Definition

Myelopathy is damage to the spinal cord due to severe compression or pressure from trauma, narrowing, degenerative diseases, or chronic inflammation. The spinal cord is a bundle of nerves in the form of tracts or fibers protected by the spine. It extends from the head to the pelvis and is part of the central nervous system, functioning to transmit messages from the brain to related organs. This is related to sensory abilities, sensations, and autonomic functions (automatic bodily functions).

The spinal cord is divided into three parts: cervical (neck area), thoracic (chest area), and lumbar (pelvic area). If any part of the spinal cord is damaged due to compression or pressure, the symptoms that arise are referred to as myelopathy. Myelopathy is different from radiculopathy, which is a set of symptoms due to pressure on the nerve branches from the spinal cord.

Causes

With age, inflammation, chronic diseases, and bone thinning, the cushioning between the vertebrae can thin, causing pressure on the spinal cord and its branches. Myelopathy develops slowly as a result of spinal degeneration due to aging (spondylosis), but it can also be caused by sudden changes in spinal structure or congenital spinal deformities.

• The most common cause of myelopathy is spinal stenosis due to aging. In this condition, there is a narrowing of the space within the spinal canal, causing pressure. 
• Central disc herniation occurs when the vertebral disc (intervertebral cushion) is pressed into the spinal canal, causing pressure on the spinal cord, and leading to myelopathy. 
• Autoimmune diseases, such as rheumatoid arthritis of the spine, can cause degenerative changes, resulting in spinal cord compression. 
• Hernias, cysts, and spinal tumors can press on the spinal cord and cause myelopathy. 
• Acute myelopathy can occur due to trauma, spinal infection, inflammation, radiation, and neurological diseases.

Risk factor

Factors that can increase the risk of myelopathy include:

• Old age
• Smoking
• Alcohol consumption
• Obesity
• Intense sports, such as football, gymnastics, and running
• Lack of physical activity
• Infections
• Chronic inflammatory conditions

Symptoms

There are three types of myelopathy based on the location of compression: cervical myelopathy, thoracic myelopathy, and lumbar myelopathy. The symptoms that arise depend on the location of the myelopathy. They include:

• Cervical myelopathy: Symptoms arise from compression in the cervical part of the spinal cord or the neck area. This type of myelopathy is the most common. Symptoms include neck pain, weakness in the arms and hands, tingling and numbness in the arms and hands, and difficulty handling small objects. 
• Thoracic myelopathy: This is caused by compression in the thoracic part of the spinal cord or the back. Thoracic myelopathy is often due to herniation or compression of the spinal cord by the surrounding bones and trauma. Symptoms include weakness in the arms, legs, and hands, difficulty walking, and imbalance. Thoracic myelopathy can also cause urinary and sexual dysfunction. 
• Lumbar myelopathy: This is a rarer condition where myelopathy occurs in the pelvic area. Symptoms can vary.

When compression occurs in the spinal cord, symptoms such as loss of sensation, function, and discomfort at the site of damage and below it can occur. Symptoms of myelopathy include:

• Pain in the neck, hands, legs, lower back.
• Numbness, tingling, and weakness.
• Decreased ability to perform fine motor movements, such as buttoning and writing.
• Increased reflexes in the arms or legs at the level of the damage.
• Difficulty walking.
• Inability to hold urine.
• Imbalance and poor coordination.

Diagnosis

Your doctor will ask about the progression of your illness, possible risk factors, and past illnesses that may cause myelopathy. Diagnostic examinations that can be conducted to diagnose myelopathy and exclude differential diagnoses include:

• X-ray to view the condition of the spine and exclude other conditions.
• MRI to view the spinal canal (the space where the spinal cord is located).
• Myelography, is a radiological examination with contrast to see abnormalities in the spinal cord. This examination can be done if the patient is uncomfortable with an MRI.
• Electromyogram to evaluate nerve function and the ability to move the arms and legs. This examination is conducted by stimulating the nerves in the hands, arms, legs, and feet.

Myelopathy is generally an accompanying diagnosis to the main diagnosis. For example, your doctor may say that you have cervical stenosis with myelopathy. If there is no involvement of the spinal cord, your doctor will say you have cervical stenosis without myelopathy.

Management

Treatment of myelopathy will depend on what causes the myelopathy. In some conditions, myelopathy can be irreversible (cannot be recovered), and treatment can only help control symptoms or slow the progression of the disease.

Non-Operative

Non-operative management of myelopathy includes bracing, physical therapy, and medication. These modalities can be used for mild myelopathy and aim to reduce pain and help you return to daily activities. This management does not cure the compression that occurs. Symptoms can still worsen, either slowly (chronic) or acutely. If you experience worsening symptoms, immediately consult your doctor. Some worsening conditions cannot be treated, so it is important to stop worsening in the mild disease phase.

Operative

Since myelopathy is caused by compression, the main treatment is surgery. Surgery aims to relieve 'pressure' on the spinal cord. For myelopathy caused by narrowing, the doctor may recommend a surgical procedure to expand the size of the spinal canal. For myelopathy caused by a tumor, if the size is small, the tumor can be removed.

Minimally invasive spine surgery methods can help reduce the risk of complications and speed up the healing process.

Spinal fusion surgery is an operation that aims to repair the structure of the spine. The mechanism of surgery is to fuse small bones until they heal into one bone. This can reduce pain from movement and restore spinal stability.

Home Care

While waiting for surgery, you can do exercises, make lifestyle changes, use warm or cold therapy, injections, and oral medication to reduce pain. It is important to take medications as prescribed by your doctor, as long-term use of pain relievers can cause certain side effects.

Complications

Complications from myelopathy surgery include nerve paralysis, infection, damage to the dura mater layer, and difficulty swallowing (especially for cervical myelopathy). More severe complications include death, stroke, and esophagus damage (cervical myelopathy). Predictors of these complications include older age, long surgery duration, and other comorbid conditions such as diabetes.

Prevention

Myelopathy can be caused by aging, so it cannot be completely prevented. However, strengthening the spinal bones can help reduce the occurrence of severe myelopathy. Prevention can be done by:

• Lifting heavy objects safely. Start with a squatting position, tighten your abdominal muscles, and use the strength in your legs to lift the object. If you cannot lift the object, ask for help from others.
• Maintaining a healthy weight. Excess weight can add pressure to the spinal cord.
• Quitting smoking. Smoking can cause the spinal discs to degenerate easily.
• Doing exercises to strengthen back and abdominal muscles, such as crunches, planks, or pilates.

When to see a doctor?

Immediately consult your doctor if you experience the following:

• Changes in walking patterns, such as loss of balance or frequent falls.
• Increasing back or neck pain.
• Numbness, tingling, and weakness in the hands, fingers, feet, and toes.

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