The MRI and Myelopathy
Lately, I have seen a few patients that have been told they had Myelopathy. After evaluating them, I was certain that they have been misinformed about the nature of Myelopathy. In the most simplest definition, Myelopathy means irritation or damage to the spinal cord.
The confusion is secondary to the definition of irritation or damage to the spinal cord. Some will confuse neck pain as irritation to the spinal cord. Most experienced spine specialists agree that neck pain is a very vague term, and neck pain can be caused by many other things. While you may have neck pain, you can also have Myelopathy, the neck pain is not the reason you have Myelopathy. In other words, neck pain, by itself does not indicate there is a true spinal cord irritation or damage.
In laymen’s terms, Myelopathy is associated with measurable weakness to the arms and/or legs, walking disturbance, loss of control of your bladder or bowels, and sensation changes with feelings of numbness or tingling that can be identified by physical examination.
The most common causes of Myelopathy is secondary to bone or disk encroachment onto the spinal cord. If it happens in a traumatic fashion, it is considered a spinal cord injury. Some will say it is the beginnings of being paralyzed by your spinal cord being crushed. In traumatic causes of Myelopathy, the presentation is typically rapid, with identifiable, and measurable weakness, sensation loss, walking difficulties, and bowel/bladder issues. Usually, a spinal cord injury protocol is necessary, with use of high doses of steroid medications, and testing such as MRI’s and CT scans to see if there is an associated fracture, instability, infection, large disc herniation or tumor that is causing the rapid development of symptoms. Usually surgery needs to be considered when the patient is medically optimized.
In a more insidious development of Myelopathy, it is secondary to the slow development of spinal stenosis over time. The spinal cord is slowly squeezed by the bones and tissues, until it can no longer accommodate the pressure. This usually happens in the older population. Spine Surgeons usually look for specific signs such as the Hoffman’s sign, or L’Hermitte’s sign to help identify the Myelopathy. Physical exam findings also include weakness to the arms and legs, clumsiness in walking, and coordination difficulties. In this form of Myelopathy, it can be monitored, but most agree that surgical opening of the areas squeezed will give the best chance to prevent progress, and possibly reverse the effects.
As I stated above, recently, I have seen a few people who were told they had Myelopathy. After evaluating them, I did not identify any of the above signs, or physical findings. The only complaint was neck pain, with some vague intermittent tingling at times. In my opinion, there was no evidence of Myelopathy. That should have been a great relief for that person, as most Myelopathy patients need to consider surgery as they are at risk of progression of the spinal cord irritation, and damage.
After further examination, the reason the person was told they had Myelopathy is secondary to an MRI finding. The MRI did show a disk herniation touching the spinal cord. But, without evidence of spinal cord irritation, this does not mean that person had Myelopathy. There must have been a misunderstanding of the explanation to the person, or the Physician was not a spinal specialist. Just because there is an MRI finding, does not mean you have Myelopathy. You must have physical evidence of spinal cord irritation, or spinal cord damage to call it Myelopathy.
As a Surgeon, it would be great if all we needed is MRI or CT evidence of a Disk Herniation touching the cord to recommend surgery. It would mean every Spine Surgeon would be incredibly busy fixing all these people with spinal cord irritations or damages. That is not the case. You must justify performing risky spinal surgery by identifying people who are having objective findings of spinal cord irritation or damage, not just an MRI showing a disk or bone pressing or touching on the spinal cord. Just having complaints of neck pain, and complaints of numbness is not enough. You should have objective physical findings.
On the other hand, if you truly have Myelopathy secondary to Cervical Spondylosis, you should consider your surgical options as Myelopathy is a progressive process. In addition, secondary to the spinal cord irritation or damage, you are at an increased risk of having a much more significant spinal cord injury by even a very trivial incident like a fall, or bumping your head.
- Uzun S, Ovak Bittar F, Sabbahi MA. Intersession reliability of thoracolumbar multisegmental motor responses. J Spinal Cord Med. 2013 Nov;36(6):679-86. PubMed PMID: 24090353