Cervical Myelopathy Associated with

Degenerative Spine Disease and Ossification

of the Posterior Longitudinal Ligament
Meic H. Schmidt, M.D.,1 Alfredo Quinones-Hinojosa, M.D.,2 and
William S. Rosenberg, M.D.3

ABSTRACT

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Cervical spondylotic myelopathy and ossification of the posterior longitudinal
ligament are two of the leading etiologies of spinal cord damage in older patients. For
most patients, the natural history is one of slow stepwise decline in function. With non-
surgical therapy only 30 to 50% of patients are expected to stabilize. Surgical options in-
clude anterior and posterior surgical decompression, spinal canal expansion, and spinal
column stabilization. Prospective, randomized trials with standardized outcome measures
are needed to clarify the benefit of surgery conclusively.

KEYWORDS: Cervical myelopathy, ossification of the posterior longitudinal

ligament, cervical spondylotic myelopathy, surgery

Objectives: On completion of this article, the reader will understand the pathophysiology, clinical presentation, diagnosis, and non-
surgical and surgical management of cervical spondylotic myelopathy.
Accreditation: The Indiana University School of Medicine is accredited by the Accreditation Council for Continuing Medical Educa-
tion to provide continuing medical education for physicians.
Credit: The Indiana University School of Medicine designates this educational activity for a maximum of 1.0 hours in category one
credit toward the AMA Physicians Recognition Award. Each physician should claim only those hours of credit that he/she actually
spent in the educational activity.

Disclosure: Statements have been obtained regarding the authors’ relationships with financial supporters of this activity. There is no
apparent conflict of interest related to the context of participation of the authors of this article.

M yelopathy is defined as a spinal cord disorder sionally ossification of the posterior longitudinal liga-
that results in clinical manifestations of upper motor ment (OPLL).
neuron dysfunction and can be associated with gait dis- Cervical spondylosis is common in the middle-
orders, weakness, sensory changes, and sphincter dis- aged and elderly population. By age 60 to 65, 95% of
turbances. Cervical spondylotic myelopathy (CSM) men and 70% of women have at least one degenerative
frequently refers to myelopathy in conjunction with de- change consistent with cervical spondylosis on a plain
generative spine disease (cervical spondylosis) and occa- X-ray film.1 The development of myelopathy secondary

Spinal Disorders; Co-Editors in Chief, Robert M. Pascuzzi, M.D., Karen L. Roos, M.D.; Guest Editor, John W. Engstrom, M.D. Seminars in
Neurology, Volume 22, Number 2, 2002. Address for correspondence and reprint requests: Meic H. Schmidt, M.D., Department of Neurosurgery,
University of Utah Medical Center, 30 North 1900 East, Suite 3B-409, Salt Lake City, UT 84132. 1Department of Neurosurgery, University of
Utah Medical Center, Salt Lake City, Utah; 2Department of Neurological Surgery, University of California, San Francisco, California; and
3Midwest Neurosurgery Associates, Kansas City, Missouri. Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New

York, NY 10001, USA. Tel: +1(212) 584-4662. 0271-8235,p;2002,22,02,143,148,ftx,en;sin00187x.

143
144 SEMINARS IN NEUROLOGY/VOLUME 22, NUMBER 2 2002

to cervical spondylosis is uncommon but because of stenosis. On average, a canal diameter less than 12 mm
the high prevalence of cervical spondylosis in the popu- is likely to be associated with myelopathy.6,7 Patients with
lation is probably the leading etiology of treatable normal anteroposterior (AP) diameters of the canal
myelopathy. have a longer presymptomatic course.8 The Torg-Pavlov
Cervical spondylosis can occur alone or be asso- ratio allows the assessment of canal size independent of
ciated with OPLL.2 In contrast to cervical spondylosis, the magnification factor of the X-ray technique; it is de-
OPLL originates in the rostral cervical canal and ex- fined as the ratio of the AP diameter of the spinal canal
tends caudally, crossing disc space and vertebral bodies. at the mid–vertebral body level to the vertebral body at
The process of OPLL appears to be distinct from cervi- the same location. It was shown that the Torg-Pavlov
cal spondylosis. The ligament is ossified in up to 20% of ratio is significantly smaller in myelopathic patients than
patients aged 50 to 60 years.3 OPLL is most commonly in control patients without CSM (0.72 vs. 0.95, p <.001)
found in the Asian population and represents one of irrespective of gender and age.9 In a congenitally small
the most common causes of cervical myelopathy in this spinal canal, further canal compromise with changes of
group. It is increasingly recognized in North America age-related cervical spondylosis can decrease the canal
and Europe.4 to critical levels.
Understanding the natural history, pathophysiol- Disc degeneration is related to the progressive
ogy, and treatment of cervical myelopathy secondary to loss of water in the nucleus pulposus with aging. This
cervical spondylosis has become increasingly complex. loss in disc height and the associated relaxation of the

