Acıbadem Comprehensive Spine Center

Aging Spine

Cervical Narrow Canal

All seven cervical vertebra contain a canal through which the spinal cord passes. As a part of normal aging process, the discs lose their water content in time and begin to bulge outwards. In some patients however, the bulging of the disc and other arthritic changes between the vertebrae constrict the space through which the spinal cord and branches of the spinal cord named nerve roots pass. Narrowing caused by the degeneration in the discs and joints between the vertebrae result in compression of the nerve roots. This is called cervical narrow canal. “Stenosis” means narrowing, and “cervical stenosis” is the narrowing of the space in the neck, which harbors the spinal cord and nerve branches.

The spinal cord transmits the signals it receives from the brain to our arms, legs, and chest. It also carries the signals it receives from our arms, legs, and chest back to the brain. Spinal nerve roots are responsible to control the muscles separately, and to sense the certain areas of structures such as the arms and legs.

The cervical spine is the part of the spine residing in our neck. This part of the spine should be flexible enough to allow movement of our neck from the right to the left and also up and down. This part should be also strong enough to protect the spinal cord and the spinal nerves. Cervical spinal column constitues of seven vertebra, the discs between them, and ligamentous bands.

What are cervical myelopathy and cervical radiculopathy?

Cervical myelopathy describes the functional loss in the upper and lower limbs (extremities) that result from compression of the spinal cord in the neck area. Cervical radiculopathy is the functional loss in a certain part of the extremity due to injury and/or compression of the nerve root.

What are the symptoms of cervical myelopathy?

In most patients, cervical myelopathy has a progressive course that increases in time. It may cause slight changes in the way hands work. The patients report that their hand dexterity is decreased, they drop objects more frequently, and fail to button their shirts as they used to do, or their handwriting is detoriated. There may be also a loss of balance, and they feel the need to hold onto objects more commonly than before. Imbalance during walking may be clear to the eye. In extreme cases there may be severe weakness and numbness in the arms and legs. Rarely there may be changes in the bowel or bladder control.

What are the symptoms of cervical radiculopathy?

Cervical radiculopathy often presents as pain that begins from the neck and radiates to certain areas of the right or left arm, forearm, or hand. In most cases, these symptoms are associated with weakness in the arm, forearm, and hand muscles of the corresponding areas.

How is the natural course of cervical myelopathy and cervical radiculopathy?

The natural course of cervical radiculopathy greatly depends on for how long the person’s complaints are present. The course is generally very good in patients who present with very early findings. In most of these patients, pain, numbness, and weakness completely disappear within a period of 6-12 weeks. The outcomes in patients who have complaints for longer period of time are more uncertain. In some patients, the pain may totally disappear with limited treatments such as activity modifications, heat, ice applications, physical therapy, and over the counter drugs. In approximately one third of the patients, the symptoms continue at a level that the patient can cope with.

In a small group of patients the complaints are intolerable, these patients may require further treatment. Although the “natural course” is more uncertain in clinically evident cervical myelopathies, there is a general aggreement that the symptoms in patients with myelopathy will progress in time. However, it is not known when, at which percentage, and with which speed the symptoms will progress. Approximately 75% of the patients show a staged worsening, and they go through periods in which they feel better. Twenty percent of the patients have a constant worsening, and 5% have rapid worsening.

How are cervical myelopathy and radiculopathy diagnosed?

If you have any worsening of the symptoms in your arms or legs and your family physician thinks that they arise from the neck vertebrae, you should refer to a spine surgeon. If you have numbness or weakness in one of your arms which persists after a brief period of observation, you should definitely go to a spine surgeon. The spine surgeon will ask you how your complaints began and how they progressed. Then the spine surgeon will ask a few questions regarding especially your neck, perform a physical examination directed toward the functions of the nerves in your arms or legs, then control your balance and assess your gait. Your doctor may ask for X rays. In these X rays, findings of degenerative changes may be seen in the disc spaces or the facet joints in some patients. X rays taken with the neck bent may show a slight slippage between the cervical vertebrae.

