Cervical Myelopathy: Symptoms, Diagnosis, and Treatment

Also called cervical spondylotic myelopathy (CSM) or spinal cord compression in the neck — cervical myelopathy is compression of the spinal cord that causes balance problems, leg weakness, and difficulty with hand coordination. Unlike most spine conditions, it carries urgency: untreated, the damage to the spinal cord can become permanent.

By Francis C. Lovecchio, MD · Attending Spine Surgeon, Hospital for Special Surgery, New York, NY

Robert presented with a primary complaint of weakness when climbing stairs, accompanied by symptoms that were harder to explain. He felt off-balance more often, and at times when walking he could not clearly feel the floor. He had been working with a physiatrist — a non-operative spine expert — who was investigating the lumbar spine as the source. That was a reasonable starting point given his presentation.

On examination, however, we suspected the problem was elsewhere.

What is cervical myelopathy?

Narrowing of the space available to the spinal cord in the neck is called cervical spinal stenosis. Many people have some degree of stenosis (i.e., narrowing) without ever knowing it. When the stenosis becomes severe enough to compress the spinal cord itself — not just the nerve roots — patients can develop cervical myelopathy. Myelopathy refers to a disorder of the spinal cord. Cervical refers to the neck.

This is distinct from what occurs in the lower back. The lumbar spine contains no spinal cord — only individual nerve roots. Compression of those roots produces leg pain, numbness, or weakness following a specific nerve distribution. That is radiculopathy. Compression in the lower back can also cause heaviness, pain, or numbness in the buttocks and thighs, called neurogenic claudication. Cervical myelopathy is a different process. The spinal cord carries signals between the brain and the rest of the body, and when it is compressed, the resulting symptoms tend to be more widespread and harder to localize — balance problems, leg weakness, and difficulty with fine motor tasks in the hands.

What are the symptoms?

The symptoms of cervical myelopathy are often subtle early in the course, which is part of what makes the condition difficult to catch. Patients frequently arrive at evaluation believing the problem originates in their lower back.

Robert's case is illustrative. His primary complaint was weakness on stairs. He was also having difficulty with balance, and he described the unusual sensation of not being able to feel the floor when walking. None of these symptoms point obviously toward a neck problem, which is why the diagnosis had been delayed.

Several findings on physical exam pointed toward the cervical spine. First, Robert had balance impairment — he was unable to walk heel-to-toe. Second, he had proximal weakness in the legs: his thighs and hips were weaker than his ankles, which is the opposite of most lumbar nerve issues. Third — and most telling — his reflexes were asymmetric. On one side of the body the reflexes were brisk and rapid; on the other side, they were nearly absent.

That combination — balance impairment, proximal leg weakness, and asymmetric reflexes — pointed to a spinal cord problem in the neck rather than a nerve root problem in the lumbar spine.

Other findings associated with cervical myelopathy include difficulty with fine motor coordination in the hands — buttoning a shirt, using a key, or writing. Some patients describe a gradual sense of clumsiness in the hands that develops over months.

How is cervical myelopathy diagnosed?

Diagnosis begins with the physical exam. Many of the key findings are accessible if you know what to look for — balance testing, the reflex pattern, the distribution of weakness.

For Robert, we obtained X-rays of the neck and lower back. The X-rays showed only age-related changes, with no acute abnormality. The cervical MRI, however, was informative. It demonstrated spinal cord compression at multiple levels.

The most severely affected level was C5-6, where the space available to the spinal cord measured slightly more than four millimeters. At an adjacent level for comparison, he had over nine millimeters — a substantial difference.

Imaging also showed that Robert had been born with a narrow spinal canal — a condition known as developmental spinal stenosis. This predisposed him to symptomatic cord compression: as normal age-related degenerative changes occurred in the cervical spine, only modest additional narrowing was required before the cord became compressed.

In some cases, the MRI shows a change within the picture of the spinal cord itself — a brighter area indicating that the cord is under distress. When that finding accompanies the appropriate symptoms and exam, the diagnostic picture is clear.

