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PRIMARY RESEARCH

The Frequency of Various “Myelopathic Symptoms” in Cervical Myelopathy

Evaluation in a Large Surgical Cohort

Niu, Shuo MD, PhD; Anastasio, Albert T. MD; Maidman, Samuel D. BA; Faraj, Razan R. MS; Rhee, John M. MD

Author Information
doi: 10.1097/BSD.0000000000000968
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Abstract

Cervical myelopathy (CM) is a relatively common spinal disorder.1 In the United States, the incidence of the disease among adults is reported to range from 1.6 to 7.88 per 100,000 yearly.2–4 As the country’s population continues to age, the incidence of CM diagnosis will likely increase.5,6 Making a timely and accurate diagnosis of CM is important when determining a treatment plan to prevent ongoing neurological injury.7–9

To make the diagnosis of CM, symptoms, physical examination, and imaging studies must all be considered together. As is the case for any medical condition, symptoms remain paramount to diagnosis. Symptoms commonly associated with CM include numbness, weakness, hand clumsiness, gait instability, pain, and sphincter dysfunction.10,11 Physical signs associated with CM include weakness, sensory change, hyperreflexia of the deep tendon reflexes, Hoffman’s sign, Babinski’s sign, and clonus.12 Imaging should demonstrate correlative spinal cord compression.

However, despite being a common disorder in spine surgical practice, CM can be challenging to diagnose for several reasons. First, history is often not straightforward. Patients usually do not present with the full spectrum of myelopathic symptoms,13–15 and there is no pathognomic or sine qua non symptom. Especially in cases that are not severe, the symptoms may be dismissed as vague or by-products of “aging,” and they can be especially difficult to diagnose as being definitely attributable to CM versus other possible etiologies. Second, the expected physical signs are not always present.12 At the same time, nonmyelopathic people may demonstrate “myelopathic” physical findings.16 Third, complicating matters even further, some degree of spinal cord compression is a relatively common imaging finding in nonmyelopathic patients, and, in and of itself, does not establish the diagnosis of CM.17 Fourth, despite general agreement as to what constitutes a “myelopathic symptom,” there is little published information as to the frequency with which these symptoms actually occur in clinical practice.11,18 Most textbook descriptions of CM, for example, will list the spectrum of associated symptoms but provide no detail as to how often they occur, or how likely it is for a myelopathic patient to present with each complaint.

Given these complexities of properly diagnosing CM, the purpose of this study was to further characterize the symptoms associated with this common yet still poorly understood disorder. In particular, we sought to determine the frequency with which various myelopathic symptoms actually present in patients undergoing surgery for CM. We also sought to investigate any association between certain myelopathic symptoms and the level of maximal cord compression, in addition to magnetic resonance imaging (MRI) findings such as T2 hyperintensity.

MATERIALS AND METHODS

Study Design

A prospectively maintained database was retrospectively reviewed on the records of 644 consecutive patients with CM over 18 years of age who were treated surgically at one academic institution between January 1, 2007 and August 31, 2017. All patients included in this study had ALL 3 of the following: at least ≥1 myelopathic symptom (as described below), associated with at least ≥1 physical signs, and correlating cervical spinal cord compression on MRI. A total of 484 patients met these criteria. One hundred sixty patients were excluded because of a history of previous cervical spine surgery or undergoing surgery for nondegenerative conditions (eg, trauma, infection, deformity, congenital anomaly, or tumor).

The primary outcome data [eg, the chief complaint (CC) about presentation to the clinic and the list of overall associated myelopathic complaints] were obtained from questionnaires completed by the patients themselves during their initial presentation and the notes of the attending surgeon. All patients also reported the Neck Disability Index (NDI) scores. The modified Japanese Orthopaedic Association (mJOA) scores were calculated on the basis of responses to direct questions about each of the mJOA domains. Additional data obtained from patient medical records included the following: age at the time of surgery, sex, body mass index, and medical history (diabetes, smoking, and use of analgesics).

