CASE REPORT

OCTOBER 2016

CERVICAL MYELOPATHY

PUJIA CAHYA AMALIA

C 111 11 295
Advisors:
dr. Padlan Pasallo
dr. Victor Gozaly
Supervisor:
dr. Jainal Arifin, M.Kes, Sp.OT(K)Spine
ORTHOPEDIC AND TRAUMATOLOGY DEPARTMENT
HASANUDDIN UNIVERSITY

PATIENT
IDENTITY

CASE
REPORT

Name
: MR
Age
: 30 y.o
Sex
: Male
Reg. Number
: 765375
Date of Admission
: 22 July 2016
Date of Consulted
from neurology to
Orthopaedic Dept.
: 30 July 2016

HISTORY
TAKING

Chief Complaint
Weakness on four limbs

History Taking
Patient was consulted by Neurology Department with weakness
on four limbs, mainly on lower limbs since 3 months ago. This
complaint was suffered gradually until hes bedridden and can not
even stand. He also complained numbness at his four limbs and
trunk.
History of trauma: Theres a history of motorcycle accident 4
months ago. Patient didnt know the details mechanism of trauma.
He can do normal activity after accident.

HISTORY
TAKING
History of unconciousness (-)
History of nausea(-), history of vomiting (-)

Chronic cough (-), Sweating at night (-)

History of fever (-), Weight loss (+)
Previous TB Treatment (-)
Defecation and urination disturbed
The

patient had the history of operation 3 months ago for urinary problem
Family history with same complaint (-)

PHYSICAL
EXAMINATION
GENERAL STATUS
Moderately Ill/ Conscious
BP
: 120/80 mmHg
Pulse : 80x/ Menit
RR
: 20x/ Menit
Temp : 36,5 C
Body Weight
: 41 kg
Body Height
: 160 cm
Body Mass Index
: 16,01 kg (underweight)

PHYSICAL
EXAMINATION

LOCALIZED STATUS

Head
: Within normal limit
Neck
: Within normal limit
Lungs : Within normal limit
Heart
: Within normal limit
Abdomen
: Within normal limit
Genitalia : Urine catheher installed
Extremity
: Edema (-), atrophy (+) on
all limbs

PHYSICAL
EXAMINATION
LOCALIZED STATUS
Spine Region
Look
: Edema (-), Deformity (-), scar (+) on
coccygeal region, hematome (-),
gibbus (-)
Feel
: Tenderness (-), step off (-)

PHYSICAL
EXAMINATION

Whole Body

PHYSICAL
EXAMINATION
Posterior
View

PHYSICAL
EXAMINATION
Lateral
View

PHYSICAL
EXAMINATION
Dorsal Hand

Palmar Hand

PHYSICAL
EXAMINATION

LOCALIZED STATUS

Hand Region
Look
Right : Athrophy on thenar, hipothenar, interosseus
muscles
Left : Athrophy on thenar, hipothenar, and interosseous
muscles
Feel
Right : Hipostesia on index finger, middle finger, ring
finger, and little finger
Left : Hipostesia on index finger, middle finger, ring
finger, and little finger

PHYSICAL
EXAMINATION

LOCALIZED STATUS

Hand Region
Finger Escape Signs : Right (+), Left (+)
Grip and release test : Patient can make a fist and
release 20 times in more than 10 seconds
Spurlings test (-)

PHYSICAL
NEUROLOGICAL STATUS
EXAMINATION

CASE
REPORT

5
3
3
2
2

5
3
0
3
2
2

1
1
0
0
0

1
1
0
0
0
No

PHYSICAL
EXAMINATION
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

Any anal sensation

N

0 Absent
1 Impaired
2 Normal
NT Not testable

PHYSICAL
EXAMINATION

CASE
REPORT

REFLEXES

Physiologic Reflex
R
Biceps (+)
Triceps (+)
Achilles (+)
Patellar (+)

L
(+)
(+)
(+)
(+)

Pathologic Reflex
R
L
Hoffman/
(+) (+)
Tromner
Babinski
(+)
(+)
Chadock
(+)
(+)
Openheim
(+)
(+)
Clonus
(+)