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The diagnosis of cervical myelopathy can be difficult anulus fibrosus result in osteophyte formation at the
because the differential diagnosis of myelopathy is broad points of bone contact. This occurs most commonly at
and asymptomatic, abnormal magnetic resonance imag- the adjacent vertebral endplates and the uncovertebral
ing (MRI) findings are frequent. Thus, proper diagnosis joints. Osteophytosis can result in the formation of bone
and understanding of the factors that contribute to the ridges that can cause canal compromise with spinal cord
pathophysiology of CSM are critical for successful and nerve root compression. In addition, osteophytosis
treatment. can result in fusion of normal motion segments, which
in turn increases biomechanical stress at adjacent seg-
ments. Alternatively, incomplete osteophyte bridging
PATHOPHYSIOLOGY can increase segmental instability (hypermobility) of the
Progression of cervical spine degenerative disease can cervical spine. Degenerative changes can also affect the
cause CSM. Several factors have been identified that apophyseal joints and ligaments in the posterior col-
can result in progressive cervical spondylosis that can umn. Facet joint hypertrophy and hypertrophic liga-
affect the cervical spinal column, nerve roots, spinal cord, mentum flavum are commonly found in CSM and can
and supportive structures (Table 1). also affect spinal canal diameter and biomechanics. His-
The normal cervical spinal canal measures 16 to tological changes and myelopathy develop when the bio-
18 mm on a lateral C-spine X-ray at the C3-C7 level. mechanical tolerance of the spinal cord for these stresses
The spinal cord diameter is 8.5 to 11.5 mm.5 The ca- is exceeded.7
pacity of the spinal canal decreases in the lower cervical Several investigators have examined the histo-
spine. The spinal cord at C1 occupies 50% of the canal, pathological changes in the spinal cord associated with
compared with 75% at the C6 level. A congenitally nar- CSM in clinical specimens and laboratory studies. The
row spinal canal has been established as a risk factor for majority of changes are consistent with demyelination
the development of cervical spondylosis. Up to 75% of of the corticospinal tract and the lateral columns.7 The
patients with CSM have associated congenital canal posterior columns are frequently involved as well. There
is relative sparing of the anterior spinal tract. Atrophied
nerve roots and anterior horn cells have also been noted.
Table 1 Factors in the Pathogenesis of Cervical The most severely affected patients have extensive de-
Spondylotic Myelopathy generation and infarction of the gray matter with dif-
fuse lateral column white matter degeneration. The im-
Congenital spinal canal stenosis
portance of a vascular factor has been debated for many
Acquired canal stenosis
years.7,10,11 Laboratory studies indicate that ischemia
Osteophytes
and compression have an additive effect on spinal cord
Facet joint hypertrophy
damage.10 The most vulnerable vessels are intramedul-
Hypertrophic ligamentum flavum
lary arteries rather than the larger extramedullary ves-
Ossification of the posterior longitudinal ligament
sels. In addition, demyelination rather than axonal dam-
Dynamic factor of the spinal column
age or gray matter infarction is predominant in the early
Biomechanical and physical properties of the cervical spinal
phase of CSM. In the most debilitated patients, spinal
cord
cord infarction is the principal pathology.
 CERVICAL MYELOPATHY/SCHMIDT ET AL 145

