Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Cervical Spinal Stenosis and MyelopathyLuc Peeters, MSc.Ost. & Grégoire Lason MSc.Ost.The International Academy of Osteopa...
A high cervical lordosis (more than 40°) increases the risk for cervical stenosis.Myelopathy is a degeneration of the gray...
Cervical stenosis                            Wasting of small muscles in handsCervical stenosis is a degenerative disease....
b. Reduce the anterior translations of the different cervical segments by:                     i. Translation of every cer...
•   Meyer F., Börm W. & Thomé C. (2008) "Degenerative cervical spinal stenosis:           current strategies in diagnosis ...
Upcoming SlideShare
Loading in …5
×

Cervical spinal stenosis and myelopathy

3,355 views

Published on

Also visit: http://www.ineuro.be/Welcome.html - A must have for every osteopath and health care provider. Simple to use and no unnecessary information. It keeps your knowledge sharp for daily patient care!

Also look for iBooks in the iBook store from Luc Peeters and Grégoire Lason.

Published in: Health & Medicine
  • Be the first to comment

Cervical spinal stenosis and myelopathy

  1. 1. Cervical Spinal Stenosis and MyelopathyLuc Peeters, MSc.Ost. & Grégoire Lason MSc.Ost.The International Academy of OsteopathyWe all know elderly patients with a variety of symptoms: • Neck pain; not always severe and of different nature. • Pain, weakness, or numbness in the shoulders, arms, and legs. • Hand clumsiness. • Gait and balance disturbances, often starting in the dark. • Burning sensations, tingling, and pins and needles in the involved extremity, such as the arm or leg. • In severe cases, bladder and bowel problems.In all these cases cervical stenosis causing myelopathy must be suspected.Typical is that the neurological signs do not always correlate with the radiologicallevel of the compression.Cervical spinal stenosis specifically refers to compression of the nerves or spinalcord by degenerative arthritic tissues (i.e. ligaments and bone spurs).These types of changes take many years to develop and in general happen toeveryone as we age. Certain factors such as genetics or lifestyle (heavy lifting,smoking), traumatic injuries can accelerate these degenerative processes.Many patients with cervical stenosis have a history of some kind of injury or traumato the neck, however this trauma may have occurred many months or even yearsbefore the onset of stenosis symptoms.Importance of the cervical lordosisThe cervical lordosis Occ-C7 averages 40°.This normal lordotic curvature is necessary to capture the weight of the head in aneconomical way. Too little lordosis will lead to discus compression and too muchlordosis to facet compression and dysfunction.Most of the lordosis occurs at the C1-2 segment. 40°     1  
  2. 2. A high cervical lordosis (more than 40°) increases the risk for cervical stenosis.Myelopathy is a degeneration of the gray matter (necrosis, cavitation, change invascular morphology) and is already seen in the third life decade (peak 51-60). Thelevels C5-6, C4-5 and C6-7 are most involved.The typical signs in myelopathy are: • Wasting of small muscles in hands. • Weakness of deltoid is characteristic. • Extension contractures of finger joints. • Numbness and paraesthesia in hands. • Difficult to use spoon, button shirt.Cervical stenosis and accompanying myelopathy seem to be one of the importantcauses for “getting old”. In a preventive way the osteopath must be aware of this.Keeping the cervical spine in good condition, especially good vascularization andsufficient flexion are good measures to maintain optimal functioning at old age.The diagnosis of cervical myelopathy can be done through the case history andcervical X-ray. Several neurological tests can also be conclusive: • The Babinski reflex is positive. • L’Hermitte’s sign: o Electric shock sensation in upper- and lower extremities or trunk. o 25% of patients with cervical spondylitic myelopathy. • Scapulohumeral reflex positive: o 95% of patients with high cord compression. o At C1 to C4 neurological levels. • Hoffman’s reflex positive: o Reflex finger and thumb flexion with sudden middle finger distal interphalengeal joint extension. o When found, especially unilaterally, this indicates cord impingement. • Prominent pectoralis jerk, significant for C2-3 and C3-4 levels. • Deltoid reflex: trend: C3-4 and C4-5. • Finger escape sign: ring and little finger drift into flexion/abduction when actively holding hand out flat with palm down. • Paradoxal brachioradialis reflex, also known as “inverted radial reflex”, diminished normal response and contraction of finger flexors.   2  
