Treatment of Cervical Spondylosis with Degenerative cervical myelopathy: Cervical spondylotic myelopathy

Ross Hauser, MD

Treatment of Cervical Spondylosis

Many patients who visit us have stories of a long medical history. They will tell us about their decades-long battle managing their “health problems.”

Many people with cervical conditions, including cervical spondylosis, choose neck surgery as a treatment option.

Many people with cervical conditions, including cervical spondylosis, choose neck surgery as a treatment option. When a single nerve root is involved from a herniated disc, a posterior microdiscectomy is performed. When nerve roots (whether single or multiple) are involved because of cervical spondylotic osteophytes, a posterior decompression with a laminectomy and foraminotomy can be performed. There are various different operations to take out the bone, disc, and even ligaments to give the nerves more space. These include anterior cervical discectomy or corpectomy, posterior microdiscectomy, posterior cervical laminectomy, and of course, if the surgeon feels that so much tissue had to be taken out that the spine is now unstable, then a fusion also has to be performed. When compression of the spinal cord occurs because of severe cervical instability, anterior cervical decompression and fusion are often the operations of choice, though artificial disc replacements are gaining in popularity.

The reasons for spinal arthrodesis or fusion of the cervical spine include:

(1) to support the spine when its structural integrity has been severely compromised (to reestablish clinical stability),

(2) to maintain correction following mechanical straightening of the spine in scoliosis or kyphosis following osteotomy/laminectomy of the spine,

(3) to alleviate or eliminate pain by stiffening a region of the spine (i.e., diminishing movement between various segments of the spine), and

(4) to prevent the progression of deformity of the spine as in scoliosis, kyphosis, and spondylolisthesis. The risks of spinal surgery include infection; excessive bleeding; adverse reaction to anesthesia; chronic neck or arm pain; inadequate symptom relief; damage to the nerves, nerve roots or spinal cord; spinal instability; damage to the esophagus, trachea, or vocal cords; injury to the carotid or vertebral arteries; and subsequent stroke and non-healing of the fusion.

In the almost 30 years I have been a physician, there is not one body part where the surgical technique is the same today as it was when I started. Unfortunately, most of the surgeries that I assisted in my training are basically not even done anymore because they were such dismal failures.

Degenerative cervical myelopathy – a lack of understanding – diagnostic confusion and surgery recommendations

These people are in our examination rooms because they are looking for answers that they have not found in years of searching and they are fighting the feeling of abandonment from doctors who they believe have a lack of understanding of how to help them.

The patients will describe diagnosis after diagnosis, medical test after medical test, and medication after medication, all with no or short-term help for them. When all these treatments have failed, the patients tell us they get recommended for psychological counseling because they are depressed and nothing has helped them. Some will tell us that even their family and friends have started to doubt that their symptoms are real. Especially when stomach problems and nausea become common.

Degenerative cervical myelopathy – a lack of understanding discussed in the medical literature

Cervical spondylosis is a non-specific degenerative process of the cervical spine, which can cause varying degrees of stenosis of both the central spinal canal and intervertebral neural foramina. Factors contributing to this narrowing include degenerative disc, osteophytes, and hypertrophy of the lamina, articular facets, ligamentum flavum, and posterior longitudinal ligament. Unfortunately, patients and many surgeons do not consider factors such as the loss of cervical lordosis, vertebral body subluxation, and most importantly cervical instability in the mix, as all of these are treatable. Many are left with the belief that it is just osteoarthritis and that nothing can be done about it or that the bone spur has to be taken out by surgery.

There are neurological symptoms to consider as well. In addition to pain, the patient may feel numbness or weakness in their hands. They may suffer from balance problems and unsteady gait. Generally, people we see have already been sent for emergency MRI to discount a more immediate neurological crisis and have been told that what they are suffering from is a slow, degenerative process.

Let’s look at an April 2021 study in the Journal of Neurosurgery. Spine, (1) lead by researchers at the University of Toronto. What the researchers said was that while “Degenerative cervical myelopathy is among the most common pathologies affecting the spinal cord but its natural history is poorly characterized.” To help with this understanding the researchers then, “investigated functional outcomes in patients with Degenerative cervical myelopathy who were managed nonoperatively (after they had cervical spine surgery that did not alleviate many of their symptoms or conditions) as well as the utility of quantitative clinical measures and MRI to detect deterioration.”

Looking at patients after they had surgery

Symptoms

Neurological Functional Assessments

These researchers discovered that progressive deterioration was best detected with grip strength, hand dexterity, and gait stability. Using an MRI to assess symptoms was considered a poor diagnostic choice.

So what does this mean? It’s an understanding. 

