Treatment of Cervical Myelopathy
For moderate to severe cervical myelopathy (mJOA score ≤12), surgical decompression is strongly recommended and should not be delayed, as it provides sustained neurological improvement maintained for 5-15 years postoperatively. 1, 2, 3
Treatment Algorithm Based on Disease Severity
Mild Cervical Myelopathy (mJOA score >12)
Either surgical decompression OR nonoperative therapy can be offered for the first 3 years, as both show equivalent outcomes at 2-year follow-up (Class II evidence). 1, 3
Nonoperative therapy consists of: 1
- 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 2
If nonoperative management is initially pursued, surgical intervention is recommended if neurological deterioration occurs, and suggested if the patient fails to improve. 3
The critical limitation: at 6 months, nonoperative therapy showed better mJOA scores and 10-m walk times compared to surgery, but these differences disappeared by 12-24 months, indicating surgery provides equivalent long-term outcomes. 1
Moderate to Severe Cervical Myelopathy (mJOA score ≤12)
Surgical decompression is the definitive treatment, with benefits maintained for minimum 5 years and up to 15 years postoperatively (Class III evidence). 1, 2
Patients with severe disability (mean mJOA score 9.5) show significant improvement after surgical intervention (mean mJOA score 10.9 at 2 years). 1
Nonoperative management results in inferior outcomes compared to surgery for moderate-severe disease and is not recommended. 4
Surgical Approach Selection
The choice of surgical approach depends on the number of levels involved and sagittal alignment: 2, 5
Anterior Approach (1-3 Level Disease)
Anterior cervical discectomy and fusion (ACDF) is effective for 1-2 level disease. 2
Anterior corpectomy with reconstruction is recommended for 3-segment disease, improving neurological scores from average 7.9 preoperatively to 13.4 at 15-year follow-up. 2
Anterior approaches show improvement rates of approximately 73-74%. 5
Average neurological improvement of 1.2 Nurick grades with anterior approach. 5
Posterior Approach (≥4 Segment Disease)
Laminectomy with lateral mass fusion is recommended for multilevel disease (≥4 segments) and prevents post-laminectomy kyphosis. 2, 5
Laminectomy with posterior fusion resulted in neurological improvement in 97% of patients, with mean JOA score improvement from 12.9 to 15.6. 2
Laminectomy with 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). 2, 5
Laminoplasty preserves motion and reduces axial neck pain, suitable for patients with lordotic sagittal alignment. 2, 6
Critical Pitfalls to Avoid
Timing-Related Errors
Delaying surgical intervention in moderate-severe myelopathy leads to irreversible spinal cord damage. 2
Patients with symptoms present for less than one year before surgery show better results across all treatment modalities. 2
Long periods of severe stenosis result in potentially irreversible spinal cord damage. 2
Technical Surgical Errors
Never perform laminectomy alone without fusion - it has a 29% rate of long-term late deterioration and increased risk of postoperative kyphosis. 2, 5
Inadequate stabilization during surgery leads to cage movement and pseudarthrosis (occurring in approximately 10.9% of cases). 2
Post-surgical kyphosis occurs in approximately 10% of patients after laminoplasty. 2
C5 nerve palsy can develop after surgery, especially when laminae are elevated to an angle >60°. 2
Monitoring Failures
For mild myelopathy treated nonoperatively, close monitoring is essential as 20-62% will deteriorate at 3-6 years of follow-up. 4
Patients with cervical stenosis and clinical radiculopathy (without myelopathy) are at higher risk of developing symptomatic myelopathy and warrant closer monitoring. 5, 3
Asymptomatic Cervical Cord Compression
Prophylactic surgery for asymptomatic patients with cord compression is NOT standard of care and is not recommended. 7, 3
These patients should be counseled about potential risks of progression, educated about signs/symptoms of myelopathy, and followed clinically with serial neurological examinations every 3-6 months. 7, 3
Non-myelopathic patients with cord compression AND clinical radiculopathy are at higher risk (approximately 8% at 1 year, 23% at 4 years) and should be offered either surgical intervention or close serial follow-up. 3, 4