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Understanding the problem

Myelopathy describes any neurologic deficit related to the spinal cord. Myelopathy is the loss of spinal cord function caused by degenerative changes to the spine or by trauma. It is often first detected as difficulty walking because of weakness or problems with balance and coordination. This process occurs more commonly in the elderly, who can have many reasons for having problems with walking and balance. Myelopathy may be caused by bone spurs or disc herniations in the cervical or thoracic spine that squeeze the spinal cord. Trauma or instability may also play a role in myelopathy. This compression can cause irreversible injury to the spinal cord with serious disability to the patient. Patients exhibiting signs of myelopathy often are considered urgent surgical candidates.

Understanding who suffers

Cervical myelopathy is more common in men and tends to present earlier than in women. Imaging shows that 13% of men in the third decade and almost 100% of men over the age of 70 are affected. In women the disease presents later, with 5% showing radiographic changes in the fourth decade going up to 96% in women over the age of 70. Changes are more common in patients with Rheumatoid Arthritis where 85% of those with moderate to severe disease will have x-ray changes.

Potential Signs and Symptoms

Clinical signs and symptoms depend on which spinal cord level (cervical, thoracic or lumbar) is affected and the extent (anterior, posterior or lateral) of the progression. . Myelopathy can be difficult to detect, because this problem usually develops gradually. Many people with myelopathy will begin to have difficulty with things that require coordination. Examples include walking up or down stairs, buttoning shirts or tying shoes, and may include:

  • upper body (weakness, spasticity, clumsiness, muscle tension, overactive reflexes, among others
  • lower body (weakness, clumsiness in the muscle group innervated at the level of spinal cord compromise, wasting away of muscle, low or absent reflexes, among others
  • sensory deficits
  • bowel / bladder symptoms and sexual dysfunction.
Examinations Usually Required

There are a number of ways that imaging can be used to diagnose the condition and help decide on a management plan. They are often used in combination to give a clear overall view of the pathology:

X-ray

Plain x-ray is the initial imaging modality of choice. Anteroposterior (AP) and lateral views should be requested. These will show spondylolisthesis, fusion and osteophytes clearly. Absolute measurements of the spinal canal size are not reliable from x-ray. However, Pavlov’s ratio can be used as a guide to indicate narrowing. Where instability is suspected to be the cause of symptoms (especially in RA) flexion and extension views of the cervical spine will show abnormal motion.

MRI

MRI gives a detailed three-dimensional image of the cervical spinal cord and any compression present. It has been a key in recent years in diagnosing the condition early. The advantages of MRI are that it involves no radiation and gives excellent imaging of the disc and nerves including intrinsic changes in the cord and nerve roots. The extent of pannus in patients with RA is also well demonstrated. In recent years new techniques have become more prevalent which reduce the impact of artefact caused by instrumentation. MRI is not as good at identifying the extent of osteophytes and disc calcification so when these are suspected MRI should be supplemented with CT.

CT

There are two main uses for CT scanning in the diagnosis of cervical myelopathy. There are some patients who are unable to undergo MRI imaging, often because of an implanted cardiac device. For these patients a CT myelogram offers an imaging option which is almost as sensitive as MRI. In general a CT can also give additional information on the presence of osteophytes or other bony compressive lesions which are underestimated on MRI scans.

Myelography

Myelography is a type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors. The procedure often involves injection of contrast medium into the cervical or lumbar spine, followed by several X-ray projections. A myelogram may help to find the cause of pain not found by an MRI or CT.

Proposing Treatment and Why AIMIS

When symptoms of cervical myelopathy worsen despite non-surgical treatment surgery maybe recommended, your doctor may recommend surgery.

The aim of the surgery is to relieve symptoms by “”decompressing,”” or relieving pressure on, the spinal cord. This can involve removing pieces of bone, spurs or soft tissue (such as a herniated disk) that may be taking up space in the spinal canal. This relieves pressure by creating more space for the spinal cord.

AIMIS provides various surgical options depending on an individual’s problem and include:

  • Minimal Invasive Decompression Surgery
  • Minimally Invasive Stabilization Surgery
  • Anterior Cervical Corpectomy
  • Anterior Cervical Discectomy and Fusion
  • Anterior Cervical Corpectomy and Fusion
  • Laminectomy
  • Laminoplasty

The procedure our experts will recommend depend on a number of factors and type and location of the problem.

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Reputable and Prestigious Surgeons

AIMIS' skilled team of neurosurgeons, orthopaedic surgeons and ancillary professionals has one of the leading experiences in the world for treating myelopathy. Our full team are consulted with each case to find the most suitable experienced doctor for the patient’s exact issue, to ensure the maximum potential outcome of treatment

Getting More Information Before Moving Forward
You may have questions like:
  • Can I get more information before I commit to this?
  • Can I get a second opinion from you before I commit to this?
  • How can I find out the cost before I have any obligation?
What AIMIS Can do:

AIMIS will provide a full review, diagnosis and potential surgical options for your condition, after receiving the relevant examinations and information from you. They will also provide an estimate for your surgical procedure before you decide.

AIMIS’ mission is to the provision of “true” healthcare for those who require it. It provides world leading surgeons using state of the art procedures to optimize potential surgical outcomes, whilst taking care of all arrangements so as to allow concentration on recovery.