CLINICAL DIAGNOSIS AND IMAGING is established early, and CSM can be static for many
The diversity of presentation, variable onset, and pro- years.19 In one series, only 18% of patients showed im-
gression of CSM are consistent with its complex patho- provement and 67% of patients had a stepwise decline.20
genesis. The hallmark of CSM is myelopathy, but this is Progression of CSM to total disability is rare
not diagnostic. Other coexisting pathology such as nerve after initial presentation. The disease can be stable for
root compression, peripheral neuropathy, and damage to many years. Complete recovery or improvement of dis-
the anterior horn cells may mask myelopathic signs. In ability status is the exception. Nonsurgical therapy is
addition, up to 14.3% of cases with cervical myelopathy limited, but 30 to 50% of patients with cervical myelop-
attributed to cervical spondylosis are later found to have athy show improvement with conservative care.21 Over-
another disease process such as amyotrophic lateral scle- all, the natural history of cervical myelopathy is one of
rosis (ALS) and multiple sclerosis.12 In general, neck slow, stepwise decline in function. Surgical therapy has
pain is uncommon. Signs and symptoms develop gradu- been the treatment of choice for many patients with
ally. Profound weakness of the lower extremities, gait progressive cervical myelopathy. Good outcome after
disturbances, and sphincter dysfunction are consistent surgery has been reported in approximately 70% of pa-
with more severe, chronic myelopathy. Good prognostic tients when anterior and posterior approaches were
indicators for surgical treatment include symptom dura- used,22–24 although the definition of good outcome var-
tion less than 1 year, unilateral motor deficit, young age ied between studies. A prospective, multicenter study
at presentation, and the presence of Lhermitte’s sign.13–15 evaluating the outcome of patients treated for cervical

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In most cases, plain X-rays and MRI are suffi- myelopathy from the Cervical Spine Research Society
cient to demonstrate cervical stenosis. Plain films define compared medical and surgical treatment and concluded
bony details and allow measurement of the canal diame- that surgical patients had a better outcome.25
ter and calculation of the Torg-Pavlov ratio. MRI pro-
vides information regarding the soft tissues including
discs and ligaments and their contribution to canal SURGERY
stenosis. Increased signal within the spinal cord on T2- The goals of surgery are to relieve the pathological
weighted images at the level of the compression may in- stresses on the spinal cord, to provide a means for maxi-
dicate spinal cord damage or edema. It is important to mal recovery, and to prevent further neurological de-
keep in mind that many changes on the MRI scan can cline. Given the complex pathogenesis and varied clini-
be asymptomatic. In a series of 100 patients without cal consequences, surgery must be designed to address
cervical spine symptoms who underwent MRI scanning the pathology in each individual patient. There is no
for the larynx, disc protrusion and spinal cord impinge- single operative technique for all patients with CSM.
ment were found in 57% and 26% of patients older than Each approach has advantages and disadvantages that
64 years, respectively.16 In addition, 7% of patients had need to be considered in order to maximize the benefit
evidence of spinal cord compression without clinical to the patient.
symptoms.
Computed tomographic (CT) myelography can
be used if the patient does not tolerate MRI and to pro- Posterior Approaches for Cervical Myelopathy
vide additional information. Bone details are better visu- Laminectomy without fusion is the most common pos-
alized with CT myelography, and the severity of the canal terior procedure performed for cervical myelopathy. It is
compromise can be assessed more accurately. MRI often most clearly indicated for patients with posterior com-
overestimates the extent of disc protrusion and canal pressive pathology and no evidence of instability. Direct
encroachment. Dynamic studies to rule out instability removal of the compressive pathology, such as excessive
should include at least flexion and extension X-rays. ligamentum flavum, can result in good surgical results.
Foraminotomies allow the decompression of cervical
nerve roots and relief from radiculopathy associated with
NATURAL HISTORY AND myelopathy. Laminectomies and facetectomy limited to
CONSERVATIVE THERAPY the most medial one fourth to one third of the facet
The natural history of CSM is quite varied. In a review joint usually do not result in instability and deformity.
of 120 patients with CSM, 75% of patients had episodic More extensive resection can result in significant bio-
worsening of symptoms. Twenty percent had a slow mechanical alteration. In experimental studies, unilat-
steady progression. Five percent of patients experienced eral facetectomy resulted in an average 31.6% decrease
rapid onset of symptoms that resulted in permanent dis- in strength, whereas bilateral facetectomy caused an
ability. Improvement without treatment was uncommon. average 53.1% decrease in strength.26 Biomechanical al-
Fifty percent of patients improved with immobilization teration can be measured under increasing compression-
in a cervical collar.17 Patients with cervical spondylosis flexion forces in cadaver models. Extensive laminec-
rarely progress to myelopathy.18 The degree of disability tomies in human cadaver specimens from C2 through
146 SEMINARS IN NEUROLOGY/VOLUME 22, NUMBER 2 2002

