Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord dysfunction and spastic paresis in adults aged 55 and older [1]. Common presentations include neck pain and stiffness, loss of manual dexterity, weakness or the feeling of burning in the arms and legs, gait imbalances, and urge incontinence. Given that it is a differential diagnosis for neck pain and many other neurological symptoms, it is important for chiropractors to be able to differentiate between the two and be able to draw a diagnosis of CSM when definitively present.
Despite the need for us to understand it, there remains a paucity of chiropractic studies pertaining to the condition. Thus, case report data gives vital insight into the clinical presentations and the ways in which chiropractors may have been able to support the individual under care.
A recent paper appearing in the Journal of the Canadian Chiropractic Association presented three contrasting cases of CSM, all of which presented to chiropractic clinics. In each case, the presentations vary, and as chiropractic care for the reduction of subluxations is a unique approach based on the needs of the person under care, each has been presented separately. It should be noted that the focus of this paper is on the presentations – ie. what to look for, as this condition may be easily misdiagnosed.
Case 1:
A 49-year-old male presented for chiropractic care, initially referred from his primary care physician for evaluation and management of chronic neck and right arm pain in the absence of trauma [2]. The neck pain had begun with no discernible reason approximately four years earlier. These episodes of neck pain had been worsening in the two years prior with a new onset of right arm pain emerging more recently. He noted increasing weakness in his right hand and lately had been unable to flex the muscles in his right arm.
His neck and arm pain were described as constant, with dull, sharp and burning characteristics (worse with movement). At the time of presentation, he was taking prescription medication for the pain but was not finding sufficient relief. Additionally, he reported attempting his own arm strengthening exercises to resolve the complaint, but again found no relief.
The recurrent pain and worsening muscle weakness in the arm and hand had started to impact his activities of daily living, as he had already begun to reduce his driving frequency. He also noted severe pain when the “air-conditioning hits my arm”. His work as a painter was also becoming increasingly difficult.
When the chiropractor reviewed his symptoms, he noted blurred vision, balance issues (unsteadiness), and episodic urinary incontinence. Past surgical history included left sided carpal tunnel release 3 years prior, with residual numbness in the left hand. During the examination the chiropractor revealed upper thoracic kyphosis with forward head posture. He had a full shoulder range of motion, but experienced increased pain at the end ranges of all motions for his cervical spine and shoulders. There was right bicep atrophy with fasciculations, exacerbated with manual muscle testing.
His neurologic examination was notable for ¾ Patellar and Achilles deep tendon reflexes on both sides. MRI findings supported the clinical diagnosis of cervical spondylotic myelopathy with concomitant right C5 radiculopathy. The patient was referred to neuro-surgery where he underwent anterior decompression consisting of disc replacement at the C4/5 and C5/6 level.
Why report on cases like this?
It is important to understand that chiropractors can be exposed to cases like these and we need to be able to differentiate between CSM, subluxation and a range of other differential diagnoses, and as a result, help people who present to our practices. It is important to note that it was the chiropractor who picked up on the extra symptoms and noted the severity of the condition.
Without the thorough postural and neurological testing, the person under care may have continue to languish without a proper diagnosis or care plan going forward. Of course, in an ideal world, we would all be able to avoid drugs or surgery. But sometimes a good outcome under chiropractic care is a proper diagnosis that someone else missed.
Case 2
A 38-year-old female presented for chiropractic care following referral from her primary care physician. The predominant complaints were acute neck pain following a recent motor-vehicle accident and a chronic burning feeling in the arms and legs. The burning sensations had begun immediately following the accident, and she noted she did sustain head trauma. She had been told she had “spinal cord impingement” at the time, and was only offered physical therapy for her symptoms. She completed the course but found no change in her presenting symptoms.
She then described her neck pain as mild, with the pain localised centrally in the neck. The patient was noticeably concerned about her worsening weakness and sensation in both hands and the “shock-like” pain travelling from her neck to her toes on occasion. She reported reduced sensation in her toes which caused her to feel unsteady when walking. The patient was becoming more fearful of dropping things while she worked and was avoiding going down her basement stairs for fear of falling. It should be noted that, at age 38, she was significantly younger than most people who suffer from CSM.
The chiropractor noted she had an unsteady gait and could not tandem walk. Her deep tendon reflexes were reduced for both upper and lower extremity. Gross motor testing revealed reduced intrinsic hand and finger flexor strength on both sides, reduced right knee flexion and extensions strength, and reduced right dorsiflexor strength. Radiographs demonstrated a straightening of the cervical spine with mild kyphosis at C5/6. Associated discogenic spondylosis and uncovertebral arthritis were also present at the same level. Following an MRI, the patient consulted with neurosurgery and underwent anterior cervical discectomy with fusion for cervical myelopathy.
As we saw in case one, a chiropractor was able to uncover additional information and draw appropriate conclusions that necessitated a referral for neurosurgery. Chiropractors need to be able to identify these issues when they present, and provide the necessary referrals when such interventions are deemed necessary and required. In this case, chiropractic care might not have come in the form of an adjustment here, but chiropractic knowledge proved very valuable indeed. Additionally, the value of having chiropractic and chiropractors respected for the knowledge they have of the nervous system and the thorough examinations they deliver is paramount when it comes to identifying significant diagnoses like this and referring to other modalities for necessary interventions.
Put simply: working with medical teams is sometimes vital.
