What are the most practical guidelines for treating cervical spondylotic myelopathy (CSM)?

Practical Guidelines for Treating Cervical Spondylotic Myelopathy (CSM)

The most practical guideline for treating CSM is to stratify treatment based on disease severity using the modified Japanese Orthopaedic Association (mJOA) scale, with mild CSM (mJOA >12) being treated with either surgical decompression or nonoperative therapy, while moderate to severe CSM (mJOA ≤12) should be treated with surgical decompression. 1

Treatment Algorithm Based on Disease Severity

• For mild CSM (mJOA scores >12):

  • Either surgical decompression or nonoperative therapy can be effective in the short term (up to 3 years) 2, 1
  • Nonoperative options include prolonged immobilization in a stiff cervical collar, "low-risk" activity modification, bed rest, anti-inflammatory medications, and physical therapy 2, 1, 3

• For moderate to severe CSM (mJOA scores ≤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
  • Early surgical intervention is crucial as delaying surgery can lead to irreversible spinal cord damage 1

Surgical Approach Selection

• Anterior approaches:

  • Anterior cervical discectomy and fusion (ACDF) is optimal for 1-2 level disease 1, 4
  • Anterior corpectomy is recommended for 3-segment disease 1, 4
  • Anterior approaches are ideal for patients with kyphosis or significant neck pain 4

• Posterior approaches:

  • Laminoplasty preserves motion and reduces axial neck pain 1, 4
  • Laminectomy with fusion prevents post-laminectomy kyphosis 1, 4
  • Posterior approaches are better suited for multilevel compression (≥3 levels) 4

Timing of Clinical Improvement

• Maximum clinical improvement typically occurs within 3 months after surgical decompression, regardless of baseline myelopathy severity 5
• Patients with mild myelopathy maintain higher overall functional scores compared to those with more advanced disease 5

Complications and Considerations

• 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
• Pseudarthrosis can occur in approximately 10.9% of cases after corpectomy 1, 3
• Inadequate stabilization during surgery can lead to cage movement and pseudarthrosis 1

Key Pitfalls to Avoid

• Delaying surgical intervention in moderate to severe myelopathy can lead to irreversible spinal cord damage 1, 6
• Failing to recognize CSM early - hallmark symptoms include decreased hand dexterity, gait instability, and sensory/motor dysfunction 6
• Neglecting to obtain MRI as the imaging modality of choice for suspected CSM (CT myelography is an alternative when MRI is contraindicated) 6
• Underestimating the importance of cervical alignment when selecting surgical approach 7

When to Refer to a Spine Surgeon

• Presence of progressive neurological deficits 3
• Failure to respond to conservative treatment after 3 months 3
• Signs of cervical myelopathy (difficulty with fine motor skills, gait disturbances) 3
• Evidence of significant spinal cord compression on imaging 3, 6
• Any patient suspected of having CSM should be promptly referred to avoid long-term disability 6