T1 can significantly change the mean stiffness (ability rior cervical diskectomy with a fusion (ACDF) for the
of the spine to resist a physiological load) and sagittal treatment of cervical myelopathy. The fusion rate for a
rotation compared with intact specimens. The greatest single-level ACDF with autologous bone graft is 92%.
changes were observed at the lower end of the laminec- Factors associated with nonunion are increased mobility
tomy.27 Such biomechanical changes may contribute to on preoperative flexion-extension X-rays, tobacco use,
the failure of laminectomy to provide a sustained thera- and allograft bone graft substitute. In these cases an an-
peutic result. terior cervical plate might be useful in order to enhance
Multiple-level anterior pathology may also be fusion rates. Multiple diskectomies also increase the like-
treated with laminectomy in the presence of an effective lihood of pseudoarthrosis from 5 to 12%, and the use
cervical lordosis. The definition of an effective cervical of cervical plating and autograft may decrease this risk.
lordosis varies among surgeons, but there is universal Cervical plating carries the risk of hardware failure in-
agreement that a severe kyphotic deformity is associated cluding screw pull-out, breakage, and esophageal erosion.34
with failure of posterior decompression. If there is an ef- In the patient with spinal cord compression
fective multiple-level cervical lordosis, wide laminec- across several disc spaces and vertebral bodies and for
tomies allow posterior translation of the spinal cord and patients with kyphotic deformity, anterior corpectomy
indirect anterior decompression. The addition of dentate is recommended. This allows excellent anterior decom-
ligament sectioning to laminectomy is safe and might pression and correction of the deformity. With increas-
enhance the decompression of the spinal cord, but this is ing number of levels involved, the surgical corpectomy

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controversial and infrequently performed.28 Preoperative and reconstruction become more complex and compli-
cervical instability, extensive laminectomy, facet joint re- cation rates increase. Anterior corpectomy is also com-
moval, and extensive foraminotomies are indications for monly used for the treatment of OPLL and good out-
fusion after a posterior decompression. This is most fre- comes have been reported.4,35 It is the treatment of
quently accomplished by lateral mass plating, facet joint choice in segmental OPLL confined to one or two lev-
wiring, and more recently cervical pedicle screw fixation. els.36,37 Because by definition the posterior longitudinal
Internal fixation can enhance posterior cervical fusion ligament is calcified and frequently adherent to the
and limit the use of a postoperative halo orthosis. Alter- dura, this procedure can be more difficult.
natively, an onlay fusion with autogenous bone graft and Potential complications associated with anterior
external halo fixation can be used. cervical spinal surgery are summarized in Table 2. In
Laminoplasty refers to a surgical technique in general, these complications are rare in single-level pro-
which the posterior elements are reconstructed in order cedures but increase with multiple-level procedures.38,39
to increase the capacity of the spinal canal.24,29–31 For Complications following the anterior cervical approach
cervical spondylitic myelopathy that is associated with range from 10 to 14%. Worsening myelopathy occurs in
decreased central canal size, a canal expansive lamino- 3 to 5% of patients and bone graft complication rates in
plasty can be performed. As with laminectomy, canal 3 to 10%. There is a higher incidence of cerebrospinal
expansive laminoplasty can directly remove posterior fluid leaks for OPLL-related corpectomy compared
compressive pathology and indirectly, by posterior trans- with anterior cervical surgery for cervical spondylosis.40
lation of the spinal cord, result in decompression of an- This is primarily due to dense adherence of the calcified
terior pathology. If there is an effective cervical lordosis, ligament to dura and neural structures. In cases in which
multiple-level, wide laminectomies allow posterior trans- resection is not possible, detaching the ossified mass lat-
lation of the spinal cord and indirect anterior decom- erally may result in floating of the calcified ligament
pression. Posterior translation refers to the ability of the away from the spinal cord.
spinal cord to migrate away from anterior compressive
pathology. Many different laminoplasty techniques have
been developed to provide decompression of the spinal Table 2 Potential Complications of Anterior Cervical
cord and to maintain biomechanical stability.32–33 Surgery