For the purpose of this study, cervical myelopathic (CM) symptoms included the following: axial neck pain; upper extremity (UE) pain; UE sensory deficit (numbness, tingling, etc); UE motor deficit (weakness, clumsiness, loss of fine motor control, etc); lower extremity (LE) sensory deficit; LE motor deficit (weakness, gait instability, balance disturbance, etc); and sphincter dysfunction (bladder/bowel). It was noted whether a symptom was the patient’s CC (ie, the main symptom for which the patient presented for evaluation) or one of the overall symptoms (OS) noted by the patient during the visit (ie, part of the list of CM symptoms identified by the patient, but not necessarily the CC). The cervical spinal level of maximal cord compression and the presence of intramedullary T2 hyperintensity on MRI were also determined from preoperative clinical imaging records confirmed by the spine surgeon and a spine fellow.

Statistical Analysis

All statistical analyses were performed using IBM SPSS Statistics 22 (IBM, New York, NY). The most common symptom(s) as CC or OS was determined by a series of Fisher exact tests. The association between the presence of each symptom and MRI findings was determined by the multivariate logistic regression that controlled for patient demographics and comorbidities. P<0.05 was considered significant throughout this study.

RESULTS

Patient Characteristics

As shown in Table 1, a total of 484 patients with an average age of 61.3 years (range, 25–97 y; 45.5% female individual) were included. Patients displayed overall moderate myelopathy (average mJOA=13.4; range, 6–16) before the surgery. C3–C4, C4–C5, and C5–C6 were the most common levels of maximal cord compression (all P<0.001). There was no significant association between the mJOA score and the level of maximal cord compression.

TABLE 1 - Patient Characteristics (n=484)
Average age (y) 61.3
Sex (% female) 45.5
Average BMI 29.3
Diabetes (%) 12.8
Active smoker (%) 17.5
Analgesics use (%) 75.7
Combined with radiculopathy (%) 10.3
Average mJOA score 13.4
Distribution of CM severity (%)
 Mild (mJOA≥15) 30.2
 Moderate (mJOA 12–14) 54.3
 Severe (mJOA≤11) 15.5
Max compression level (# of patients, n)
 C1–C2 8
 C2–C3 18
 C3–C4 206
 C4–C5 215
 C5–C6 218
 C6–C7 96
 C7–T1 11
BMI indicates body mass index; mJOA, modified Japanese Orthopaedic Association.

CC

The frequency of each CC was analyzed overall and according to the level of maximal cord compression. As shown in Figure 1, the most common CC was UE sensory deficit (46.5%), which was significantly more common compared with the other symptoms. UE pain (36.6%), UE motor (34.3%), neck pain (32.6%), and LE motor (29.3%) were the next most common. Sphincter dysfunction was very uncommon, occurring as a CC in only 0.6%. Neck pain was the most common complaint when the maximal cord compression was in the upper cervical spine at C1–C2 or C2–C3, but this difference was not significant.

FIGURE 1
FIGURE 1:
Frequency of chief complaints at each cervical level of maximal compression. *Frequency of indicated chief complaint is significantly higher than any other chief complaint at the same level of maximal compression (all P<0.05). LE indicates lower extremity; UE, upper extremity.

We also examined the frequency of the various CCs according to the level of maximal cord compression. Of the symptoms evaluated, a significant correlation was found with the presence of UE pain. As shown in Figure 2, the presence of UE pain was significantly more common when the level of maximal cord compression was more distal in the cervical spine.

FIGURE 2
FIGURE 2:
A positive correlation between the frequency of UE pain (as a chief complaint) and the cervical level of maximal compression. (Pearson’s correlation test). LE indicates lower extremity; UE, upper extremity.

