|Year : 2015 | Volume
| Issue : 2 | Page : 74-78
Magnetic Resonance Imaging Findings in Cervical Spondylosis and Cervical Spondylotic Myelopathy in Zaria, Northern Nigeria
Sefiya Adebanke Olarinoye-Akorede1, Phillip Oluleke Ibinaiye1, Aliu Akano2, Ahmed Umdagas Hamidu1, Gbenga Abimbola Kajogbola1
1 Department of Radiology, Ahmadu Bello University, Zaria, Nigeria
2 Department of Radiology, National Hospital, Abuja, Nigeria
|Date of Submission||25-Nov-2014|
|Date of Acceptance||18-Feb-2015|
|Date of Web Publication||20-May-2015|
Dr. Sefiya Adebanke Olarinoye-Akorede
Department of Radiology, Ahmadu Bello University, Zaria
Background: Cervical spondylosis (CS) has received little attention in the Nigerian medical literature even in the present era of magnetic resonance imaging (MRI). Unfortunately, cervical spondylotic myelopathy (CSM) is the most common form of functional debility from spinal cord disease in older adults. Objective: We sought to describe the clinico radiologic findings in CS and CSM with the hope of familiarizing clinicians with this prevalent and potentially devastating disorder. Materials and Methods: This study was a retrospective analysis of 76 patients who underwent cervical MRI examination on account of CS, associated with either radiculopathy, myelopathy, or myelo radiculopathy. The patients comprised of 54 (71.1%) males and 22 (28.9%) females, their ages ranged from 26 to 78 years. Each patient was also scored clinically using the Nurick's classification for cervical myelopathy and scores compared with their MRI examination findings. Results: The condition was commoner in males than females (M:F = 2.5:1). Multi-level disease was seen in almost all patients and the commonest disc levels affected in spondylosis were C4/5, followed by C5/6; while for spondylotic myelopathy, it was C3-4 level. The prevalence of CSM in this study was 42.10%. The patients' clinical scores compared well with their MRI findings. Conclusion: CS should not be dismissed as a mere consequence of aging 'but a disease with possible debilitating outcome and early prevalence due to an interplay of environmental and genetic factors'. On the strength of this, we have presented the MRI and clinical findings in CS and spondylotic myelopathy; and also reviewed previous reports in the light of the current findings in the literature.
Keywords: Cervical, magnetic resonance imaging, myelopathy, spondylosis, Zaria
|How to cite this article:|
Olarinoye-Akorede SA, Ibinaiye PO, Akano A, Hamidu AU, Kajogbola GA. Magnetic Resonance Imaging Findings in Cervical Spondylosis and Cervical Spondylotic Myelopathy in Zaria, Northern Nigeria. Sub-Saharan Afr J Med 2015;2:74-8
|How to cite this URL:|
Olarinoye-Akorede SA, Ibinaiye PO, Akano A, Hamidu AU, Kajogbola GA. Magnetic Resonance Imaging Findings in Cervical Spondylosis and Cervical Spondylotic Myelopathy in Zaria, Northern Nigeria. Sub-Saharan Afr J Med [serial online] 2015 [cited 2020 Dec 5];2:74-8. Available from: https://www.ssajm.org/text.asp?2015/2/2/74/157424
| Introduction|| |
Cervical spondylosis (CS) refers to osteoarthritic changes in the cervical spine which occurs from vertebral wear and tear. Spondylosis generally tends to be ignored under the guise of normal aging process, which is destined to occur once the individual is old enough. Attention is even less serious in the cervical region where the outcome of myelopathy could be grievous. Cervical spondylotic myelopathy (CSM) is considered the commonest cause of spinal cord dysfunction in individuals above 55 years of age and if left untreated, permanent cord damage may occur.  This could contribute to increased dependence and reduced quality of life in older individuals.
In asymptomatic individuals, radiographical evidence of spondylosis is present in 25-50% 0f 50-year-old and 75-90% of individuals above 65 years of age.  The risk factors for development of CS include repeated macro and micro trauma which could result from environmental and occupational conditions as well as genetic predisposition. Myelopathy develops when the degenerative process causes a reduction in both the spinal canal diameter and sagittal mobility of the spinal cord. , This results in ischeamic cord compression leading to cord atrophy, neuronal loss in the grey matter and white matter demyeliation.
