Overview
Cervical myelopathy is a progressive neurological syndrome resulting from compression of the spinal cord within the cervical spine. It is the most common cause of spinal cord dysfunction in adults over 55 and one of the most consequential — and frequently underdiagnosed — conditions in spine medicine. Unlike radiculopathy, which involves single nerve root compression, myelopathy reflects dysfunction of the spinal cord itself and carries a fundamentally different prognosis and urgency for treatment.
Pathophysiology
Cervical myelopathy most commonly develops as a consequence of multilevel degenerative changes: disc herniation, osteophytic spur formation, ligamentum flavum hypertrophy, and ossification of the posterior longitudinal ligament (OPLL). These structural changes progressively narrow the spinal canal, compressing the cord and impairing its microvascular supply. The cervical cord is particularly vulnerable given the proximity of its cross-sectional area to the critical diameter of the native canal. Without decompression, the majority of patients experience stepwise or gradual neurological deterioration over time.
Symptoms
- Hand clumsiness — difficulty with fine motor tasks (buttoning, writing, handling utensils)
- Gait instability — broad-based, shuffling, or unsteady walking
- Bilateral upper or lower extremity numbness or tingling
- Grip weakness and intrinsic hand muscle wasting
- Hyperreflexia, clonus, Hoffman sign, and Babinski response on examination
- Lhermitte’s phenomenon — electric sensation radiating down the spine with neck flexion
- Bladder urgency or incontinence in advanced cases
- Neck pain is often absent or minimal, making early diagnosis challenging
Diagnosis
MRI of the cervical spine is the essential diagnostic study, demonstrating the level and severity of cord compression and any intrinsic cord signal change (T2 hyperintensity) which indicates established myelopathic injury. CT myelography supplements MRI when OPLL or bony pathology requires detailed characterization. Neurophysiological testing (somatosensory and motor evoked potentials) objectively documents corticospinal tract dysfunction and establishes a functional baseline.
Severity Classification
The modified Japanese Orthopaedic Association (mJOA) scale is widely used to quantify myelopathy severity across domains of motor function, sensation, and sphincter control. Surgical planning and expected outcomes are informed in part by baseline mJOA score and duration of symptoms prior to intervention.
Surgical Treatment
Surgical decompression is the only treatment that can halt progression and facilitate neurological recovery in cervical myelopathy. The approach — anterior or posterior — is determined by the number of affected levels, the primary direction of compression, cervical alignment, and patient-specific anatomy.
- ACDF (anterior cervical discectomy and fusion): Ideal for 1–2 level anterior compression; directly removes the offending disc and osteophyte
- Cervical disc arthroplasty: Motion-preserving alternative to ACDF in carefully selected patients
- Posterior laminoplasty: Expands the spinal canal while preserving motion; preferred for multilevel compression with preserved lordosis
- Posterior laminectomy and fusion: Indicated when decompression must be accompanied by instrumented stabilization due to kyphosis or instability
Urgency of Treatment
Cervical myelopathy is a progressive condition. Once spinal cord signal change is present on MRI, the window for optimal neurological recovery begins to close. Early surgical consultation is strongly recommended for any patient with myelopathic signs or symptoms.
Consult Dr. Kevin Kwan
Dr. Kwan has subspecialty expertise in the surgical management of cervical myelopathy, including complex multilevel cases and those with ossification of the posterior longitudinal ligament. His approach emphasizes precise decompression, sagittal alignment restoration, and durable neurological preservation.