Affordability

AIMIS provide competitive prices for state of the art procedures. We also work with a large range of Insurance companies where your policy allows you to have surgery abroad.

Further information on the problem:

Myelopathy is spinal cord dysfunction related to abnormal pressure placed on the spinal cord. Unlike conditions that cause pressure on individual nerve roots, this type of damage can result in loss of nerve function anywhere along the spinal cord below the damaged area. The effects of myelopathy can range from mild to severe, and can worsen over time.

Myelopathy most commonly results from pressure on the spinal cord because of a reduction in the space available for the cord. This can occur from disc herniation, bone spur formation, spinal stenosis, or a thickening of the soft tissues that surround the spinal cord, such as the ligamentum flavum or the posterior longitudinal ligament.

Patients may present with a range of symptoms and many of these are non-specific. It is important to remember that although cervical myelopathy is a disease of the cervical spine it may manifest with lower as well as upper limb symptoms. Some symptoms may include difficulty walking or maintaining balance, loss of bladder control or other functions, loss of fine motor skills, weakness, numbness, tingling, pain, and paralysis. Pain is a symptom in many patients but it is important to remember that it may be absent which often leads to a delay in diagnosis. In older patients it often manifests with a rapid deterioration of gait and hand function Treatment options vary depending on the cause of the loss of nerve function. Some conditions that cause myelopathy can be treated successfully with surgery. Medication may be needed to manage chronic pain.

Cervical lesions in the region of C3 - C6 cause a loss of manual dexterity with difficulties in writing and nonspecific alteration in arm weakness and sensation. Cervical lesions from C6 - C8 tend to lead to a syndrome of spasticity and loss of proprioception in the legs. These patients often have gait disturbance and suffer multiple falls. Multilevel disease is common causing a mixture of symptoms.

Late in the disease where compression is severe, if surgical decompression is not performed the symptoms can progress to sphincter dysfunction and paralysis (partial or total). Cervical spondylotic myelopathy is the most common cause of acquired spastic paresis in adults.

Further Information on Increased Risk Groups

The underlying cause of the condition is compression of the long tracts in the spinal cord.

The common pathological processes underlying cervical myelopathy are outlined below:

Disc Herniation.
Discogenic disease may cause myelopathy in the acute setting as a large central soft disc herniation causing cord compression. Disc disease is also often seen as part of the compressive lesion in spondylotic disease.

Congenital.
Myelopathy due to congenital stenosis does not have a specific underlying lesion. It is caused by a canal diameter which is narrower from birth. It is often not symptomatic until secondary degeneration further narrows the canal.

Spondylosis.
CSM is the result of degenerative changes which develop with age, including ligamentum flavum hypertrophy or buckling, facet joint hypertrophy, disc protrusion and posterior spondylotic ridges. One or all of these changes contribute to an overall reduction in canal diameter which may result in cord compression. Spondylolisthesis usually occurs in the lower cervical spine. It is caused by arthrosis of the facet joints combined with disc degeneration leading to instability.

Post traumatic myelopathy
Trauma may induce myelopathy or precipitate symptoms of an underlying stenosis of the spinal canal. Smaller diameter canals have an increased chance of neurological injury in trauma.

Ossification of the posterior longitudinal ligament (OPLL).
This is a common feature in patients with cervical myelopathy with up to 25% being affected. It is particularly common in patients from the Far East. It is seen on imaging as areas of ossification behind the vertebral bodies.

Myelopathy due to tumour expansion.
Intraspinal tumours are a relatively uncommon cause of cervical myelopathy but must always be considered given the potentially catastrophic consequences of the diagnosis being missed. Tumours may originate in the spinal cord (intramedullary tumours) or compress from outside (extra medullary tumours). Metastatic deposits are usually slow growing with gradual onset of symptoms.

Further examination that maybe required or requested

Patients present with a number of clinical findings which are predominantly upper motor neuron signs.

  • Weakness is more severe in the upper limbs.
  • Gait is usually affected with an ataxic broad based gait.
  • Hypertonia – increased resting muscle tone identified by passive movement.
  • Hyperreflexia – exaggerated response to normal physiological reflexes.
  • Ankle clonus – forced dorsiflexion at the ankle giving rise to sustained beats of clonus (more than three beats is considered pathological).
  • Babinski sign – extension of the great toe on scratching of the sole of the foot.
  • Hoffman’s reflex – flicking of the terminal phalynx of the middle or ring finger causing concurrent flexion at the terminal phalynx of the thumb and index finger.
  • Finger escape sign – the small finger spontaneously abducts due to weak intrinsic muscles.
Why AIMIS for this Surgery

AIMIS strives for excellence in delivering the best surgical outcomes, via the extensive expertise of its prestige surgeons, its technologies, its highly trained staff and superior facilities to provide an individualized and compassionate experience in a comfortable environment. All patients are treated with the individual care they deserve in an effort to provide the best chance of successful treatment.

Other Services Provided by AIMIS

In addition to its Innovative Healthcare, AIMIS provides seamless service along the way. From the start of your journey you’ll know the best flights to take, where you’ll be staying, what paperwork you will need. You will have a personal assistant assigned; from your pick up at the airport, to your accommodation, continuous assistance at your pre-consultation, through surgery and in your postsurgical care. Our Patients have said that they feel they have become “”part of our family”” and some even asked to stay a little longer! AIMIS is here to assist you in an all you requirements, allowing you to focus on your health and recovery.

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