Bill Klaproth (Host): This is The Healing Podcast, brought to you by MarinHealth. I'm Bill Klaproth, and with me is Dr. Akash Shah, a spine surgeon at MarinHealth Spine Institute at UCSF Health Clinic as we talk about cervical stenosis. Dr. Shah, welcome.

Dr. Akash Shah: Hey, Bill. Thanks so much for having me on. Great to talk to you again.

Host: Yeah, always a pleasure. So glad to have you on, as we've talked about before, back pain, spine issues. It's a big thing. So, always glad to talk to you about these things. So, to start, what are cervical stenosis and myelopathy and how are they different from everyday neck pain?

Dr. Akash Shah: So, you know, I think it can be helpful to think about it a little bit with respect to the anatomy that's actually being affected. So, the cervical spine— kind of like the lower back—it's just comprised of the actual bones, the discs between the bones that act as shock absorbers, the joints that allow for motion, the ligaments that provide stability, and then the muscles that surround these. And typical everyday neck pain comes from degeneration of these structures. So, disc height loss, arthritic pain, muscle strain, spasms, poor posture, et cetera.

And I talked about everything that makes up the spine, but I left out one key part, which is the spinal cord, right? The most important part of the spinal column, obviously. Cervical stenosis refers to narrowing within the spinal canal. And when that narrowing affects. Individual nerves, we call it radiculopathy. You can get shooting pain, numbness, tingling, affecting one or both arms. But when that narrowing becomes severe enough to affect the spinal cord itself, we call it myelopathy. And so, cervical myelopathy is not just a pain problem, like your regular neck aches, it's a spinal cord problem, which makes it quite a bit more serious.

Host: So then, what symptoms should we be looking out for? Which symptoms raise red flags at something more serious than a stiff neck might be going on?

Dr. Akash Shah: The biggest red flags are progressive neurologic symptoms. So for cervical myelopathy, these include balance problems, like folks might say that they feel wobbly or unsteady. Patients often have fine motor dexterity or hand coordination issues as well. So, you can be noticing trouble with buttoning buttons, putting on jewelry, dropping objects. Some people notice a change in handwriting if they're still using a pen or paper to write instead of their phone. Numbness and tingling in both hands, feeling of weakness in the arms or the hands. And rarely, in more severe cases, you can develop problems with bowel or bladder function as well.

And the key point is that these can be quite subtle at first, and a lot of them are non-specific, right? Like, who doesn't have occasional feelings of imbalance or dropping items or occasional hand numbness at night? If they're intermittent and occasional, it's one thing. But if they're persistent and progressive, like if they're getting worse, that's when I start to worry. And any one of these symptoms can be caused by something other than myelopathy, but the constellation or combination of these symptoms should raise some concerns.

And so, if someone was to start noticing declining balance or coordination, I'd recommend getting evaluated by a set of trained eyes. You know, I've had quite a few patients now come in for hand numbness, only to realize upon questioning that they have actually had some worsening balance as well. Then, we get an MRI, and then there's some severe spinal cord compression. You're not always necessarily clued into associating balance and numbness and coordination, and nor should you be. You know, that's not your job.

Host: So, do these symptoms, Dr. Shah, always accompany neck pain? So if I have neck pain And then, I also have motor dexterity, balance issues, change in handwriting, are they always together or can you have these symptoms without neck pain?

Dr. Akash Shah: You can absolutely have these symptoms without neck pain. Now, some of the things that result in neck pain like facet joint arthritis or disc degeneration, et cetera, those same processes can lead to narrowing within the spinal canal that can then turn into myelopathy. So, they are often associated. However, it is certainly possible to have only balance or hand numbness or tingling issues or coordination issues without associated neck pain.

Host: Okay. So, you mentioned balance that motor dexterity, change in handwriting, et cetera. Which one of those should really raise a red flag that something serious is going on, something more than just a regular stiff neck?

