Current Diagnosis and Management of Cervical Spondylotic Myelopathy

Abstract

Study design: Review.

Objectives: Cervical spondylotic myelopathy (CSM) is a major cause of disability, particular in elderly patients. Awareness and understanding of CSM is imperative to facilitate early diagnosis and management. This review article addresses CSM with regard to its epidemiology, anatomical considerations, pathophysiology, clinical manifestations, imaging characteristics, treatment approaches and outcomes, and the cost-effectiveness of surgical options.

Methods: The authors performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives.

Results: The clinical presentation and natural history of CSM is variable, alternating between quiescent and insidious to stepwise decline or rapid neurological deterioration. For mild CSM, conservative options could be employed with careful observation. However, surgical intervention has shown to be superior for moderate to severe CSM. The success of operative or conservative management of CSM is multifactorial and high-quality studies are lacking. The optimal surgical approach is still under debate, and can vary depending on the number of levels involved, location of the pathology and baseline cervical sagittal alignment.

Conclusions: Early recognition and treatment of CSM, before the onset of spinal cord damage, is essential for optimal outcomes. The goal of surgery is to decompress the cord with expansion of the spinal canal, while restoring cervical lordosis, and stabilizing when the risk of cervical kyphosis is high. Further high-quality randomized clinical studies with long-term follow up are still needed to further define the natural history and help predict the ideal surgical strategy.

Keywords: anterior cervical discectomy and fusion; cervical disk replacement; cervical laminoplasty; cervical spine stenosis; cervical spondylosis; cervical spondylotic myelopathy; degenerative disc disease.

Figure 1.

A general algorithm in the surgical approach of treating cervical spondylotic myelopathy.

Figure 2.

Cervical sagittal alignment parameters can be associated with clinical symptoms. A. Cervical spine lateral radiograph in an asymptomatic patient. The C2-C7 sagittal vertical axis (SVA) is measured as the deviation of the C2 plumb line from the posterior superior end plate of C7 (white arrow) B. Patient presented with severe myelopathy and radiograph demonstrated bony destruction at C6-C7 and T1 vertebral bodies with an angulated kyphosis at the C7-T1 region and compression fracture T1-T2. There was evidence of failure in the posterior lateral mass screws at C5-6 and pedicle screws at C7-T1. There was also an obvious kyphotic deformity along that region and evidence of pedicle screw failure in the lower levels. Cobb angle measured approximately 80° going from the endplate of C5 to the endplate of T2. C2-C7 SVA is also more pronounced in this patient (white arrow).

Figure 3.

Illustrative case demonstrating a 3-level anterior cervical discectomy and fusion (ACDF). (A) Magnetic resonance imaging (MRI) of the cervical spine demonstrating multilevel cervical stenosis due to disc herniation from C4-C6. (B) Lateral cervical radiograph demonstrated multilevel advanced degenerative disc disease and straightening of the normal cervical lordosis. (B) ACDF extending from the C4-C7 levels with interbody graft seen at the C4-5, C5-6, and C6-7 levels.

Figure 4.

Case example of a 3-level laminoplasty. (A) Magnetic resonance imaging (MRI) cervical spine shows diffuse cervical spondylosis with multilevel cervical stenosis due to a combination of disc and ligamentous hypertrophy, worse at C4-5 and C5-6 with moderate to severe stenosis at these levels and some suggestion of cord signal change. (B) Anterior-posterior and (C) lateral radiographic views of the laminoplasty technique, with the open door side on the right side with plates, and the hinged side was on the left.

Figure 5.

Illustrative case demonstrating a combined anterior-posterior approach completed in 2 stages. (A) Magnetic resonance imaging (MRI) demonstrating moderate cord compression C3-C6. With normal signal within the C3-C6 vertebral bodies with large heterogeneous prevertebral fluid collection at these levels. possibly reflecting severe spondyloarthropathy of dialysis. (B) Lateral views of the cervical spine demonstrate vertebral body deformity, height loss, near complete loss of the disc spaces and endplate irregularity from C3-C6. Anterior osteophytes were also seen at all levels in the cervical spine. (C) Demonstrating cervical corpectomy at C4-C6 with graft placement at C3-C7 levels, and anterior plate fusion extending from C3 to C7. (D) MRI demonstrating postsurgical changes related to anterior cervical corpectomy at C4- C6 and anterior plate fusion from C3-C7. Subsequent decompression of the cervical spine at the operated levels was appreciated. (E) C2-T2 posterolateral fusion with rod and lateral mass and pedicle screw fixation, with lateral mass screws sparing the C4-C6 levels and pedicle screws in the thoracic levels.