Cervical myelopathy: treatment and surgery

Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in adults over 50. Unlike lumbar disc herniation, it does not resolve spontaneously. Without appropriate treatment, the condition progresses inexorably — sometimes in subtle steps, sometimes abruptly — towards permanent neurological disability. Dr Christian Dimitriu, spine neurosurgeon at Paris, explains the treatment options, surgical techniques and expected outcomes.

Background: what is cervical spondylotic myelopathy?

Cervical spondylotic myelopathy results from chronic compression of the spinal cord at the cervical spine level, caused by age-related degeneration of the discs and vertebrae: disc protrusions, osteophytes (bone spurs), and ligament hypertrophy. The cord, compressed within a narrowed spinal canal, gradually deteriorates.

Unlike peripheral nerves, the spinal cord only partially regenerates. The longer the compression persists, the greater the risk of permanent deficit. This is why myelopathy must be treated before neurological damage becomes irreversible.

Symptoms: how to recognise cervical myelopathy?

Symptoms of cervical spondylotic myelopathy are often progressive and may be mistaken for normal ageing. The following signs should raise suspicion:

• Gait disturbance: unsteady, clumsy walking, tendency to stumble — patients often describe it as “walking as if drunk”
• Loss of hand dexterity: difficulty buttoning a shirt, writing, gripping small objects, using cutlery
• Limb weakness: heavy legs, arms that tire quickly
• Sensory disturbances: tingling in the hands, finger numbness, burning sensation in the arms or legs
• Lhermitte’s sign: electric shock sensation radiating down the spine on neck flexion — a pathognomonic sign of cord involvement
• Hyperreflexia: brisk or polykinetic deep tendon reflexes on clinical examination
• Late bladder disturbance: urinary urgency, difficulty voiding — a sign of advanced myelopathy

Conservative treatment: when is it appropriate?

Unlike lumbar disc herniation, conservative management of cervical myelopathy is limited. It cannot relieve spinal cord compression — only surgery can. Nevertheless, in mild, stable forms, close monitoring combined with conservative measures may be considered:

• Soft cervical collar: reduces aggravating micro-movements during the acute phase, but is not a definitive treatment
• Analgesics and anti-inflammatories: symptomatic relief only
• Gentle physiotherapy: stretching, strengthening of paraspinal cervical muscles — cervical traction is contraindicated
• Activity avoidance: contact sports, scuba diving, trampolining — any cervical trauma can cause sudden deterioration

Conservative treatment is reserved for mild myelopathy (mJOA score ≥ 15) that has been stable for at least 6 months, with annual MRI surveillance. Any clinical deterioration or imaging progression mandates surgical reassessment.

When to operate for cervical myelopathy?

Dr Dimitriu recommends surgery when any of the following is present:

• Moderate to severe myelopathy (mJOA score < 14): significant gait disturbance, loss of hand dexterity affecting daily activities
• T2 hyperintensity on MRI: indicates active cord injury — surgery should be performed before the lesion becomes irreversible
• Documented progression: worsening symptoms over 3 to 6 months, even if mild
• Mild but unstable myelopathy: young patient, physically demanding occupation, quality of life impaired
• Sudden deterioration: relative surgical emergency — intervene within days

Surgical techniques: anterior or posterior approach?

The choice of technique depends on the number of levels involved, the type of compression, the cervical curvature (lordosis or kyphosis) and the patient’s overall condition. There is no single universal technique.

Anterior approach (1 to 3 levels)

The anterior approach uses a small incision in the neck, in front of the trachea. It gives direct access to the discs and vertebrae causing compression.

• Anterior cervical discectomy and fusion (ACDF): removal of the compressive disc, decompression of the cord and nerve roots, followed by vertebral fusion with an interbody cage (titanium or PEEK). The reference technique for 1 to 2 levels.
• Corpectomy: removal of an entire vertebral body (and adjacent discs) for more extensive compression. Reconstruction with a corpectomy cage and plate. Indicated for significant central compression or retrovertebral lesions.
• Cervical disc arthroplasty: replaces the disc with a mobile prosthesis, preserving segmental motion. Indicated in young patients with mild myelopathy at a single level, in the absence of instability.

Posterior approach (3 or more levels)

The posterior approach accesses the cervical spine from the back of the neck. It is preferred for multilevel compression and when cervical lordosis is well preserved.

• Cervical laminoplasty: enlargement of the spinal canal by opening the laminae (posterior arches) of the vertebrae without removing them. This technique preserves cervical mobility and has solid long-term results. Indicated for 3 or more levels with preserved lordosis.
• Cervical laminectomy + posterior fusion: removal of the laminae to decompress the cord, stabilised with pedicle screws and rods. Indicated in the presence of cervical kyphosis or associated instability.

Recovery after cervical myelopathy surgery

Recovery after myelopathy surgery differs from recovery after simple disc herniation. The spinal cord regenerates slowly — patience is essential.

Immediate phase (Day 0–7)

The patient stands and walks the day after surgery. A soft cervical collar is sometimes prescribed for 4 to 6 weeks depending on the technique used. Post-operative neck pain is managed with analgesics. Mild transient swallowing difficulty (anterior approach) is possible in the first few days.

Months 1 to 3: stabilisation

This is the neurological stabilisation phase. Improvement in gait and balance is often noticeable within the first few weeks. Neurological rehabilitation (specialist physiotherapy) begins around week 3 to 4 and plays an essential role in functional recovery.

Months 3 to 18: progressive neurological recovery

Recovery of hand dexterity is slower — it may continue for up to 18 months after surgery. Sensory disturbances (tingling, numbness) gradually regress. It is important not to judge the surgical outcome before 12 to 18 months.

Expected outcomes

Surgery for cervical spondylotic myelopathy delivers solid results when performed before cord damage becomes too severe:

• Stabilisation in 90% of cases: arrest of neurological deterioration
• Improvement in 70 to 80% of cases: partial or full recovery of gait and coordination
• Poorer results with severe pre-operative myelopathy (mJOA score < 10) or intense T2 hyperintensity on MRI
• Main prognostic factor: time between symptom onset and surgery — earlier decompression yields better recovery

Frequently asked questions

Sources: EANS, AOSpine, EuroSpine, SFNC — Laigle-Donadey et al., Neurochirurgie 2021 — Fehlings MG et al., Global Spine J 2017.