Myelopathy

Definition/Description

Myelopathy is the term used to describe any neurological disorder involving the spinal cord. It is usually caused by compression of the spine by osteophyte or extruded disc material. It most commonly occurs in the cervical spine but can also occur in the thorax and duodenum.[1]

There are many major infectious diseases that cause neoplastic vascular idiopathic and nutritional disorders that cause myelopathy. These features are far less common than metastatic discogenic diseases or schizophrenia. Further explanation will be given in the following paragraphs.[1]

To determine the severity of the myelopathy you can use the Nurick classification. The classification is based on the abnormal gait of the patient.[2] This study has proven to be sensitive and valid.[3]

The diagnosis of myelopathy is based on metastasis to the spinal cord rather than to the brain or peripheral nervous system. Also the presence or absence of severe pain or trauma and the mode of onset are basic criteria for assessing the myelopathy in different clinical groups.[1]

Clinically Relevant Anatomy

The spinal cord originates in the cervical region below the skull. It continues to the thoracic region and finally to the lower spine where it connects to the pelvis and pelvis. The cervical segment consists of 7 vertebrae a thoracic segment with 12 vertebrae and a ventral segment with 5 vertebrae.

Between the corpus and the function of the spinal cord is the spinal canal. It is a region in the middle of the spinal cord where the spine descends and the muscles run towards the tip of its spine. The brain and spinal cord are packed with 3 layers: the dura mater the arachnoid mater and the pia mater. Each of them has their own structure and function.

Even though the spinal cord is well protected, it can be damaged by epidural or intradural factors. This is what happens when we talk about myelopathy.[4]

Epidemiology /Etiology

Sometimes myelopathy can be a slow process. Symptoms may develop slowly over a period of months or may progress very rapidly.Differentiating myelopathy clinically from other non-traumatic causes of myelopathy is difficult because conventional history is often absent or difficult to obtain from a critically ill patient.

There are many risk factors that can or will cause thoracic myelopathy.

Thoracic myelopathy occurs due to: • Disc herniation [1] • Spinal degeneration • Facet joint degeneration • Hypertrophy of the ligamentum flavum [5][6] • Calcification of the ligamentum flavum [5][6] • Compression of an epidural mass (spinal tumor )[1]• Posttraumatic Deformities[1]• Infections[1]• Angular kyphosis (congenital tuberculous neurofibromatosis and posttraumatic kyphoscoliosis)[7]• Vascular disorders (vascular malformation spinal cord infarction and epidural hematoma)[1 ]• Nutritional disorders[1]

Risk factor

1. Age 2. Extent of motor and sensory deficits [8]

Degree of spinal cord compression without proximal stenosis and intramedullary hypertension are predictors of surgical outcome.

Characteristics/Clinical Presentation

The following features may be present • Muscle weakness • Altered muscle tone • Sensory loss (trunk and legs) and spasticity • Impaired coordination • Difficulty walking[8][5] • Back pain[5] • Urinary disturbance

Cook et al [9] described the following clusters to identify the presence of cervical spondylotic myelopathy:

• Hoffmann’s Sign Test
• Cervical Deep Tendon Reflex Test
• Inverted Supinator Test
• Suprapatellar Quadriceps Test
• Hand Withdrawal Reflex Test
• Babinski Sign Test
• Clonus of the Ankle Test

1. Any 1 of 2 positive Inverted Supinator (IVS) and Supra-patellar reflexes
2. 2 of 2 positive Babinski sign and (IVS) .
3. 2 of 3 positive Babinski sign Hoffmann Reflex and (IVS) .
4. 3 of 4 Hoffmann Nerve Suprapatellar Reflex Babinski and (IVS) .

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Differential Diagnosis

Myelopathy can be difficult to diagnose because the clinical presentation varies and sometimes resembles that of other disorders. That is why it is important to have a thorough history and a thorough physical examination of the patient. In this case it is very hard to tell which symptoms are manifested by myelopathy or interstitial disorders.[10]

Other diseases that may accompany myelopathy include:• Spinal hernia• Discus hernia• Spondylolisthesis• Discus bulging

Diagnostic Procedures

The diagnosis of myelopathy is based on neurologic localization.[1] Imaging for myelopathy is very important.

Primary technique:Magnetic resonance imaging (MRI)[5][7][1]This may show reduced thickness or abnormality of the spinal cord in the cord and hypertension in the central nervous system.

