This slide consists of Cervical Myelopathy in detail with its assessment and Treatment

1. CERVICAL
MYELOPATHY,
PHYSIOTHERAPY
ASSESSMENT AND
MANAGEMENT
PRESENTED BY :
Dr. DWARIKANATH ROUT (PT)
MPT (ORTHOPEDICS)
KIMS HOSPITAL, Odisha

2. CONTENTS -
• Definition
• Epidemiology
• Etiology
• Clinical presentation
• Clinical sign & Symptoms
• Physiotherapy assessment
• Investigation
• Differential Diagnosis
• Management
• References

3. DEFINITION -
A form of neurologic impairment caused by
compression of the cervical spinal cord , most
commonly due to degenerative cervical spondylosis .
EPIDEMIOLOGY -
 Most common in men > women
 Earlier in men ( 50 years ) than in women ( 60
years )
It causes hospitalization at a rate of 4.04 per
100,000 person-years.

4. ETIOLOGY
STATIC FACTORS:
• A narrowing of the spinal canal size commonly results from
degenerative changes in cervical spine such as disc
degeneration, spondylosis, stenosis, osteophyte formation
at the level of facet joints, segmental ossification of
posterior longitudinal ligament and yellow ligament
hypertrophy, classification or ossification.
DYNAMIC FACTORS:
• Due to mechanical abnormalities of the cervical spine or
instability.
VASCULAR AND CELLUALR FACTORS:
• Spinal cord ischemia affects oligodendrocytes which results
in demyelination exhibiting feature of chronic degenerative
disorders.

5. ETIOLOGY
CONGENITAL
• Myelopathy due to congenital stenosis does not have a
specific lesion but caused by a canal diameter which is
narrower from birth.
SPONDYLOSIS
• Degenerative changes which develop with age, including
ligamentum flavum hypertrophy or buckling, facet joint
hypertrophy and disc protrusion. One or all of these
changes contribute to an overall reduction in canal diameter
which may result in cord compression.
DISC HERNIATION:
• Discogenic disease may cause myelopathy in the acute
setting as a large central soft disc herniation causing cord
compression

6. POST TRAUMATIC MYELOPATHY:
• Trauma may include myelopathy or precipitate symptoms of
stenosis of spinal cord. Smaller diameter canals have an increased
chance of neurological injury in trauma.
MYELOPATHY DUE TO TUMOR EXPANSION:
• Intraspinal tumors may originate in spinal cord or compress from
outside.
OTHER ETIOLOGIES:
• Cervical rheumatoid arthritis especially upper cervical spine and
to a lesser extend the lower cervical spine may present with the
clinical picture of cervical myelopathy.
• Rare neurologic complications which can cause narrowing of
cervical canal such as ankylosing spondylitis, gouty tophi from
posterior joint and paget’s disease.

7. CLINICAL PRESENTATION
• Neck stiffness (early complaint)
• Leg weakness, stiffness (proximal-distal)
• Gait abnormalities
• Difficulty with fine motor movements and tasks with hands “clumsy
myelopathic hands”
• Loss of bowel or bladder control
• Heavy feeling in the legs
• Poor exercise tolerance
• Radiculopathy
• Numbness and tingling in the limbs
• Chronic suboccipital headache : suboccipital may radiate to base of the
neck and vertex of the skull
• L’Hermitte’s phenomenon- intermittent electric shock sensations down
the neck, back and limbs, exacerbated by neck flexion
• Myelopathy’s hand: clumsiness, intrinsic wasting

8. CLINICAL SIGNS AND SYMPTOMS
• Patients may present with pain, paresthesia, weakness
or combination of these symptoms.
• Pain usually is in the cervical region, upper limb,
shoulder and/or intrascapular region, intermittent
shoulder pain.
• >2/3 patients present with unilateral or bilateral
shoulder pain.
• 1/3 patients present with headache
• Radicular signs: often non dermatomal
• Radiculopathy most commonly 6th and 7th roots occurs
from C5-6 or C6-7 spondylosis
• More pain proximally in their limbs, while parasthesias
dominate distally

9. CLUSTER FOR MYELOPATHY -
According to cook et al, selected combinations of the
following clinical findings are effective in ruling out and
ruling in cervical spine myelopathy. Combinations of 3
or 4 or 5 of these tests enable post-test probability of
the condition to 90-99% :
① Gait deviation
② +ve Hoffman's sign
③ Inverted Supinator sign
④ +ve Babinski sign
⑤ Age > 45 years or older