Patients who had cervical spine surgery to address functional symptoms of degenerative cervical myelopathy following the surgery can have the severity of their degenerative condition better understood by loss of grip strength and gait instability. MRIs, for the most part, will not help with diagnosis or treatment for this patient group. Okay, we have this information. What do we do with it?

Static spinal stenosis and dynamic spinal stenosis

Severe spinal stenosis requiring surgery. The image below is of a patient we saw at our clinic. The patient had horrific nerve symptoms along with signs and symptoms compatible with spinal cord compression. Severe compression of the spinal canal can be seen by an extremely large bone spur from the C5 vertebrae in the A Neutral panel to the left. Panel compression is made significantly worse by an extension (looking up). In the far left panel, the neutral view spinal canal is narrowed by 25% in the center panel the spinal canal is narrowed by 50%.

Severe cervical spinal stenosis requiring surgery

In my opinion, it is of great importance for the patient contemplating cervical surgery, including fusion, to know the difference between static spinal stenosis and dynamic spinal stenosis.

Dynamic spinal canal or neural foramina stenosis means symptomatic narrowing of the space occurring with motion. The reason for this is the inability of the primary stabilizing structures, the spinal ligaments, from keeping the adjacent vertebrae from moving. This can only be objectively documented by motion x-rays, MRI, or CT scans. With these scans, it is easy to tell the difference between static and dynamic spinal canal and neural foraminal stenosis.

Degenerative cervical myelopathy symptoms worsened with certain neck movements

In this next segment, we will be discussing various neck movements that may cause the worsening of cervical myelopathy symptoms. In the image below we see what can happen when a patient looks down (cervical flexion) and the impact that cervical instability can cause on the cervical spine from C0-C7.

Degenerative cervical myelopathy symptoms worsened with certain neck movements

A November 2021 exploratory study published in the journal Frontiers in Neuroanatomy (7) revealed that the motor and somatosensory conductive functions (in simplest terms the control system of movement and many body functions) of the cervical cord changed in different ways in certain dynamic neck positions in cervical spondylotic myelopathy conditions.

Compared with somatosensory conduction (the electric signals and messaging centers), the motor conductive function of the cervical cord suffered more severe deteriorations upon cervical flexion, which could partly be attributed to its higher susceptibility to spinal cord ischemia (severe and sudden pain followed by limb or neck and upper back weakness).

The uneven angiogenesis (new blood vessel formation) and vascular distribution (blood flow) in the spinal cord parenchyma (the components of the electric signaling messenger system, the neurons, glial cells, and axonal) might underlie the transient ischemia (mini-strokes) of the cord at flexion. (7)

When the head is looking down, it disrupts new blood vessel formation and blood flow that supports the nervous system a further complication is that this may cause transient ischemia (mini-strokes).

Treatment for degenerative changes in the cervical spine

It typically begins with repetitive actions “overuse injury” that results in sprains (ligament damage) and rotational strains or compressive forces to the spine. This causes injury to the cervical facet joints which in turn can jeopardize the natural function of the cervical ligaments and cause cervical facet joint pain. Further degeneration can lead to abnormal motion in the cervical spine and cartilage breakdown.

In our own published research, we documented that the use of conventional modalities for chronic neck pain remains debatable, most treatments have had limited success and despite providing temporary relief of symptoms, these treatments do not address the specific problems of healing and are not likely to offer long-term cures. (2)

In this research, our team led by Danielle Steilen-Matias, MMS, PA-C, noted that the capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Such pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as:

Cervical Spondylosis cervical ligament damage

In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain. In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.

Degenerative cervical myelopathy and cardiovascular symptoms

A paper with an April 2023 (6) publication date in the journal Neural regeneration research discusses the restoration, rebuilding, and repair of blood vessels that service the heart and other organs, among them the brain in a situation of Cervical spondylotic myelopathy.

Surgery

Let’s look at a paper with an April 2023 publication date in the journal Neural Regeneration Research (6). Explanatory notes are added:

“In the progression of this condition (cervical spondylotic myelopathy), the microvascular network is compressed and destroyed, resulting in ischemia (restricted and reduced blood flow, so in this case the spinal cord and brain) and hypoxia (lack of oxygen). The main pathological changes are inflammation, damage to the blood-spinal cord barriers, (the barrier which protects the spinal cord from toxins, disease-causing pathogens, and blood cells from entering the delectate environment of the spinal cord), and cell apoptosis (cell death) at the site of compression. Studies have confirmed that vascular regeneration and remodeling (blood getting healing elements and oxygen to repair neural damage) contribute to neural repair by promoting blood flow and the reconstruction of effective circulation to meet the nutrient and oxygen requirements for nerve repair.

