What is the treatment for cervical compression myelopathy?

Treatment of Cervical Compression Myelopathy

Surgical decompression is strongly recommended for moderate to severe cervical compression myelopathy (mJOA score ≤12), with benefits maintained for 5-15 years postoperatively. 1

Treatment Algorithm Based on Disease Severity

Mild Myelopathy (mJOA score >12)

• Either surgical decompression or nonoperative therapy can be offered for the first 3 years after diagnosis. 2, 1
• Nonoperative options include:
  • Prolonged immobilization in a stiff cervical collar 2
  • "Low-risk" activity modification or bed rest 2
  • Anti-inflammatory medications 2
  • Physical therapy to strengthen neck muscles 1
• If nonoperative management is initially pursued, surgical intervention is recommended if neurological deterioration occurs, and suggested if the patient fails to improve. 3
• At 2-year follow-up, operative and nonoperative management yield similar results for mild-to-moderate disease 2

Moderate to Severe Myelopathy (mJOA score ≤12)

• Surgery is the definitive treatment and should not be delayed. 1, 3
• Nonoperative treatment has inferior outcomes compared to surgery in this population 4
• Patients with severe disability (mean mJOA score 9.5) show significant improvement after surgical intervention, with scores improving to 10.9 at 2 years 2
• Delaying surgical intervention can lead to irreversible spinal cord damage, as long periods of severe stenosis result in potentially irreversible neurological injury. 1

Surgical Approach Selection

The choice of surgical approach depends on the number of compressed levels and location of pathology:

Anterior Approaches

• Anterior cervical discectomy and fusion (ACDF) is effective for 1-2 level disease 1
• Anterior corpectomy is recommended for 3-segment disease 1
• Subtotal corpectomy with reconstruction improves neurological scores from an average of 7.9 preoperatively to 13.4 at 15-year follow-up 1
• The anterior approach has the advantage of directly removing intervertebral disks, osteophytes, and ossification of the posterior longitudinal ligament that compress the spinal cord 5

Posterior Approaches

• Laminoplasty preserves motion and reduces axial neck pain 1
• Laminectomy with fusion prevents post-laminectomy kyphosis 1
• The posterior approach is mainly used for multisegment spinal cord compression in patients with cervical lordosis 5

Critical Pitfalls to Avoid

Timing of Intervention

• Do not routinely prescribe nonoperative treatment as the primary modality for moderate to severe myelopathy, as it is a typically progressive disorder. 4
• Spontaneous clinical improvement is rare, and surgery is the main treatment to prevent further neurological deterioration 6

Surgical Complications

• Post-surgical kyphosis occurs in approximately 10% of patients after laminoplasty 1
• C5 nerve palsy can develop after surgery, especially when laminae are elevated to an angle >60° 1
• Pseudarthrosis occurs in approximately 10.9% of cases after corpectomy 1, 7
• Inadequate stabilization during surgery can lead to cage movement and pseudarthrosis 1, 7
• Complications of laminectomy with fusion may include neurological deterioration, deep infection, and pseudarthrosis 1

Management of Pseudarthrosis

• Anterior revision with plate stabilization achieves 83.3% good/excellent outcomes 7
• Posterior approach revision has a 94% fusion rate compared to 45% with anterior revision 7

Asymptomatic Cord Compression

• Prophylactic surgery is not recommended for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. 3
• These patients should be counseled about potential risks of progression and educated about relevant signs and symptoms of myelopathy 3
• Non-myelopathic patients with cord compression and clinical evidence of radiculopathy are at higher risk of developing myelopathy and should be offered either surgical intervention or nonoperative treatment with close serial follow-up 3