Other methods:1 Computed tomography (CT) – Can detect bony injury or ligamentous injury when present2. Myelogram[5]3. Radiographs[1] – Radiography may show osteophytic narrowing of the spinal canal or bone destruction

Outcome Measures

• Nurick Classification
• Japan Orthopedic Association scale (JOA)[11]
• Oswestry Disability Index
• VAS – scale
• 30 minute walk test

Another systematic review published in The Journal of Spinal Surgery reviewing the literature to determine the measurement properties of all existing gait assessment tools for DCM found[12]:

• Both the Nurick scale 30-meter walk test and the (mJOA) modified Japanese Orthopedic Association scale had high levels of construct validity compared to other measures used in the systematic review.
• Both JOA and mJOA were found to have adequate levels of inter-rater reliability and test-retest reliability
• The 10-second step test Both the 30-meter walk test and the foot tap test also had acceptable levels of inter-rater reliability
• This study recommends the combination of mJOA and 30MWT (an objective functional test) for clinicians evaluating walking in DCM[12].

Examination

The diagnosis of myelopathy is based on mechanical determination of spinal cord stability. It should be noted that MRI is considered the gold standard for the diagnosis of myelopathy.[13] Physical examination often presents with long muscle signs such as spasticity hyperreflexia and abnormal reflexes. Written by Hoffmann Babinski and clonus are the most frequently tested reflexes[14]. A person with myelopathy has a positive Hoffman and/or Babinski and/or clonus test. We also often see a gradual deterioration in their hand and walking function. It may therefore be useful to assess the patient’s gait cycle if a toe-to-heel walk and the Romberg test.Myelopathy causes generalized weakness and nerve damage. That is why it is also important to test certain muscles with tests such as the Finger escape sign or the Rapid grip and release test.[14]

The Japanese Orthopedic Association Scale can help us assess the severity of clinical symptoms in patients with myelopathy [15]. It consists of 6 scales (upper extremity motor dysfunction lower extremity motor dysfunction upper extremity sensory function Trunk sensory function and bladder function of the lower extremities) are based on motor and sensory function with a maximum score of 17 points [14] [15] We should note that a modified Japanese Orthopedic Association score is used in Europe. The two scores show There is a good correlation between them in terms of their total score and recovery rate. [15]

For more specific information on the cervical myelopathy physical exam, please read this page.

Medical Management

Conservative treatment such as physical therapy for cervical spine immobilization or anti-inflammatory drugs is preferred. However, when patients develop intractable pain or progressive neurologic symptoms, surgical intervention is required. [16] As we mentioned above, myelopathy is usually due to compression. When surgical intervention is required, we will focus on decompression of the spinal cord and nerve roots. Prevention of deformity by maintaining or supplementing spinal stability would be another goal of this intervention. [16] There are a number of techniques describing spinal cord and root decompression Can be front and rear focal circles. The choice of the most effective technique depends on many factors, such as the positional comorbidity stability of the spine and the experience of the surgeon. [16] The following surgical techniques can be used for spinal cord decompression:

• Laminectomy is a posterior approach that has proven to be a safe and effective technique
• Laminoplasty is a posterior approach that allows decompression of the spinal cord while maintaining motion with minor substantial changes to natural biomechanics
• Anterior cervical discectomy is effective for ventral lesions such as osteophytes or disc complexes

The pathological efficacy of Anterior Cervical Corpectomy extends beyond the intervertebral spaces

Looking at the efficacy of laminectomy and laminoplasty we find that both show improvement in clinical disease severity functional status and quality of life as measured by 24 months in patients with degenerative cervical myelopathy.

When we look at the differences between anterior and posterior laminectomy in patients with cervical spondylotic myelopathy we find none regarding health-related outcome measures. We find that the anterior approach is more frequently used in the younger patient with the myelopathy is less severe.[17]

When we look at compressive myelopathy initially we realize that lumbar spine stenosis can be dangerous. Secondly we find that metastatic compression of the spinal cord can occur in myelopathy.

Lumbar spinal stenosis can be treated conservatively with the use of medications that focus on increasing the diameter of blood vessels and thus increasing blood flow. This is because the diameter of the cauda equina vessels in LSS patients is significantly smaller than Healthy blood vessels.

• Medications: vitamins NSAIDs muscle relaxants and prostaglandins.

