Traumatic Myelomalacia

Diagnosis & Collaborative Management Between the Chiropractor as the Primary Spine Care Provider and the Neurosurgeon


By: Matt Erickson DC, FSBT


John Edwards MD, Neurosurgeon

Clay Wickiser DC






Myelomalacia is defined as softening of the spinal cord and can be a result of injury and represents a serious and potentially life-threatening sequella to injury if not treated. According to Zhou, Kim, Vo and Riew (2015), “Cervical myelomalacia is a relatively uncommon finding on MRI, with anoverall prevalence of 4.2% among all patients who underwent cervical MRI. Males had a higher prevalence (5.6%) than the females (3.0%).” (pg. E250) 


Zhou et al., (2015) also reported, “There were considerable variations in the prevalence of myelomalacia in patients referred by different specialties/subspecialties. Specialists in spinal cord injury had the highest rate (28.7%), followed by neurological (8.4%) and orthopedic (6.4%) spine surgeons, general neurosurgeons (5.5%), and neurologists (4.2%). Specialists who generally do not treat patients with spine problems had the lowest (1.2%) followed by non-spine orthopedists (1.6%) and primary care doctors (2.1%)” (p. E248).


Platt, McConnel and Bestbier (2006) reported, “Myelomalacia is ischemic or hemorrhagic necrosis of the spinal cord that can occur following acute spinal cord injury, and represents extensive damage of the intramedullary spinal vasculature” (pg. 78). According to Lu, Lamb and Targett (2002), “In small animal neurology, the term myelomalacia … is normally used to refer to hemorrhagic infarction of the spinal cord that can occur as a sequel to acute injuries, such as that caused by intervertebral disc extrusion. Myelomalacia may occur as a focal lesion or may spread cranially and caudally along the spinal cord, resulting in a diffuse, severe lesion. Histologic lesions of myelomalacia are compatible with ischemic necrosis” (pg. 326).


According to a website article titled, “Myelomalacia” by Foster and Wilborn (2019), “Myelomalacia is a medical condition in which the spinal cord becomes soft. It is caused by the insufficient blood supply to the spinal cord, either as a result of bleeding or because of poor circulation. Myelomalacia most often occurs as a result of the injury” ( Foster and Wilborn (2019) added, “Caused by mild to severe spinal cord injury, myelomalacia leads to neurological problems, often related to muscle movement. Often, the onset of the condition is slow and subtle, making it difficult for doctors to catch at an early stage. The condition may present simply as high blood pressure, for example, and may not be diagnosed until after the point at which it has become inoperable. While symptoms vary, they may include loss of motor function in the lower extremities, sudden jerking of the limbs, an inability to sense pain, depression, difficulty breathing, and paralysis. The damage can migrate towards the brain in a condition known as ascending syndrome. Myelomalacia can be fatal if it causes paralysis of the respiratory system (para. 2-3).


Platt, McConnel and Bestbier (2006) also reported, “The exact pathophysiology is poorly understood but it seems to be the result of the concussive effects of trauma, ischemia, and the release of vasoactive substances, oxygen-free radicals and cellular enzymes. When the spinal cord is acutely damaged, cell death in the gray matter may occur within 4 hours, with this area of necrosis expanding for a few days” (pg. 78). This means that many patients can have significant underlying progressive pathology with symptoms that have not yet fully expressed themselves, but the evidence is demonstrative to the trained expert. This further supports the necessity and importance of having a primary spine care provider with trauma qualifications to diagnose the issue early on and coordinate care with the neurosurgeon.


Operative Neurosurgery, “Myelomalacia” (administrator updated) (2018, para. 4), explained, “Gradual cranial migration of the neurological deficits (problems relating to the nervous system), is known as ascending syndrome and is said to be a typical feature of diffuse myelomalacia. Although clinical signs of myelomalacia are observed within the onset (start) of paraplegia, sometimes they may become evident only in the post-operative period, or even days after the onset of paraplegia. Death from myelomalacia may occur as a result of respiratory paralysis when the ascending lesion (abnormal damaged tissue) reaches the motor nuclei of the phrenic nerves (nerves between the C3-C5 region of the spine) in the cervical (neck) region” (


As such, it is imperative for there to be collaborative case management between the primary spine care expert and the neurosurgeon. The role of the primary spine care provider is an early diagnosis to be able to identify, treat and involve the neurosurgeon when clinically indicated because if left undiagnosed and untreated, myelomalacia can become a seriously debilitating and/or life-threatening injury. Those injuries are from and trauma the spinal cord is exposed to (auto accidents, sports injuries, falls, etc.).   Currently, there is a growing body of chiropractors nationally that are primary spine care and trauma qualified and trained in the early detection (diagnosis) and management of this population of patients.




