What is the treatment for cervical compressive myelopathy?

Treatment for Cervical Compressive Myelopathy

For patients with cervical compressive myelopathy, treatment should be determined by disease severity, with surgical decompression recommended for moderate to severe cases (mJOA score ≤12) and either surgical intervention or a supervised trial of structured rehabilitation for mild cases (mJOA score >12). 1

Treatment Algorithm Based on Disease Severity

Mild Cervical Myelopathy (mJOA score >12)

• Either surgical decompression or nonoperative therapy can be effective in the short term (3 years) 2
• Nonoperative therapy options include:
  • Prolonged immobilization in a stiff cervical collar 2
  • "Low-risk" activity modification or bed rest 2
  • Anti-inflammatory medications 2
  • Physical therapy and exercises to strengthen neck muscles 3
• If nonoperative management is initially pursued, surgical intervention is recommended if neurological deterioration occurs 1
• Caution: Even with stable symptoms for 3 years, the long-term risk of deterioration beyond this timeframe remains unknown 2

Moderate to Severe Cervical Myelopathy (mJOA score ≤12)

• Surgical decompression is strongly recommended 2
• Benefits of surgery are maintained for at least 5 years and up to 15 years postoperatively 2
• Patients with severe myelopathy (average mJOA score 9.5) show significant improvement after surgical intervention 2
• Nonoperative treatment for moderate and severe myelopathy results in outcomes inferior to surgery and is not recommended 4

Surgical Approach Selection

Anterior Approaches

• Anterior cervical discectomy and fusion (ACDF) is effective for 1-2 level disease 3
• Anterior corpectomy is recommended for 3-segment disease 3
• Anterior approach is preferred as first-line when osteophytic spurs are more dominant anteriorly 5
• Subtotal corpectomy with reconstruction can improve JOA scores from an average of 7.9 preoperatively to 13.4 at 15-year follow-up 2

Posterior Approaches

• Laminoplasty preserves motion and reduces axial neck pain 3
• Laminectomy with fusion prevents post-laminectomy kyphosis 3
• Laminectomy and posterior fusion with plate fixation showed significantly greater rates of neurological recovery (average 2.0 Nurick grades improvement) compared to anterior approach (1.2 grades) and laminectomy alone (0.9 grades) 2
• Dorsolateral decompressive procedures using a unilateral approach can avoid postoperative deformity of the cervical spine while achieving 56% functional recovery 6

Complications and Considerations

• Post-surgical kyphosis occurs in approximately 10% of patients after laminoplasty 3
• C5 nerve palsy can develop after surgery, especially when laminae are elevated to an angle > 60° 3
• Pseudarthrosis (nonunion) can occur in approximately 10.9% of cases after corpectomy 7, 3
• Complications of laminectomy with fusion may include neurological deterioration, deep infection, and pseudarthrosis 2
• Failure of solid fusion between corpectomy cage and adjacent vertebral bodies can lead to persistent pain, neurological symptoms, and eventual hardware failure 7

Prognostic Factors for Surgical Outcomes

• Positive predictors for good surgical outcomes in cervical spondylotic myelopathy include:

  • Increased transverse area of the cord ≥60% 8
  • Single-level anterior fusion 8
  • High preoperative neurological score 8
  • Normal epidural spinal cord evoked potentials 8
  • Clinical features of brachialgia and cord type 8

• For patients with ossification of the posterior longitudinal ligament (OPLL), positive predictors include:

  • Mixed or localized OPLL 8
  • Normal epidural spinal cord evoked potentials 8
  • High preoperative neurological score 8
  • Single-vertebra spondylectomy with anterior fusion 8

Non-myelopathic Patients with Cord Compression

• For patients without myelopathy but with evidence of cord compression:
  • Without radiculopathy: Prophylactic surgery is not recommended; patients should be counseled about risks of progression, educated about symptoms of myelopathy, and followed clinically 1
  • With radiculopathy: These patients are at higher risk of developing myelopathy (approximately 8% at 1 year and 23% at 4 years) 4
  • Either surgical intervention or close follow-up with structured rehabilitation should be offered to patients with radiculopathy 1

Key Pitfalls to Avoid

• Delaying surgical intervention in patients with moderate to severe myelopathy can lead to irreversible spinal cord damage 3
• Long periods of severe stenosis can result in potentially irreversible damage to the spinal cord 3
• Failing to recognize the unpredictably progressive nature of cervical myelopathy when considering nonoperative management 4
• Inadequate stabilization during surgery can lead to cage movement and pseudarthrosis 7