OS

The frequency of each OS was analyzed in the same way as the CC. As shown in Figure 3, UE (82.6%) and LE (81.2%) motor deficits were the most common OS, which was significant. Although it was the most common CC, UE sensory was the third most common OS (70.9%). Neck pain was present in only about half of the patients (55.4%), as was UE pain (53.5%). LE sensory (17.4%) and sphincter dysfunction (16.5%) were the least common. None of the OS demonstrated a significant association with the level of maximal cord compression.

FIGURE 3
FIGURE 3:
Frequency of overall symptoms at each cervical level of maximal compression. *Frequency of either indicated overall symptom is significantly higher than any other unindicated overall symptom at the same level of maximal compression (all P<0.05). LE indicates lower extremity; UE, upper extremity.

Logistic Regression Analysis

A multivariate logistic regression analysis was performed to evaluate associations between symptoms and demographic factors, level of maximal cord compression, and presence of intramedullary T2 hyperintensity (Table 2 for CC and Table 3 for OS).

TABLE 2 - Multivariate Logistic Regression for Association With the Presence of Chief Complaints
Neck Pain UE Pain UE Sensory Deficit UE Motor Deficit LE Sensory Deficit LE Motor Deficit Sphincter Dysfunction
Chief Complaints OR P OR P OR P OR P OR P OR P OR P
Demographics
 Age ≥65 y 0.511 0.005 1.055 0.807 0.805 0.293 0.996 0.987 0.226 0.001 1.040 0.865 1.300 0.866
 BMI ≥30.0 0.782 0.281 1.041 0.850 1.391 0.104 0.960 0.960 3.088 0.001 1.036 0.874 <0.001 0.994
 Female 1.505 0.064 1.912 0.002 0.882 0.526 0.822 0.345 0.885 0.729 0.730 0.156 <0.001 0.994
 Diabetes 1.613 0.137 1.347 0.332 0.999 0.998 0.941 0.846 0.135 0.135 1.453 0.246 <0.001 0.997
 Smoker 1.090 0.769 0.836 0.536 0.739 0.255 1.014 0.959 0.360 0.360 1.745 0.043 <0.001 0.996
 Analgesics 2.588 0.001 1.459 0.132 0.829 0.408 0.838 0.451 0.581 0.153 0.760 0.259 0.163 0.249
Max compression level
 C1–C2 6.078 0.035 0.139 0.085 1.189 0.825 2.355 0.256 3.035 0.371 2.526 0.237 <0.001 0.999
 C2–C3 1.945 0.224 0.723 0.571 0.751 0.589 0.956 0.933 <0.001 0.998 0.742 0.620 <0.001 0.999
 C3–C4 1.008 0.974 0.861 0.498 1.377 0.121 1.105 0.639 1.560 0.220 1.036 0.875 9.666 0.999
 C4–C5 0.964 0.870 0.630 0.029 1.387 0.098 1.350 0.147 0.897 0.760 1.034 0.880 <0.001 0.994
 C5–C6 1.101 0.677 1.098 0.669 1.343 0.152 0.810 0.327 1.639 0.177 0.690 0.106 <0.001 0.995
 C6–C7 0.838 0.526 1.058 0.828 1.057 0.826 1.282 0.338 0.712 0.459 1.377 0.245 <0.001 0.998
 C7–T1 0.530 0.401 2.355 0.219 1.045 0.949 0.754 0.696 3.400 0.174 1.185 0.816 <0.001 0.999
(+) T2 hyperintensity 0.378 <0.001 0.661 0.051 1.389 0.098 0.848 0.425 1.586 0.194 2.101 0.001 0.834 0.908
Bold and italic value indicates significance at P<0.05.
BMI indicates body mass index; LE, lower extremity; OR, odds ratio; UE, upper extremity.