According to Zohrabian and Flanders, Chapter 37: Imaging of trauma of the spine from the Handbook of Clinical Neurology Part II, “MRI is the only available imaging modality that is able to clearly depict the internal architecture of the spine cord, and, as such, has a central role in depicting parenchymal changes resulting from injury” (pg. 760). Further, “It may be difficult to distinguish spinal cord white matter from gray matter, especially in the sagittal plane, due to the similar T1 and T2 relaxation characteristics. Many prior investigations have shown that MRI characteristics of (SCI) Spinal Cord Injury, including presence and extent of cord edema and hemorrhage, are concordant with neurologic impairment at the time of injury and predict recovery” (pg.760).

Zohrabian and Flanders also wrote, “The most common location of posttraumatic spinal cord hemorrhage is the central gray matter of the spinal cord at the point of mechanical impact. The lesion most often represents hemorrhagic necrosis; true hematomyelia is rarely encountered. The lesion appears as a discrete focus of hypointensity on T2-weighted and gradient echo images, developing rapidly after SCI” (pg.760).




In the above T2 weighted image, the superior (upper) yellow arrow is pointing to a disc herniation resulting in moderate to severe central canal stenosis and cord compression at the C4-C5 level. The inferior (lower) red arrow is pointing to a high signal (bright white spot) within the spinal cord that is just posterior (behind) the superior vertebral endplate of C6 and demonstrates myelomalacia.



The image above is a graphic representation of a spinal cord injury. The hemorrhage in red is the epicenter of the injury. It is surrounded by yellow edema and cord swelling outlined in black. 


Zohrabian and Flanders (2016) stated, “Moreover, the location of cord hemorrhage has been shown to closely correspond to the neurologic level of injury, with frank hemorrhage correlation with poor neurologic recovery” (p. 760).


Zohrabian and Flanders (2016) further added, “Although several MRI classification schemes have been proposed, there are three common imaging observations: spinal cord hemorrhage, spinal cord edema, and spinal cord swelling. Each of these characteristics can be further described by their rostra-caudal (top to bottom) location in the cord and the amount of cord parenchyma they involve” (p. 760).


“Spinal cord edema, colloquially referred to as a cord contusion, can occur with or without hemorrhage. Edema involves a length of the spinal cord above and below the level of injury, with the length of the spinal cord show to be proportional to the degree of initial neurologic deficit. Spinal cord hemorrhage always coexists with spinal cord edema. Cord edema alone usually confers a more favorable prognosis that cord hemorrhage” (pg. 761). 



According to D.J. Seidenwurm MD (for the Expert Panel on Neurologic Imaging), “In traumatic myelopathy, the first priority is mechanical stability. Plain radiographs are sometimes useful for this purpose, but CT is more useful when a high probability of bony injury or ligamentous injury is present. In many centers, routine multidetector CT with sagittal and coronal reconstructions has replaced plain radiographs, especially in the setting of multiple trauma” (pg. 1032). 


Concerning CT, Foster and Wilborn (2019) reported, “Myelography uses a contrast medium injected into the spine to reveal injuries in x-rays. It is more invasive than an MRI, but can also detect injury in some cases in which MRI cannot. Therefore, myelography is typically used as a follow up to MRI when the latter fails to identify the source of pain or injury.” (para. 4)Finally, Zohrabian and Flanders reported, “Unlike in spinal cord cysts, myelomalacia will not parallel CSF (cerebral spinal fluid) signal intensity and its margins will usually be irregular and ill-defined (Falcone et al., 1994). The cord may be normal in size, although it is frequently atrophic at the site of myelomalacia (Fig. 37.24).” (pg. 763)


Zhou, Kim and Vo (2015) further explain, “Myelomalacia is a radiographical finding on magnetic resonance imaging (MRI) manifested by an ill-defined area of cord signal change, visible on T1- and T2-weighted sequences as hypo- and hyperintense areas, respectively. It is commonly associated with focal cord atrophy. It occurs as a sequel to spinal cord injury (SCI) due to different causes such as cord compression, ischemia, and hemorrhage. It is the most common finding in patients with previous spinal cord injury with a prevalence of 55% among patients with SCI” (p. E248).




