What is the recommended treatment approach for a patient with spondylotic (degenerative) myelopathy presenting with symptoms such as numbness, weakness, or clumsiness in the arms or legs?

Spondylotic Myelopathy: Treatment Approach

Immediate Treatment Decision

For patients with spondylotic myelopathy presenting with numbness, weakness, or clumsiness, surgical decompression is the recommended treatment for moderate to severe disease, while mild disease may be managed either surgically or conservatively with close monitoring. 1, 2

Disease Severity Stratification

The modified Japanese Orthopaedic Association (mJOA) scale determines the treatment pathway:

• Mild CSM (mJOA score >12): Either surgical decompression or nonoperative therapy can be offered for the first 3 years, as both show equivalency in short-term outcomes 1, 2
• Moderate to Severe CSM (mJOA score ≤12): Surgical decompression is strongly recommended, with benefits maintained for 5-15 years postoperatively 1, 2

Nonoperative Management (Mild Disease Only)

For patients with mild myelopathy (age <75 years, mJOA >12), conservative treatment includes:

• Prolonged immobilization with a stiff cervical collar 1, 2
• Activity modification focusing on "low-risk" activities or bed rest 1, 2
• Anti-inflammatory medications 1, 3
• Physical therapy to strengthen neck muscles 2

Critical caveat: Approximately 70% of patients with mild CSM maintain stable symptoms over 3 years with nonoperative treatment, but close clinical monitoring is essential as progression can occur 3

Surgical Approach Selection

The surgical approach depends on the number of levels involved and location of compression:

Anterior Approach (ACDF or Corpectomy)

• Indicated for: 1-3 level disease 1
• Outcomes: Improvement rates of 73-74%, with average neurologic improvement of 1.2 Nurick grades 1
• Fusion rates: 92% with anterior cervical decompression and arthrodesis 1

Posterior Approach (Laminectomy with Fusion or Laminoplasty)

• Indicated for: Multilevel disease (≥4 segments) 1, 2
• Outcomes: Laminectomy with posterior fusion demonstrates significantly greater neurological recovery with average 2.0 Nurick grade improvement compared to anterior approach (1.2 grade) or laminectomy alone (0.9 grade) 1, 2
• Laminectomy with lateral mass fusion: 97% of patients showed neurological improvement, with mean JOA score improving from 12.9 to 15.6 2

Combined Approaches

• Indicated for: Complex cases with multilevel disease and mixed pathology 1

Critical Prognostic Factors

When counseling patients about surgical outcomes, discuss these evidence-based prognostic factors:

• Age: Younger patients have better outcomes 4, 1
• Duration of symptoms: Shorter symptom duration correlates with better outcomes; patients with symptoms <1 year show superior results across all treatment modalities 4, 2
• Preoperative neurological function: Better baseline function predicts better outcomes 4, 1
• Preoperative somatosensory-evoked potentials: May provide valuable prognostic information when clinical factors don't provide clear guidance 4, 1

Critical Pitfalls to Avoid

Laminectomy Alone Without Fusion

Never perform laminectomy alone without fusion - this approach has a concerning 29% rate of late deterioration and increased risk of postoperative kyphosis 4, 2. Laminectomy with fusion prevents post-laminectomy kyphosis and provides superior neurological recovery 4, 2

Delayed Surgical Intervention

Do not delay surgical intervention in patients with moderate to severe myelopathy, as long periods of severe stenosis can result in potentially irreversible spinal cord damage 2. The natural history of untreated CSM involves progressive stepwise neurological decline in many patients 4

Inadequate Stabilization

Inadequate stabilization during surgery can lead to cage movement and pseudarthrosis, which occurs in approximately 10.9% of cases 2

Relying Solely on Imaging

Do not rely solely on imaging findings for treatment decisions, as spondylotic changes are commonly identified on radiographs and MRI in patients >30 years of age and correlate poorly with the presence of symptoms 1

Special Considerations

Patients with Cervical Stenosis Without Myelopathy

For patients with cervical stenosis without myelopathy who have clinical radiculopathy or abnormal EMG findings, closer monitoring is warranted as this is associated with development of symptomatic CSM 4, 1

Natural History Without Treatment

The natural history of CSM is variable, with approximately 75% of patients experiencing episodes of new symptoms and signs, while 20% show slow steady progression without stepwise decline 4. However, most reports involve periods of quiescent disease with intermittent episodes of neurologic decline 4