Cervical Myelopathy
What is cervical myelopathy?
Cervical myelopathy is a condition in which the spinal cord in the neck region is compressed, producing dysfunction in the cord itself — not just the nerve roots, but the cord that carries signals between the brain and the rest of the body. It is the most common cause of spinal cord dysfunction in adults over 55 and is frequently underdiagnosed in its early stages because symptoms develop gradually and can be mistaken for normal ageing.
The distinction between myelopathy and radiculopathy is clinically important. Cervical radiculopathy involves compression of nerve roots as they exit the spine, producing pain, numbness or weakness in a specific arm distribution. Cervical myelopathy involves compression of the spinal cord itself, and produces a broader pattern of dysfunction affecting coordination, balance, hand function and bladder control — often bilaterally and below the level of the compression.
Myelopathy is a progressive condition in most cases — without treatment it tends to worsen over time, though the rate of progression varies considerably between individuals. This is one of the reasons prompt recognition and appropriate management is important.
What causes cervical myelopathy?
The most common cause is cervical spondylosis — degenerative changes in the cervical spine including disc degeneration, osteophyte (bone spur) formation, ligament thickening, and facet joint hypertrophy that progressively narrow the spinal canal over years or decades. When the canal narrows sufficiently to compress the spinal cord, myelopathy develops. People with a congenitally narrow spinal canal are more vulnerable to developing myelopathy from relatively minor degenerative changes.
Other causes include cervical disc herniation, ossification of the posterior longitudinal ligament (OPLL), rheumatoid arthritis affecting the upper cervical spine, atlantoaxial instability, and less commonly tumours or infections affecting the cervical spine.
What are the symptoms?
The classic myelopathy presentation includes a combination of upper and lower limb signs that reflect spinal cord rather than nerve root dysfunction. Common symptoms include clumsy or weak hands — difficulty with fine motor tasks like buttoning shirts, handling cutlery or writing — grip weakness, and the sensation that the hands don't respond as expected. Gait disturbance — a broad-based, unsteady or shuffling walk — is characteristic and is often described by patients as feeling like they might fall, particularly on uneven ground or in the dark. Leg weakness and spasticity (stiffness and increased tone) develop as the condition progresses.
Neck pain and arm symptoms may or may not be prominent — some patients with significant myelopathy have surprisingly little neck pain, which can delay recognition of the condition. Bladder dysfunction — urgency, frequency or difficulty initiating urination — indicates more significant cord involvement.
The Lhermitte sign — an electric shock sensation running down the spine and into the limbs with neck flexion — when present is a strong indicator of myelopathy and should prompt urgent assessment.
How is it diagnosed?
MRI of the cervical spine is the gold standard investigation for cervical myelopathy, showing cord compression, changes in cord signal intensity (indicating cord damage), and the nature of the compressing structures. CT myelography may be used when MRI is contraindicated or when bony detail is important for surgical planning. Neurophysiological studies including EMG and nerve conduction studies help characterise the pattern of involvement and distinguish myelopathy from other neurological conditions.
If you have symptoms consistent with cervical myelopathy, prompt medical assessment is important — MRI and referral to a spine specialist or neurosurgeon should not be delayed. Do not allow a physiotherapy assessment to substitute for or significantly delay specialist medical review when myelopathy is suspected.
What is the treatment for cervical myelopathy?
Cervical myelopathy is one of the conditions where physiotherapy has an important but clearly defined and limited role — and being honest about this is more helpful to patients than overstating what we can achieve.
For significant or progressive myelopathy, surgical decompression — either from the front of the spine (anterior cervical discectomy and fusion, ACDF) or the back (laminectomy or laminoplasty) — is often the recommended treatment. Surgery aims to halt progression and, in many cases, produces neurological improvement. The decision to operate depends on the severity of cord compression, the degree of neurological deficit, the rate of progression, and patient factors including age and general health. Physiotherapy does not reverse established cord compression and is not a substitute for surgery when surgery is indicated.
For mild or stable myelopathy — particularly in older patients where surgical risk is significant — careful monitoring and conservative management may be appropriate. In this context physiotherapy has a genuine and meaningful role.
How can physiotherapy help?
Physiotherapy for cervical myelopathy focuses on maintaining and optimising function within the limits imposed by the cord compression, rather than treating the compression itself. The key areas are balance and fall prevention, gait retraining and optimisation, upper limb function and fine motor rehabilitation, and maintaining strength in the muscles not directly affected by the myelopathy.
Fall prevention is particularly important — myelopathic gait disturbance significantly increases fall risk, and the consequences of a fall for someone with an already-compressed spinal cord are serious. Balance training, walking aid assessment and home environment advice all contribute to fall risk reduction.
Manual therapy to the cervical spine requires extreme caution in the presence of myelopathy — manipulation is absolutely contraindicated, and even mobilisation needs to be approached carefully and selectively depending on the stability of the spine and the nature of the compressing pathology. For patients with cervical instability contributing to myelopathy, gentle stabilising approaches rather than mobilising techniques are appropriate.
Exercise physiology has a role for patients with myelopathy who are managing significant deconditioning alongside their neurological symptoms — structured, safe exercise programming that accounts for balance and coordination deficits can meaningfully improve overall function and quality of life.
For patients who have had surgical decompression, post-operative physiotherapy addresses any residual neurological deficits, rebuilds strength and coordination, and monitors for signs of adjacent segment disease over time.