Due to the seriousness and progressive nature of myelomalacia, it is important for the Primary Spine Care Provider, to recognize the signs and symptoms associated with myelomalacia and to identify the lesion on MRI and if identified, immediately refer the patient for a neurosurgical consultation. This also underscores why physical therapists, although licensed to treat spine, should never be the first provider to manage a spine case as diagnosing these and other conditions are not within their scope.


Foster and Wilborn (2019, para. 5) also reported, “Unfortunately, neurological damage due to myelomalacia is permanent. It can also worsen, as the nerve damage can cause affected muscles to whither. Treatment is focused on preventing further damage. Possible treatments include spinal cord surgery and medication with steroids, which serves to relax spastic muscles, reduce pain, and reduce swelling of the spinal cord.” Foster and Wilborn (2019, para. 6) also suggested, “Stem cell therapy may be used to repair neurological damage caused by myelomalacia in the future, but the therapy is currently experimental and controversial. Recent technology suggests that adult stem cells, which can be harvested from the patient's own body, show promise in treating neurological damage by allowing new, healthy tissue to grow”(


Zhou, Kim, Vo and Riew (2015) reported, “The presence of myelomalacia in the cervical spinal cord has prognostic value after decompression surgery. Some surgeons consider operative treatment of all patients with myelomalacia based on the assumption that myelomalacia is a relatively uncommon finding.” (p. E248) The authors also reported, “Many patients with myelomalacia are clinically asymptomatic or have only mild myelopathic symptoms and signs. The extent of intramedullary changes on MRI does not always correlate with clinical symptoms. Hence, for patients with asymptomatic or mild myelopathy with myelomalacia on MRI, the appropriate management remains controversial” (p. E249).


Zhou et al (2015) further added, “Several articles have suggested that conservative management is not an unreasonable option for patients with myelomalacia and mild myelopathy. It has been reported that the condition of 56% of patients with mild CSM (cervical spine myelomalacia) had not deteriorated or required surgery after 10 years. However, 2 of 45 (4.4%) patients who were treated nonoperatively with T2 hyperintensities experienced catastrophic neurological deficits with trivial trauma. Early-stage myelomalacia may be reversible, depending on the severity of the initial SCI (spinal cord injury), and may be reversed after decompression surgery” (p. E249).

This is not suggesting surgery for myelomalacia is always required. According to Dr. Mark Kotter (n.d., para. 3) in a website article titled “Myelomalacia” from,“The presence or absence of myelomalacia should not be used to define when surgery should occur.” Although he further stated, “its presence and extent may be related to prognosis” ( Myelomalacia, like any spinal related injury never uses imaging findings exclusively as an arbiter for surgery. That decision is reserved for combining a clinical examination with imaging findings and the surgeon decides if surgery will benefit the patient. It is the role of the primary spine care provider to ensure and early diagnosis and referral to try to develop treatment protocols to surgically decompress the spinal cord to help reverse this pathology and often can be done if damage has been minimized.


Surgery for Myelomalacia


A patient with myelomalacia may require surgery to decompress the spinal cord. Different techniques are used depending on the pathology that may or may not include spinal fusion. Many patients are treated with an anterior approach. The offending material is removed and the spine is reconstructed either with a fusion or an artificial disc replacement. Some patients, especially with multilevel pathology, require posterior decompression with or without fusion.





The primary goal of surgery for myelomalacia is to decompress the spinal cord. Secondary goals include maintaining spinal structural integrity, alignment, and biomechanical function.

The image on the left is courtesy of Jed Weber MD, Neurosurgeon. You can see the severe spinal cord compression creating an hour glass affect secondary to a disc extrusion. Myelomalacia is also present as a white spot in the spinal cord at the compression site.


