Case of the Week

Background:

• Cervical spondylotic myelopathy (CSM) is a clinical syndrome due to a spinal cord compression secondary to degenerative changes in the cervical spine. Congenital spinal canal stenosis can be a predisposing factor for developing CSM.
• Cervical spondylosis is the degeneration of vertebrae, disks, and joints in the spine. This can occur with “wear and tear” of the backbone with aging.

Clinical Presentation:

• Presents with various signs and symptoms including, but not limited to: gait impairment or other coordination problems; tingling and/or numbness in the arms, fingers, or hands; loss of hand dexterity; hyperreflexia; pain or stiffness in the neck.
• Can occur as a slow decline with periods of some remission. Some patients may have improvement of clinical symptoms without intervention.

Key Diagnostic Features:

• Presence of an intramedullary contrast enhancement with a flat transverse “pancake-like” pattern (on sagittal images) and a circumferential pattern with sparing of central gray matter (on axial images), at the site or just below the maximal spinal canal stenosis highly indicative of cervical spondylotic myelopathy. Enhancement in the cord is due to disruption of the blood–spinal cord barrier. Craniocaudal extent of enhancement is less than 1 vertebral segment. The recognition of this radiologic pattern helps to make correct diagnosis, aids in proper management/treatment, and avoids unnecessary interventions.

Differential Diagnoses:

• Although intraspinal enhancement can be seen in a variety of entities, this specific pattern of enhancement in association with the degenerative changes should guide in differentiating spondylotic myelopathy from the entities listed below:
  • Spinal cord tumors are usually expansile, heterogeneous signal, and may or may not demonstrate enhancement, which, if present, is usually long craniocaudal segment of enhancement.
  • Demyelinating disease usually has long craniocaudal lesions with variable enhancement (none, diffuse, patchy, peripheral) and may be associated with additional lesions in the spinal cord and brain.
  • Inflammatory/infective diseases usually have long craniocaudal segments of enhancement.
  • Vascular lesions usually have long craniocaudal extent with variable enhancement pattern (none, mild, patchy, nodular).

Treatment:

• Surgical: Decompressive surgery, usually for patients with progressive deterioration and moderate to severe myelopathy
•  Nonsurgical: Cervical immobilization, steroids, and pain control medications