Nonsurgical treatments also include physical therapy epidural injections and facet joint injections. In following up (up to 6 months) LSS patients treated non-surgically, we concluded that pain was significantly reduced and physical function improved after 3 months After 6 months of follow-up, COMI scores improved significantly. [18] Level of Evidence 3B

No differences were found between LSS patients treated with epidural steroid injections and physical therapy, both supplemented with a home exercise program and treated with diclofenac. Although there was no difference between the two treatments, the same Control group [19] Evidence level 1B

Lumbar spinal stenosis can be treated surgically with mild decompression surgery. This is a minimally invasive procedure. They will remove some of the posterior fibers of the hypertrophic ligamentum flavum and some interlaminar bone while maintaining anatomical stability and biomechanics of the lumbar spine spine.

The use of decompression compared to open laminectomy has shown the following benefits:

• fewer complications
• Fewer minor instability problems found postoperatively
• have a shorter operating length
• have less blood loss
• Shorter hospital stay (discharge same day)
• patient safety is much better

When the milder procedure is used, there is serial epidural contrast lateral oblique fluoroscopic imaging.

Metastatic spinal cord compression is another cause of compressive myelopathy. Spinal tumors are divided into 3 categories: epidural, intradural, extramedullary, and intradural. This metastatic spinal cord compression is diagnosed in 25-5% of cancer patients. [20] level Evidence 2A The type of medical management of these tumors will depend on spinal neurological stability and pain status. Surgical intervention is required when:

• Patient experiences paraplegia for no more than 12 – 24 hours
• spinal instability
• bony compression of the spinal cord

Performing surgery to preserve neurological function and pain will improve median survival by at least 6 months. Postoperative complications include respiratory complications, deep vein thrombosis, pulmonary embolism, cerebrospinal fluid leakage and wound infection. radiation Treatment can be applied postoperatively, with beneficial effects (higher outpatient rates) when combined with corticosteroids or with dexamethasone before radiotherapy. [6] Evidence Level 2B

In patients with good prognosis, radiation therapy can reduce pain and protect or improve neurological function. In poor prognosis patients with a life expectancy of 6 months, radiotherapy does not help with neurological problems and only relieves pain. single dose Radiotherapy was associated with a higher rate of field recurrence. [1] Evidence Level 1A

Physical Therapy Management

As we know, myelopathy can occur for many reasons. This is why myelopathy is so difficult to treat. Before we can treat myelopathy, we must understand the cause. A high percentage of symptoms of mild myelopathy have also been reported to improve with conservative management patient. Continuous spinal traction may also improve myelopathy symptoms. [twenty one]

Spondylotic myelopathy

Based on data from case reports, physical therapy can achieve satisfactory results in patients with spondylotic myelopathy. Unfortunately, the symptoms were not completely relieved. It has been reported that manual therapy techniques can be used in the initial stage to reduce pain. The goal of therapy is to give some space. So stretching and rotating at pain level is useful. [22] Hypotheses have been developed to explain the reduced pain and improved function of manual therapy. [twenty three]

In the second stage, manual therapy may be necessary but is not a major part of treatment. This phase includes dynamic upper and lower body exercises and functional or primitive diagonal exercises for upper and lower body PNF. PNF is only required if the patient shows signs of Paresthesia[23]

In the final phase, the therapist may perform cardio exercises such as 20 minutes on a treadmill with balance exercises such as standing on one leg with eyes open or closed, and core stability exercises such as back bridges or side bridges. [23] Level of Evidence 4

Another study reported that it is important to note that the number of patients with myelopathy treated conservatively is decreasing due to recent improvements in surgical outcomes. [21] This study performed continuous traction on the spine by the Good-Samaritan method, if the patient want it. Do it 3-4 hours a day. This is a combination of drug therapy and exercise therapy. Conservative treatment was considered effective if patients were intensively selected for CSM. [twenty one]

Surgery is required when symptoms do not improve or become worse. Therefore, long-term follow-up is only performed in patients who respond well to conservative treatment. [21] Level of Evidence 3B

Viral myelopathy

In our case, only a few studies have considered the outcome of physical therapy in viral myelopathy, specifically T-lymphotropic virus 1 patients. Physical exercise showed the best results. Therefore, a simple protocol of only six functional exercises appears to be Function. The protocol includes the use of toe standing, squatting, and standing stairs. [24] Evidence Level 2A

Degenerative myelopathy

When we looked at the effects of physical therapy before and after surgery in patients with degenerative lumbar disease, we found little evidence to describe the physical therapy used. Some researchers suggest that when given early rehabilitation and early exercise Postoperatively, patients will resume work activities, be discharged early and achieve some postoperative milestones early. [25] Human T-lymphovirus type II causes degenerative myelopathy. So the above suggestion could be [26] Evidence Level 1A