Biomechanical Management


Concerning surgically balancing the spine, sagittal (front to back) balance is associated with better post-surgical outcomes. reported on lectures by Serena Hu, MD, Jean Charles LeHuec, MD, PhD and J.N. Alastair Gibson, MD, FRCS(Ed), FRCS (Tr &Orth), MFSTEd related to outcomes of lumbar spine surgery about sagittal balance. According to Dr. Hu (2016, para 3), “Surgical outcomes for spine surgery are improved when spinal, pelvic and hip alignment is considered in both degenerate and deformity cases, and how we better understand these will help us better improve outcomes for our patients” (


Dr. Hu (2016) further reported, “Sagittal imbalance in a patient can negatively affect the outcomes of a surgical procedure. But, how extensive the surgery required is to correct the imbalance must be carefully considered for the individual patient” (para. 4). Dr. LeHuec (2016) added, “Sagittal balance is an active phenomenon for patients. “The best course of action is to strive to achieve sagittal balance in patients” (para. 8).


In a study by Tang, Scheer, Smith, Deviren, Bess, Hart, Lafage, Shaffrey, Schwab and Ames (2015), the authors concluded, “Our findings demonstrate that, similar to the thoracolumbar spine, the severity of disability increase with positive sagittal malalignment following surgical reconstruction” (p. S21).


In an article by Yeh, Lee, Chen, Yu, Liu, Peng, Wang, and Wu, (2018) they concluded, “The results of this study support previous findings that functional outcomes are closely associated with sagittal radiographic parameters in the patients with the degenerative thoracolumbar spinal disease who received long-segment fusion. The achievement of global and regional sagittal alignment balance is a crucial factor for improved postoperative functional outcomes” (p. 1361).


The primary care spine provider and the neurosurgeon can work together to best achieve spinal alignment and balance. If the patient has been cleared for mechanical treatment, the primary care spine provider can work to balance the spine (front to back and side to side) before any necessary surgical intervention. The neurosurgeon can work to maintain and improve spinal alignment with surgery. Post-operatively, ongoing chiropractic spinal adjustments can help maintain and continue to improve spinal alignment. This can lead to the best possible surgical outcomes.


Patients with myelomalacia present an ideal opportunity to further the relationship between the Doctor of Chiropractic as the primary care spine provider and the neurosurgeon. The finding of myelomalacia requires surgical consultation. If the chiropractor identifies myelomalacia, he or she can then refer to the neurosurgeon and begin the discussion necessary for further co-management. The chiropractor can ask if surgery is necessary. If so, the Doctor of Chiropractic can ask if mechanical treatment can be done pre-operatively or ask if it should wait until after surgery. If the patient needs close monitoring over time, the astute chiropractor can regularly check on and provide education to the patient under the direction of the neurosurgeon.


In patients with myelomalacia, the ability of the Doctor of Chiropractic to monitor symptoms, prepare a patient for surgery, and manage the spine mechanically after surgery are advantageous to the surgeon, who can spend more of their time performing surgery and also enjoy greater patient satisfaction and outcomes.




Myelomalacia represents a softening of the spinal cord that commonly results from trauma. If myelomalacia is observed on imaging, the advanced trained Doctor of Chiropractic in the capacity of a primary spine care provider, should refer the patient out for a neurosurgical consultation. In the event surgery is not indicated, the chiropractor can create a treatment plan with the surgeon to help axially balance and stabilized the spine, thereby reducing the compressive forces on the spinal cord and maintaining spinal mechanics. If surgery is required, the chiropractor can coordinate conservative care with the surgeon to help biomechanically balance and then manage the patient’s spine to promote a better long term post-surgical outcome. Whether surgical or not, the chiropractor can play an integral role in the patient’s car and should the chiropractor have additional training in MRI Spine Interpretation, Spinal Biomechanical Engineering and/or other advanced spinal knowledge, it provides the basis for better collaboration.