10. PHYSIOTHERAPY ASSESSMENT
• DEMOGRAPHIC DATA
• NAME- AGE- SEX- OCCUPATION-
• CHIEF COMPLAINT:
• HISTORY:
• PRESENT HISTORY: Date of onset of symptoms, mechanism of injury,
mode of onset, condition (Improved, stationary, Deteriorated), muscular
weakness
• PAIN HISTORY: Duration, type, aggravating and relieving factors
• PAST HISTORY: Any history of TB, Bronchial asthma, BP, diabetes, cardiac
problems, enquiry made for any accidental injury)
• FAMILY HISTORY: Hereditary?, consanguinity?
• PERSONAL HISTORY: Cigarettes, Alcohol
• SOCIO-ECONOMIC HISTORY:
• MEDICAL HISTORY: Present medication patient is on

11. • ON OBSERVATION :
• General condition of patient- poor, good, fair built
• Wasting
• Oedema
• Attitude of limbs : supine, sitting, standing
• Types of gait
• Bony contours
• Deformities

12. ON PALPATION:
• Tenderness- grading (1-patient complains of pain,
2-patient complains of pain and winces, 3- patient
winces and withdraws, 4- patient will not allow
palpation of the joint)
• Tissue tension and texture
• Temperature variation of skin
• Spasm
• Type of skin – Dry or excessive moisture
• Scar – adherent/ Non adherent

13. Swelling
• Comes on soon after injury- blood
• Comes on after 8-24 hours- synovial
• Boggy, spongy feeling- synovial
• Harder, tense feeling with warmth- blood
• Tough, dry- callus
• Leathery thickening – chronic
• Soft fluctuating- acute
• Hard- bone
• Thick , slow moving- pitting oedema

14. ON EXAMINATION :
• Patients present with a number of clinical findings which are
predominantly upper motor neuron signs.
• Weakness is more severe in the upper limbs.
• Gait is usually affected with an ataxic broad based gait, usually
spastic and spastic
• Hypertonia- increased resting muscle tone identified by passive
movement
• Hyperreflexia- exaggerated response to normal physiological reflexes
• Exaggerated tendon reflexes (patellar and achilles), presence of
pathological reflexes (e.g. clonus, Babinski and Hoffman’s sign)
• Ankle clonus- forced dorsiflexion at the ankle giving rise to sustained
beats of clonus (more than 3 beats is considered pathological)

15. • Muscular atrophy: supraspinatus, infraspinatus, deltoid,
triceps and the first dorsal interosseus muscle
• Motor weakness, most commonly in the iliopsoas followed
by quadriceps femoris
• Sensory abnormalities: variable pattern
• Loss of vibratory sense or proprioception in the extremities
can occur
• Spinothalamic sensory loss may be asymmetric
• Most commonly sensory symptoms including:
• Upper extremity numbness & pain, paresthesias initially,
followed by lower extremity sensory changes
• Motor dysfunction may be unilateral or bilateral depending
on the extend and location of cord damage

16. • Babinski sign – extension of the great toe on scratching
of the sole of the foot
• Hoffman’s reflex- flicking of the terminal phalanx of the
middle or ring finger causing concurrent flexion at the
terminal phalanx of the thumb and index finger
• Finger escape sign – the small finger spontaneously
abducts due to weak intrinsic muscles
• Spurling’s test
• Distraction test
• Hyper reflexic biceps, quadriceps, achilles
• Romberg test

17. SPURLING TEST & LHERMITTE’S SIGN

21. NERVE ROOT INVOLVEMENT SYMPTOMS
C3 Nerve Root ① uncommon
② Rx pain may be present as
neck pain or occipital pain
C4 Nerve Root ① C4 Rx ī pain radiating to post
neck , trapezius and ant. chest.
C5 Nerve Root ① presents with Pain and/or
numbness over lat. aspect of
shoulder & deltoid.
② weakness of biceps,
supraspinatus, infraspinatus
③ Abduction relief sign
C6 Nerve Root ① Weakness of biceps , ECR
② Impaired EF & WE
③ sensation loss over thumb &
lat. portion of index finger.
④ dim. biceps & brachioradialis
reflex
⑤ pain radiates from neck-lateral
arm & forearm into the thumb

