By Jeffrey R. Carlson, MD
As a Spine Specialist, I regularly complete cervical spine assessments on patients with balance issues. Cervical Spondylotic Myelopathy (CSM) is related to the compression of the spinal cord in the neck. This compression disrupts the normal communication between the brain and the body, slowing the information flow through the spinal cord to the rest of the body. Most commonly, this compression can be caused by arthritic or degenerative changes to the boney structure of the cervical vertebrae and the spinal discs, which lead to narrowing of the spinal canal.
Arthritis-related CSM can be the cause of balance issues for patients over the age of 50. Genetic, occupational or environmental influences may also contribute to compression of the spinal cord earlier in life. Rheumatic Arthritis and injury, such as a sports injury or MVA, may also cause spinal cord compression in the cervical spine. Patients born with a smaller spinal canal are pre-disposed to early spinal cord compression. Early diagnosis and treatment is essential to mitigate permanent nerve damage and loss of function.
Reported symptoms can vary widely, but a loss of balance and coordination is often seen, along with typical nerve pain symptoms. Fine motor skills may suffer as patients find it harder to write or button clothes. Hyperreflexia may be present, which can make it more difficult for patients to know how much pressure is needed for tasks with their hands and feet. The patient may have trouble walking, a wider stance, balance or gait disturbance and weakness in the legs. Muscle atrophy may be observed. Sensations of spinning, dizziness or vertigo do not occur.
Symptoms usually start gradually and worsen with time, typically with periods of dormancy and episodic worsening of neurologic function. Often, changes to motor or sensory functioning are so subtle that patients ignore them until function becomes significantly impaired. These symptoms can be confused with signs of aging and/or dementia, totally unrelated to the actual diagnosis, and can be a great source of worry for the patient. Patients with traumatic CSM see a dramatic onset of symptoms and rapid worsening.
Diagnosis of cervical spondylotic myelopathy is made after a comprehensive history and physical, a discussion of symptoms and radiographic evidence provided by x-ray, and MRI or CT scan. A positive Romberg’s sign test and balance testing provides confirmation of CSM.
Operative treatment remains the standard of care for the majority of CSM cases. The presentation of symptoms, along with age, activity level and level of functioning considerations, will predicate treatment. Mild cases can be treated with anti-inflammatory medications or epidural steroid injections, physical therapy, and the judicious and limited use of a soft cervical collar. These patients should be monitored carefully for active disease progression and should be informed of the potential for permanent neurologic dysfunction.
The surgical options to be considered will be determined by the severity of symptoms and at which vertebral level the spinal cord is compressed. Anterior and/or posterior surgical approaches may be used, depending on the number of levels involved, for ACDF, laminectomy, laminectomy with fusion or decompression with laminectomy (laminoplasty).
Each surgery and approach has unique risks and the potential for complications. Patients should be advised of those risks and be made aware of the likelihood of longer-lasting recovery issues. The most important issue is early diagnosis. As patients deteriorate due to compression on the spinal cord, the nerves will become permanently damaged. If the process continues until the patient is wheelchair bound, there may not be a way to improve their functional ability, even with surgery. Patients with early signs should be monitored closely and informed that there is no guarantee of a return to normal neurologic function or balanced walking if the spinal cord and nerves are damaged.
Jeffrey R. Carlson, MD is the President and Managing Partner of Orthopaedic & Spine Center in Newport News, VA. He holds a fellowship in Orthopaedic Trauma surgery and a combined Neurosurgery-Orthopaedic fellowship in complex spine surgery from Brigham and Women’s Hospital in Boston. osc-ortho.com
