What is the treatment for cervical spondylotic myelopathy (CSM)?

Treatment for Cervical Spondylotic Myelopathy

The treatment for cervical spondylotic myelopathy (CSM) should be determined by disease severity, with surgical decompression strongly recommended for moderate to severe cases (mJOA score ≤12) and either surgical or nonoperative therapy acceptable for mild cases (mJOA score >12). 1

Treatment Algorithm Based on Disease Severity

Mild CSM (mJOA score >12)

• Either surgical decompression or nonoperative therapy can be effective in the short term (up to 3 years) 2, 1
• Nonoperative therapy options include:
  • Prolonged immobilization in a stiff cervical collar 2
  • "Low-risk" activity modification or bed rest 2
  • Anti-inflammatory medications 2, 3
  • Physical therapy to strengthen neck muscles 3

Moderate to Severe CSM (mJOA score ≤12)

• Surgical decompression is strongly recommended 2, 1
• Benefits of surgery are maintained for at least 5 years and up to 15 years postoperatively 2, 1
• Patients with severe myelopathy (mean mJOA score of 9.5) show significant improvement after surgical intervention (mean mJOA score 10.9 at 2 years postoperatively) 2
• Delaying surgical intervention can lead to irreversible spinal cord damage 1, 4

Surgical Approach Selection

The choice of surgical approach depends on several factors:

Anterior Approaches

• Anterior cervical discectomy and fusion (ACDF) is effective for 1-2 level disease 1, 5
• Anterior corpectomy is recommended for 3-segment disease 1
• Subtotal corpectomy with reconstruction can improve neurological scores from an average of 7.9 preoperatively to 13.4 at 15-year follow-up 1

Posterior Approaches

• Laminoplasty preserves motion and reduces axial neck pain 1, 5
• Laminectomy with fusion prevents post-laminectomy kyphosis 1, 3
• Laminectomy alone has shown a concerning trend of long-term late deterioration 2

Complications and Considerations

Anterior Approach Complications

• Pseudarthrosis (nonunion) can occur in approximately 10.9% of cases after corpectomy 1, 6
• Insufficient plate fixation or stabilization can contribute to cage movement 6
• Excessive motion at operated segments increases risk of cage movement 6

Posterior Approach Complications

• Post-surgical kyphosis occurs in approximately 10% of patients after laminoplasty 1, 3
• C5 nerve palsy can develop after surgery, especially when laminae are elevated to an angle > 60° 1, 3
• Laminectomy without fusion has higher rates of late deterioration (29%) 2

Important Clinical Considerations

• The natural history of CSM is variable and unpredictable, with 20% to 62% of nonoperatively treated patients deteriorating at 3 to 6 years of follow-up 7
• For patients without myelopathy but with spondylotic cord compression, the rate of myelopathy development is approximately 8% at 1 year and 23% at 4 years 7
• Clinical and/or electrophysiological evidence of cervical radiculopathy predicts progression to myelopathy and should prompt consideration of surgical decompression 7
• Early recognition and treatment of CSM, before the onset of significant spinal cord damage, is essential for optimal outcomes 4
• The goal of surgery is to decompress the cord with expansion of the spinal canal, while restoring cervical lordosis and stabilizing when the risk of cervical kyphosis is high 4

Common Pitfalls to Avoid

• Delaying surgical intervention in patients with moderate to severe myelopathy 1, 8
• Using laminectomy alone without fusion, which can lead to post-laminectomy kyphosis and late neurological deterioration 2, 5
• Inadequate stabilization during surgery leading to cage movement and pseudarthrosis 6
• Overlooking the diagnosis of CSM as initial symptoms can be subtle 8