The reports on the natural history of CSM fluctuates, therefore, its outcome for each patient remains unpredictable. However, for most patients, they experience progression of symptoms followed by periods of stable or worsening function and in rare instances, improvement. Between 20% and 60% of patients are said to degenerate over time without surgical intervention. ,
The purpose of this study was to describe the Clinico Radiologic findings in CS and CSM in our locality, which is first of such report to the best of our knowledge.
| Materials and Methods|| |
In the 2-year time-frame of this retrospective study, 130 patients underwent cervical magnetic resonance imaging (MRI) in the radiology department of Ahmadu Bello University Teaching Hospital. Out of these patients, 76 of them were diagnosed clinically and confirmed radiologically as CS and they formed our study cohort. We analysed their presenting symptoms and clinical findings from their hospital records. Each patient was then scored clinically using the Nurick's classification for myelopathy [Table 1]. Their cervical MRI were reported by 2 consultant Radiologists. The patients who met our criteria included all those in which there was no reasonable doubt that their symptoms was due to CS. We excluded all cases of trauma, tumor, infection, metabolic disease, or other forms of neurologic diseases even when spondylosis was present.
Only one MRI machine (MAGNETOM Concerto Siemens medical) with a field strength of 0.2 Tesla was used to image all patients. T1 and T2 weighted (T1W, T2W) images were acquired using the fast spin echo technique in both sagittal and axial planes. Patients were imaged lying supine with the head in neutral position with the use of a neck coil. The imaging protocols were as follows:
T1 W sagittal image: TR/TE = 345-478/13-15; Field of view-251 mm × 251 mm; Section thickness-4.5 mm.
T2 W sagittal image: TR/TE -3500-4500/110-128; Field of view-253 mm × 253 mm; section thickness = 4.5 mm
For axial T2 W images, the protocol was: TR/TE = 7580/128, Field of view-176 mm × 260 mm
Both T1W and T2W images were evaluated, while axial images were occasionally reviewed to compliment findings when required. Both T1W and T2W images were evaluated for cervical spine alignment, bony changes, discal abnormality and cord compression, while the axial images were assessed for central cord compression and nerve root exit compression'.
| Results|| |
Out of our study population, 54 (71.1%) of the patients were males, while 22 (28.9%) were females (M:F = 2.5:1) [Table 2]. Their ages ranged from 26 to78 years old, with a mean age of 52.7 ± 11.31 years. The patients' symptoms included neck pain, radicular pain (involving arm, shoulder, and hand), gait abnormalities, motor dysfunction (paralysis, paresis), sensory abnormalities (paresthesia, tingling sensation), loss of proprioception/dizziness, muscle wasting, and sphincteric dysfunction [Figure 1].
The C4/5 level was mostly involved in the spondylotic process which included osteophytosis, disc dehydration, disc bulge, disc space narrowing; the next in frequency was C5/6 [Figure 2]a and [Table 3].
|Figure 2: (a) Sagittal T2 Weighted Cervical MRI in a 50 year old female showing marginal osteophytes involving C4-7 vertebrae with intervening disc desiccation and adjacent end plate irregularities. There is no spinal cord compression. (b) Sagittal T2W cervical MRI in a 45-year-old male showing disc herniation at C4/5 and C5/6 levels and reversal of the normal cervical curvature. Although the cervical cord is displaced posteriorly, it is not compressed|
Click here to view
|Table 3: Spondylotic findings versus total no of lesions per cervical disc level|
Click here to view
There was reversal of cervical cord curvature in 7 (9.2%) [Figure 2]b while degenerative spondylolisthesis was present in only 5 (6.7%) of the patients.
32 (42.10%) of the patients had cord compression involving a total of 55 levels. Most cases 38.1% involved C3/4 level [Figure 3], followed by C4/5 level 30.9%. CSM occurred more frequently in older males (51-60 years).
|Figure 3: Sagittal T2 weighted magnetic resonance imaging (MRI) of a 59-year-old male showing cord compression and hyper intense signal change at C3/4 level. There is also mild compression noted at C4/5, straightening of the normal cervical curvature, multi-level disc dehydration and marginal osteophytes|
Click here to view
Cervical spondylotic injury (CSI) was seen in 15 (46.87%) of the 32 patients with CSM. They had between grades 3-4 Nurick scores, with associated MRI findings of high T2 signal intensity (SI) [Figure 3].
| Discussion|| |
The findings from our study support a preponderance of spondylosis in older males as previously reported. ,, Spondylosis is usually associated with advancing age however, microscopic changes of spondylosis can be seen in almost all individuals as early as 30 years of age ,, while plain X-ray changes are seen by 40 years. , Our youngest patient was 26-year-old which also agrees with the fact that spondylosis could even begin in teenage and progress with advancing age.  The disease course and progression involves an interplay of environmental and genetic factors and these factors can predispose some individuals to develop CS earlier in life. 