22. NERVE ROOT SYMPTOMS
C7 Nerve root ① impaired EE and WF
② dim. Tricep reflex
③ pain & numbnessfrom neck to
arm & digits 2-4
④ Horner's syndrome rarely seen
C8 Nerve root ① Weakness in hands intrinsic
muscles , Wrist extensors , and
flexors
② not sble tofully extend 4th &
5th digits
③ sensory loss- medial forearm &
4th 5th digits
④ pain radiating - neck->medial
forearm-> last 2 digits
⑤ Horner's syndrome-rare
T1 Nerve Root ① weakness- intrinsic muscles
② froment's sign +ve
③ Horner's syndome rare

23. INVESTIGATION
① Radiographs
• Pavlov index – the antero-
posterior diameter of the
spinal canal measured from
the middle of the posterior
vertebral body to the
nearest point of the
spinous process is equal to
or less than the antero-
posterior diameter of the
vertebral body.
• Should be 1.0 with <0.85
indicating stenosis

24. 2 . MRI
• Compression Ratio -
( < 0.4 indicates poor
prognosis )
CR =
smallest AP diameter of
cord
Largest transverse
diameter of cord

25. • A canal diameter of 17mm or greater at the mid
vertebral body level is considered normal.
• < 10-13mm - risk of cervical spondylosis
• DIAMETER OF CERVICAL SPINAL CANAL
C1 22.1mm
C2 18.8mm
C3 16.2mm
C4 15.8mm
C5 15.7mm
C6 15.6mm
C7 15.9mm

29. Differential Diagnosis

30. MANAGEMENT
1. Surgical
①Ant. decompression
& fusion
②Ant. corpectomy &
fusion
③Laminectomy ī
Posterior fusion
④Laminoplasty
⑤Occipitocervical
fusion
2. Non-Surgical
①Medications -
②Immobilisation -
(Hard collar in flexion
)
③Physical Therapy

31. PHYSIOTHERAPY MANAGEMENT
GOALS -
①To relieve pain
②To improve function
③To prevent neurological functions
④To reverse or improve neurological deficits

32. INITIAL PHASE -
① A. Electrotherapeutics
modalities like , TENS, US ,
IFT ( to reduce pain )
②
B. CERVICAL STABLISATION
EX'S
③ Chin Tuck
④ Chin tuck into towel
⑤ Cervical Extension
⑥ Shoulder Shrugs
⑦ Shoulder Rolls
⑧ Scapular Retraction

33. B. ISOMETRIC NECK EXERCISES -
① Cervical Flexion
② cervical Extension
③ Cervical Side Bending
④ Cervical Rotation

34. D. Streching EX'S
① Trapezius
② Rhomboids
③ Levators

35. SECOND PHASE -
① Dynamic upper & lower limb
ex's with use of PBU on the
neck
② PNF diagonals for both U/L &
L/L

36. FINAL PHASE -
① Core stability ex's
② Balance training
③ Improving posture
④ Aerobic ex's - Treadmill
training ( 20 min )

37. POST - OP MANAGEMENT
PHASE I - ( 0 to 6 WEEKS )
GOALS -
① Diminish
pain/inflammation
and minimize UE
radiating symptoms.
② Postural correction ,
body mechanics ,
tranfers taught.
③ walking ( 30min × 2
times a day )
EDUCATION
①Postural education
②Body Mechanics
③Driving

38. Exercises -
I. Cardio
II. Deep cervical flexors
stabilisation
III. Scapular Retractions
IV. Isometrics
V. Cervical AROM
VI. Light stretching
Dose - one to twice / day
PRECAUTIONS -
①Avoid
bending,twisting,liftin
g , pushing & pulling.
②Cervical movements
with in painfree range
only.

39. PHASE II - (6-12 WEEKS )
GOALS
① pt. to have proper
neuromuscular control
& posture with
stabilisation &
strengthening
② initiate light
strengthening -> long
term home ex's
③ aerobic endurance to
30mins
④ release soft tissue
restrictions .
PRECAUTIONS
①keep spine in neutral
and good posture
②progression as
tolerated.

40. STRENGTH
* only initiate these once pt can
complete phase I ex's
① Postural/scapular
strengthening
② Cervical postural
strengthening
③ Aquatic ex's

41. PHASE III ( +12WEEKS )
Return to work / work conditioning / Return to
sport ( if applicable ).
① No aggressive rotation or side bend range of
motion
②Functional / sport/job drills may begin now with
supervision
③Possible referral to work reconditioning program

42. THANK YOU !