What is the initial treatment for cervical myopathy?

Initial Treatment for Cervical Myelopathy

For patients with moderate to severe cervical myelopathy, surgical decompression is recommended as the primary treatment, while patients with mild myelopathy (mJOA score >12) may be offered either surgical intervention or a supervised trial of structured rehabilitation with close monitoring for neurological deterioration. 1

Treatment Algorithm Based on Disease Severity

Severe Myelopathy (mJOA score <12)

• Surgical decompression is strongly recommended as patients with severe cervical spondylotic myelopathy (CSM) demonstrate statistically significant improvement in mJOA scores beginning at 6 months and continuing through 24 months postoperatively. 2
• Anterior surgical approaches (anterior cervical discectomy and fusion or corpectomy) are preferred for 1-3 level disease. 3
• Posterior approaches (laminectomy with fusion or laminoplasty) are better suited for multilevel disease involving ≥4 segments. 3
• 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). 3

Moderate Myelopathy

• Surgical intervention is recommended for patients with moderate DCM to prevent further neurological deterioration and optimize functional outcomes. 1
• Surgical decompression provides significant improvement in neurological function that can be maintained for at least 5 years and up to 15 years postoperatively. 4

Mild Myelopathy (mJOA score >12)

• Either surgical intervention OR a supervised trial of structured rehabilitation may be offered. 1
• Class II evidence suggests equivalency between surgery and nonoperative management over 3 years for mild CSM, though this evidence has limitations including nonblinded allocation and selection bias. 2
• If nonoperative management is initially pursued, surgical intervention is recommended if neurological deterioration occurs, and suggested if the patient fails to improve. 1
• Nonoperative therapy in the acute phase has success rates averaging 90% for cervical radiculopathy, though the natural history of mild myelopathy is less predictable. 2

Nonoperative Management Components (When Appropriate)

For mild myelopathy or initial conservative trial:

• Structured rehabilitation with close serial follow-up is the cornerstone of nonoperative management. 1
• Physical therapy focusing on neck stabilization and range of motion exercises. 2
• Anti-inflammatory medications for symptomatic relief of associated neck pain. 5
• Duration should be limited to 3 months maximum before reassessing for surgical candidacy if symptoms persist or worsen. 5

Critical Monitoring Parameters

• Serial neurological examinations to detect any progression of myelopathy. 3
• Assessment for development of progressive neurological deficits, which mandates surgical referral. 3
• Evaluation of activities of daily living limitations. 4

Important Caveats and Pitfalls

Common pitfall: Delaying surgical intervention in patients with progressive neurological symptoms or moderate-to-severe myelopathy. The natural history shows that approximately 70% of patients with mild CSM maintain clinical status over 3 years with nonoperative treatment, but this leaves 30% who deteriorate. 5

Timing consideration: While there is insufficient evidence to make firm recommendations regarding optimal surgical timing, younger patients and those with shorter symptom duration typically have better outcomes. 3

Avoid: Relying solely on imaging findings without clinical correlation, as spondylotic changes are commonly identified in patients >30 years of age and correlate poorly with symptoms. 3

Special consideration: Patients with cervical stenosis and clinical radiculopathy (without myelopathy) require closer monitoring as they are at higher risk for developing symptomatic CSM. 3

Prognostic Factors Affecting Treatment Decisions

• Younger age correlates with better surgical outcomes. 5, 3
• Shorter duration of symptoms predicts better response to treatment. 3
• Better preoperative neurological function is associated with superior postoperative outcomes. 3
• Preoperative somatosensory-evoked potentials may provide valuable prognostic information when clinical factors are unclear. 3

Note on muscle relaxants: Cyclobenzaprine is indicated only as an adjunct for acute, painful musculoskeletal conditions for short periods (2-3 weeks) and has not been found effective for spasticity associated with spinal cord disease. 6 It has no role in treating cervical myelopathy itself.