Surgical decompression is the most effective clinical treatment for this condition; however, in some patients, residual neurological dysfunction remains after decompression. Facilitating revascularization during compression and after decompression is therefore complementary to surgical treatment.”

We are going to return to this paper.

Please see my article Chronic Cerebrospinal Venous Insufficiency for a continuation of this discussion.

Cervical laminoplasty and cervical  laminectomy with posterior fixation

A November 2022 paper (8) compared the back approach cervical laminoplasty against cervical laminectomy with posterior fixation. Writing “There is still controversy concerning the technique in terms of outcome and complications,” the researcher’s aim was to analyze and compare from the clinical and radiological points of view these 2 techniques.

Many people with cervical conditions, including cervical spondylosis, choose neck surgery as a treatment option. When a single nerve root is involved from a herniated disc, a posterior microdiscectomy is performed. When nerve roots (whether single or multiple) are involved because of cervical spondylotic osteophytes, a posterior decompression with a laminectomy and foraminotomy can be performed. There are various different operations to take out the bone, disc, and even ligaments to give the nerves more space. These include anterior cervical discectomy or corpectomy, posterior microdiscectomy, posterior cervical laminectomy, and of course, if the surgeon feels that so much tissue had to be taken out that the spine is now unstable, then a fusion also has to be performed. When compression of the spinal cord occurs because of severe cervical instability, anterior cervical decompression and fusion are often the operations of choice, though artificial disc replacements are gaining in popularity. The reasons for spinal arthrodesis or fusion of the cervical spine include (1) to support the spine when its structural integrity has been severely compromised (to reestablish clinical stability), (2) to maintain correction following mechanical straightening of the spine in scoliosis or kyphosis following osteotomy/laminectomy of the spine, (3) to alleviate or eliminate pain by stiffening a region of the spine (i.e., diminishing movement between various segments of the spine), and (4) to prevent progression of deformity of the spine as in scoliosis, kyphosis, and spondylolisthesis. The risks of spinal surgery include infection; excessive bleeding; adverse reaction to anesthesia; chronic neck or arm pain; inadequate symptom relief; damage to the nerves, nerve roots, or spinal cord; spinal instability; damage to the esophagus, trachea, or vocal cords; injury to the carotid or vertebral arteries; and subsequent stroke and non-healing of the fusion.

Returning to the above research, the study authors continue: “However, since most people with Chronic cerebrospinal venous insufficiency present with obvious neurological symptoms, surgical decompression alone cannot completely reverse the pathological changes. It is reported that between 11% and 38% of patients still have some degree of dysfunction after decompression and delayed treatment can lead to worse outcomes or even lifelong disability.

Cerebrospinal fluid biomarkers (proteins indicating injury and inflammation) of brain white matter could predict the surgical outcome of degenerative cervical spondylotic myelopathy

In November 2022, European researchers writing in the Spine Journal (9) assessed whether cerebrospinal fluid biomarkers (proteins indicating injury and inflammation) of brain white matter could predict the surgical outcome of degenerative cervical spondylotic myelopathy. Going into the study, the researchers hypothesized CSF biomarkers levels would reflect the severity of preoperative neurological status (the compression of the brainstem in the neck for example); correlate with radiological appearance (radiological evidence of compression), and correlate with clinical outcome. Simply, CSF biomarkers would be elevated in people with neurological-type symptoms and MRI evidence of degenerative disc disease. The same results could help predict who would have a more successful surgery than others.

The researchers looked at twenty-three degenerative cervical spondylotic myelopathy patients, with an average age of 66 years old years. They found inflammatory markers were significantly higher in the degenerative cervical spondylotic myelopathy group compared to controls (people without degenerative cervical spondylotic myelopathy). The results suggest that Cerebrospinal fluid biomarkers of white matter injury and astrogliosis (damage to astrocytes specialized glial cells that protect neurons) make may be a useful tool to assess myelopathy severity and predict outcome after surgery while providing valuable information on the underlying pathophysiology.

In other words, Cerebrospinal fluid biomarkers may be able to provide the level of damage caused by spinal cord compression in degenerative cervical spondylotic myelopathy and how successful surgery may be for correcting it.

Understanding Prolotherapy treatment is understanding that we are treating Cervical Spondylosis by treating cervical instability

In our research study cited above we looked at how Cervical Spondylosis was described in the medical literature:

The degenerative cascade that causes Cervical Spondylosis, however, begins long before symptoms become evident.

When the ligaments aren’t strong enough to support the cervical spine – Doctors do not expect recovery with conventional treatments

Korean doctors writing in the medical publication the Asian Spine Journal give a good summary of the problem of Ossification of the posterior longitudinal ligament.