  1. Zhou Yihua, MD, PhD, Kim D. Sang, MD, Vo Katie, MD, and Riew K. Daniel, MD.
  2. Lu D, Lamb CR, Targett MP. Results of Myelography in Seven Dogs with Myelomalacia. (2002). Veterinary Radiology and Ultrasound, 43(4), 326-330.
  3. Platt R. Simon, McConnel J. Fraser, Bestbier Mark. (2006). Magnetic Resonance Imaging Characteristics of Ascending Hemorrhagic Myelomalacia in a Dog. Veterinary Radiology and Ultrasound. 47(1), 78-82.
  4. Foster Niki and Wilborn C. (Ed.). (2019, March 12). What is Myelomalacia? Retrieved from
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  7. Seidenwurm D.J., MD (for the Expert Panel on Neurologic Imaging). (2008). Myelopathy- ACR Appropriateness Criteria. .
  8. Shields Christopher B., Shand Ping Yi and Shields Lisa B.E. (2012). Chapter 22: Post-traumatic syringomyelia: CSF hydrodynamic changes following spinal cord injury are the driving force in the development of PTSM. Handbook of Clinical Neurology, 109, 355-367.
  9. Al-Shatoury Hassan Ahmad Hassan, MD, PhD, MHPE, Galhom Ali Ayman, MD, PhD, Benbadis, R. Selim (Ed.). (2017, Nov 10). Syringomyelia. Retrieved from
  10. Roser Florian, Ebner Florian H, Sixt Carolin, Müller Jennifer v. Hagen and Tatagiba Marcos S. (2010). Defining the line between hydromyelia and syringomyelia. A differentiation is possible based upon electrophysiological and magnetic resonance imaging studies. Acta Neurochirugica, 152, 213-219.
  11. María José García Antelo, Teresa Lema Facal, Tamara Pablos Sánchez, María Soledad López, Facal and Eduardo, Rubio Nazabal Man-In-The-Barrel. (2013). A Case of Cervical Spinal Cord Infarction and Review of the Literature. The Open Neurology Journal, 7, 7-10.
  12. “Myelomalacia” (n.d.). Retrieved from
  13. Kenzo Uchida MD, PhD Hideaki Nakajima MD, PhD Naoto Takeura MD, Takafumi Yayama MD, PhD Alexander, Rodriguez Guerrero MD, Ai Yoshida MD, Takumi Sakamoto MD, Kazuya Honjoh MD, Hisatoshi Baba MD, PhD. (2014). Prognostic value of changes in spinal cord signal intensity on magnetic resonance imaging in patients with cervical compressive myelopathy. The Spine Journal, 14(8), 1601-1610.
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  16. Serena S. Hu, MD, Jean Charles LeHuec, MD, PhD and J.N. Alastair Gibson, MD, FRCS(Ed), FRCS(Tr &Orth), MFSTEd. (2016 Jan/Feb). “Proper sagittal balance may correlate with better surgical outcomes.” Retrieved from
  17. Jessica A. Tang, BS Justin K. Scheer, BS, Justin S. Smith, MD, PhD, Vedat Deviren, MD, Shay Bess, MD, Robert A. Hart, MD, Virginie Lafage, PhD Christopher I. Shaffrey, MD, Frank Schwab, MD and Christopher P. Ames, MD. (2015). The Impact of Standing Regional Cervical Sagittal Alignment on Outcomes in Posterior Cervical Fusion Surgery. Neurosurgery 76, S14-S21.
  18. Kuang-Ting Yeh, MD, PhD, Ru-Ping Lee, RN, PhD, Ing-Ho Chen, MD, Tzai-Chiu Yu, MD, Kuan-Lin Liu, MD, PhD, Cheng-Huan Peng, MD, Jen-Hung Wang, MD, and Wen-Tien Wu, MD, PhD. (2018). Correlation of Functional Outcomes and Sagittal Alignment After Long Instrumented Fusion for Degenerative Thoracolumbar Spinal Disease. Spine, 43(19), 1355-1362.
  19. Ammerman Joshua M. MD, (2019 February 6). “Adjacent Segmental Disease and Back Pain.” Retrieved from

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Published in Neck Problems

CASE REPORT: The chiropractic management of cervical Myelomalacia

By Timothy Weir, D.C., Mark Studin DC

Title:  The chiropractic management of cervical Myelomalacia

Abstract:  To examine the diagnosis and condition of a patient suffering from neck pain and radiation of pain into arms following a motor vehicle accident.   Diagnostic studies include the chiropractic orthopedic and neurological examination, digital x-rays, range of motion and cervical MRI.    