Cervical spondylosis could present with three syndromes: Axial neck pain, cervical radiculopathy and CSM. , Symptoms of myelopathy occurs when at least 30% of the cord has been compressed but this varies between patients. 
Although no disc level is spared, CS mostly commences from C4 to 7 levels.
The order of frequency in foreign literature is: C5/6, C6/7 and C4/5. ,,,, In our study however, the commonest cervical level involved in spondylosis was C4/5, followed by C5/6. This same finding was noted in other studies done on Nigerian population and could be due to racial difference. ,,
The C1 vertebra (atlas) was not involved in CS in any of our patients. The radiological findings at the intervertebral disc usually begin with dehydration, herniation of disc material, disc space narrowing and ligamental hypertrophy. The development of osteophytes is an attempt by the vertebral body to increase the weight bearing surface of the end-plates. However, while disc space narrowing was not a common finding in the present study, it was the 2 nd commonest finding in CS in a previous report.  Multiple disc level affectation was however the norm. Degenerate listhesis and reversal of cervical spine curvature also occurred in 9.2% and 6.7% of our patients. The loss of normal cervical lordosis is known to exacerbate anterior compression of the spinal cord. 
Cervical spondylotic myelopathy occurs as a late sequel to CS as a result of static and dynamic factors.  The static factors cause mechanical narrowing of the spinal canal and it includes congenital canal stenosis (AP diameter <13 mm), osteophytes, disc herniation and ligamental hypertrophy. The dynamic factors include abnormal forces placed on the cord and spinal canal during flexion and extension of the cervical spine under normal physiologic loads. During flexion, the cord is susceptible to more compression in the presence of herniated discs or osteophytes, causing stretching of the cord; while during extension, cord compression could be increased by infolding of ligamentun flavum or facet joint capsules leading to shortening and thickening of the cord.
In our series, the prevalence of CSM in spondylotic patients was 42.1%. Several authors have reported that CSM predominated in the lower cervical levels (C5-7). This has been attributed to the fact that the spinal cord occupies three quarters of the spinal canal at these levels and also the vulnerable blood supply to this segment of the cord. , We, on the other hand observed that the commonest level for CSM was higher, at C3/4 level. While C3/4 myelopathy is said to be uncommon, occurring 5 times more frequently in patients above 65 years old, , the patients in our study were younger (mean age 52.7 years). This finding of C3/4 myelopathy in younger patients was however similar to the report by Vyas et al. (mean age 50.6 years in his study population).  He concluded that a lower spondylotic level transfers the stress to a higher level in order to help maintain cervical alignment and sagittal motion. Thus, where C4/5 is spondylotic, C3/4 level is predisposed to higher mobility and subsequent development of CSM as was observed in the present study where the most spondylotic level was C4/5.
Magnetic resonance imaging is the investigation of choice in CSM due to its high soft tissue resolution which affords this imaging modality the superior ability to directly visualize the disc elements and the spinal cord.
The MRI findings in our patients compared well with their presenting symptoms. T2W SI at point of compression which represents oedema or inflammation signified severe clinical symptoms of CSM. T1 hypointensity represented an even greater severity, signifying ischaemia, myelomalacia or gliosis and it is associated with poor postoperative outcome. MRI signal abnormalities therefore serves as an important prognosticating factor. Generally, we observed that all patients with abnormal MRI signal changes also had high Nurick scores that is, from grades 3-4. MRI is invaluable tool in deciding the algorithm for patient management.
The bulk of the evidence in the current literature show that the clinical course of CSM is progressive deterioration. ,,,,,, Surgery is therefore advocated as the standard care for patients with moderate to severe symptoms. Patients with mild symptoms could be managed conservatively with close clinical and radiologic follow up. However, in a large series by Wu et al.,  CSI occurred more in patients with CSM who were managed conservatively than those who underwent surgery. Rhee et al.,  opined that there is little evidence that conservative treatment could halt or reverse the disease process. Early surgical treatment on the other hand has proved to improve long term functional recovery and neurologic prognosis. ,,
| Conclusion|| |
Cervical spondylosis and its sequalae, cervical spine myelopathy are not mere consequences of aging but a disease spectrum with high prevalence in our locality and with serious debilitating outcome'.
Clinicians should lower their threshold in requesting for cervical spine MRI in these patients as it is the key diagnostic tool for instituting early and appropriate treatment.
| References|| |
Montgomery DM, Brower RS. Cervical spondylotic myelopathy. Clinical syndrome and natural history. Orthop Clin North Am 1992;23:487-93.