Why does cervical myelopathy usually require surgery?

Cervical myelopathy is unlike most other spinal conditions. A lumbar disc herniation causing leg pain often responds well to non-surgical treatment — injections, physical therapy, medications — and many patients improve without operation.

Cervical myelopathy is different. When the spinal cord is being compressed to the point that it is showing dysfunction (e.g., numbness in the hands, balance changes, weakness), permanent changes can occur.

"This isn't like other conditions where it's just for quality of life. If he left this alone, there was a chance that he could get to the point where he would really lose feeling in his legs, or even that the hands would stop working or that he would get really off balance."

The spinal cord contains the highways for signals to travel between the brain and nerves. The cells are nearly identical to brain cells. Once damage has occurred, full recovery is not always possible. For this reason, surgery for cervical myelopathy is generally recommended earlier than for most other spine conditions.

In Robert's case, the diagnosis was made early enough in the course of the disease that there appeared to be sufficient time to intervene before he developed a permanent disability.

How is cervical myelopathy surgery performed?

The approach to decompressing the spinal cord varies. There is genuine debate within spine surgery between anterior (from the front) and posterior (from the back) approaches, and in most cases the cord can be decompressed by either method. The choice depends on the patient's specific anatomy and the surgeon's experience.

Laminoplasty

For Robert, the appropriate procedure was a laminoplasty. This procedure decompresses the spinal cord from the back without fusing the spine, which preserves neck motion while addressing multiple levels through a single approach.

The lamina functions as a roof on the back of the spine. In a laminoplasty, a hinge is created on one side of the lamina and the lamina is opened — much like opening a door. This expands the spinal canal and relieves pressure on the cord.

Small plates are used to keep the lamina in its new open position. They function similarly to stents, secured with small screws that hold the lamina permanently in place.

Anterior approaches

The alternative is an anterior cervical procedure, performed from the front of the neck. The disc or bone compressing the cord is removed and the affected levels are fused. This works well when the compression involves fewer levels and the source of pressure is anterior.

How the approach is chosen

The choice between anterior and posterior approaches depends on several factors: the source of compression, the number of levels involved, and the patient's overall cervical alignment. When the compression involves many levels — as in Robert's case — a posterior approach such as laminoplasty often makes sense because it can address all of the affected levels through one operation, and because it does not require fusion, neck motion is preserved.

What is recovery like?

Robert was discharged from the hospital on post-operative day one. He wore a soft cervical collar for approximately two weeks to allow the surgical site to heal, then began range-of-motion exercises.

Neck pain in the first two weeks was significant but controlled with appropriate medication. By six weeks post-op, the pain had largely resolved.

At six months, his recovery has been favorable. Balance is substantially improved. Leg strength is substantially improved. He has not returned fully to baseline, which is often the case after significant spinal cord compression. Even so, his function is meaningfully better than it was before surgery.

He continues with physical therapy for balance, and gradual ongoing improvement is expected. Recovery from cord compression can be slow. At his six-month follow-up imaging, neck motion was preserved, the plates were intact, and the screws had not migrated. Continued improvement could still occur, though it is always difficult to know with myelopathy.

What are the risks?

Surgery on the cervical spine for myelopathy carries higher stakes than a typical nerve root decompression. The spinal cord does not always react predictably to surgery. Even in perfect surgeries, the risk of spinal cord injury still exists.

Other risks include infection, injury to nerve roots at the operated levels, and — specific to laminoplasty — persistent neck stiffness, pain, or gradual forward posturing of the head.

In nearly all cases, the risk of leaving cervical myelopathy untreated outweighs the risk of surgery. This is one of the reasons that patient selection and timing matter. Early identification allows surgery to prevent further decline. When the diagnosis is delayed and the cord has been compressed for an extended period, surgery can still help, but the degree of recovery is less predictable.

Frequently asked questions

What is cervical myelopathy?

