Q. Can balancing issue occur due to vestibular lesion or cervical myelopathy?

Answered by
Dr. Chirag Ashok Berry
and medically reviewed by iCliniq medical review team.
Published on Jun 14, 2016 and last reviewed on: Oct 09, 2018

Hi doctor,

I am a 45 year old male. My weight is 96 kg and height is 184 cm. I have severe sleep apnea and minor CAD with hypertension. I am facing problems of imbalance and lightheadedness. This started some six months back. Then, I was diagnosed with an uncompensated vestibular lesion. After a while, the symptoms improved. But now, again for the last two to three weeks the symptoms have become more pronounced. I feel unbalanced while standing and I cannot easily stand in a queue. Once I start walking it improves. I also feel lightheaded from time to time. The feeling is not of vertigo, but rather a feeling that I might faint, though I have not actually fainted. This feeling comes on at any time, even while sitting down. My doctor, a spine specialist, on examination noted Romberg positive, Hoffman positive and DTR ++ exaggerated reflexes. He advised me to have a cervical spine MRI. I have taken an MRI and the report is attached herewith. What does the MRI reveal? It is mentioned as moderate cervical cord compression with myelopathic changes. How serious is this? What would be the treatment and prognosis? Is this cord compression the cause of my imbalance and lightheadedness? I also feel breathless on exertion like bending down. Can this be related to the above? I had an angiogram recently which shows only minor artery disease and I am currently on medication for the same. Thank you.

Dr. Chirag Ashok Berry

Orthopedics And Traumatology Spine Health Spine Surgery
#

Hello,

Welcome to icliniq.com.

  • From the information you gave me, it looks like your imbalance is due to a condition called cervical myelopathy. The examination findings of your spine specialist also correlate with your diagnosis.
  • This happens when there is undue pressure or compression of the spinal cord in the cervical spine.
  • From the findings of your MRI, this is likely due to disc degeneration and herniation or bulging into the spinal canal.
  • Disc degeneration is the most common cause for cervical myelopathy. The spinal cord no longer has adequate space for itself (spinal stenosis) and its blood supply may also, in severe cases, be compromised.
  • While there can be other causes of your lightheadedness like a vestibular or cerebellar lesion, some patients of cervical myelopathy do have some lightheadedness with imbalance.
  • Breathlessness on exertion may be related to your cardiovascular health and it will be better assessed by your physician.
  • The written report of an MRI (attachment removed to protect patient identity) that you attached shows that your C5-C6 and C6-C7 disc levels have moderate spinal cord compression. This means that the space available for your spinal cord is reduced at those vertebral levels.
  • The prognosis is cervical myelopathy most often has a ladder pattern of progression. This means that the level of functional loss and symptoms may stay constant for a period of time, followed by worsening and the cycle continues.
  • Worsening of symptoms is the usual end result and very few cases show any improvement spontaneously.
  • Since the usual end result is worsening spinal cord compression, most spine surgeons do recommend surgical decompression - removal of the compressing element or increasing the space available for the spinal cord, at an early stage when it is still easier to perform a safe decompression, rather than waiting till the stenosis reaches critical proportions.
  • It is very difficult to predict how slow this condition will progress. It may so happen that this imbalance may stay constant and not worsen for years at a stretch.
  • Imbalance and clumsiness of hands usually signify the early stages of spinal cord compromise and can often be corrected if surgical decompression is performed. Once paralysis sets in, it becomes more unpredictable whether function will be regained completely even after surgery.
  • Treatment for this condition can be an initial trial of soft collar. This may give some comfort in mild cases, but often does not work on controlling the symptoms of imbalance and definitely does not prevent further worsening. But, this can be tried if surgery is being awaited or the other medical comorbidities prevent safe surgery.
  • Your cardiac status, high blood pressure and sleep apnea may have to be re-evaluated to assess how well you will tolerate surgery.
  • If these medical conditions are not well controlled, you may need to spend some time to optimize these with the help of your physician and other specialties before you sign up for surgery.
  • Please visit your spine surgeon and find out whether surgery is right for you.
  • I would suggest you take multiple opinions if you are contemplating surgery. This will not only answer a lot of your questions, but it will also educate you about expectations from such treatment.
  • I will be happy to explain various surgical techniques that are commonly used for cervical myelopathy. It will help if you are able to attach images of your MRI and x-rays.

