May 06, 2024

Prognosis for Patients with Cervical Stenosis

Spinal canal narrowing, or stenosis, typically develops as people age and can lead to discomfort or complications. Cervical stenosis refers to the narrowing of the spinal canal in the cervical spine, the uppermost part of the spine at the level of the neck. Patients with severe cervical stenosis suffer from gait impairment, balance difficulties, and bladder/bowel troubles. Although this condition does not lead to cervical spinal myelopathy (CSM) in most cases, patients who do develop myelopathy secondary to cervical stenosis typically have a poor prognosis, as most of the body’s nerves must pass through the cervical spine.2

What are the risk factors that indicate cervical stenosis can lead to cervical spinal myelopathy? According to Zhang et al., older patients with longer symptom duration are at greater risk for CSM. These patients experience prolonged periods of cord compression accompanied by persistent inflammation, cell apoptosis, and nerve damage. Even with surgical intervention that relieves compression, the damage to the nerves is largely irreversible. Thus, for the best prognosis, it has become increasingly crucial to surgically intervene in cases of cervical stenosis as soon as it is necessary. To assess progression to CSM, clinicians commonly measure symptoms on the Nurick grade scale or the JOA scale; meanwhile, the VAS scale is used for pain measurement. The symptom associated with the most negative prognosis for cervical stenosis patients is hand muscle atrophy.2,6

Clinicians recommend surgical anterior or posterior decompression with arthrodesis, arthroplasty, or laminoplasty. In this procedure, surgeons remove or reposition the intervertebral disk, osteophytes, and posterior longitudinal ligament ossification that compress the spinal cord. Du et al. report that laminoplasty and laminectomy have positive outlooks for patients since the procedure has been refined to reduce the incidence of long-term complications. When performed with a lateral mass screw fixation, laminoplasty and laminectomy are accompanied by superior neurological improvement. Du et al. report a statistically significant difference in their preoperative and final follow-up scores for patients who underwent a modified laminoplasty and laminectomy with a lateral mass screw fixation compared with those who did not. A statistically significant difference between the laminoplasty and laminectomy group indicated that the former had a more favorable patient prognosis.  The study showed that the lateral mass screw fixation might help prevent postoperative cervical curvature loss and reduce axial symptom incidence, which is associated with an unfavorable prognosis and poorer patient outcomes. 4

The main treatment for cervical stenosis is surgery, as there is a risk for the condition to progress, cause further damage, and worsen prognosis without surgery. Unfortunately, clinicians cannot agree on the timing of surgery despite the reality that timing is critical for a favorable prognosis with cervical stenosis. A study from Chikuda et al. examines this question among a patient cohort aged 20 to 79 years with motor-incomplete cervical injury and preexisting stenosis without fracture or dislocation. The study compares early vs delayed surgical treatment for incomplete cervical spinal cord injury which has not progressed to severe myelopathy. Intervention before six months was associated with an accelerated recovery, but there was no statistically significant difference with intervention at two weeks, three months, or six months. Surgical treatment within the first six months was associated with higher motor scores than delayed surgical treatment.3

Akter et al. tackle research gaps linked to poor patient outcomes and have outlined pathobiology issues that must be studied further. More research is needed to understand axonal degeneration from mechanical stress, cell death in CSM, the mechanisms, genes, and pathways that cause chronic spinal cord compression-induced neurological, the potential of autophagy to prevent neuronal and axonal loss and slow disease progression, the effects of CNS cellular constituents like oligodendrocytes, astrocytes, microglia, and pericytes on neurology decrease and recovery after cord compression, and patterns of inflammation, with a focus on the innate immune response.5

References

  1. Choi, S. H., & Kang, C.-N. (2020). Degenerative Cervical Myelopathy: Pathophysiology and Current Treatment Strategies. Asian Spine Journal, 14(5), 710–720. https://doi.org/10.31616/asj.2020.0490
  2. Zileli, M., Maheshwari, S., Kale, S. S., Garg, K., Menon, S. K., & Parthiban, J. (2019). Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations. Neurospine, 16(3), 435–447. https://doi.org/10.14245/ns.1938196.098
  3. Chikuda, H., Koyama, Y., Matsubayashi, Y., Ogata, T., Ohtsu, H., Sugita, S., Sumitani, M., Kadono, Y., Miura, T., Tanaka, S., Akiyama, T., Ando, K., Anno, M., Azuma, S., Endo, K., Endo, T., Fujiyoshi, T., Furuya, T., … Yoshii, T. (2021). Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis. JAMA Network Open, 4(11), e2133604. https://doi.org/10.1001/jamanetworkopen.2021.33604
  4. Du, W., Wang, L., Shen, Y., Zhang, Y., Ding, W., & Ren, L. (2013). Long-term impacts of different posterior operations on curvature, neurological recovery, and axial symptoms for multilevel cervical degenerative myelopathy. European Spine Journal, 22(7), 1594–1602. https://doi.org/10.1007/s00586-013-2741-5
  5. Akter, F., Yu, X., Qin, X., Yao, S., Nikrouz, P., Syed, Y. A., & Kotter, M. (2020). The Pathophysiology of Degenerative Cervical Myelopathy and the Physiology of Recovery Following Decompression. Frontiers in Neuroscience, 14. https://doi.org/10.3389/fnins.2020.00138
  6. Zhang, J. T., Wang, L. F., Wang, S., Li, J., & Shen, Y. (2016). Risk factors for poor outcome of surgery for cervical spondylotic myelopathy. Spinal Cord, 54(12), 1127–1131. https://doi.org/10.1038/sc.2016.64