Keywords:  cervical spine pain, whiplash, myelomalacia, cervical disc degeneration, uncovertebral hypertrophy, spinal canal stenosis

Introduction:  On 10/10/2016, a 38-year-old male presented to our office for injuries he had sustained in an MVA on 10/01/2016.  The patient stated that he was stopped at an intersection when the pickup behind him hit him at a fast speed, pushing him through the intersection.  The patient stated that he had neck pain and stiffness the radiated into the trapezius area.  He also complained about “tingling” into both hands.  He also complained of lower back pain that he felt more than the neck.  His review of systems was benign, other than the current symptoms of neck and back pain and tingling.

The patients Social/Family Medical History included his mother having high blood pressure and Diabetes.

Clinical Findings:

The patient is 6’0”.   The patient weighs 211 pounds.   The sitting blood pressure measured was 122/74. 

An evaluation and management exam was performed.  The exam consisted of a visual inspection of the spinal ranges of motion, digital palpation, manual testing of muscles, deep tendon reflexes and orthopedic and neurological findings. The Cervical exam showed the following decreased motion on visual exam in flexion, extension, left rotation, right rotation, right lateral flexion and left lateral flexion.  All of the above motions produced pain.

When digital palpation was performed in the cervical and thoracic spinal areas, there was moderate spasm noted bilaterally in paraspinal areas with moderate tenderness noted.

In performing the cervical orthopedic and neurological testing, positive findings were present bilaterally with Foraminal Compression and Foraminal Decompression.  Soto Hall test was positive when performed in the thoracic spine area.  Manual, subjectively rated muscle testing was performed on certain muscles of the upper extremities.  Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero.  Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness. The Deltoids and Triceps tested normally bilaterally at 5. The Biceps, forearm muscles and the intrinsic hand muscles all tested as a four on the right and a three on the left. 

Grip Strength tests the strength of the hands which indicate nerve integrity from the cervical spine.  In evaluation, the normal would be for a difference of strength in the preferred hand of 10% more.  More than that would be a weakness in the opposite hand, less than that would be a weakness in the preferred hand.   The preferred hand for this patient is the right hand.  The testing below shows a definite decrease in strength in the left hand.

Hand tested

Rep one

Rep two

Rep three









Deep Tendon Reflexes were performed on the patient and were noted at a plus two bilaterally.

Using a Whartenburg pinwheel, dermatomes showed normal findings except for C8, which was hyposensitive on the left.

A Lumbar orthopedic and neurological exam was then performed.  Upon visual examination, there was decreased motion in flexion, extension. right and left lateral flexion with pain present on all of the motions.

Lasegue’s Straight Leg Raising test was performed and  was negative with 80 degree movement. Braggards test was performed and was negative bilaterally. 

Kemps was done with the patient on both sides and was noted as negative.  Ely test was noted as negative.

Digital palpation was performed and there was severe tenderness and spasm bilaterally in the lumbar paraspinal muscles. 

Manual, subjectively rated muscle testing was performed on certain muscles of the lower extremities.  Based on the AMA Guides to the Evaluation of Permanent Impairment, 4th Ed., 1993/5th ed. 2001, differences were noted using the rating scale of five to zero.  Five is full Range of Motion/Maximum Strength, Four is Full Range of motion with Moderate Resistance, Three is Full Range of Motion/Perceptible Weakness.    Muscle testing was done bilaterally in the Quadriceps, Hamstrings, Calf Muscles and Extensor Hallicus Longus and showed Full ROM and Strength.

Deep Tendon Reflexes were performed.  They negative in the Achilles bilaterally, but +3 in the Patella bilaterally.

Based on the ortho/neuro findings and the history, the following x-rays were ordered:

AP/Lat/Flex/Ext/Bilateral Oblique’s/ APOM of the cervical spine, AP/Lat Thoracic

AP/Lat/Lateral Flexion/Oblique Lumbar’s.  The x-rays were read and the Lumbar spine showed the discs were of a normal height and Georges line was un-interrupted.  There the Lumbar curve appeared to be hypolordotic.  On visual inspection, there was a decrease in the lateral bending bilaterally.

The Cervical spine showed that there was anterior spurring present in the C5/6 region of the cervical spine.  In the lateral view, the normal curvature of the spine was no longer lordotic, but noted as a “Military Neck.”  There was decreased range of motion noted in the flexion as well as the extension views.  Also, noted on flexion and extension was paradoxical motion present at C1.  Disc spaces were normal throughout the spine, except for narrowing of the disc space at C5/6, as well as spurring noted in the anterior part of the vertebral body.