Pseudoarthrosis
Iliac donor site complication
Anterior Approach for Cervical Myelopathy
Hoarseness
On occasion, cervical myelopathy is caused by a single-
Tracheoesophageal tears
level disc herniation or associated osteophyte. Anterior
Recurrent laryngial nerve injury
cervical diskectomy can be performed without fusion,
Carotid artery injury
but this is done primarily for patients who have only
Dysphagia
radiculopathy without spinal cord compression. Pseudo-
Graft dislodgement
arthrosis after diskectomy alone may result in increased
Kyphosis
motion of that segment and may worsen preexisting
Spondylolisthesis
canal compromise. Thus, most surgeons advocate ante-
 CERVICAL MYELOPATHY/SCHMIDT ET AL 147

Cervical corpectomy results in iatrogenic insta- 3. Kurata A, Tokiwa K, Kitahara I, et al. [Myelopathy caused by
bility. Even if there was no prior evidence of instability, hypertrophy of the posterior longitudinal ligament (HPLL):
fusion is indicated. Fusion techniques vary and depend case report]. No Shinkei Geka Neurol Surg 1987;15:651–655
4. Harsh GRT, Sypert GW, Weinstein PR, Ross DA, Wilson
on the number of cervical corpectomies performed. CB. Cervical spine stenosis secondary to ossification of the
Bone grafting with iliac crest or fibular autograft, allo- posterior longitudinal ligament. J Neurosurg 1987;67:349–357
graft, interbody cages, and anterior cervical plating have 5. Burrows H. The sagittal diameter of the spinal canal in cervi-
been advocated. Postoperative orthosis with either a rigid cal spondylosis. Clin Radiol 1963;14:77–88
collar or a halo vest is frequently necessary. 6. Adams CB, Logue V. Studies in cervical spondylotic myelop-
athy: II. The movement and contour of the spine in relation
to the neural complications of cervical spondylosis. Brain
1971;94:568–586
7. Cusick JF. Pathophysiology and treatment of cervical spondy-
OUTCOME
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In a meta-analysis of surgical and nonsurgical manage- 8. Edwards WC, LaRocca H. The developmental segmental
ment, nonsurgical therapy had an acceptable outcome in sagittal diameter of the cervical spinal canal in patients with
36% of patients.41 Posterior surgery resulted in improve- cervical spondylosis. Spine 1983;8:20–27
ment or stabilization of symptoms in 68% of patients, an- 9. Yue WM, Tan SB, Tan MH, Koh DC, Tan CT. The Torg-
terior surgery in 73%. Factors associated with good out- Pavlov ratio in cervical spondylotic myelopathy: a compara-
come are young age, short duration of symptoms, and tive study between patients with cervical spondylotic myelop-
athy and a nonspondylotic, nonmyelopathic population. Spine

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mild myelopathy. Poor outcome is associated with end-
2001;26:1760–1764
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improvement rate for anterior versus posterior surgery effects of compression and ischemia on the canine cervical
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parison of different studies is difficult because indications 11. Taylor A. Vascular factors in the myelopathy associated with
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thopedic Association Scoring system of CSM is increas-
post-operative computed myelography and MR imaging.
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13. Phillips DG. Surgical treatment of myelopathy with cervical
spondylosis. J Neurol Neurosurg Psychiatry 1973;36:879–
884
SUMMARY 14. Reale F. Long-term results in 102 cases of cervical myelo-
CSM results in spinal cord damage secondary to degen- radiculopathy operated on for spondylosis and disc hernia-
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tients with congenital spinal stenosis. OPLL can also J Neurosurg Sci 1984;28:89–92
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