Cervical myelopathy is compression of the spinal cord in the neck, severe enough to disrupt how signals travel between the brain and the rest of the body. It is distinct from a "pinched nerve" — which causes pain along a single nerve path — because it affects the spinal cord itself. Typical symptoms include balance problems, leg weakness, hand clumsiness, and asymmetric reflexes.

What is the difference between myelopathy and radiculopathy?

Myelopathy is a disorder of the spinal cord itself. Radiculopathy is compression or irritation of a single nerve root after it leaves the spinal cord. Radiculopathy produces pain, numbness, or weakness along one specific nerve path — typically down a leg or into an arm. Myelopathy produces more widespread and harder-to-localize symptoms because the spinal cord carries signals to the entire body below the level of compression.

Can cervical myelopathy be reversed?

Symptoms can be stabilized and often improved with surgical decompression — particularly when the diagnosis is made early. Once the spinal cord has sustained damage from prolonged compression, however, full recovery to baseline is not always possible. The cells of the spinal cord are nearly identical to brain cells, and they do not regenerate the way a compressed peripheral nerve can. This is why surgery is generally recommended earlier for cervical myelopathy than for most other spine conditions.

What happens if cervical myelopathy is left untreated?

Untreated cervical myelopathy tends to progress. Patients can develop worsening balance, increasing leg weakness, loss of fine motor control in the hands, and eventually difficulty walking. The progression is not always linear — some patients deteriorate gradually, others in stepwise fashion. Because the spinal cord does not reliably recover from prolonged compression, delay in treatment makes the post-surgical outcome less predictable.

Considering cervical myelopathy treatment in NYC?

Dr. Francis Lovecchio is an attending spine surgeon at the Hospital for Special Surgery in New York City, specializing in cervical myelopathy, laminoplasty, and complex cervical spine reconstruction. He sees patients from across the New York tri-state area — Manhattan, Brooklyn, Queens, Long Island, New Jersey, and Connecticut.

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Key takeaways

Definitions

Cervical spinal stenosis. Narrowing of the spinal canal in the neck. When the space for the spinal cord shrinks due to disc degeneration, bone spurs, or thickened ligaments, it can lead to compression of the spinal cord.

Developmental spinal stenosis. A spinal canal that is narrower than average from birth — sometimes also called congenital spinal stenosis. People with developmental stenosis are predisposed to developing symptomatic spinal cord compression because there is less margin before the cord gets pinched.

Lamina. The bony arch on the back of each vertebra that forms the "roof" of the spinal canal. In a laminoplasty, the lamina is hinged open to create more room for the spinal cord.

Laminoplasty. A surgical procedure where the lamina is hinged open — like opening a door — to expand the spinal canal and relieve pressure on the spinal cord. Unlike a laminectomy, the lamina is not removed. Unlike a fusion, the spine is not locked in place, so the patient keeps neck motion.

Myelopathy. A disorder of the spinal cord, usually caused by compression. When the spinal cord is squeezed by bone, disc, or ligament, it can cause widespread symptoms including balance problems, leg weakness, and difficulty with hand coordination. Different from radiculopathy, which affects individual nerve roots.

Neurogenic claudication. Heaviness, pain, or numbness in the buttocks and thighs caused by compression of the nerve roots in the lower back. Distinct from cervical myelopathy, but sometimes present in the same patient when there is degeneration in both the neck and the lumbar spine.

Physiatrist. A physician specializing in physical medicine and rehabilitation. In spine care, physiatrists are non-operative spine experts who manage pain through injections, medications, and therapy rather than surgery.

Proximal weakness. Weakness in muscles closer to the center of the body — the thighs and hips rather than the ankles and feet. In cervical myelopathy, proximal weakness in the legs is a common finding because the spinal cord fibers controlling the hips and thighs are affected by compression in the neck.

Radiculopathy. Pain, numbness, or weakness that radiates along a nerve path — typically down the leg (lumbar radiculopathy) or into the arm (cervical radiculopathy) — caused by a compressed or irritated nerve root in the spine. Different from myelopathy, which involves the spinal cord itself.