Myelopathy: A Difficult Diagnosis

I first met Mrs. Smith about three years ago. By the time she came to our clinic, she had seen three doctors. She first noticed her symptoms about nine months prior to our meeting. It started with some faint tingling, primarily in the hands. Within a month or two, she began to notice that she wasn’t walking quite as well as normal. Despite being 67 years old, she was in excellent condition and had been walking regularly until this point in her life.

When she first told her family doctor about these problems, he thought she might have diabetes. He ran the necessary tests and brought her back to clinic, but that work up didn’t show anything. Well, nothing, besides that she didn’t have diabetes. Her family doctor asked her to see a neurologist in town. It took a while to get an appointment, and a few months had passed before she reported to the neurologist’s office. He was concerned that she may have carpal tunnel syndrome and ordered a nerve conduction study. It turns out she did have carpal tunnel syndrome, but it was quite mild, and really didn’t explain her symptoms.

The neurologist sent her for an MRI scan of her whole spine. The MRI cervical spine revealed severe arthritic changes at multiple levels in the neck with compression of the spinal cord. He then sent her to our clinic to discuss surgical options.

As I listened to her tell the story I couldn’t help but remark on how bad she had gotten over these months. She had had a very slow, but steady, decline. As I asked her to walk up and down the hall, she reached for her walker. When this whole journey first started, she walked independently. Then came the cane. Now the walker.

Similarly with her hands. Initially she had had very mild numbness in her hands. Then came the fumbling with her keys and spilling her drinks. Now, she could barely write.

In the end, she underwent a rather simple decompression surgery, improved, and was very happy with how things went. But she did not improve to her original baseline. She still had some difficulty with walking, still use a cane for long walks, and still had trouble with writing.

She was the first patient I saw that showed me how insidious myelopathy can be. During the course of under a year she had a rather substantial loss of function. Granted, much of it came back, but it still impressed me how slowly the medical system recognized this problem. Everyone knows chest pain can be from the heart, or shortness of breath from the lungs. But the general public, and even doctors not typically involved in treating neurologic disorders, might not think of spinal cord compression when they hear a patient has hand numbness and clumsiness.

Defining myelopathy

Myelopathy is a condition of spinal cord impairment. It’s a general term, like shortness of breath. Shortness of breath might be a mild viral illness, or it might be something more severe - it is a symptom of an underlying condition. So too with myelopathy. The first step in diagnosing the cause of myelopathy is to diagnose the myelopathy itself, which in many cases is easier said than done.

So, what can be done to improve early diagnosis. I think patient education can go a long way. Patients now know that spinal arthritis can cause pinching of the nerves. No one is surprised when, as a neurosurgeon, I tell them that their shooting leg pain is due to a herniated disc. But it is often very surprising when patients discover their broad-based gait, or subtle tendency to drop things, is due to compression of the spinal cord. After all, shouldn’t compression of the spinal cord cause paralysis? Patients often don’t feel like they have overt weakness. They simply don’t know that the symptoms can correlate.

Treatment of myelopathy and other cervical spine disorders is a particular interest of mine. I enjoy the surgeries, and I enjoy diagnosing the conditions. But what I would enjoy more is having early referrals for patients with mild symptoms for whom my surgery would have the maximum benefit - preserving near the normal neurological function. I believe that if patients were more aware of the symptoms of myelopathy, they would be more likely present for treatment.

Medical science and myelopathy

The story of spine surgeons improved understanding of myelopathy is a quiet history of medical science over ignorance. For years, the standard advise on the treatment of myelopathy was that surgery prevented neurologic worsening. “It would be nice if you improved, but even if you don’t, we consider it a success if you don’t get worse.” That is what we used to tell patients. We told them that because we didn’t know any better - we just didn’t know if our surgery made them better or not.

But many spine surgeons weren’t happy with that degree of understanding. As a doctor I can empathize with them - it is always embarrassing to have to tell a patient suffering with severe neurologic symptoms that they might get better. Or they might not; we just don’t know.

So surgeons around the country and around the world set off to better understand this disease. And over the last decade we have had scientific publications to help us understand the true story of treatment for myelopathy. We now know that many patients do improve. We can actually help people regain function that they had lost. Now, when I see a patient with myelopathy, I can confidently tell him that our surgery has two goals: to improve the neurologic problems he already has, and to prevent any new neurologic problems in the future.

I think the treatment of myelopathy seems to be at a turning point. More surgeons are interested in the disorder, and we are finally getting more definitive answers about which treatments are best. For instance, it was long assumed that surgeries in the front of the neck - anterior cervical fusion - were better for the treatment of myelopathy because they offered better decompression. Many people avoided decompression surgeries in the back of the neck for that same reason. But recent studies with excellent quality show that treatment from the front or back of the neck seem to be equivalent. The only thing that seems to matter is making this diagnosis and safely decompressing the spinal cord.

Thinking back on Mrs. Smith, what are some of the things I recommend that patients watch out for? Dropping things is never normal. Especially if it becomes a recurring habit. Pay attention to the way you walk. Aging is going to change things, but if you are progressively going from a vibrant person with a brisk gait to someone who has to hold the walls to make it through the house, there is a problem. And trust your instincts. Mrs. Smith knew something was wrong. She got diagnosed quickly and underwent successful surgery. That’s the goal for all my patients.