Cervical spondylotic myelopathy

Overview

Compression of the cervical spinal cord by degenerative changes (osteophytes, disc, ligamentum flavum) — the commonest cause of spinal cord dysfunction in older adults. An insidious, often painless, mix of upper-limb clumsiness/numbness and a spastic gait with UPPER motor neuron signs in the legs. Easily missed, and a delayed diagnosis costs recovery.

Recognise

• Insidious loss of hand dexterity (buttons, handwriting), numb/clumsy hands, and a progressively stiff/unsteady (spastic) gait
• UMN signs below the level: leg spasticity, hyperreflexia, upgoing plantars, Hoffmann sign; often mixed LMN signs at the compressed root level in the arms
• Frequently little or no neck pain — the deficit, not pain, is the presentation; Lhermitte phenomenon may occur

Differentials & how to tell them apart

Investigations

MRI cervical spine (cord compression ± myelopathic signal change) — the key investigation. Assess function (e.g. mJOA). Urgent referral if progressive.

Management

MRI cervical spine + spinal surgical referral for decompression if progressive

1. 1MRI of the cervical spine; refer to spinal/neurosurgery. Progressive myelopathy → surgical decompression (the deficit at the time of surgery predicts the final outcome, so do not delay).Gate: UMN leg signs + clumsy numb hands + a spastic gait in an older adult — often with LITTLE neck pain — is cervical myelopathy: image the cord and refer, because the longer the compression, the less the recovery; a painless presentation is the trap that delays diagnosis
2. 2Mild/stable disease may be monitored with physiotherapy; progressive or significant compression → timely decompressive surgery.

Monitor & prognosis

Functional scores (mJOA), progression, post-op recovery.

Surgery halts progression; established deficits may not fully recover — hence early referral.