Due to the injuries, orthopedic and neurological and x-ray findings, a cervical MRI was ordered.  I recommended that the patient receive palliative therapy until a Cervical MRI could be obtained.  

The MRI was obtained and personally reviewed.  The Cervical MRI performed on 10/14/2016 revealed that C1/2 was unremarkable.  There was a mild disc bulge at C2/3 and a moderate disc bulge which abuts the ventral cord and results in mild spinal canal stenosis at C3/4.  There is also bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing noted at C3/4. At C4/5, There is a mild disc bulge which abuts the ventral cord.  There is a mild spinal canal stenosis.  There is a bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing.  At C5/6, There is a moderate disc bulge which indents the ventral cord and results in severe spinal canal stenosis.  There is a resultant T2 weighted hyperintense (high) signal abnormality in the spinal cord at this level.  This may represent edema or myelomalacia. C6/7 shows that there is a mild disc bulge which abuts the ventral cord and results in mild spinal canal stenosis.  There is bilateral uncovertebral hypertrophy with moderate bilateral neural foraminal narrowing. C7/T1 presents as unremarkable.

IMPRESSION: At C5/6, there is a moderate disc bulge which indents the ventral cord and results in severe spine canal stenosis.  There is resultant abnormal signal in the spinal cord at C5/6, which may represent myelomalacia or edema.

An alert was placed on this study.  

Fig.1 (A)  Sagittal T2 MRI of Cervical Spine

         (B)   Axial T2 MRI of the Cervical Spine.



The patient was notified of the MRI findings.   The patient was informed that care would be discontinued until a consultation was done with a neurosurgeon.  The patient stated that he was going to do that.  He continued to try to get care, but we refused.  The patient was instructed to go to the emergency room.  The patient became angry stating that he wanted his records, that he was going to go to another chiropractor for them to “crack his neck”.   The patient went to another chiropractor and based on our records, also refused to see the patient.  The patient finally decided to go to the surgeon where disc surgery was performed to decompress the spinal cord. 


The patient contacted our office and thanked us for being so adamant about his treatment.  



There is much discussion in the MRI report concerning “bulges” and one must first have a handle on what is a bulge and herniation. 

General radiologists often utilize various nomenclature such as bulge, protrusion, prolapse, herniation and a myriad of other descriptors. However, the nomenclature has been standardized and accepted by the North American Spine Society, the American Spine Society of Radiology and the American Society of Radiology by Fardone, Williams, Dohring, Murtagh, Rothman and Sze (2014): 

 “Degeneration may include any or all of the following: desiccation, fibrosis, narrowing of the disc space, diffuse bulging of the annulusbeyond the disc space, fissuring (i.e. ., annular fissures), mucinous degeneration of the annulus, intradiscal gas, osteophytes of the vertebral apophyses, defects, inflammatory changes, and sclerosis of the endplates.” pg. 2528(1) 


“Bulging disc, bulge (noun [n]), bulge (verb [v]) (1) 

1. A disc in which the contour of the outer annulus extends, or appears to extend, in the horizontal (axial) plane beyond the edges of the disc space, usually greater than 25% (90°) of the circumference of the disc and usually less than 3 mm beyond the edges of the vertebral body apophysis. 

2. (Nonstandard) A disc in which the outer margin extends over a broad base beyond the edges of the disc space. 

3. (Nonstandard) Mild, diffuse, smooth displacement of disc. 

4. (Nonstandard) Any disc displacement at the discal level.


Note:Bulging is an observation of the contour of the outer disc and is not a specific diagnosis. Bulging has been variously ascribed to redundancy of the annulus, secondary to the loss of disc space height, ligamentous laxity, response to loading or angular motion, remodeling in response to adjacent pathology, unrecognized and atypical herniation, and illusion from volume averaging on CT axial images. Mild, symmetric, posterior disc bulging may be a normal finding at L5–S1. Bulging may or may not represent pathological change, physiological variant, or normalcy. Bulging is not a form of herniation; discs known to be herniated should be diagnosed as herniation or, when appropriate, as specific types of herniation.” Pg. 2537(1) 


Studin and Owens discuss this “nomenclature” in their article “Bulging Discs and Trauma: Causality and a Risk Factor”. 

