What are the differences in diagnosis and treatment between myelopathy and radiculopathy?

Myelopathy vs Radiculopathy: Key Diagnostic and Treatment Differences

Myelopathy represents spinal cord compression requiring urgent surgical evaluation, while radiculopathy involves nerve root compression that typically responds to conservative management initially.

Clinical Distinction

Myelopathy Presentation

• Spinal cord dysfunction manifests with gait disturbance, balance problems, hand clumsiness, hyperreflexia, positive Babinski sign, and potential bladder dysfunction 1
• Symptoms are often bilateral and involve multiple levels, with upper motor neuron signs predominating 1
• Progressive neurological deterioration is the hallmark concern, though the natural history shows stepwise decline with periods of quiescence in many patients 1

Radiculopathy Presentation

• Dermatomal pain radiating into the arm or leg, following specific nerve root distributions 2
• Sensory changes, weakness, and reflex changes confined to single nerve root territory 2
• Symptoms are typically unilateral and may include sharp, shooting pain exacerbated by specific movements 1, 2

Critical pitfall: The American College of Radiology emphasizes that imaging findings do not always correlate with symptoms—disc abnormalities appear in 20-28% of asymptomatic patients, and MRI alone should never be used to diagnose radiculopathy without clinical correlation 2.

Diagnostic Approach

For Suspected Myelopathy

• MRI of the spine without contrast is the initial imaging of choice when myelopathy or radiculopathy is suspected 1
• Imaging should identify cord compression, signal changes within the cord, and structural causes including disc herniations, spinal stenosis, or ligamentum flavum ossification 1
• Urgent MRI is mandatory when progressive neurological deficits are present 1

For Suspected Radiculopathy

• Conservative management trial of 6 weeks is recommended unless red flags or severe/progressive deficits are present 3
• MRI lumbar or cervical spine without contrast should be obtained only if symptoms persist beyond 6 weeks or if the patient is a candidate for surgery or epidural steroid injection 1, 3
• The natural history of disc herniation with radiculopathy shows improvement within the first 4 weeks with noninvasive management in most patients 1

Key distinction: Radiculopathy warrants a trial of conservative care first, while myelopathy demands prompt surgical evaluation due to risk of irreversible cord damage 1, 4.

Treatment Algorithms

Myelopathy Management

Moderate to Severe Myelopathy (mJOA ≤12)

• Surgical intervention is recommended as the primary treatment 4
• Long periods of severe stenosis are associated with demyelination and potential necrosis leading to irreversible deficit 1
• Surgical outcomes are better when intervention occurs before prolonged compression causes permanent cord damage 5

Mild Myelopathy (mJOA >12)

• Either surgical intervention or supervised structured rehabilitation may be offered 4
• If nonoperative management is pursued initially, surgical intervention is recommended if neurological deterioration occurs 4
• Clinical gains after nonoperative treatment are maintained over 3 years in 70% of mild cases 1

Asymptomatic Cord Compression Without Myelopathy

• Prophylactic surgery is not recommended for patients without myelopathic signs 4
• Patients should be counseled about progression risks, educated about myelopathy symptoms, and followed clinically 4
• Exception: Non-myelopathic patients with cord compression AND clinical radiculopathy are at higher risk and should be offered either surgical intervention or close follow-up 1, 4

Radiculopathy Management

Initial Conservative Approach (First 6 Weeks)

• Advise patients to remain active rather than bed rest 1
• Provide evidence-based information about the generally favorable prognosis, with high likelihood of substantial improvement in the first month 1
• Consider structured rehabilitation or physical therapy 4, 6

Persistent Symptoms Beyond 6 Weeks

• Obtain MRI (preferred) or CT only if patient is a potential candidate for surgery or epidural steroid injection 1
• For cervical radiculopathy, one trial found surgery provided faster pain relief than physiotherapy in the short-term, but no significant differences at one year 6
• Surgical discectomy or epidural steroids are options for prolapsed disc with persistent radicular symptoms despite conservative therapy 1

Urgent Surgical Evaluation Required When:

• Severe or progressive neurological deficits develop 1, 3
• Red flag symptoms suggesting cauda equina syndrome, infection, or cancer with cord compression 1

Prognostic Factors

Myelopathy

• Duration of symptoms prior to surgery and transverse spinal cord area at maximum compression are the most significant prognostic parameters for surgical outcome 5
• Earlier surgical intervention generally yields better outcomes before irreversible cord damage occurs 1, 5
• Both myelopathy and myeloradiculopathy patients demonstrate significant improvement in pain, disability, and quality of life at 3 months sustained through 2 years postoperatively 7

Radiculopathy

• Size and type of disc herniation do not reliably predict patient outcomes 2
• Most patients improve with conservative management within 4 weeks 1
• Physical examination findings have limited diagnostic accuracy compared to imaging 2

Important caveat: Intraoperative electrophysiological monitoring during cervical spine surgery for myelopathy or radiculopathy does not reduce neurological injury rates and is not routinely recommended, though it may serve as a sensitive diagnostic tool in select cases 1.