Oguntona SA. Cervical spondylosis in South West Nigerian farmers and female traders. Ann Afr Med 2014;13:61-4.
Yarbrough CK, Murphy RK, Ray WZ, Stewart TJ. The natural history and clinical presentation of cervical spondylotic myelopathy. Adv Orthop 2012;2012:480643.
White AA, Punjabi MM, editor. Clinical; Biomechanics of the Spine. Philadelphia: Lippincott; 1990.
Karadimas SK, Erwin WM, Ely CG, Dettori JR, Fehlings MG. Pathophysiology and natural history of cervical spondylotic myelopathy. Spine (Phila Pa 1976) 2013;38 22 Suppl 1:S21-36.
Fehlings MG, Arvin B. Surgical management of cervical degenerative disease: The evidence related to indications, impact, and outcome. J Neurosurg Spine 2009;11:97-100.
Wu JC, Ko CC, Yen YS, Huang WC, Chen YC, Liu L, et al.
Epidemiology of cervical spondylotic myelopathy and its risk of causing spinal cord injury: A national cohort study. Neurosurg Focus 2013;35:E10.
Eduwem DU, Uduma FU, Eke B, Inyang C, Nwashidi A. Conventional radiographic evaluations of cervical spondylosis in university of uyo teaching hospital Uyo, Uyo, Nigeria. World J Med Med Sci 2014;2:1-9.
Mustapha Z, Okedayo M, Ibrahim K, Ali AA, Ahmadu MS, Abubakar A, et al
. Cervical spine MRI findings in patients presenting with neck pain and radiculopathy. Int Res J Basic Clin Stud 2014;2:20-6.
Teresi LM, Lufkin RB, Reicher MA, Moffit BJ, Vinuela FV, Wilson GM, et al.
Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology 1987;164:83-8.
Milhari H, Ohnari k, Hachiya M, Kondo S, Yamada K. Cervical myelopathycaused by C3-4 spondylosis in elderly patients: a radiographic analysis of pathogenesis. Spine 2000;25:769-800.
Hirsch C, Schajowicz R, Galante J. Structural changes in the cervical spine. A study on autopsy specimens in different age groups. Acta Orthop Scand 1967:Suppl 109:7-77.
Lebl DR, Hughes A, Cammisa FP Jr, O′Leary PF. Cervical spondylotic myelopathy: Pathophysiology, clinical presentation, and treatment. HSS J 2011;7:170-8.
Kelly JC, Groarke PJ, Butler JS, Poynton AR, O′Byrne JM. The natural history and clinical syndromes of degenerative cervical spondylosis. Adv Orthop 2012;2012:393642.
Chen TY. The clinical presentation of uppermost cervical disc protrusion. Spine (Phila Pa 1976) 2000;25:439-42.
Bohlman HH. Cervical spondylosis with moderate to severe myelopathy. A report of 17 cases by Robinson anterior cervical discectomy and fusion. Spine 1977;2:151-62.
Friedenberg ZB, Miller WT. Degenerative disc disease of the cervical spine. J Bone Joint Surg Am 1963;45:1171-8.
Bailey RW. The Cervical Spine. Philadelphia: Lippincott-Raven; 1974.
Bosijen E. The cervical spine canal in intraspinal expansive process. Acta Radiol 1954;42:1001-115.
Hochman M, Tuli S. Cervical spondylotic myelopathy: A review. Internet J Neurol 2004;4:1.
Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine (Phila Pa 1976) 1988;13:831-7.
Mattei TA, Goulart CR, Milano JB, Dutra LP, Fasset DR. Cervical spondylotic myelopathy: Pathophysiology, diagnosis, and surgical techniques. ISRN Neurol 2011;2011:463729.
Vyas KH, Banerji D, Behari S, Jain S, Jain VK, Chhabra DK. C3-4 level cervical spondylotic myelopathy. Neurol India 2004;52:215-9.
Baron EM, Young WF. Cervical spondylotic myelopathy: A brief review of its pathophysiology, clinical course, and diagnosis. Neurosurgery 2007;60:S35-41.
Brain WR, Northfield D, Wilkinson M. The neurological manifestations of cervical spondylosis. Brain 1952; 75:187-225.
Furlan JC, Kalsi-Ryan S, Kailaya-Vasan A, Massicotte EM, Fehlings MG. Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: A prospective study of 81 cases. J Neurosurg Spine 2011;14:348-55.
Rhee JM, Shamji MF, Erwin WM, Bransford RJ, Yoon ST, Smith JS, et al.
Nonoperative management of cervical myelopathy: A systematic review. Spine (Phila Pa 1976) 2013;38 22 Suppl 1:S55-67.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]