Cervical Myelopathy: When the Spinal Cord Is Compressed in the Neck

What Is Cervical Myelopathy?

Cervical myelopathy is spinal cord dysfunction resulting from compression of the cervical spinal cord within the cervical spine canal. Unlike cervical radiculopathy — which involves compression of a single nerve root, producing symptoms in one arm — myelopathy involves the cord itself and produces a constellation of bilateral and multi-limb neurological signs and symptoms. It is the most common cause of spinal cord dysfunction in adults over 55, arising most commonly from cervical spondylosis: the progressive accumulation of disc degeneration, osteophyte formation, hypertrophy of the ligamentum flavum, and facet joint enlargement that narrows the spinal canal and compresses the cord with age. Less commonly, acute disc herniation, ossification of the posterior longitudinal ligament (OPLL), or rheumatoid atlantoaxial instability can produce myelopathy at a younger age. Cervical myelopathy is important not only because of its clinical impact, but because it is frequently unrecognised — misattributed to ageing, peripheral neuropathy, or other neurological conditions — delaying treatment that can prevent progression to permanent neurological disability.

Recognising the Warning Signs

The clinical presentation of cervical myelopathy is characterised by a combination of upper motor neuron signs (reflecting cord compression) and lower motor neuron signs at the level of compression (reflecting nerve root involvement at the compressed segment). Key features to recognise include: gait disturbance — a broad-based, unsteady, or "clumsy" walking pattern that is often the first functional sign; hand clumsiness — difficulty with fine motor tasks such as buttoning clothing, writing, and handling small objects; upper limb symptoms — numbness, tingling, or weakness in both arms, often without a clear dermatomal pattern; lower limb spasticity — stiffness and heavy legs, with brisk reflexes and a positive Babinski sign; Lhermitte's sign — an electric shock sensation radiating down the spine or into the limbs with neck flexion; and bladder dysfunction — urinary urgency or frequency without urological cause. Neck pain itself may be absent or mild, making the diagnosis easy to miss if clinicians do not specifically screen for the neurological features.

Management and Prognosis

The natural history of cervical myelopathy is variable but broadly unfavourable without treatment: approximately 20–60% of patients experience clinical deterioration over time. Mild myelopathy (nuisance symptoms without significant functional limitation) may be managed conservatively with close monitoring — a cervical collar provides symptomatic support, and activity modification reducing cervical compression is recommended. The development of moderate or severe myelopathy — functional gait disturbance, significant upper limb deficit, or progressive neurological deterioration — is an indication for surgical decompression: anterior cervical discectomy and fusion (ACDF) or posterior laminectomy with or without fusion. Surgery stabilises and in many cases reverses the neurological signs, particularly when performed before significant cord damage has occurred. Post-operative rehabilitation — rebuilding gait, balance, and upper limb function — is an essential component of the recovery pathway and substantially influences functional outcome.