What is the appropriate management and treatment for a patient with cervical myelopathy?

Management 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 for 5-15 years and prevents irreversible spinal cord damage. 1, 2

Disease Severity Stratification

The modified Japanese Orthopaedic Association (mJOA) scale determines your treatment pathway 1:

• Mild myelopathy: mJOA score >12
• Moderate to severe myelopathy: mJOA score ≤12

The presence of gait disturbance or balance difficulties indicates established myelopathy requiring urgent surgical evaluation, regardless of mJOA score 2.

Treatment Algorithm by Severity

Moderate to Severe Myelopathy (mJOA ≤12)

Proceed directly to surgical decompression 1, 2:

• Approximately 97% of patients experience neurological recovery after surgery 2
• Benefits are maintained for 5-15 years postoperatively 1
• Delaying surgery risks permanent neurological deficit from demyelination and necrosis that cannot be reversed even with eventual decompression 2

Critical pitfall to avoid: Do not delay surgery waiting for "failed conservative management" in patients with gait disturbance or established myelopathy 2. Long periods of severe stenosis cause irreversible white matter demyelination and gray matter necrosis 2.

Mild Myelopathy (mJOA >12)

For mild disease, you have two evidence-supported options for the first 3 years 1:

Option 1: Surgical decompression (preferred if any red flags present)

Option 2: Nonoperative management consisting of:

• Prolonged immobilization in a stiff cervical collar 1
• "Low-risk" activity modification or bed rest 1
• Anti-inflammatory medications 1

However, convert to surgical management immediately if 3:

• Neurological deterioration occurs
• Patient fails to improve with conservative treatment
• Gait disturbance develops

Note that 20-30% of patients with mild myelopathy will progress and require surgery within 3 years 4.

Surgical Approach Selection

The number of compressed levels and location of compression determine your surgical technique 1, 2:

For 1-3 Level Disease with Anterior Compression

Choose anterior cervical discectomy and fusion (ACDF) or anterior cervical corpectomy and fusion (ACCF) 1, 2:

• Both techniques yield similar neurological outcomes (73-74% improvement rates) 1
• Use anterior plate fixation to achieve equivalent fusion rates between techniques 1
• Without anterior plating, ACCF provides higher fusion rates but also higher graft failure rates compared to multilevel ACDF 1

For Multilevel Disease (≥4 Segments)

Choose posterior laminectomy with fusion 1, 2:

• Demonstrates significantly greater neurological recovery (average 2.0 Nurick grade improvement) compared to anterior approach (1.2 grade improvement) 1
• Fusion prevents late deterioration and iatrogenic instability 2

Avoid laminectomy alone due to:

• 29% rate of late deterioration 2
• Increased risk of postoperative kyphosis 1
• Only 0.9 Nurick grade improvement compared to 2.0 with fusion 1

Alternative: Laminoplasty

Laminoplasty is an equivalent option to laminectomy with fusion for multilevel posterior compression in patients with preserved cervical lordosis 1, 5:

• Produces comparable neurological improvement to anterior and posterior fusion techniques 1
• Avoids fusion-related complications
• 89% of patients show neurological improvement 1

Prognostic Factors Affecting Outcomes

Factors predicting better surgical outcomes 2, 4:

• Younger age
• Shorter symptom duration (<12 months)
• Higher preoperative mJOA scores
• Earlier surgical intervention

Factors predicting worse outcomes 2, 4:

• Symptom duration >12 months
• Lower preoperative functional scores (mJOA <12)
• Multisegmental T2 hyperintensity on MRI (indicates established cord injury)
• Female sex and older age (for natural history without surgery)

Importantly, age alone is not a contraindication to surgery—recovery rates are similar between patients >70 years (62%) and younger patients (59%) 2.

Contraindications to Surgery

The only true contraindication is severe comorbid conditions making anesthesia prohibitively dangerous 2. Otherwise, surgical decompression should be offered to all patients with moderate to severe myelopathy.

Natural History Without Treatment

Understanding disease progression patterns is critical 4:

• Episodic deterioration (75% of patients): New symptoms appear in discrete episodes, though 2/3 show gradual deterioration even during "stable" periods 4
• Slow steady progression (20% of patients): Gradual worsening without stepwise decline 4
• Rapid onset followed by plateau (5% of patients): Acute symptom development that then stabilizes 4

Untreated severe cervicomedullary compression carries a 16% mortality rate 2.

Key Clinical Pearls

• MRI T2 hyperintensity represents established cord injury and indicates need for urgent surgical evaluation 2
• Gait disturbance represents established myelopathy, not simple radiculopathy—conservative management is futile at this stage 2
• Most neurological deterioration after surgery occurs within the first year and is often due to preventable surgical trauma, instability, or progression of disease at adjacent levels 6
• The likelihood of improvement with nonoperative measures is extremely low for severe and/or long-lasting symptoms 2