Myelopathy
Myelopathy is spinal cord dysfunction from extrinsic compression or intrinsic cord pathology, most often degenerative cervical spondylosis, producing combined upper and lower motor neuron findings. MRI of the suspected level confirms the diagnosis; management ranges from a 6 to 8 week conservative trial to emergent surgical decompression, antibiotics, or high dose glucocorticoids depending on cause.
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What this article covers
- Overview
Myelopathy is dysfunction of the spinal cord itself, distinct from radiculopathy (nerve root) or peripheral neuropathy.
- Epidemiology
Age distribution: Compressive cervical myelopathy from spondylosis typically presents in the sixth or seventh decade after preceding neck pain and stiffness.
- Risk factors
Age-related degeneration: Osteophytes, disc bulging, and ligamentum flavum hypertrophy narrow the cervical canal over years.
- Pathophysiology
Corticospinal tract injury produces spastic paresis, hyperreflexia, increased tone, and extensor plantar responses below the lesion, often with sensory loss at that level.
- Clinical features
Onset pattern: Chronic compressive myelopathy evolves over months with gait unsteadiness, leg spasticity, and later bladder impairment; noncompressive causes evolve over hours to days.
- Differential diagnosis
Cervical radiculopathy: Arm pain with dermatomal paresthesias and reduced reflexes, but gait is normal with no upper motor neuron signs.
- Diagnosis
What establishes the diagnosis: Combined upper motor neuron signs below a level and lower motor neuron signs at that level place disease in the spinal cord; a structural cause is confirmed once a…
- Management
First, any patient with new or progressive myelopathy needs urgent MRI and prompt neurology or neurosurgery consultation, since recovery correlates with how quickly compression is relieved.
- Complications
Permanent deficit: Severe weakness before decompression rarely fully recovers even after surgery, favoring earlier intervention.
- Prognosis
Compressive causes: Outcome depends on duration and severity of compression before decompression; symptomatic care controls most chronic stenosis, and surgery is reserved for refractory or progressive cases.
- Prevention
Recognize red flags early: Fever, weight loss, cancer history, injection drug use, or anticoagulant use with new back or neck pain should prompt urgent evaluation.
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Related articles
- Cervical radiculopathy
Cervical nerve root compression from disk herniation or degenerative spondylosis causes neck pain with dermatomal arm pain, paresthesia, weakness, and reduced reflexes, diagnosed clinically with the Spurling test and treated conservatively with NSAIDs and exercise before imaging or surgery.
- Spondylosis
Spondylosis is degenerative osteoarthritis of the spine, with facet joint arthropathy and disk degeneration producing anterolateral osteophytes and disk-space narrowing on imaging, most consequential in the cervical spine where it can compress a nerve root (radiculopathy) or the spinal cord (myelopathy), diagnosed clinically and with MRI when neurologic compression is suspected, and managed conservatively unless myelopathy or progressive deficit develops.
- Spinal cord compression
Spinal cord compression is mechanical narrowing of the spinal canal by tumor, hematoma, abscess, disc herniation, or trauma that produces myelopathy; it is a neurologic emergency requiring urgent MRI of the affected level and immediate treatment of the cause, since surgical decompression rarely restores function once paraplegia develops.
- Malignant spinal cord compression
Malignant spinal cord compression (metastatic epidural spinal cord compression) is an oncologic emergency from vertebral metastasis that requires whole-spine MRI within 24 hours, immediate high-dose dexamethasone, and urgent radiotherapy or surgical decompression to prevent irreversible paralysis.
- Transverse myelitis
Transverse myelitis is inflammation across one or more contiguous spinal cord segments causing subacute weakness, a sensory level, and bladder or bowel dysfunction; diagnosis requires spinal MRI showing cord enhancement or CSF inflammation with exclusion of compressive and infectious causes, and idiopathic disease is treated with high-dose intravenous methylprednisolone.
- Multiple sclerosis
Multiple sclerosis is an autoimmune, demyelinating CNS disorder causing optic neuritis, myelitis, and brainstem/cerebellar syndromes separated in space and time. Diagnosis uses the McDonald MRI-based criteria; acute relapses are treated with high-dose glucocorticoids, and disease-modifying therapy (interferon beta, glatiramer, or a higher-efficacy agent such as ocrelizumab or natalizumab) is started early to prevent relapse and disability accumulation.
- Pernicious anemia
Pernicious anemia is autoimmune atrophic gastritis that destroys gastric parietal cells and abolishes intrinsic factor production, causing vitamin B12 malabsorption, megaloblastic macrocytic anemia, and a potentially irreversible myelopathy and neuropathy. Diagnosis rests on a low or borderline B12 with an elevated methylmalonic acid, confirmed by anti-intrinsic factor antibody, and treatment is lifelong vitamin B12 replacement.
- Cauda equina syndrome
Cauda equina syndrome is compression of the lumbosacral nerve roots below the spinal cord causing saddle anesthesia, bladder or bowel dysfunction, bilateral leg weakness with areflexia, and low tone, most often from a large central lumbar disk herniation. It is a surgical emergency diagnosed by emergent MRI of the lumbar spine and treated with urgent decompression.