Dr. Akash Shah: Oftentimes what folks complain about first or notice first is a feeling of wobbliness or unsteadiness. There isn't necessarily an order in which these symptoms actually occur. It isn't as if, oh, you start with balance, and then you go to numbness, and then you go to this. Any one of them really ought to clue you into getting an evaluation. The one exception being in very severe cases, folks can have bowel or bladder dysfunction. And obviously, if something like that were to happen, like if you feel like you're needing to go to the bathroom more frequently or you're not going enough, et cetera, those are reasons to prompt a somewhat more urgent evaluation.

Host: It is interesting that the spinal cord can cause balance problems. I don't really associate neck or back problems with balance problems. But apparently, that's true.

Dr. Akash Shah: Yeah, it is. And so, chronic spinal cord compression can absolutely result in balance issues. We experience the world and our surroundings through, essentially, our nerves, touching the ground, and determining proprioception, like kind of where we are in space. And that information has to get from the outside world up to our brain. And information on how to walk has to go from our brain to the outside world. And the pathway through which that occurs is the spinal cord.

Host: Yeah. Very interesting. So, I'm curious, who is most at-risk for developing cervical stenosis or myelopathy? And are there lifestyle or age-related factors involved?

Dr. Akash Shah: For most people, this is an age-related process. In fact, many of the processes that result in neck pain can cause stenosis as well, right? So, our discs lose height over time. And as they flatten, they can bulge backwards and compress the spinal cord. As the discs lose height, the joints take more stress. You develop arthritis, bone spurs form, ligaments thicken, et cetera. All of these result in space for the spinal cord decreasing.

There are also some congenital conditions. Some people are just born with a narrower spinal canal. So, this is called congenital spinal stenosis or congenital cervical stenosis. And you can imagine that if you have less space available to start with, it takes less degeneration to result in subsequent spinal cord compression. There's also a condition called OPLL or ossification of the posterior longitudinal ligament. Basically, these are just one of the ligaments that runs in front of the spinal cord that can become replaced with bone in some folks. And this progressively narrows the spinal canal that can result in chord compression.

Symptomatic spinal cord compression is significantly more common in people above the age of 60. Some studies have shown that some degree of cord compression is present in as many as 35% of people above the age of 60. But of course, the number that is actually symptomatic is quite a bit lower than that.

Host: So, what happens if these conditions progress, if they're left untreated? And can you talk about why early diagnosis is so important?

Dr. Akash Shah: If left untreated cervical myelopathy, unfortunately, only goes in one direction. It's an insidious process with stepwise decline, but it is typically progressive. Some patients might plateau for a period of time. But the natural history is that function does slowly decline, particularly with hand function and balance.

So, early diagnosis is important. Because by the time myelopathic symptoms occur, there is by definition, spinal cord injury and spinal cord injury is not fully reversible. Surgery can stop progression and improve symptoms in a subset of patients, but the longer the cord is compressed, the less complete and predictable recovery will be. And so, the goal is to diagnose it before significant permanent deficits develop.

Host: Okay. So, what does that diagnostic process look like? What tests or imaging studies are usually needed?

Dr. Akash Shah: We diagnose cervical stenosis and myelopathy with a combination of the patients story of their symptoms, their physical exam and imaging, just like you mentioned. So first I want to know if they have any of the symptoms that I've talked about already, right? Balance, coordination, numbness, and. Crucially, if any of those symptoms have progressed at all, I then examine them in the office, right?

I test their balance and coordination. And I also look for the presence of abnormal reflexes, which can sometimes emerge if the spinal cord is compressed for a long period of time. And if I'm concerned for myelopathy in the slightest, I have a low threshold to obtain an MRI of the cervical spine. This lets me visualize a spinal cord And the degree of compression, along with whether there's any swelling or changes in how the spinal cord looks that, indicates spinal cord injury.