TABLE 3 - Multivariate Logistic Regression for Association With the Presence of Overall Symptoms
Neck Pain UE Pain UE Sensory Deficit UE Motor Deficit LE Sensory Deficit LE Motor Deficit Sphincter Dysfunction
Overall Symptoms OR P OR P OR P OR P OR P OR P OR P
Demographics
 Age ≥65 y 0.771 0.222 0.864 0.482 0.568 0.011 0.961 0.881 0.384 0.001 2.419 0.002 1.306 0.342
 BMI ≥30.0 0.806 0.296 0.919 0.681 1.396 0.148 1.316 0.304 1.814 0.024 1.373 0.234 1.120 0.683
 Female 1.423 0.086 1.616 0.017 1.074 0.745 1.665 0.052 1.062 0.821 1.780 0.028 1.741 0.042
 Diabetes 1.409 0.281 1.605 0.127 0.538 0.043 0.778 0.503 0.878 0.760 2.301 0.096 1.405 0.362
 Smoker 1.262 0.398 0.891 0.666 1.351 0.339 1.290 0.465 0.740 0.398 2.297 0.026 1.600 0.172
 Analgesics 2.004 0.003 1.210 0.403 1.059 0.820 1.338 0.301 1.263 0.469 1.482 0.169 0.918 0.779
Max compression level
 C1–C2 2.186 0.390 0.538 0.428 1.067 0.935 1.827 0.591 1.704 0.643 1.035 0.976 3.558 0.117
 C2–C3 2.754 0.107 1.778 0.293 1.340 0.631 0.381 0.092 0.488 0.374 0.599 0.416 0.558 0.460
 C3–C4 0.789 0.265 0.829 0.367 1.005 0.983 1.043 0.875 1.356 0.260 1.212 0.477 1.296 0.352
 C4–C5 0.703 0.087 0.580 0.007 1.047 0.836 1.330 0.268 1.389 0.214 0.894 0.665 1.396 0.218
 C5–C6 0.938 0.761 1.054 0.800 1.239 0.356 0.942 0.822 1.419 0.198 0.635 0.085 1.106 0.720
 C6–C7 0.671 0.123 0.696 0.152 1.352 0.302 0.757 0.365 1.141 0.686 0.908 0.755 0.612 0.211
 C7–T1 0.673 0.565 1.568 0.537 0.771 0.706 0.912 0.912 1.884 0.461 0.543 0.434 1.631 0.577
 (+) T2 hyperintensity 0.414 <0.001 0.685 0.058 1.510 0.065 1.065 0.807 2.264 0.002 1.752 0.034 1.429 0.186
Bold and italic value indicates significance at P<0.05.
BMI indicates body mass index; LE, lower extremity; OR, odds ratio; UE, upper extremity.

Axial neck pain was a significantly less likely CC in those over 65, but significantly more likely in those with analgesic usage and maximal compression at the C1–C2 level. Neck pain was also significantly less likely to be a CC in those with T2 hyperintensity. T2 hyperintensity was also associated with a higher likelihood of LE motor deficit as a CC.

When evaluating OS, neck pain was again more likely in those with analgesic usage and less likely in the presence of T2 hyperintensity. Patients with intramedullary T2 hyperintensity also had significantly lower mean mJOA scores (12.9 vs. 14.0, P<0.001). T2 hyperintensity was also associated with a higher likelihood of LE motor and sensory disturbance as OS.

DISCUSSION

Although CM is a relatively common disorder, it can remain very difficult to diagnose, even for experienced spine practitioners, especially when it is not severe. Symptoms remain the foundation for diagnosis, as neither physical findings nor spinal cord compression alone is sufficient to definitively rule in or rule out CM. However, despite the primacy of symptoms, there is considerable overlap in “myelopathic” symptoms versus those seen in other disorders, and there is no symptom that serves as a sine qua non. On top of all this, there is a dearth of information to guide the practitioner on the frequency with which various myelopathic symptoms arise. Behrbalk and colleagues reported the most common symptoms on admission for surgery including upper-limb paresthesia (85.7%), unbalanced gait (66.6%), and upper-limb weakness (61.9%), whereas pain was not a dominant feature and sphincter dysfunctions were unusual. However, the sample size was limited to 42 patients.18 Therefore, in the present study, we sought to further elucidate the presentation of CM by determining the frequency of various myelopathic symptoms in a large cohort of surgical patients. The average mJOA score in this cohort was 13.4, representing overall a “moderate” degree of myelopathy, but included a range from very severe (mJOA=6) to mild (mJOA=16).