Case 3
The third case in the series contains a different trajectory than the first two. In this case, a 49-year-old male presented for care following referral from his primary care physician. The predominant complaint was left sided back and leg pain, described as “sciatica”. There was an abrupt onset of neck pain with left sided numbness in his arms and legs following a lifting accident at work. An MRI taken at the time revealed central canal stenosis at the C3/4 level secondary to a disc-bone complex, with a superimposed left paracentral disc extrusion. There was related spinal cord compression and T2 hyperintensities consistent with myelomalacia.
The extrusion had reabsorbed when a follow up MRI was taken approximately 4 years later, but the spinal stenosis secondary to degenerative changes and the myelomalacia persisted.
The patient was told he was not a candidate for neurosurgery following the MRI, and his symptoms continued to worsen.
The chiropractor noted his main symptoms were left-sided lower back, left gluteal, and entire left leg pain, pain the patient rated as severe. He was taking some medication to manage the pain, but with little relief. The patient felt “unsteady” with occasional falls and his gait was described as slow and unsteady. He experienced pain along the left hemithorax, left sided low back, and entire left leg to light touch. All lumbar ranges of motion were limited due to pain, however he had a full passive hip range of motion. Upper and lower deep tendon reflexes were reduced.
A chiropractic care plan including additional myofascial therapies as a means of desensitisation was initiated. The patient reported benefit in the short-term. It was discerned that the back and leg symptoms were likely secondary to the incomplete spinal cord injury at C3/4 with subsequent neuropathic pain. The patient ceased care in the short-term and returned to care later on with similar but worsening symptoms.
What is important about this paper?
A broader and more vivid understanding of the pathobiology and clinical features of this condition is important, as it has the capacity to present in many different ways which can be perplexing to the practitioner not versed in CSM or with sufficient functional neurological expertise. The key takeaways for practitioners in helping have a deeper understanding of CSM include:
- Long-term mechanical forces applied to the spinal cord as a result of structural degenerative changes can result in impaired blood flow to the spinal cord. This has long been considered a key pathophysiologic component of CSM.
- Chronic compression caused by degenerative changes in the cervical spine result in ischemia in both the extra- and intra-spinal blood vessels. Ongoing compression on extra-spinal vessels induced wall-thickening and hyalinisation further reducing regional perfusion (flow in and out of blood vessels, flow through capillaries and extracellular space. Oxygen, nutrients, waste product) [3].
- This can also reduce perfusion to axonal pathways which may explain the distribution of motor deficits observed in CSM patients [4].
- The authors discuss emerging evidence pointing to the activation of an immune response in chronic ischemia. This may be a key patient-specific factor explaining the highly variable nature of manifestation.
- They also cite previous research demonstrating neuronal and oligodendrocyte cells undergoing active apoptosis in a 5mm area around the area of maximal compression in CSM patients – supporting neuroinflammation as a player in this condition.
- Diagnosis of CSM is based on clinical features with imaging confirmation. Common signs and symptoms: gait dysfunction in over 60s, gait dysfunction and balance disturbances are common early manifestations but can be incorrectly attributed to old age and delay accurate diagnosis.
- The natural progression of CSM is variable, ranging from stepwise or gradual decline to rapid neurological deterioration. A review cited by the authors highlighted that patients with circumferential spinal cord compression were at a greater risk of neurological deterioration than those with only partial compression.
A key takeaway from this paper is that CSM can look like many different things, including sciatica, neuropathy or other pathologies. The authors of the paper were quick to note that “Early recognition of signs consistent with myelopathy may mitigate future disability and improve quality of life. Key predictors of patient outcome are the age of initial presentation, baseline CSM severity…, and the presence of gait disturbances.” While gait disturbances might be present in a range of other neurological conditions and ageing more generally, the authors also noted that a “thorough understanding of this entity by chiropractors is important to optimise spine care.”
The benefit to the chiropractic profession and our patients when we are able to optimise spine care is the ability to serve our community at a more efficient and effective level. We note that in this particular paper, there was no significant detail as to the chiropractic care plan beyond detection alone. And while in these cases, detection was significant as it had been overlooked before and required significant intervention, we would like to see further research on chiropractic care in the prehabilitation, rehabilitation or surgery prevention in the future.
REFERENCES:
- de Oliveira Vilaça, C., Orsini, M., Leite, M. A., de Freitas, M. R., Davidovich, E., Fiorelli, R., Fiorelli, S., Fiorelli, C., Oliveira, A. B., & Pessoa, B. L. (2016). Cervical Spondylotic Myelopathy: What the Neurologist Should Know. Neurology international, 8(4), 6330.
- https://doi.org/10.4081/ni.2016.6330Bolles, C., Battalgia, P., & Moore, C., (2022). Varied presentations of cervical spondylotic myelopathy presenting to a chiropractic clinic. Journal of the Canadian Chiropractic Association. https://chiropractic.ca/wp-content/uploads/2022/09/124885-1_Chiro_66_2e_Bolles.pdf retrieved 20 Oct 2022
- Badhiwala JH, Ahuja CS, Akbar MA, et al. Degenerative cervical myelopathy — update and future directions. Nat Rev Neurol. 2020; 16: 108–124.
- Karadimas SK, Erwin WM, Ely CG, Dettori JR, Fehlings MG. Pathophysiology and natural history of cervical spondylotic myelopathy. Spine. 2013;38(22 Suppl 1): S21-36.