LABORATORY
FINDINGS
WBC

30,38 x 103 /ul

Na

142 mmol/l

RBC

4,76 x 106 /ul

4,2 mmol/l

HGB

13,3 g/dl

Cl

106 mmol/l

HCT

42,5%

GOT

20 U/L

PLT

379 x 103/ul

GPT

41 U/L

PT

8,6 detik

GDS

199 mg/dl

APTT

21,9 detik

Ureum

28 mg/dl

Hbs Ag

Negatif

Kreatinin

0,33 mg/dl

RADIOLOGY
FINDINGS
Chest X-Ray AP :
Theres no any
abnormality in this
radiograph

RADIOLOGY
FINDINGS
Cercival X-Ray
AP/Lateral:
- Spondylolisthesis CV
C5-C6
- Destruction of CV C5
and C6

RADIOLOGY
FINDINGS

RADIOLOGY
FINDINGS

RADIOLOGY
FINDINGS

RADIOLOGY
FINDINGS

RESUME
Man, 30 years old, consulted by neurology
department with Weakness on four limbs suffered
since 3 months ago.
Mechanism of Trauma : The patient had a traffic
accident 4 months ago but can still do activity after
accident.

RESUME
From Physical examination at spine region theres scar at
coccygeal region. There were also muscle atrophy at four
limbs.
Motoric examination resulted motoric function 3 on bilateral
C6 and C7 levels, motoric function 2 on bilateral C8 and T1
levels.
Sensory examination resulted a hypostesia below C5 level.
Physiologic reflex increased and there were pathological
reflex.

RESUME
From Physical examination at hand region there were
muscle atrophy on thenar, hipothenar, and interosseus along
with hipostesia on hipothenar and index finger, middle
finger, ring finger, and little finger on both hands.
Finger escape sign was positive on both hands
Grip and release test was positive for both hands
Spurlings sign was negative

RESUME
Laboratory finding, White Blood Cells were 30,8 x 103 /ul
(leukocytosis)
Radiologic finding at x-ray of cervical region, there were
spondylolisthesis CV C5-C6, destruction of CV C5-C6.
MRI Cervical T1W1 without contrast, T2W1 axial and
sagittal and MR-Myelography, there were destruction of CV
C5 and C6 with narrowing of discus intervertebralis on that
levels as the picture of spondylitis and intradural abcess.

DIAGNOSIS
Physical
Examination

History
Taking

Investigation

Cervical myelopathy due to destruction of CV

C5-C6 suspect infection process

PLANNING
CASE
REPORT

Antibiotics
Mobilization right and left lateral
decubitus
Use of decubitus bed
Decompression
Stabilization

DISCUSSION

ANATOMY

mpson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

DENNIS
CLASSIFICATION

The three columns of the spine, as proposed by Francis Denis. The anterior
column (A) consists of the anterior longitudinal ligament, anterior part of the
vertebral body, and the anterior portion of the annulus fibrosis. The middle
column (B) consists of the posterior longitudinal ligament, posterior part of the
vertebral body, and posterior portion of the annulus. The posterior column (C)
consists of the bony and ligamentous posterior elements. (Modified from Denis F.
The three-column spine and its significance in the classification of acute
thoracolumbar spinal injuries. Spine 1983;8:817831.)

Kenneth A.Egol, Kenneth J.Koval, Joseph D. Open fracture in: Handbook of Fracture, Fourth edition, chapter 3.

ANATOMY

mpson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

ANATOMY

mpson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

ANATOMY

mpson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

ANATOMY
Column vertebrae:

Bodies

Arch :
o Pedicles
o Laminae

Processes:
o Transverse
o Spinosus

Foramina
o Vertebral
o Neural

mpson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

LIGAMENT

mpson JC. Netters Concise Orthopaedic Anatomy 2nd Edition.