I'll also get plain x-rays to look at the patients neck alignment and stability, because this is going to impact decision-making for any subsequent surgery. And I typically also always get a CT scan, to better define the patients bony anatomy, again, for surgical planning. But, you know, it's important to remember right, that, we don't treat MRIs, we treat the people in front of us. And so, the most important thing in all spine surgery is whether the patient's symptoms correlate with what we see on imaging. So if the patient has severe compression on an MRI but absolutely zero myelopathic symptoms, then we don't necessarily have to do anything. Maybe we'll monitor them more closely, but we don't have to intervene.

Similarly, if the patient has symptoms of myelopathy, but I don't see anything on the MRI, we have to broaden our search for what's going on. This might include imaging of the thoracic spine, actually, because you can have thoracic myelopathy, like compression of the spinal cord and the thoracic spine. That might be a conversation for another time. or, we include some other specialists like neurologists, do some nerve conduction studies to determine what exactly is going on.

Host: Okay. So, let's talk about treatment now. So, you've got the full picture, you've done the MRI, the CT scan. When can symptoms be managed then without surgery? After you find out or after you do these initial tests? And then, when does surgery become necessary?

Dr. Akash Shah: For 90% of the patients that come into my office, I tell them that they probably will improve without surgery. One of the exceptions of that is cervical myopathy. Once myelopathy is present, I typically recommend surgery usually within three months because the earlier we operate, the sooner we can arrest the progression of symptoms before they become permanent.

Now, if the patient doesn't want surgery or is too sick to safely undergo surgery, we can try to temporize things with physical therapy and maybe some balance training. But most of the evidence shows that non-operative management does not reliably stop progression of cervical myelopathy. And there's also, unfortunately, no useful role for steroid injections for myelopathy.

Host: So cervical myelopathy, that's the one where if you see that, that's when generally you know that surgery is going to be involved.

Dr. Akash Shah: That's correct.

Host: So, let's talk about the surgical options then. What are they? I know things have progressed and you have different techniques and ways of operating on people. Let's talk about the surgical options and what should patients realistically expect from recovery.

Dr. Akash Shah: Cervical myopathy, as we've talked about, is pretty simply an issue of space available for the spinal cord, right? There just isn't enough of it. And so, of course, surgery is aimed at providing more space for the spinal cord. And as spine surgeons, we typically decompress things that are compressed, and then fuse whatever is unstable.

And so, there are two approaches of how we go about treating cervical myelopathy. So, you can go in from the front, that's an anterior approach, or from the back, that's a posterior approach. Additionally, there are motion preservation options as well as fusions. So if most of the patients compression of the spinal cord is coming from. Anterior pathology, like from the front of the neck, like a disc herniation, or if the patient's neck alignment needs to be improved, like if their neck is too straight, we tend to approach from the front. And the most common surgery from the front is called an ACDF or an anterior cervical discectomy and fusion. Kind of just what it sounds like. We go in from the front anterior, we remove the intravertebral disc, discectomy; adequately decompress the spinal cord from the front. And then, we replace the disc with a metal cage. That's the fusion.

Usually, we do this for one to two levels, but sometimes some surgeons will do it for three or four levels. If there's significant compression just behind the bone itself and not just the disc, sometimes you need to perform what is called a corpectomy, where you have to take a little bit of the bone itself away. If the patient has multilevel compression with reasonable alignment, we can address this from the back. So, this can be either a laminectomy infusion where you unroof the back of the spine to open up the canal, and then stabilize the spine with screws and rods. Or you can do what's called a laminoplasty, which is a motion preserving approach where you partially unroof the spine and provide some more space for the spinal cord.

Laminoplasty happens to be my preferred surgery for multilevel stenosis from the back. But there are some times when you have to fuse, like if there are some instability present.

Host: So then, after surgery, what kinds of improvements do patients most often notice after treatment? And what challenges can come up during recovery?