Investigations to be done:

Upright neck x-rays, if not already done.

Differential diagnosis:

Cerebellar and vestibular lesions.

Probable diagnosis:

Cervical spondylotic myelopathy (CSM).

Regarding follow up:

Revert back with the report images to a neuro surgeon online.---> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

Thank you doctor,

I am so grateful for your detailed and prompt answer. I have attached the photos of my MRI report. I do not know if it would be clear enough. As you have suggested I visit a spine doctor. He advised me that this may progress, but the rate is not certain that is, it may go slow or fast. He suggested a surgery. He said that if I did not wish it now, I could wait and watch and if symptoms worsen then go ahead for surgery. MRI shows cord is 6 mm in C4-C5 and C5-C6. Is this level of compression dangerous? Will it become 5 or 4 mm later? At which stage is it a threat to life and cause paralysis, etc? It was suggested that if left untreated, it may progress to paralysis. Also, if I suffer a sudden jerk or fall or injury, it may lead to such a thing. Does paralysis mean one would be totally immobilized like in a coma? Or does it mean some part of body like hand or leg may not function? Would alternate therapies like acupressure help in any way? If I can live with my symptoms, will postponing surgery be a risk? Please explain.

Dr. Chirag Ashok Berry

Orthopedics And Traumatology Spine Health Spine Surgery
#

Hi,

Welcome back to icliniq.com.

Thanks for attaching all the images (attachment removed to protect patient identity). It was very helpful.

  • The space available for the spinal cord, which as measured by the radiologist, is 6 mm in diameter at C5-C6 and C6-C7. This measurement gives us a rough idea of how bad the compression is. But, it does not tell us how bad the spinal cord function is.
  • If there is a sudden decrease in the space for the spinal cord such as by a fracture or a fast growing tumor, the function (strength in muscles) usually deteriorates rapidly leading to paralysis.
  • If it is a slow progression of compression, like in your case disc related, it is very difficult to predict how fast the function will deteriorate and paralysis will ensue.
  • There is a risk of worsening imbalance and progressing to paralysis, but we cannot give a number to it. We cannot say if that will happen when the space for the spinal cord is 5 or 3 or 1 mm.
  • Often, the compression is so slow that the spinal cord gets enough time to get acclimatized to the tight space and you may not have worsened for years.
  • However, this diameter does tell us how risky your surgery will be. The more the compression, the more difficult it gets to safely remove the compressing element without causing any injury to the spinal cord with the instruments used in surgery.
  • Yes, sudden whiplash-like injuries to your neck may severely injure your spinal cord as there is very little wiggle room for the spinal cord within the vertebral canal.
  • Paralysis can range from partial weakness of arms and legs to complete loss of muscle power from the neck down. It depends on the severity and suddenness of the spinal cord injury.
  • I personally have no experience or knowledge in the use of acupressure, but I really doubt if it will help with what you have.
  • It is very difficult to say regarding postponing of the surgery. If you think you can live with your current symptoms, I would strongly suggest that you maintain close follow up with your spine surgeon. Report to him or her as soon as you perceive even the slightest worsening of your imbalance and completely avoid any activities that might risk sudden injuries to your neck.
  • Symptoms of hand function, like dropping things from your hand, change in your handwriting, clumsiness in fine activities of the hands, may be important signs that suggest your problem is worsening.

For further information consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

Thank you doctor,

I am happy to have found a doctor like you who is able to take the time to give such clear replies. I have a few more queries. The spine surgeon I had consulted mentioned a surgery called anterior cervical discectomy fusion. Is this a major surgery? How long will it take to do the surgery? How long will take to fully recover and go back to work? Will it be painful? Right now, I do not have any pain. What are the risks and possible complications? Is there a risk of damage the spinal cord? I suffer from severe sleep apnea. Will this be a complicating factor? Can this surgery further narrow my airways? A general physician, to whom I had shown my report, felt that there was nothing grossly abnormal in the report. He said it as a part of the aging process and many people's MRIs would show such a picture. Of course he has not seen the film or examined me. Is it true? You had advised that I should avoid any activity that might strain the neck. What is covered in this? Should I avoid lifting weights? Please explain.