HISTORY
TAKING

Devlin VJ. Spine Secrets Plus. 2nd ed. Elsevier; 2012

INTRODUCT
ION
Myelopathy Any disease or disorder of the spinal cord
Cervical Myelopathy Results from cervical cord
compression due to a narrow cervical vertebral canal.
The constriction of the canal enclosing the cervical cord
is due to:
Congenital narrowing
Cervical spondylosis involving hypertrophy of the facet
joints and osteophyte formation
Hypertrophy of the ligamenta flava
Bulging (or prolapse) of a cervical disc
Excessive mobility, usually associated with
cervical spondylosis.
Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

INTRODUCT
ION
The morphological changes within the cord include :
Degeneration and loss of nerve cells, cavitation and
proliferation of glia within the grey matter
Demyelination of the lateral and posterior columns
Wallerian degeneration in ascending tracts above and
descending tracts below the compression
Proliferation of small blood vessels with thickening of
the vessel walls
Rare involvement of the anterior columns.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

ETIOLOGY

> 50% Cervical Myelopathy are Cervical

Spondylosis Myelopathy.
Other causes for myelopathy are trauma,
tumour and congenital

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

CLINICAL
FEATURES
The presenting features are pain and neurological
disturbance attributable to cervical cord involvement.

Neck pain. This is not due to the cervical myelopathy

itself but may occur as part of the degenerative disease
of the cervical spine.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

MUSCULAR
WEAKNESS

This is the most common initial symptom and

usually occurs earlier in the lower limbs.
The patient initially notices clumsiness involving
the hands and fingers, particularly in fine skilled
movements, and dragging or shuffling of the feet.
Fasciculation may be present but is usually not
severe.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

SENSORY
SYMPTOMS

These frequently occur as diffuse numbness and

paraesthesiae in the hands and fingers.
The sensory changes may be limited to the upper
limbs and may involve a dermatomal pattern if a
particular nerve root is being compressed.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

PHYSICAL
FINDINGS
The supinator (brachioradialis) reflex may be of value in
localizing the level. If it is absent, but the reflex evokes
flexion of the digits and sometimes the biceps or triceps,
this is regarded as evidence of a lesion restricted to the
C6 segment (the inverted supinator reflex).

Hyperreflexia, positive Hoffmanns sign, Babinski test,

clonus, sensory and motor changes.

Myelopathic hand syndrome: thenar atrophy, positive

finger escape sign and grip release test.
Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

CLASSIFICA
TION

Nuricks Classification
Grade

Level of Neurological Involvement

Grade I

No difficulty in walking

Grade II

Mild gait involvement not interfering with employment

Grade III

Gait abnormality preventing employment

Grade IV

Able to walk only with assistance

Grade V

Chairbound or bedridden

orthobullets.com/spine/2031/cervical-myelopathy

CLASSIFICA
TION

Japanese
Orthopaedic
Association
Classification

orthobullets.com/spine/2031/cervical-myelopathy

RADIOLOGICAL
INVESTIGATION

Plain X-rays of the cervical spine may show a

narrow vertebral canal which could be either
congenital and/or due to spondylolytic
degenerative disease and osteophyte formation.

CT Scan may confirm a narrow canal, it is

necessary to perform MRI to confirm the nature
and extent of the cord compression.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

RADIOLOGICAL
INVESTIGATION
MRI :
Show the exact pathological basis for the
compression

Show cervical disc prolapsse well : whether it

is primarily an anterior compression due to disc
bulging or osteophyte formation or whether the
compression is mostly from a posterior bulging
hypertrophied ligamentum flava.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

DIFFERENTIAL
DIAGNOSIS

The major differential diagnoses are:

Spinal tumour
Multiple sclerosis
Motor neurone disease (particularly if
only minor sensory changes)
Syringomyelia subacute combined
degeneration of the cord.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

NON OPERATIVE
TREATMENT

Mild, non-progressive myelopathy patients will

often improve with conservative treatment,
including NSAIDs, rest in a cervical collar.

However, surgery is usually advisable

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

OPERATIVE
TREATMENT
Surgery is definitely indicated for clinically progressive
or moderate or severe myelopathy.
A further reason for advising early surgery is that any
existing neurological deficit may not improve following
an operation, due to irreversible changes within the
cervical cord

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

OPERATIVE
TREATMENT
The type of surgical procedure performed will depend
upon:

The extent of the compression

The number of vertebral levels involved
Whether the compression is predominantly in
Front of or behind the cord
The presence of cervical instability.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

PROGNOSIS

Surgery should arrest the progress of the

cervical myelopathy and only in a minority of
patients will there be marked improvement of
neurological function following the operation.
A small percentage of patients who have
severe neurological impairment and evidence of
myelomalacia on MRI may have further
neurological deterioration following surgery.

Andrew H. Kaye : Essential Neurosurgery Chapter 15 ( 3th

THANK YOU