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Massage Today
December, 2008, Vol. 08, Issue 12

The Progression of Cervical Stenosis Toward Cervical Spondylotic Myelopathy (CSM), Part 4

By Dale G. Alexander, LMT, MA, PhD

There is an assumption that the progression of CSM emerges in males more often than females, according to my Google searches of the literature.1 My own clinical experience with clients since beginning to recognize and research this progression eight years ago is fairly 50/50 in terms of gender occurrence.

Richard MacDonald, DO, explains an osteopathic distillation in his functional anatomy courses suggesting that, based on his profession's cadaver studies, males have a tendency toward lower back weakness because the iliolumbar ligament generally does not extend to L4 as it does more typically in women. The inferred evolutionary implication of this anatomic difference is that this extended stabilization represents a pragmatic genetic selection providing women with more low back, pelvic stability for birthing a child. Correspondingly, the first rib and sometimes the second rib of most women tend to be less stable in their unifacet mooring to the T1 and T2 spinal vertebrae.2

These anatomical gender-specific differences have been cited as a possible explanation as to why males experience more low back pain and dysfunction, while females tend to experience more craniofacial, neck and upper extremity pain and dysfunction. A further inference based on personal speculation is that these gender differences have functioned in our human evolution as sexual stimuli - the quality of power that is reflected in the strut of a male as he walks and the elevated positioning of the breasts in females. Nature is relentless in its drive for the genders to notice each other and to reproduce. In my opinion, both of these anatomic tendencies can feed into the eventual expression of CSM.3

The principle assertion in the orthopedic literature is that men have larger cervical vertebral bodies relative to the space for the spinal canal (canal/body ratio) that may encroach upon the circumference of the spinal canal more easily than for females; thus they have a greater tendency to exhibit the more acute symptoms of CSM. In numerous Google searches, I was unable to verify with recent studies that this gender difference in etiology is generally accepted. My speculation is that CSM is simply less often diagnosed in females because it is more often diagnosed in its acute expression in males. The orthopedic notion that a congenitally smaller spinal canal in either gender is highly correlated to the expression of CSM was verified.

Let's now add to the theories about how and why CSM begins and progresses, beginning with the obvious - the carriage of the head. Wherever the head goes, the rest of the body must follow.4 There exists within human neurology an exquisitely fine-tuned sense of tracking where the head is in relationship to the field of gravity. The subcortical flexor/extensor relationships are intimately linked to two of nature's most crucial imperatives - "don't fall" and "live long enough to reproduce." The writings of Thomas Hanna are one of the few places where you will find a comprehensive description of these righting reflexes.5 With gratitude, I had the opportunity to study and receive many treatments from him shortly before his too-youthful passing.

What I have found to be missing in the orthopedic theories of CSM are four principles of anatomy and physiology that have evolved from my trainings and my clinical experience with clients:

  1. The flexors dominate the extensors in how the righting reflexes protect us in "almost" or actual falling episodes.6 When one adds the echoing effects of actual and accumulated head, neck or impact traumas, this influence ratchets the tension between the flexors and extensors more exquisitely.
  2. The viscera are slung forward as well as down from the axial skeleton. As a result, their suspensory ligaments can transmit tensions directly to their osseous moorings, further adding to the sum total flexor and extensor tension.7
  3. Neurologically, the autonomic nervous system discharges the tensions of the viscera into the musculoskeletal system via viscerosomatic reflexes, adding a compounding stream of neurological tension to the central nervous system. This eventually disrupts the neurovascular delivery of nutritious and oxygenated blood, and impedes venous and lymphatic return to the heart.
  4. The difference in the pressure relationships between the body's great cavities (the cranium, thorax and abdominal/pelvic) is in "how" the efficiency of the low pressure venous and lymphatic systems is normally maintained.8

Based on my clinical experience, what is totally neglected is the capacity of the esophagus to pull the head down onto the neck and thus add direct compression to the cervical discs. The fascial mooring of the esophagus, the pharyngeal raphe, attaches to the basilar portion of the occipital bone just posterior to the sphenobasilar junction.9 The influence of a shortened esophagus is completely overlooked in most whiplash/impact injuries and as an influence in progressive anterior kyphosis of the spine. Additional soft-tissue structures that I find to be locked in a state of contracture or spasm include the CSMs, the longus colli muscles and the scalenes. Diaphragmatic and iliopsoas contracture or spasm adds strain to the extensor musculature.