Ossification of the posterior longitudinal ligament is a condition of abnormal calcification of the posterior longitudinal ligament. The most common location is at the cervical spine region. Compression of the spinal cord caused by ossification of the posterior longitudinal ligament may lead to neurologic symptoms and in cases with severe neurologic deficit, surgical treatments are required.

However, the exact pathogenesis (origins) and natural history (progression) of ossification of the posterior longitudinal ligament remain unclear, there is no standard treatment for patients with asymptomatic ossification of the posterior longitudinal ligament, and there is disagreement about the best surgical approach for cervical fusion surgery. (3)

The same research team also gives us a good idea of the progression of treatments that lead to unsure surgery recommendation

As symptomatic treatments, pain medication, topical agents, anti-inflammatory drugs, antidepressants, anticonvulsants, non-steroidal anti-inflammatory drugs, and opioids can be applied, and bed rest and assist devices, such as a brace, are recommended for local stabilization. However, once the symptoms of myelopathy, such as gait disturbance and disorders of fine motor movement in the hand develop, appropriate recovery is not expected with conservative treatments. The patient moves on to surgery.

The research cited above comes from 2011, in a new study from August 2017, doctors at the Fujian Medical University in China published research in the medical journal Medicine that evaluated the effectiveness of various surgical interventions for the management of cervical spondylosis due to the ossification of the posterior longitudinal ligament. (4)

What is interesting in this study is that the doctors found success in treating patients surgically in a manner similar to the concepts of Prolotherapy. Let’s look at this fascinating comparison in bullet points:

Let’s finish up this comparison with conclusion notes from surgeons:

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms without many of the short-term and long-term risks of cervical fusion. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Medical research validating the use of Comprehensive Prolotherapy, from simple dextrose injections to stem cell prolotherapy injections is not new. There are 55 years of research supporting the use of Prolotherapy for problems of the neck and head. (5)

If you have questions about Cervical Spondylosis, you can get help and information from our Caring Medical Staff

 

References for this article:

1 Martin AR, Kalsi-Ryan S, Akbar MA, Rienmueller AC, Badhiwala JH, Wilson JR, Tetreault LA, Nouri A, Massicotte EM, Fehlings MG. Clinical outcomes of nonoperatively managed degenerative cervical myelopathy: an ambispective longitudinal cohort study in 117 patients. Journal of Neurosurgery: Spine. 2021 Apr 9;1(aop):1-9. [Google Scholar]
2. Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. Open Orthop J. 2014 Oct 1;8:326-45. doi: 10.2174/1874325001408010326. eCollection 2014. [Google Scholar]
3. Choi BW, Song KJ, Chang H. Ossification of the posterior longitudinal ligament: a review of literature. Asian spine journal. 2011 Dec 1;5(4):267-76.  [Google Scholar]
4. Wu D, Liu CZ, Yang H, Li H, Chen N. Surgical interventions for cervical spondylosis due to ossification of posterior longitudinal ligament: A meta-analysis. Medicine. 2017 Aug 1;96(33):e7590. Google Scholar]
5. HACKETT GS, Huang TC, RAFTERY A. Prolotherapy for headache. Headache: The Journal of Head and Face Pain. 1962 Apr 1;2(1):20-8. [Google Scholar]
6 Ren ZX, Xu JH, Cheng X, Xu GX, Long HQ. Pathophysiological mechanisms of chronic compressive spinal cord injury due to vascular events. Neural Regen Res. 2023 Apr;18(4):790-796.
7 Yu Z, Cheng X, Chen J, Huang Z, He S, Hu H, Lin S, Zou Z, Huang F, Chen B, Wan Y. Spinal cord parenchyma vascular redistribution underlies hemodynamic and neurophysiological changes at dynamic neck positions in cervical spondylotic myelopathy. Frontiers in neuroanatomy. 2021;15. [Google Scholar]
8 Domínguez VR, González ML, Feijoo PG, Alegre MS, Sánchez CV, López CP, Guerrero AI. Treatment of cervical myelopathy by posterior approach: Laminoplasty vs. laminectomy with posterior fixation, are there differences from a clinical and radiological point of view?. Neurocirugía (English Edition). 2021 Nov 17. [Google Scholar]
9 Tsitsopoulos PP, Mondello S, Holmström U, Marklund N. Cerebrospinal fluid biomarkers of white matter injury and astrogliosis are associated with the severity and surgical outcome of degenerative cervical spondylotic myelopathy. The Spine Journal. 2022 Jun 24. [Google Scholar]

 

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