Myelopathy is a 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.
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.
To determine the severity of the myelopathy you can use the Nurick classification. The classification is based on the abnormal gait of the patient. This study has proven to be sensitive and valid.
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 evaluating the myelopathy in different clinical groups.
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.
Myelopathy can sometimes be a slow process. Symptoms may develop slowly over a period of months or may progress very rapidly.Clinical distinction between myelopathy and other non-traumatic causes of myelopathy is difficult because the 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:• Discus hernia• Spinal cord infection• Facet degeneration• Ligamentum flavum hypertrophy• Calcification of ligamentum flavum• Compression by extradural mass (Spinal epilepsy) 1]• After tragedy deformities• Diseases• Angular kyphosis (congenital tuberculous neurofibromatosis and posttraumatic kyphosis)• Neurological disorders (abnormal spinal cord infarction and epidural hematoma)• Nutritional disorders
1. Years2 Increased rates of motor impairment and cognitive impairment.
Degree of spinal cord compression without proximal stenosis and intramedullary hypertension are predictors of surgical outcome.
The following characteristics may occur• Muscle weakness• Altered muscle strength• Loss of sensation (in the trunk and legs) and muscle weakness• Impaired coordination• Walking problems • Back pain• Urinary confusion
Cook et al. describe the following Cluster for the diagnosis of Cervical 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
- Inverted Supinator (IVS) and positive Supra-patellar reflex 1 each
- 2 of 2 positive Babinski sign and (IVS) .
- 2 of 3 positive Babinski sign Hoffmann Reflex and (IVS) .
- 3 of 4 Hoffmann Nerve Suprapatellar Reflex Babinski and (IVS) .
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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.
Other pathologies that may be involved in myelopathy are: • Spinal stenosis • Disc hernia • Spondylolisthesis • Disc bulge
The diagnosis of myelopathy depends on neurologic localization.  Imaging studies for myelopathy are critical.
Primary method: Magnetic resonance imaging (MRI) This can show reduced diameter of the spinal cord or abnormalities of the spinal cord and central spinal cord hypertension.
Other methods: 1. Computed tomography (CT) – you can see where there is bone damage or ligament damage2. Bone marrow imaging 3. X-rays – X-rays may show osteophyte narrowing of the spinal canal or bone destruction
- Nurick Classification
- Japanese Orthopedic Association Scale (JOA) 
- 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:
- Both the Nurick grade 30-metre walk test and the (mJOA) modified Japanese Orthopedic Association scale have high construct validity compared to the other measures used in the systematic review.
- Both JOA and mJOA were found to have high 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.
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. 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. 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 general 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.
The Japanese Orthopedic Association Scale can help us assess the severity of clinical symptoms in patients with myelopathy . 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   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. 
For more specific information on the cervical myelopathy physical exam, please read this page.
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.  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.  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.  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
Pathologically valid anterior cervical corpectomy extending beyond the spinal space
When we looked at the efficacy of laminectomy and laminoplasty, we found that they both showed an improvement in clinical disease severity in terms of functional status and quality of life, as measured at 24 months in patients with degenerative cervical spondylotic myelopathy. improved.
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.
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.
Hypertension can be managed conservatively with pharmacological interventions that will focus on increasing blood vessel size and use this to manage hypertension. This is because the diameter of the blood vessels in the cauda equina in the LSS patient is much smaller than in the. blood vessels in healthy individuals.
- Drugs : vitamin NSAID’s muscle relaxant and prostaglandin.
Non-surgical treatments also include physical therapy epidural injection and facet joint injection. When performing follow-up (up to 6 months) on LSS patients who underwent non-surgical treatment we conclude that there is significant pain relief and improvement in physical function for 3 months follow-up and significant improvement in COMI scores after 6 months. number of proofs 3B
There was no difference between LSS patients treated with epidural steroid injections and physical therapy in which both included a home-based exercise program and given diclofenac. Although there was no difference between both treatments they showed significant improvement in control group. number of proofs 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.  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
A surgical procedure is performed to preserve neurological function and pain and improve survival for at least 6 months.Postoperative complications and respiratory complications deep venous thrombosis pulmonary embolism cerebral edema and wound infection.Radiation therapy can be used postoperatively and may benefit when combined with corticosteroids or with Dexamethasone before radiotherapy (high ambulatory rate).level of evidence 2B
In a patient with a good prognosis, radiotherapy is indicated for maintaining pain relief or improving neurological function. In patients with a poor prognosis with a median survival of 6 months, radiotherapy will not help in the matter of neurological function and will only provide pain relief. A single dose radiation is associated with increased in-field recurrence.level of evidence 1A
Physical Therapy Management
As we know many causes can cause myelopathy. This is why myelopathy is so difficult to treat. Before treating myelopathy we need to have an idea of the cause. Improvement of symptoms of mild myelopathy with conservative treatment has also been reported in high doses about patients. Also continuous traction of the spinal cord improves symptoms of myelopathy.
In case-report-based case studies, physical therapy can achieve satisfactory results in patients with spondylotic myelopathy. Unfortunately, the symptoms were not completely alleviated. It has been reported that in the early stages manual therapy techniques can be used for reduction pain. The goal of the treatment is to create some space. Stretching and rotation at the pain level may therefore be beneficial. Hypotheses have been raised to explain the decreased pain and improved function achieved with manual therapy.
In the second phase, manual therapy may be necessary but not an integral part of treatment. This phase consisted of dynamic stretching exercises and active PNF or basic diagonals for the upper and lower limbs. The PNF is necessary when the patient exhibits symptoms of allergic rhinitis.
In the final phase the therapist may include aerobic exercises such as 20 minutes on a treadmill balance training such as standing on one leg with your eyes open or closed and core stability exercises sit as a posterior bridge or side bridge.level of evidence
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.  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.  Level of Evidence 3B
As far as we know very few studies have evaluated the results of physical therapy for viral myelopathy especially patients with T-lymphotropic virus 1. Exercise has shown the best results. So a simple protocol of six functional exercises only looks to have a positive impact on functional functionality. This protocol includes the use of an ankle-based ladder with a sitting and standing squat.level of evidence 2A
When we look at the effects of physical therapy pre –and post-surgical for patients with degenerative lumbar disorders we find that there is limited evidence to explain the use of physical therapy. Some researchers suggest that when early rehabilitation and early exercise are provided after surgery the patient will resume work activities are discharged early from the hospital and some measured postoperative milestones are reached early.Human T – lymphotropic virus type II will cause degenerative myelopathy. So divine counsel can do background.evidence level 1A
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