Our physiotherapists Yulia Khasyanova and Mauricio Bara both have experience in complex cervical spine conditions including myelopathy. Mauricio holds an APA Sports Physiotherapist title with extensive complex cervical spine experience. Both are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Cervical myelopathy is a condition in which the spinal cord in the neck region is compressed, producing dysfunction in the cord itself — not just the nerve roots, but the cord that carries signals between the brain and the rest of the body. It is the most common cause of spinal cord dysfunction in adults over 55 and is frequently underdiagnosed in its early stages because symptoms develop gradually and can be mistaken for normal ageing.
The distinction between myelopathy and radiculopathy is clinically important. Cervical radiculopathy involves compression of nerve roots as they exit the spine, producing pain, numbness or weakness in a specific arm distribution. Cervical myelopathy involves compression of the spinal cord itself, and produces a broader pattern of dysfunction affecting coordination, balance, hand function and bladder control — often bilaterally and below the level of the compression.
Myelopathy is a progressive condition in most cases — without treatment it tends to worsen over time, though the rate of progression varies considerably between individuals. This is one of the reasons prompt recognition and appropriate management is important.
What causes cervical myelopathy?
The most common cause is cervical spondylosis — degenerative changes in the cervical spine including disc degeneration, osteophyte (bone spur) formation, ligament thickening, and facet joint hypertrophy that progressively narrow the spinal canal over years or decades. When the canal narrows sufficiently to compress the spinal cord, myelopathy develops. People with a congenitally narrow spinal canal are more vulnerable to developing myelopathy from relatively minor degenerative changes.
Other causes include cervical disc herniation, ossification of the posterior longitudinal ligament (OPLL), rheumatoid arthritis affecting the upper cervical spine, atlantoaxial instability, and less commonly tumours or infections affecting the cervical spine.
What are the symptoms?
The classic myelopathy presentation includes a combination of upper and lower limb signs that reflect spinal cord rather than nerve root dysfunction. Common symptoms include clumsy or weak hands — difficulty with fine motor tasks like buttoning shirts, handling cutlery or writing — grip weakness, and the sensation that the hands don't respond as expected. Gait disturbance — a broad-based, unsteady or shuffling walk — is characteristic and is often described by patients as feeling like they might fall, particularly on uneven ground or in the dark. Leg weakness and spasticity (stiffness and increased tone) develop as the condition progresses.
Neck pain and arm symptoms may or may not be prominent — some patients with significant myelopathy have surprisingly little neck pain, which can delay recognition of the condition. Bladder dysfunction — urgency, frequency or difficulty initiating urination — indicates more significant cord involvement.
The Lhermitte sign — an electric shock sensation running down the spine and into the limbs with neck flexion — when present is a strong indicator of myelopathy and should prompt urgent assessment.
How is it diagnosed?
MRI of the cervical spine is the gold standard investigation for cervical myelopathy, showing cord compression, changes in cord signal intensity (indicating cord damage), and the nature of the compressing structures. CT myelography may be used when MRI is contraindicated or when bony detail is important for surgical planning. Neurophysiological studies including EMG and nerve conduction studies help characterise the pattern of involvement and distinguish myelopathy from other neurological conditions.
If you have symptoms consistent with cervical myelopathy, prompt medical assessment is important — MRI and referral to a spine specialist or neurosurgeon should not be delayed. Do not allow a physiotherapy assessment to substitute for or significantly delay specialist medical review when myelopathy is suspected.
What is the treatment for cervical myelopathy?
Cervical myelopathy is one of the conditions where physiotherapy has an important but clearly defined and limited role — and being honest about this is more helpful to patients than overstating what we can achieve.
For significant or progressive myelopathy, surgical decompression — either from the front of the spine (anterior cervical discectomy and fusion, ACDF) or the back (laminectomy or laminoplasty) — is often the recommended treatment. Surgery aims to halt progression and, in many cases, produces neurological improvement. The decision to operate depends on the severity of cord compression, the degree of neurological deficit, the rate of progression, and patient factors including age and general health. Physiotherapy does not reverse established cord compression and is not a substitute for surgery when surgery is indicated.
For mild or stable myelopathy — particularly in older patients where surgical risk is significant — careful monitoring and conservative management may be appropriate. In this context physiotherapy has a genuine and meaningful role.
How can physiotherapy help?
Physiotherapy for cervical myelopathy focuses on maintaining and optimising function within the limits imposed by the cord compression, rather than treating the compression itself. The key areas are balance and fall prevention, gait retraining and optimisation, upper limb function and fine motor rehabilitation, and maintaining strength in the muscles not directly affected by the myelopathy.
Fall prevention is particularly important — myelopathic gait disturbance significantly increases fall risk, and the consequences of a fall for someone with an already-compressed spinal cord are serious. Balance training, walking aid assessment and home environment advice all contribute to fall risk reduction.
Manual therapy to the cervical spine requires extreme caution in the presence of myelopathy — manipulation is absolutely contraindicated, and even mobilisation needs to be approached carefully and selectively depending on the stability of the spine and the nature of the compressing pathology. For patients with cervical instability contributing to myelopathy, gentle stabilising approaches rather than mobilising techniques are appropriate.
Exercise physiology has a role for patients with myelopathy who are managing significant deconditioning alongside their neurological symptoms — structured, safe exercise programming that accounts for balance and coordination deficits can meaningfully improve overall function and quality of life.
For patients who have had surgical decompression, post-operative physiotherapy addresses any residual neurological deficits, rebuilds strength and coordination, and monitors for signs of adjacent segment disease over time.
Our physiotherapists Yulia Khasyanova and Mauricio Bara both have experience in complex cervical spine conditions including myelopathy. Mauricio holds an APA Sports Physiotherapist title with extensive complex cervical spine experience. Both are members of the Australian Physiotherapy Association.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
