What is the treatment for cervical myelopathy?

Treatment of Cervical Myelopathy

For moderate to severe cervical myelopathy (mJOA score ≤12), surgical decompression is strongly recommended and provides sustained neurological improvement for 5-15 years postoperatively. 1, 2, 3

Treatment Algorithm Based on Disease Severity

Mild Cervical Myelopathy (mJOA score >12)

For the first 3 years after diagnosis, either surgical decompression or nonoperative therapy can be offered, as Class II evidence shows equivalency between these approaches in the short term 1, 2, 3. However, this evidence has limitations including nonblinded allocation and selection bias 2.

Nonoperative therapy components include: 1, 2

• Prolonged immobilization in a stiff cervical collar
• "Low-risk" activity modification or bed rest
• Anti-inflammatory medications (NSAIDs as first-line)
• Physical therapy focusing on neck stabilization and range of motion exercises

Important caveat: The natural history of mild myelopathy is unpredictable, and nearly 50% of patients may have residual or recurrent symptoms up to 1 year after initial presentation 2. Close monitoring for neurological deterioration is essential, as patients with cervical stenosis and clinical radiculopathy are at higher risk for developing symptomatic myelopathy 2.

Moderate to Severe Cervical Myelopathy (mJOA score ≤12)

Surgical decompression is the definitive treatment, with benefits maintained for a minimum of 5 years and as long as 15 years postoperatively 1, 2, 3. Delaying surgery in this population can lead to irreversible spinal cord damage 3.

Surgical Approach Selection Algorithm

The choice of surgical technique depends primarily on the number of levels involved and cervical spine alignment 2, 4, 5:

Anterior Approach (ACDF or ACCF)

Indications: 1, 2, 4

• 1-3 level disease
• Compression primarily at disc levels
• Presence of kyphotic deformity

Technical considerations:

• ACDF and ACCF yield similar results for multilevel decompression at disc levels when anterior plating is used 1
• Anterior plating provides equivalent fusion rates between ACDF and ACCF 1
• Without anterior fixation, ACCF provides higher fusion rates than multilevel ACDF but carries a higher graft failure rate 1
• Anterior approaches show improvement rates of approximately 73-74% 2
• Average neurological improvement of 1.2 Nurick grades 2

Posterior Approach (Laminoplasty or Laminectomy with Fusion)

Indications: 2, 4, 5

• Multilevel disease (≥4 segments)
• Preserved or lordotic cervical alignment
• Compression posterior to the spinal cord

Laminectomy with fusion is superior to other approaches for multilevel disease, demonstrating significantly greater neurological recovery with an average 2.0 Nurick grade improvement compared to anterior approach (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 2, 3. This approach resulted in neurological improvement in 97% of patients, with mean JOA scores improving from 12.9 to 15.6 3.

Laminoplasty is comparable to anterior approaches for multilevel compression and preserves motion while reducing axial neck pain 2, 4. However, post-surgical kyphosis occurs in approximately 10% of patients, and C5 nerve palsy can develop, especially when laminae are elevated to an angle >60° 3.

Critical Pitfalls to Avoid

NEVER perform laminectomy alone (without fusion) 1, 3, 4

This is the single most important technical consideration. Laminectomy without fusion is associated with:

• Late deterioration in 29% of patients 2, 3
• Increased risk of postoperative kyphosis 2
• Inferior long-term outcomes compared to all other surgical approaches

Timing Considerations

• Patients with symptoms present for less than one year before surgery show better results across all treatment modalities 3
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 2

Imaging Interpretation

• Do not rely solely on imaging findings for treatment decisions, as spondylotic changes correlate poorly with the presence of symptoms in patients >30 years of age 2
• However, evidence of spinal cord compression on imaging with corresponding clinical symptoms is an indication for surgical intervention 2

Prognostic Factors

Better surgical outcomes are associated with: 2, 3

• Younger age
• Shorter duration of symptoms (especially <1 year)
• Better preoperative neurological function
• Higher preoperative mJOA scores

Poor prognosis factors include: 2

• Female gender
• Older age (>75 years)
• Coexisting psychosocial pathology
• Radicular symptoms