What is the management for spondylosis myelopathy?

Management of Cervical Spondylotic Myelopathy

Surgical intervention is the recommended treatment for moderate to severe cervical spondylotic myelopathy (CSM) with progressive neurological deficits, while mild CSM may be managed either surgically or non-operatively depending on individual factors. 1, 2

Assessment and Diagnosis

• MRI is the preferred imaging method for evaluating suspected CSM due to its superior soft-tissue contrast and ability to detect spinal cord compression 1, 3
• Radiographic monitoring is generally not needed more often than once every 2 years, except in rapidly progressing cases 4
• Clinical assessment should include evaluation of:
  • Hand dexterity (decreased in 75% of patients) 5
  • Gait stability (affected in 80.3% of patients) 5
  • Upper extremity sensory function (affected in 82.9% of patients) 5
  • Muscle strength, particularly in hand intrinsic muscles (weakness in 56.6%) and triceps (weakness in 28.9%) 5

Prognostic Factors

• Age, duration of symptoms, and preoperative neurological function significantly affect surgical outcomes 6
• Younger patients and those with shorter symptom duration typically have better surgical outcomes 1
• Preoperative somatosensory-evoked potentials may provide valuable prognostic information in cases where clinical factors don't provide clear guidance 6

Treatment Algorithm

For Mild CSM (mJOA score >12):

• Either surgical decompression or non-operative management can be considered 1, 3
• Non-operative management includes:
  • Regular exercise and physical therapy 4
  • NSAIDs for pain and inflammation 4
  • Close monitoring for disease progression 1

For Moderate to Severe CSM (mJOA score ≤12):

• Surgical decompression is strongly recommended 3, 2
• Surgical approach options:
  • Anterior approach (ACDF or corpectomy): Preferred for 1-3 level disease 6
  • Posterior approach (laminectomy with fusion or laminoplasty): Better for multilevel disease (≥4 segments) 6
  • Combined approaches for complex cases 6

Surgical Outcomes

• Anterior surgical approaches show improvement rates of approximately 73-74% 6
• Laminectomy with posterior fusion demonstrates significantly greater neurological recovery (average 2.0 Nurick grade improvement) compared to anterior approach (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 6
• Individual muscle strength improvement occurs at rates of 80-90% after anterior cervical decompression 5
• Upper extremity functional improvement occurs in 75.4% of patients, while lower extremity improvement is seen in only 46.7% (likely due to persistent spasticity) 5

Post-Treatment Monitoring

• Regular follow-up is essential as disease progression varies significantly between patients 4
• Monitor for late deterioration, which occurs in approximately 29% of patients who undergo laminectomy alone 6
• Watch for recurrent symptomatic spondylosis at unoperated levels, which occurs at an incidence of approximately 2% per year 5

Common Pitfalls to Avoid

• Delaying referral to a spine surgeon for patients with suspected CSM, as early intervention before spinal cord damage is essential for optimal outcomes 1, 2
• Overreliance on imaging findings without correlation to clinical symptoms, as degenerative changes are common in asymptomatic individuals over 30 years of age 4, 1
• Failure to recognize that neurological symptoms may not correspond directly with the level of stenosis—myotomal involvement is often due to canal stenosis 1-4 levels above the lesion 7
• Neglecting to consider both pharmacological and non-pharmacological approaches in the management plan 4