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Cervical myelopathy — Clinical Guidelines

Overview

Cervical myelopathy results from degenerative changes in the cervical spine leading to spinal cord compression, often causing gait disturbances, upper extremity weakness, and sensory deficits 1 14.

Diagnosis

Clinical Presentation: Gait disturbances, upper extremity weakness, numbness, and clumsiness 1 14.

Imaging Studies: MRI is essential for assessing spinal cord compression, disc degeneration, and spinal alignment 6 16.

Grading Systems: Modified Pfirrmann grading system for disc degeneration 6.

Comorbidities: Facet joint degeneration and ossification of the posterior longitudinal ligament (OPLL) may be present 3 7.

Management

Surgical Interventions:

- Anterior Approaches: - Anterior Cervical Discectomy and Fusion (ACDF): Common for single- or multilevel disease 2 5 10 22. - Cervical Corpectomy with Fusion: Effective for short-segment disease using PEEK cages 1 16. - Total Disc Replacement (cTDR): Alternative to fusion with promising outcomes 25. - Posterior Approaches: - Laminectomy and Fusion: Versus laminoplasty, outcomes vary 31. - Endoscopic Decompression: Minimally invasive option for single-level disease 24.

Non-Surgical Management:

- Pain Management: Multimodal approaches including NSAIDs and muscle relaxants 4. - Physical Therapy: To maintain function and strength 4.

Special Populations

Elderly: Hyperpolypharmacy and potentially inappropriate medications (PIMs) are concerns 4.

Comorbidities: Presence of comorbidities like facet joint degeneration and bone mineral density impact surgical outcomes 7 26.

Key Recommendations

Surgical Intervention for Symptomatic Patients: Consider surgical decompression (ACDF, corpectomy) for patients with significant neurological deficits or progression 1 2 14 (Evidence: Strong).

Choice Between Fusion and Arthroplasty: For single-level disease, cervical disc replacement may offer similar outcomes to ACDF in mid-term follow-up 9 25 (Evidence: Moderate).

Posterior vs Anterior Approaches: Outcomes of laminoplasty versus laminectomy and fusion are comparable, but patient-specific factors should guide choice 31 (Evidence: Moderate).

Monitor for Adjacent Segment Disease: Postoperatively monitor patients for adjacent segment disease, especially after multilevel ACDF 30 (Evidence: Moderate).

Consider Bioresorbable Implants: For multi-level degenerative disc disease, bioresorbable plates may be a viable alternative to traditional titanium plates 41 (Evidence: Weak).

References

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European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2025. link 4 Takeda H, Tobe T, Michikawa T, Imai T, Akaike Y, Kawabata S et al.. Clinical Features of Hyperpolypharmacy in Older Patients With Degenerative Cervical Myelopathy. Geriatrics & gerontology international 2025. link 5 Baram A, Riva M, Franzini A, Rossini Z, De Robertis M, Capo G et al.. Outcomes of non-contiguous two-level anterior cervical discectomy and fusion in patients with degenerative cervical myelopathy: a retrospective study. Acta neurochirurgica 2024. link 6 Xu C, Yin M, Mo W. An independent agreement study of modified Pfirrmann grading system for cervical inter-vertebral disc degeneration in cervical spondylotic myelopathy. British journal of neurosurgery 2024. link 7 Wu Y, Sun B, Huang Z, Han W, Zheng W, Zhang C et al.. 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Cervical myelopathy