical spine, tissue presses on a single nerve root: the pain runs into one arm, along a strip, and the root usually recovers. In myelopathy the main cable is affected: the signs are found on both sides, in the hands and legs at the same time, often without appreciable pain — and damage that has occurred does not reliably resolve. A narrowing on the image alone is not yet a myelopathy; it becomes one only when the spinal cord shows signs of disturbance.
What symptoms occur?
Myelopathy begins insidiously, and the first signs are unspectacular: buttons become harder to do up, handwriting becomes untidy, small change falls out of the hand, the fingers feel furry or tingly — often in both hands. Added to this is an unsteadiness of gait: broad-based, stiff, unsure on uneven ground, in the dark and on stairs, with falls. The legs feel heavy or cramped. Some feel an electric sensation running down the back when bending the head forwards. Problems with passing urine — urgency, difficulty emptying — usually appear late. Neck pain can be present, but is often absent, which is why many of those affected do not connect the symptoms with the cervical spine.
The course is unpredictable: in many people the symptoms remain stable over a long time, in others they deteriorate step by step, occasionally also rapidly. Anyone who has long not dared to climb stairs without a handrail often already has part of the course behind them.
Causes
The cause is almost always wear, which increases with age: the discs lose height and bulge, bony outgrowths form on the vertebral bodies and joints, the yellow ligament thickens and folds into the canal on leaning back. Anyone who has had a narrow spinal canal from birth has less reserve. Less often, an ossification of the posterior longitudinal ligament, a slipped vertebra or an instability — for instance in rheumatoid arthritis in the region of the uppermost cervical vertebrae — narrows the canal. A herniated disc alone rarely leads to myelopathy, but a large central herniation can. Those affected are predominantly people from middle age onwards, men somewhat more often than women.
How is it diagnosed?
The diagnosis begins with the neurological examination, and here it is more decisive than any image. We test the fine motor control of the hands — for example, how often you can open and close your fist in ten seconds —, the walking pattern, standing with the eyes closed, the reflexes in the arms and legs, which are typically brisk, and certain signs that point to a disturbance of the long spinal cord pathways. From this a severity grade emerges, which we record as a score so that the course can be compared later.
MRI of the cervical spine shows where and how strongly the spinal cord is under pressure and whether it already shows a signal change — an indication of damage to the tissue. X-rays in forward and backward bending show an instability, a CT shows ossified ligaments. Electrical measurements of the nerve pathways can help when the findings and the symptoms do not fit together. Because an unsteady gait and clumsy hands also have other causes — diseases of the nervous system, a vitamin deficiency, nerve damage at the legs or wrists — a neurological assessment is part of it where things are unclear. The terms in your report are explained on the page Understanding your MRI report.
Warning signs
A myelopathy is usually not an emergency in the sense of hours, but it does not tolerate a delay of months. What belongs in an emergency department immediately — if in doubt via the emergency number 112 — is a weakness in the arms or legs that increases within hours or days, a new bladder or bowel problem, and deficits after a fall or a blow to the head with a known narrowing of the spinal canal: a spinal cord under pressure tolerates even minor injuries badly. More on this on the page Warning signs.
Conservative treatment
We say it openly: no medicine, no injection and no physiotherapy removes the narrowing that is pressing on the spinal cord. Treatment without an operation therefore has a different aim — to hold the condition steady and to notice a deterioration early. It comes into consideration in mild, stable myelopathy and in people for whom an operation would be too risky.
- Close monitoring — examination of nerve function at fixed intervals using the same score, so that a deterioration does not remain a matter of vague impressions. You yourself keep an eye on hands, gait and bladder.
- Supervised physiotherapy — gait and balance training, strengthening, fall prevention; aids where needed. Forceful manipulations of the neck, as are usual in some manual treatments, we expressly advise against where the spinal cord is under pressure.
- Pain treatment — for accompanying neck or arm pain, as with a herniated disc; it does not change the myelopathy itself.
- Protection from injury — caution with sports involving falls or blows to the head; no cervical collar as a permanent solution, because it weakens the muscles.
If the MRI shows a narrowing or compression but the examination shows no sign whatsoever of a spinal cord disorder, no preventive operation is carried out. You should, however, then know which signs you have to watch for, and be checked regularly — above all if a nerve root is irritated in addition, because the risk of a later myelopathy is then higher.
When an operation is considered
With a herniated disc, the pain decides, and one can wait, because the root recovers. In myelopathy, function decides, and waiting costs something, because lost spinal cord function does not reliably come back. The aim of an operation is therefore first and foremost to halt the deterioration; an improvement of existing deficits is possible, but not promised. Observational studies show that the prospects become worse the longer the symptoms have existed and the more severe they are at the time of the operation — that is the reason why we advise an operation earlier here than elsewhere.
