Neurosurgery notes/Spine/Spinal Degenerative Diseases/Cervical degenerative disease/Silent spondylotic cervical cord compression

Silent spondylotic cervical cord compression

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Cervical degenerative disease

Definition:

  • Presymptomatic spondylotic cervical cord compression (P-SCCC)
    • Definition
      • No myelopathic symptoms
      • No myelopathic signs
      • MRI shows significant cord compression
  • Non-myelopathic Spondylotic Cervical Cord Compression (N-SCCC)
    • Definition
      • No myelopathic symptoms
      • Presence of myelopathic signs
      • MRI shows significant cord compression

Numbers

  • Kovalova 2016:
    • MRI signs of cervical cord compression without myelopathy were found in 59.0%
    • 50 years old: 31.6%
    • 80 years old: 66.8%
  • Smith 2021
    • 24% of healthy individuals have asymptomatic spinal cord compression (ACCC) on MRI;
    • prevalence rises to 35% in those over 60 years old.

Clinical presentation

  • Neck pain
    • Acute neck pain
      • Soft tissue sprains
      • muscle strains,
    • Chronic neck pain is more suggestive of a spondylotic source.

Modifiable factors

  • Smoking
  • Obesity
  • Occupational hazards
  • Psychological factors.

Investigation

  • Kovalova 2016: AP cervical canal diameter at the level of intervertebral disc < 9.9 mm OR = 32.5 of Non myelopathic spondylotic cervical disorder

Management

  • Annual clinical examination + MRI scan
  • Advice for patients
    • Good Patient-Doctor Relationship
    • Inform about Red Flags (Early):
      • Tingling in both hands
      • Radiculopathy
      • Dragging of leg
      • Lhermitte's sign +
    • Avoid Accidents (Potential for Rapid Worsening):
      • Acceleration/Declaration
      • Rigorous physical/sporting activity
      • Chiropractor procedure
  • if mild symptoms
    • Brief trial of rest and immobilisation with a soft cervical collar.
    • Medications
      • Narcotics
      • NSAIDs
      • Oral steroids
      • Antidepressants
    • Short-term (< 2 weeks) use of cervical collars
      • Prolonged immobilization should be avoided to prevent atrophy of the cervical musculature.
    • Traction (at home)
      • Should be avoided in myelopathic patients to prevent stretching of a compromised spinal cord.
    • Physio
      • Participation in an active rehabilitation protocol seems much more likely to be successful than use of passive modalities.
      • Cervical manipulation should not be undertaken without an adequate radiographic examination to screen for potential instability, given complications that include radiculopathy, myelopathy, spinal cord injury, and vertebrobasilar artery injury.
    • Injections
      • Cervical epidural injections, or selective root blocks
      • Help most in those with neck pain and radiculopathy
      • Unclear whether they alter the natural history of radiculopathy or surgical management.
      • Complications
        • Dural puncture
        • Meningitis
        • Epidural abscess
        • Intraocular hemorrhage
        • Adrenocortical suppression
        • Epidural hematoma
  • Surgery
    • Indicated for
      • Myelopathy
      • severe or progressive neurologic symptoms,
      • failure to improve with time
    • Poor outcome if surgery done for
      • axial neck pain alone from disc degeneration are not.

Natural hx

  • 40-50% becoming pain free/no recurrence
  • 20-30% getting worse/persisting (i.e. 70-80% improve to varying degree).
  • Wilson 2013
    • 8% of non-myelopathic patients develop myelopathy in 12 months;
    • 22.6% at a median of 44 months
    • The absence of MRI intramedullary T2 hyperintensity has been shown to predict early myelopathy development (<12-mo follow-up)
    • The presence of MRI intramedullary T2 hyperintensity has been shown to predict late myelopathy development (mean 44-mo follow-up).
  • Bednarik 2008
    • Early progression into SCM in 81.4% of the cases
    • Risk factors for progression:
      • Onset of radiculopathy
      • Electrophysiological abnormalities (< 12 Months)
        • SSEP
        • MEP
      • MRI hyperintensity,
        • some how time-to-CSM development was later (>12 months)