Treatment for Compressive Cervical Myelopathy
Surgical decompression is strongly recommended for moderate to severe cervical myelopathy (mJOA score ≤12), with benefits maintained for at least 5-15 years postoperatively. 1
Treatment Algorithm Based on Disease Severity
Mild Cervical Myelopathy
- Either surgical decompression or nonoperative therapy can be effective in the short term (up to 3 years) for patients with mild disease 1
- Nonoperative options include prolonged immobilization, activity modification, anti-inflammatory medications, and physical therapy to strengthen neck muscles 1
- However, close observation is critical as the natural history is variable, alternating between quiescent periods and stepwise decline or rapid neurological deterioration 2, 3
Moderate to Severe Cervical Myelopathy
- Surgical intervention is superior to conservative management and should be pursued without delay 1, 2
- Delaying surgery in moderate to severe cases leads to irreversible spinal cord damage 1
- Long periods of severe stenosis result in potentially irreversible damage to the spinal cord 1
Surgical Approach Selection
The choice of surgical technique depends on the number of levels involved, location of pathology, and baseline cervical sagittal alignment:
Anterior Approaches
- Anterior cervical discectomy and fusion (ACDF) is effective for 1-2 level disease with documented improvement rates of 70-80% 1, 4
- 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 is preferred as first-line when osteophytic spurs are more dominant anteriorly 5
Posterior Approaches
- Laminoplasty preserves motion and reduces axial neck pain 1
- Laminectomy with fusion prevents post-laminectomy kyphosis and is recommended for ≥4-segment disease 6, 1
- Laminectomy with lateral mass fusion resulted in neurological improvement in 97% of patients with mean JOA score improvement from 12.9 to 15.6 6
- Laminectomy and posterior fusion showed significantly greater rates of neurological recovery (average 2.0 Nurick grade improvement) compared to anterior approach (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 6
Critical Pitfalls to Avoid
Timing-Related Complications
- Do not delay surgical intervention in moderate to severe myelopathy as this leads to irreversible spinal cord damage 1
- Patients with symptoms present for less than one year before surgery show better results across all treatment modalities 6
Technical Complications
- Inadequate stabilization during surgery leads to cage movement and pseudarthrosis (occurring in approximately 10.9% of cases after corpectomy) 1, 7
- 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
- Laminectomy alone (without fusion) has a concerning trend of long-term late deterioration (29% rate) and should be avoided 6