Magnetic resonance imaging (MRI) may be also requested. MRI enables visualization of the tissues on the spinal cord or nerve roots that have a possibility of compression. In some patients, a study after giving contrast substance to the spinal cord may be needed (myelogram), a computer tomography (CT) is performed afterwards. In some patients, electrical evaluation of the spinal cord or nerve may be carried out with electromyogram (EMG) nerve conduction studies. Electromyogram (EMG) and nerve conduction studies help to differentiate cervical radiculopathy (illness due to nerve roots) from other nerve diseases in the arm and forearm such as carpal tunnel. Somatic sensory evoked potentials (SSEP) are electrical tests which evaluate signal transduction in the spinal cord, and can be performed in some patients with cervical myelopathy.

How is the treatment process in cervical myelopathy?

Most patients with cervical radiculopathy are initially treated with nonsurgical methods. These methods typically involve activity modifications for a brief period of time.

Activity modifications include simple measures such as adjusting the height of your computer or your chair. Your doctor may recommend you to apply ice or heat to the painful area. Additionally, he or she may suggest over the counter painkillers. However, it should be remembered that all drugs may have side effects when used excessively. Long term bed rest is often not recommended as it may affect physical fitness negatively. In patients whose pain is not cured with these measures, use of antiinflammatory drugs, muscle relaxants, or narcotic painkillers that are more potent and need prescription may be needed for a short period. Physical therapy is an important part of the rehabilitation process. In physical therapy your body functions will be evaluated and you will be informed about proper ergonomics, also a light program for stretching and flexibility will be started.

Mild strenthening exercises are added to the program as your pain decreases. A significant benefit of gaining physical conditioning with physical therapy is the prevention of secondary stifness in the shoulders, elbows, neck, and arms that may frequently occur. In some patients with cervical root disease, the spine surgeon may recommend injection treatment. The most common of these are epidural steroid injections. These are cortisone injections made around the inflamed nerve. The purpose of the injection is to decrease the inflammation and relieve the pain. In patients with mild neck stenosis and without significant affection of the spinal cord, nonsurgical treatment may be an appropriate solution when performed carefully. This treatment often begins with giving extensive information to rhe patients regarding their illnesses. The patients should understand that the narrowing of the canals inside the spine will create a tendency for spinal cord problems (myelopathy) in the future. The patients should be careful about avoiding conditions or injuries that may risk their spinal cords. A short period of immobilization inside a soft collar may be useful for some patients. Physiotherapists may give information on gait mechanics or applications such as the use of cranes or walkers to prevent falls. Occupational physiotherapists can make suggestions on daily activities such as bathing, dressing, opening jars, or using keys. Among factors that trigger the development of progressive myelopathy in patients with narrowing in the spinal canal include age related degenerative changes, injury of the already constricted spinal cord with a fall or traffic accident, spinal instability, or their combination. If the cervical myelopathy symptoms are evident or progressive, you need to be evaluated by a spine surgeon.

What are the surgical methods for cervical stenosis, myelopathy, and radiculopathy?

Surgery is an appropriate alternative in patients with failure of nonsurgical measures. Your spine surgeon may offer an operation that will be carried out from the front (anterior), back (posterior), or both. Your surgeon will first examine some factors to determine the type of operation. These factors include the precise determination of the compression sites in the spinal cord or the nerve roots, the number of level sustaining the compression, the alignment of your cervical spine, and your general medical condition. If the operation will be carried out from the front part of your neck, a small cut (incision) will be made on the front part of your neck. The tissues will be pulled aside meticulously, and the cervical vertebra will be accessed easily. The tissues compressing the nerve root are removed. A limited amount of bone, taken from bone bank or your hip, is often inserted between both vertebrae, and the two vertebrae are stabilized to each other with plates and screws. The anterior (front) surgery may be performed at more than one level, it may also require removal of discs and vertebrae.

The resultant space is restored with bone filled titanium cage, and fixed with plate from the front.

Depending on the type of operation, you may need to wear a collar for a short period. When surgery is performed from the back of the neck, the operative incision is made exactly on the point where the nerves exit the spinal cord. Bone prominences making compression on the nerve can be removed with a high speed burr. Small disc fragments can be removed from this hole. A brief period of rest may be necessary. In posterior surgery, there are two types of operations in which all the spinal cord is released (decompressed) : laminectomy and laminoplasty. In laminectomy the part at the back of the vertebra is completely removed. In laminoplasty, a hinge is seated over the back part of the vertebrae, and the lamina is elevated on this hinge to open space for the spinal cord. Sometimes metal screws and plates may be used for stabilizing the spinal column in the neck.

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