Cervical Myelopathy Does Not Present as Syncope
Cervical myelopathy involving C2-C3 and C4-5 does not cause syncope through direct neurological mechanisms, and syncope in a patient with cervical spondylosis should prompt evaluation for standard cardiac, vasovagal, or orthostatic causes rather than attributing it to the myelopathy itself.
Why Cervical Myelopathy Doesn't Cause Syncope
The hallmark symptoms of cervical spondylotic myelopathy (CSM) are decreased hand dexterity, gait instability, and sensory/motor dysfunction in the extremities 1. While CSM can present with atypical patterns—including rare cases without upper extremity symptoms where patients present with lower extremity weakness and sensory changes from the trunk down 2—syncope is not a recognized manifestation of cervical cord compression.
The autonomic centers that regulate blood pressure and consciousness are located in the brainstem (medulla), not in the cervical spinal cord at C2-C5 levels 3. Compression at these cervical levels affects descending motor tracts and ascending sensory pathways, but does not directly impair the cardiovascular control centers necessary to maintain consciousness.
The Hypertension Connection Is Not Syncope
There is an interesting association between CSM and hypertension (not hypotension/syncope). Studies show that 46.6% of CSM patients have concomitant hypertension, and remarkably, 73.6% of these patients experience normalization of blood pressure after decompression surgery 4, 5. This hypertension likely results from sympathetic nervous system hyperactivity due to cord compression 4, 5.
However, this association works in the opposite direction from syncope—CSM is associated with elevated blood pressure, not the hypotension required for syncope.
Evaluate for Standard Syncope Causes
When a patient with cervical spondylosis presents with syncope, the evaluation should follow standard syncope guidelines 3, 6:
High-risk cardiac features requiring immediate evaluation include 3, 6:
- Structural heart disease or heart failure
- Abnormal ECG findings (conduction abnormalities, arrhythmias)
- Syncope during exertion or while supine
- Family history of sudden cardiac death
- Age >60-65 years
Orthostatic hypotension is particularly common in elderly patients and should be assessed with blood pressure measurements supine and after 1 and 3 minutes of standing 3, 7, 6. This is especially relevant if the patient takes antihypertensives, diuretics, or other medications that can cause orthostatic changes 3, 7.
Carotid sinus hypersensitivity can cause syncope, particularly in elderly patients with neck turning as a trigger 3. However, this is a reflex originating from the carotid sinus baroreceptors, not from cervical cord compression 3.
Critical Pitfall to Avoid
Do not attribute syncope to cervical myelopathy and delay appropriate cardiac or autonomic evaluation 3, 6. The 23-50% of syncope cases diagnosed through initial history, physical examination with orthostatic vitals, and ECG alone require this standard workup 3, 6. Missing a cardiac cause of syncope carries significant mortality risk—patients with cardiac syncope have 18-33% one-year mortality versus 3-4% for noncardiac causes 6.
When Neurological Causes Are Relevant
True neurological causes of syncope are rare and typically involve 3:
- Severe bilateral carotid or basilar artery disease (with focal neurological symptoms)
- Autonomic failure from neurodegenerative disorders (Parkinson's disease)
- Seizures (with aura, postictal confusion, or focal signs)
- Increased intracranial pressure (subarachnoid hemorrhage, tumors)
None of these mechanisms are caused by cervical cord compression at C2-C5 levels 3.