Dr. Chirag Ashok Berry

Orthopedics And Traumatology Spine Health Spine Surgery
#

Hi,

Welcome back to icliniq.com.

Thanks for your appreciation.

  • Almost all spine surgeries are major surgeries. They are all more in severity than most other surgeries in the body.
  • The surgery can take anywhere from 2 to 4 hours. You should be able to get up the next day. You may need to wear a collar for some period after surgery.
  • There is going to be some pain for a week or two, should be controlled with standard pain medication. The above aspects may be different for different surgeons and hospitals. Please refer to your spine surgeon for details on these aspects.
  • Minor and common complications include pain while swallowing and temporary hoarseness of voice. Pain in the area of bone graft harvest, if performed.
  • Major complications are uncommon and include possible injury to the spinal cord, food pipe, nerves and blood vessels, blood collection pressing on breathing pipe.
  • Long term complications can include lack of healing or fusion, disc degeneration in an adjacent level and needing further surgery. This is in no way a comprehensive list and your surgeon should be able to discuss all these in detail with you prior to surgery.
  • Sleep apnea is usually in the area of the upper throat and your surgery is near the lower throat or neck. So, the surgery as such should not complicate your sleep apnea.
  • However, your anesthesiologist will have to keep in mind your history of sleep apnea while he puts you to sleep and wakes you up after surgery. This is routine for any surgery.
  • In cervical myelopathy, often the symptoms are mild. But, the clinical signs elicited in a detailed neurological examination are more important.
  • Your spine surgeon did find positive Hoffman and exaggerated reflexes, which are important signs that tell us that the spinal cord is not comfortable in the tight space.
  • If you had no clinical signs or symptoms, but had the MRI picture as you have now, then surgery would not have been anyone's suggestion.
  • As I mentioned previously, the spinal cord can acclimatize to tighter spaces if the compression has been very gradual. So, it is not uncommon to find some patients with MRI like yours, but no clinical signs and symptoms. It is very essential that your physician performs a complete examination and correlates with the MRI.
  • Avoid walking on slippery surfaces and try not to run on uneven surfaces. Avoid any activities with risk of falling. Preferably avoid two wheelers. I would not want to forbid you from travelling by car, air, bus, etc. The risk is too low in such travel, but you never know. Lifting weights should be avoided as this can strain your discs with further bulging.

For further information consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

Hi doctor,

For my balance issue, I had gone to an ENT doctor who specializes in balance issues (neuro otologist). He had done some tests like VEMP and diagnosed me with an uncompensated vestibular lesion. After that my balance seemed to be a bit better, but then again as I said last few weeks it is not so good. How to know whether my balancing issue is due to vestibular lesion or cervical myelopathy? Is there any definitive test for this? Another peculiar feature of my condition is that when I stand still I find more difficult to balance than when I try to walk. After I start walking it gets easier. Standing still is more difficult. Why? Please explain.

Dr. Chirag Ashok Berry

Orthopedics And Traumatology Spine Health Spine Surgery
#

Hi,

Welcome back to icliniq.com.

  • This can be a tricky situation. It is important for us to know whether the imbalance you are experiencing is a result of cervical myelopathy or a vestibular lesion or both.
  • If there is a component of vestibular origin, you may not experience complete relief from your imbalance after decompressive spine surgery.
  • We spine surgeons usually rely on the assessment of a qualified neurologist or neurophysician to determine whether the symptoms are related to the spinal cord compression or something else
  • From what I have heard from your earlier notes, it seems like you have exaggerated reflexes and positive Hoffman. Both these findings, combined with your MRI picture suggest that you definitely have cervical myelopathy.
  • It will be advisable to see a neurologist for a complete assessment and see if he or she agrees with the findings of exaggerated reflexes and whether the spine surgery will help with the symptom of imbalance or not.
  • The rest of my explanation in my previous answers regarding the prognosis of cervical myelopathy remains the same.
  • This is indeed peculiar. Imbalance from myelopathy is usually similar in standing and walking. Besides walking difficulty, there is often clumsiness of hand function, like dropping things from hand, change in handwriting, etc.
  • Do you have any hand symptoms? As mentioned above, a detailed assessment by a neurologist should give us more answers.

For further information consult a neuro surgeon online --> https://www.icliniq.com/ask-a-doctor-online/neuro-surgeon

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