The most common CC was UE sensory deficit (eg, numbness or tingling). Although this finding was statistically significant, it was present in less than half (46.5%). Intuitively, numbness and tingling might be expected to drive patients to seek care, as they are probably more immediately noticeable than subtle symptoms such as hand clumsiness. In many other spinal conditions, the presence of pain is also immediately noticeable and can point to the location of the pathology. However, the pain was often not a CC in myelopathy. Neck and UE pain were the CC only about a third of the time (32.6% and 36.6%, respectively), confirming the need for heightened awareness among practitioners evaluating these patients. When assessed by the level of maximal spinal cord compression, we did find that UE pain was significantly more likely to be a CC with distal levels of compression (eg, C5–C6, C6–C7, C7–T1). Whether that pain results from compression of the spinal cord itself, coexisting radiculopathy, or a combination of both, is unclear. In the logistic regression model, maximal compression at C1–C2 was associated with neck pain as a CC.

In addition to the CC, we also evaluated the overall list of symptoms (OS) present. The most common OS were UE and LE motor deficits, occurring in 82.6% and 81.2% of patients. These were significantly more common than other symptoms, even more so than the most common CC (UE sensory deficit, which was an OS in 70.9%). As was the case for the CC, the pain was not a consistent guide to diagnosis, being an OS in only about half (neck pain 55.4%; UE pain 53.5%). Sphincter dysfunction was an uncommon OS (16.5%) and a very uncommon CC (0.6%). When evaluated according to the level of maximal spinal cord compression, none of the OS demonstrated an association.

We also evaluated symptoms according to the presence of T2 hyperintensity on MRI. T2 hyperintensity was associated with significantly lower (worse) mJOA scores. It was also associated with significantly less neck pain as either a CC or an OS. Thus, these results would suggest that those with more severe myelopathy are likely to present with T2 hyperintensity but less neck pain.

There are several limitations to this study. First, our population consisted of those undergoing surgery for CM. As a result, it is possible that its characteristics may differ from a general population of myelopathic patients including those who, for whatever reason, do not undergo surgical treatment. Second, this paper represents a single institution experience and does not account for regional differences in the patient population. Although we controlled for sex, diabetes, body mass index, and smoking status, various other factors, such as genetic variation, other medical comorbidities, and other lifestyle habits could certainly play a role in the presentation of CM and limit the generalizability of our findings. Nevertheless, we believe that our relatively large sample size of nearly 500 patients is likely representative of those typically seen at a tertiary university setting in a major American metropolitan area and that our results are applicable to that population of myelopathic patients at a minimum.

CONCLUSIONS

In conclusion, patients with CM are most likely to present with UE sensory symptoms as a CC, whereas UE and LE motor symptoms are the most common OS. Neck pain is present only about half of the time. Those with T2 hyperintensity generally have worse myelopathy and also are less likely to complain of pain. Although those with greatest cord compression at C1–C2 are more likely to have neck pain as a CC, and those with more distal compression are more likely to have UE pain, the level of maximal cord compression is otherwise not associated with a specific CC or OS. LE sensory symptoms and sphincter dysfunction are relatively uncommon and should not be relied upon to make the diagnosis. To our knowledge, this study is the largest to quantify the frequency of myelopathic symptom presentation in a surgical population. These findings provide valuable insight into the symptomatic presentation of CM in clinical practice and can be used to better inform diagnosis and treatment in this complex patient population.

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Keywords:

cervical myelopathy; myelopathic symptoms; chief complaint; cervical spine surgery; maximal cord compression; MRI T2 hyperintensity; diagnosis

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