What is the treatment for cervical myelitis?

Treatment for Cervical Myelitis

Critical Distinction: Inflammatory vs. Compressive Myelopathy

The treatment for cervical myelitis depends entirely on whether you are dealing with inflammatory myelitis (infectious or autoimmune) versus compressive cervical myelopathy—these require completely opposite management strategies and misdiagnosis can lead to irreversible disability.

Inflammatory Cervical Myelitis (Transverse Myelitis, Viral Myelitis)

For acute inflammatory cervical myelitis, immediate high-dose corticosteroids combined with antiviral therapy (if infectious etiology suspected) is the treatment of choice, with dramatic improvement typically seen within 5 days of initiation. 1

Immediate Medical Management

• Administer parenteral acyclovir for suspected varicella zoster virus myelitis, particularly if vesicular rash preceded neurological symptoms by weeks to months 1
• Start high-dose intravenous corticosteroids immediately upon diagnosis confirmation, as delay in treatment correlates with permanent disability 1, 2
• Provide ventilatory support if respiratory muscles affected, as transverse myelitis can rapidly progress to involve higher cervical segments requiring mechanical ventilation 2

Diagnostic Confirmation Required

• Obtain CSF analysis to confirm inflammatory myelitis showing elevated protein, pleocytosis, and potentially oligoclonal bands 2
• MRI will show T2 hyperintensities spanning multiple cervical cord levels without significant canal stenosis 2
• Rule out compressive myelopathy before initiating immunosuppression, as misdiagnosis leads to delayed surgical intervention and irreversible neurological disability 3

Key Pitfall to Avoid

• Do not mistake cervical spondylotic myelopathy for inflammatory myelitis—intramedullary cord enhancement can occur with compressive myelopathy and may persist for years even after decompressive surgery, leading to inappropriate immunosuppressive treatment 3
• Lack of new lesion formation over time and absence of intrathecal antibody production argue against primary demyelinating disorder and should prompt reconsideration of compressive etiology 3

---

Compressive Cervical Myelopathy (Degenerative/Spondylotic)

For moderate to severe cervical compressive myelopathy (mJOA score ≤12), surgical decompression is strongly recommended with benefits maintained for 5-15 years postoperatively. 4

Treatment Algorithm Based on Severity

Mild Myelopathy (mJOA score >12):

• Either surgical decompression or nonoperative therapy can be effective for 3 years 4
• Nonoperative options include prolonged cervical immobilization, low-risk activity modification, anti-inflammatory medications, and physical therapy to strengthen neck muscles 4, 5
• Patients with symptoms <1 year show better results across all treatment modalities, so early intervention is preferred 4

Moderate to Severe Myelopathy (mJOA score ≤12):

• Surgical decompression is mandatory—delaying surgery leads to irreversible spinal cord damage 4
• Benefits are maintained for minimum 5 years and up to 15 years postoperatively 6, 4
• Patients with severe myelopathy show significant improvement after surgical intervention (mean mJOA improving from 9.5 to 10.9 at 2 years) 6

Surgical Approach Selection

Anterior Approach:

• Use anterior cervical discectomy and fusion (ACDF) for 1-2 level disease 4
• Use anterior corpectomy for 3-segment disease, which can improve neurological scores from average 7.9 preoperatively to 13.4 at 15-year follow-up 4
• Anterior approach shows 1.2 Nurick grade improvement on average 6

Posterior Approach:

• Use laminectomy with lateral mass fusion for ≥4-segment disease to prevent post-laminectomy kyphosis 4
• Laminectomy with fusion shows significantly superior neurological recovery (2.0 Nurick grade improvement) compared to anterior approach (1.2 grade) or laminectomy alone (0.9 grade) 6, 4
• Laminectomy with lateral mass fusion results in neurological improvement in 97% of patients with mean JOA score improving from 12.9 to 15.6 4
• Laminoplasty preserves motion and reduces axial neck pain but has 10% risk of post-surgical kyphosis 4

Critical Surgical Pitfalls

Never perform laminectomy alone without fusion:

• Laminectomy without fusion has 29% rate of long-term late deterioration and should be avoided 4

Prevent pseudarthrosis:

• Pseudarthrosis occurs in 10.9% of corpectomy cases—ensure adequate anterior column support and plate fixation 7
• If pseudarthrosis develops, anterior revision with plate stabilization achieves 83.3% good/excellent outcomes, while posterior approach revision achieves 94% fusion rate 7

Avoid C5 nerve palsy:

• C5 nerve palsy can develop when laminae are elevated to angle >60° during laminoplasty 4

Timing Considerations

• Patients with symptoms <1 year before surgery show better results, so do not delay surgical referral in moderate-severe cases 4
• Long periods of severe stenosis result in potentially irreversible spinal cord damage 4