Is surgical intervention indicated for myelopathy without initial conservative management?

From the Guidelines

Myelopathy generally warrants surgical intervention without initial conservative management, especially when neurological deficits are present. This approach is supported by the most recent and highest quality study, which emphasizes the importance of prompt surgical intervention to prevent further neurological deterioration 1. The goal of surgery is to decompress the spinal cord, stabilize the spine if needed, and prevent further neurological deterioration. Common surgical approaches include anterior cervical discectomy and fusion (ACDF), laminoplasty, or laminectomy with fusion, depending on the specific pathology and location.

Some key points to consider in the management of myelopathy include:

• The presence of neurological deficits, which necessitates prompt surgical intervention to prevent further deterioration 1
• The importance of decompressing the spinal cord to prevent progressive neuronal damage through direct mechanical pressure and secondary inflammatory processes
• The role of surgery as the first-line treatment for myelopathy, as it directly addresses the underlying spinal cord compression, which conservative measures cannot resolve
• The potential for permanent neurological damage if myelopathy is left untreated or if treatment is delayed

While other studies may provide additional guidance on the management of myelopathy, the most recent and highest quality study 1 prioritizes surgical intervention as the primary treatment approach, especially in cases with neurological deficits. Therefore, surgical intervention without initial conservative management is generally recommended for myelopathy, particularly when neurological deficits are present.

From the Research

Myelopathy and Surgical Indications

• Myelopathy is a condition that can be caused by narrowing of the cervical spinal canal, and surgical decompression is often considered an obvious indication for spinal cord stenosis 2.
• However, there is limited evidence to determine that surgery is the most indicated intervention for milder forms of myelopathy, and some studies suggest that nonoperative treatment may be effective in these cases 2, 3.
• A systematic review found that nonoperative treatment may yield equivalent or better outcomes than surgery in patients with mild myelopathy, but the evidence is limited and further studies are needed to determine the role of nonoperative treatment in myelopathy management 3.

Nonoperative Management of Myelopathy

• Nonoperative treatment of myelopathy may include physical therapy, medications, injections, orthoses, and traction, but the evidence for these treatments is limited and further studies are needed to determine their effectiveness 3.
• A case report found that physical therapy treatment with emphasis on manual therapy and therapeutic exercise achieved satisfactory results in a patient with mild myelopathy 2.
• The severity of myelopathy may affect the outcomes of nonoperative treatment, and patients with moderate to severe myelopathy may have inferior outcomes with nonoperative treatment compared to surgery 3.

Surgical Indications for Myelopathy

• Absolute surgical indications for myelopathy include deteriorating neurological deficits with myelopathy or cauda equina syndrome 4.
• Relative indications for surgery in cervical disc herniation include six months of persisting symptoms that do not respond to conservative treatment, but high-quality studies are lacking and further research is needed to clarify the indications 4.
• Intraoperative neuromonitoring with motor evoked potentials (MEPs) may be useful in predicting postoperative neurological deficits in patients undergoing surgery for myelopathy, and can assist the surgeon in taking corrective measures to reduce or prevent permanent neurological deficits 5.