The international guideline recommends an operation in moderate and severe myelopathy. In mild myelopathy both paths are justifiable — operation or supervised treatment with close monitoring — with the clear rule that an operation should be performed with any deterioration. No operation is carried out for a narrowing without signs of a spinal cord disorder. Beyond the guideline, your age, your other conditions, the number of levels affected and what you yourself expect from a procedure all count. We make the decision together, but without losing sight of the time.
Surgical options
The aim of every procedure is to create room for the spinal cord and in doing so to keep the cervical spine stable. Whether this is done from the front or from the back depends on where the narrowing sits, how many levels are affected, how the cervical spine is curved and whether it is unstable. From the front, the disc — and where needed a vertebral body as well — is removed and the space filled with a spacer (cage) that grows in with bone; from the back, the vertebral arches are removed and the segments stabilised with screws and rods. We offer both procedures, the decompression from the front with cage implantation and the decompression from the back with stabilisation. A laminoplasty, in which the vertebral arches are hinged open and held open, may come into consideration with several levels and a preserved curvature.
- ProcedureUnder general anaesthetic. From the front: lying on the back, a short skin incision at the front of the neck, the approach running between the carotid artery and the oesophagus to the spine; under the operating microscope the disc and constricting bone are removed, the cage is inserted and, where needed, a plate is fitted. From the back: lying face down, an incision in the middle of the neck, removal of the vertebral arches, screws and rods under X-ray guidance. The function of the spinal cord can be monitored electrically during the procedure. Duration and hospital stay depend on the number of levels; usually it is a few days.
- RisksAs with any operation, infection, bleeding, thrombosis and the risks of anaesthesia. With the approach from the front: difficulty swallowing and hoarseness, which usually pass, rarely an injury to the oesophagus or to vessels, a bleed with shortness of breath that has to be treated immediately. With the approach from the back: wound healing problems, persisting neck pain, a temporary weakness on lifting the arm, a later tipping forwards of the cervical spine. With both: an injury to the membrane around the nerves with leakage of spinal fluid, damage to a nerve root or the spinal cord with new or increased paralysis, a failure of the bone to fuse, loosening of implants, accelerated wear of the neighbouring segments — and the possibility that existing deficits remain despite a successful decompression. Which of these is to the fore in your situation, we discuss before the procedure.
- AftercareGetting up on the day of the operation or the day after; a cervical collar is as a rule not needed, or only briefly. For a few weeks no heavy lifting and no jerky head movements. Physiotherapy with gait and fine motor training, and rehabilitation where deficits are pronounced. The recovery of the spinal cord takes months; checks of nerve function and X-rays are part of it. Driving only after medical clearance.
Alternatives
In mild and stable myelopathy, supported waiting with firm monitoring and supervised physiotherapy is a justifiable alternative — on condition that you know the signs of a deterioration and that we measure them at every appointment. In progressive myelopathy there is no equivalent alternative to an operation. If you have been advised elsewhere to have a procedure, or advised against one, you can obtain a second opinion from us — in myelopathy, please without a long wait.
What to expect
After an operation the spinal cord recovers slowly, over months, sometimes up to a year; sensation and fine motor control often come later than strength, and a residue can remain. The most important success is unspectacular: that it does not get worse. What you can do yourself: continue the gait and balance training, avoid falls — light, handrails, firm footwear —, challenge your hands daily, and report every new deterioration, even if it seems small. With or without an operation, regular checks are part of it for as long as the narrowing exists.
Frequently asked questions
My MRI says “compression of the myelon” — do I have a myelopathy?
Not necessarily. The MRI shows the narrowing; the myelopathy shows itself in the examination. Many people have a compression on the image without a functional disorder. You should, however, be examined and know the signs you have to watch for.
Why is an operation performed earlier here than for a herniated disc?
Because a nerve root recovers and the spinal cord does not do so reliably. With a herniated disc, waiting buys time for self-healing; in myelopathy, waiting risks the loss of function that no operation brings back.
Will my hands be normal again after the operation?
That we cannot promise. The aim is to halt the deterioration; an improvement is possible and takes months. The shorter the symptoms have existed and the milder they are, the better the prospects are on average.
Can physiotherapy or chiropractic cure the myelopathy?
No. Physiotherapy keeps gait and strength in practice and prevents falls, but does not remove the narrowing. We advise against forceful manipulations of the neck where the spinal cord is under pressure.
What should I bring to my first appointment?
All images of the cervical spine on CD together with the reports, neurological reports if you have them, and your list of medicines. Everything else is on the page Your first appointment.