Dr. Akash Shah: I try to be very t transparent from the start. The goal of surgery is to prevent you from getting worse. That said, about 70% of patients do experience some improvement of symptoms. It's just hard to know who those patients will be and how much recovery they'll experience. The most common improvements are imbalance and improved hand function. So, I tell patients that it can take 12 to 18 months to determine the full extent of neurologic recovery. But within the first three or four months, patients who do experience benefit start to see some of the improvement.

In terms of kind of recovery after surgery, obviously, that varies based on the number of levels and whether we go from the front or the back or whether we fuse. But one to two level ACDF tends to go home within one day, same with laminoplasties. And the laminectomy and fusions tends to have a greater hospitalization and recovery. They usually stay for two or three nights. But most people go home. They then work with physical therapy. They're up and walking the same-day or the next morning. Usually, you're requiring narcotics for a few days to two weeks after surgery. And within the first six weeks after surgery, patients gradually start to walk more.

And typically, at the six week to three-month mark, patients usually feel that they're much more mobile with some more endurance. The timeline is a little bit longer in fusion surgery since the bone has to heal. But overall, that pattern is similar.

Host: And at that point, I'm sure they're very happy because basically you've given them great quality of life back after alleviating that pain and that they were going through as far as some of the symptoms that you were naming off before.

So, somebody might be listening to this, Dr. Shah, and be saying, "I don't want to go through that." What can I do now to try to protect my neck? Things like posture changes maybe, or exercise or lifestyle adjustments. Are there things people can do now to contribute to better neck health, if you will?

Dr. Akash Shah: Absolutely. I mean, you know, there's no guaranteed way to prevent cervical stenosis, but there are some general principles to improve neck health and slow the degeneration that might lead to stenosis down the road.

The first is what you mentioned, right? Maintain good posture, especially these days with desk jobs, prolonged screen use. And look, I mean, I recognize how hard it is to do. I'm a spine surgeon and I admit that my own job of looking down while operating isn't the best for neck health. But trying to be mindful of posture is important. It's important to stay physically active, to work on strengthening your paraspinal muscles in the cervical spine and trapezial muscles as well. Strong muscles keep pressure off the discs and the joints. And they reduce the load that they experience, which would also slow degeneration.

In terms of maybe like a lifestyle choice that I think folks ought to make is avoid smoking. Every doctor tells you to avoid smoking. There's a lot of great reasons to not smoke. But from a spine standpoint, smoking significantly accelerates disc degeneration. And if you ever do need a surgery, nicotine reduces the success of fusion and also increases the risk of complications like infection. And , finally, be aware of your body. No one knows your body better than you. And that includes your doctors. If something feels wrong, if something feels off, have it evaluated.

Host: That is always good advice. I'm making sure that I'm sitting up straight right now, Dr. Shah. So, for listeners who are worried about symptoms right now, what's the most important first step they can take?

Dr. Akash Shah: Just get evaluated early. If you have balance issues, if you're dropping objects, if you're having hand numbness, just go see your doctor. And if you have some associated neck or arm pain, maybe insist on seeing a spine surgeon as well. Most of the time, I caution folks against paranoia. Most things get better and most things are probably nothing. But the difference in outcomes is so vast between mild and severe myelopathy and a missed diagnosis of myelopathy that I think it is absolutely worth seeing an expert and ruling cervical myelopathy out If you have any of those symptoms that we've talked about.

Host: Well, that is a great way to wrap it up. Dr. Shah, thank you so much. Always great to talk with you. Always love the information you bring. Thank you so much for your time.

Dr. Akash Shah: Yeah, absolutely. Thank you for having me on.

Host: You bet. Once again, That is Dr. Akash Shah. And for more information, go to mymarinhealth.org dot org. And if you enjoyed this podcast, please share it on your social channels and check out the entire podcast library. For topics of interest to you, I'm Bill Klaproth. This is The Healing Podcast, brought to you by MarinHealth. Thanks for listening.