  3. 3. Cervical stenosis Wasting of small muscles in handsCervical stenosis is a degenerative disease. This means that the osteopath must becareful in treating this condition. Often the degeneration comes with calcifiedligaments (often the posterior longitudinal ligament), panis of the dens, ankylosis ofapophyseal joints and osteophytes.Osteopathic treatmentElderly people with cervical stenosis and myelopathy can best be treated with thefollowing aims: 1. Mechanical: a. Reduce the cervical lordosis by: i. Gentle stretch of all posterior soft tissues. ii. Strengthen the anterior musculature. iii. Mobilize the thoracic spine towards extension will also reduce the cervical lordosis.   3  
  4. 4. b. Reduce the anterior translations of the different cervical segments by: i. Translation of every cervical segment towards posterior through gentle mobilization. (note: in some cases of cervical stenosis there is a reduced cervical lordosis – in these cases, mobilization in translation is not advised). c. Decompress the cervical canal by mobilizing gently towards flexion without irritating eventual fused segments. i. Decompression can also be achieved by gentle axial traction of the cervical spine. d. Mechanically the treatment aim must not be to increase mobility (ROM) amplitude. More important is equal mobility (ROM) in all possible directions. 2. Vascular: a. Increase the vascularization of the cervical spine as well venous drainage as arterial supply. b. Both aims can be addressed by treating the upper thoracic region and the thoracic outlet/inlet: i. To improve the heart – lung function (increase the oxygen level in the body and normalize the CO2 – O2 relation). ii. To improve the venous drainage of head and neck. 3. Neurological: a. To address the neurovegetative segments for arteries and other cervical tissues (upper thoracics). b. The upper thoracic region must also be addressed by active “sport” because this is still the best way to improve circulation and heart function. c. The vascularization of the cervical spine must also be addressed by treating the local soft tissues with long lever.Let’s not forget that the structural damage that has been made by the canal stenosiscan’t be cured. This doesn’t mean that the suggested treatment is worthless, it willalways improve the symptoms and prevent the problem to progress.Bibliography • Benzel E.C. (2001) Biomechanics of spine stabilisation. • De Riggo J., Benčo M., Kolarovszki B., Lupták J. & Svihra J. (2011) Urinary incontinence in degenerative spinal disease. Acta. Chir. Orthop. Traumatol. Cech. 78(1): 67-70. • Good et al (1984) “numb clumsy hands” and high cervical spondylosis. Surg Neurol; 22:285-291. • Kawaguchi Y., Seki S., Hori T. & Kimura T. (2008) Characteristics of ossified lesions in the upper cervical spine associated with ossification of the posterior longitudinal ligament in the lower cervical spine. J. Bone Joint Surg. Am. Apr; 90(4): 748-753.   4  
  5. 5. • Meyer F., Börm W. & Thomé C. (2008) "Degenerative cervical spinal stenosis: current strategies in diagnosis and treatment". Dtsch. Arztebl. Int. 105 (20): 366–372. • Ono K. et al (1987) Myelopathy hand: new clinical signs of cervical cord damage. J Bone Joint Surg Br.; 69:215-219. • Peeters L. & Lason G. (2005) Integration and Applied Principles in Osteopathy – Osteo 2000. • Ronthal M. (2000) Neck Complaints. Boston, Butterworth-Heinemann. • Shimizu T., Shimada H. & Shiradura K. (1993) Scapulohumeral reflex (Shimizu): its clinical significance and testing maneuver. Spine; 18:2182-2190. • Sung R.D. & Wang J.C. (2001) Correlation Between a Positive Hoffmann’s Reflex and Cervical Pathology in Asymptomatic Individuals. Spine; 26: 67–70. • Swartz E.E., Floyd R.T. & Cendoma C. (2005) Cervical Spine Functional Anatomy and the Biomechanics of Injury Due to Compressive Loading. J. Athl. Train. Jul-Sep; 40(3): 155–161. • Watson et al (1997) Hyperactive pectoralis reflex as an indicator of upper cervical spinal cord compression. Report of 15 cases. J Neurosurg; 86(1): 159-161.   5  

×