The most commonly spoken somatoemotional statements of my clients over the years mirror this strain pattern. These include that someone or some situation is a prevailing "pain in the neck," that they feel an overwhelming sense of pressure within their body, or that they feel "all twisted up inside." Trace the pattern down and forward from the neck ... pressure strains the cervical vertebrae given its build-up within the thoracic and abdominal/pelvic cavities. The gut tube is suspended directly from the craniocervical junction. Both of these influences are speculated to directly contribute to the how and why cervical stenosis can progress toward spinal cord compression and CSM symptomatic expressions. I am admittedly postulating an interface between anatomy, physiology and consciousness, so please do consider these as theories.

In part 2 of this article series, I encouraged you to release the tension and lengthen the fascia of any muscular structures that have attachments to the back and the front of the body, to ease the tensions of these myofascial elements. The sternocleidomastoid muscle is a clear example of this.

Massage therapists who desire to become more comprehensive in their work with clients need to seek out training in how to therapeutically work with the visceral suspension of organs and also explore how consciousness can participate in escalating the tensions of visceral organs themselves, thus adding a significant strain to the musculoskeletal system. The educational resources that provided me with such training gave me dynamic insights, leading to my most significant leaps in comprehension of how the dance between psyche and soma expresses itself. (Contact me for information on educational resources.)

My intention has been to draw open the curtain of CSM neurological progression, which is highly correlated to diminishing the quality of life during the aging process and is often not considered, diagnosed or treated until it reaches an acute expression. Many clients will end up on your doorstep in the early and moderate phases of the progression.

In conclusion, the possibility that CSM may underlie many of the chronic somatic complaints of our clients ages 50 and older is what we want to anchor in our awareness. Do remember to inquire as to whether the client has or is currently experiencing any difficulty with urination, ranging from urgency to difficulty initiating a stream. Share with them that it is your understanding that an inability to interrupt the urinary stream is one possible clinical indication that warrants a visit to their physician.

The somatic complaints of CSM tend to come and go, sometimes being expressed in upper extremity problems and then switching to lower extremity difficulties commonly expressed as sciatic pain or the internal feeling of heaviness in the thigh or leg. Often they will bounce back and forth between the upper and lower extremities. As noted in earlier articles, when the complaints involve the same-sided upper and lower extremity, there is a high probability that the CSM progression is expressing itself. Another significant caveat is that in a study that followed patients who had undergone surgery for CSM, the degree and longevity of a successful outcome was based on the symptom profile being discovered earlier than later in its progression.10

Our job is to enhance both the functional capacity and coordinated mobility of our clients. This translates into quality of life. Allow your perception to become a therapeutic modality. Sense, feel and touch from the "inside-out." When I teach classes, I often draw upon an agrarian analogy that emerged early in my career - we plow the field, plant the seeds, weed the field and sometimes are there to assist in the reaping of a harvest of healing. May this continuum reflect your daily opportunity with clients.


  1. Hukuda S, Kojima Y. Sex discrepancy in the canal/body ratio of the cervical spine implicating the prevalence of cervical myelopathy in men. Spine, Feb. 1, 2002;27(3):250-3.
  2. Functional Anatomy Courses. Dr. Richard MacDonald, Upledger Institute Education, April and June 1989, Denver and Los Angeles.  
  3. Durrant DH, True JM. Myelopathy, Radiculopathy and Peripheral Entrapment Syndromes. CRC Press LLC, 2002.
  4. Alexander DG. "Survival vs. Quality of Life." Part 1: Massage Today, November 2005;5(11); Part 2: Massage Today, December 2005;5(12).
  5. Hanna T. Somatics. Addison-Wesley Publishing, 1988.
  6. Barral JP. Visceral Manipulation Courses (course notes), 1987-1993.
  7. Alexander DG. "Healing From the Core." Part 1: Massage Today, September 2004;4(9); Part 2: Massage Today, October 2004;4(10).
  8. Alexander DG. "Equalizing the Pressure." Massage Today, March 2005;5(3).
  9. Netter FH. Atlas of Human Anatomy, 4th ed. Plates 63, 65, 67 (via pharyngeal raphe). Saunders/Elsevier, 2006.
  10. Emery SE, Bohlman HH, Bolesta MJ, Jones PK. Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up, Cleveland. Journal of Bone and Joint Surgery 1998;80:941-51.

Click here for more information about Dale G. Alexander, LMT, MA, PhD.


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