“There is now, based upon the literature and well respected experts, categories of disc bulges that can be deemed as direct sequella from trauma vs. those cases where there is pre-existing degeneration.  It can also now be concluded, again based upon the literature that those patients can have an aggravation of the pre-existing condition that could persist a lifetime requiring perpetual care. To conclude these findings, a doctor trained in understanding the underlying pathology and sequella must be consulted to be able to render an accurate diagnosis that is demonstrable.”2 Pg. 26 

What is Myelomalacia?  According to the MedicoLexicon, it is simply the “softening of the spinal cord”.3  Basically, it is ischemia that takes place in the spinal cord from abnormal pressure placed upon it.  If left untreated, then that continues to spread and cause further damage to the cord.  Once the cord has been damaged, there is no repair.  gives us a concise definition and the ramifications of it left untreated: 

“The myelomalacia definition, strictly speaking is the “softening of the spinal cord”.  After an acute injury, bleeding of the spinal cord may occur.  As a result, there is “subsequent softening of normal tissues”.  Myelomalacia can be caused by trauma or disease, but if it worsens, and if the bleeding reaches the cervical region of the body, it can be fatal.  Bleeding can make the tissue necrotic.  Fractured vertebrae can lead to bleeding in the spinal cord, as can some back surgery.  Osteoporosis may also contribute to spinal instability and hemorrhaging.  Sometimes circulatory problems can lead to a deterioration of tissues and bleeding.  Myelomalacia can progress into impairment in the functioning of the lower extremities, below-normal or absent reflexes of the anus and pelvic limbs, loss of pain perception in the caudal region (near the coccyx), depression, respiratory problems due to “diaphragmatic paralysis”, and even neurological issues.  Death could result from the respiratory paralysis.  Damage occurs to the central nervous system.  At first, the spinal cord damage may be minor.  The most commonly injured areas are the lumbar spine (lower back) and cervical vertebrae (upper spine area). 

Disc degeneration, herniations (all variations) and bulging all describe what has happened to the disc itself.  Once you have established a definitive diagnosis, then the question becomes, how is the disc affecting surrounding neurological components?  Myelomalacia is the effect of that disc when the cord is affected by pressure.  If there is bleeding into the cord, then the cord begins a degenerative spiral that can happen rather quickly.  As you have read above, it can take what may simply appear as a minor issue to the patient that can lead to major neurological compromise and in extreme cases may lead to paralysis or death. Therefore, it is important carefully analyze the clinical indicators and image accordingly.      

Myelomalacia is a relatively rare occurrence.  According to Zhou, Kim, Vo and Riew, 

“The overall prevalence of cervical myelomalacia was relatively low in the studied population, and it was affected by age, sex, and the specialties/subspecialties of referring providers. These results may help direct treatment guidelines and allow for informed discussions with patients in terms of the risk versus the benefit of surgery.”Pg. E252

It is a very common occurrence for the presence of disc bulging and herniations in chiropractic practices.  It is of utmost importance for the chiropractor to not only order MRI when clinically indicated, it is important to be able to interpret those images as well.  Once the clinical indicators begin to show a different story than presented by the patient symptomatically, it is the responsibility of the chiropractor to make the appropriate diagnosis, prognosis and treatment plan.  In this case, that is an immediate neurosurgical referral.  Although not a common finding in a chiropractic office, one must still be alert to the possibility of Myelomalacia.   Managing the patient based upon an accurate diagnosis is your ultimate goal, and sometimes adjusting the patient isn’t the best first option as diagnosis and prognosis supersede treatment.


  1. Fardon, D. F., Williams, A. L., Dohring, E. J., Murtagh, F. R., Gabriel Rothman, S. L., & Sze, G. K.
  2. Studin M., Owens W. (2016) Bulging Discs and Trauma: Causality and a Risk Factor, American Chiropractor 34(6) 18, 20,22-24, 26, 28
  4. Carrelli, B (2016)  What is Myelomalacia?
  5. Zhou, Yihua; Kim, Sang D.; Vo, Katie; Riew, K. Daniel (2015) Prevalence of cervical myelomalacia in adult patients requiring a cervical magnetic resonance imagingSpine (Phila Pa 1976). 2015 Feb 15;40(4):E248-252. 


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