Surgical Management of Cervical Myelopathy: Current Algorithm

Abstract

Cervical myelopathy (CM) is a progressive disorder associated with a varied spectrum of etiological factors. Cervical spondylotic myelopathy (CSM) encompasses two-thirds of the cases of CM, while ossified posterior longitudinal ligament (OPLL) and ossified ligamentum flavum (OLF) are significant regional etiological factors. Microvascular disruption, resulting from repetitive dynamic compression or static pressure to the spinal cord, is attributed as a primary pathophysiological mechanism for CM. Magnetic resonance imaging (MRI) is the investigation of choice to assess the spinal cord. Lateral cervical radiographs are crucial for lordosis assessment, and tomographic scans (CT) can delineate the extent of OPLL and OLF. Non-surgical treatment is usually not successful once the patient develops progressive myelopathy. Anterior cervical procedures are ideal for one or two level disc-osteophytes complexes or in patients with kyphotic cervical alignment. Laminoplasty is an effective motion-preserving option in patients with adequate cervical lordosis. Laminectomy or laminoplasty and fusion are optimal for patients with significant preoperative neck pain. Posterior surgery is preferred over anterior surgery for CM involving three or more levels. Older age at presentation, longer duration of symptoms, and severity of pre-operative symptoms are adverse prognostic factors. Progressive cervical myelopathy is a surgical disease, and early intervention is rewarded with better outcomes. Keywords: Cervical myelopathy, Cervical spondylotic myelopathy, OPLL, OLF, Laminoplasty, Laminectomy, ACDF, Cervical corpectomy.