Conservative and newer drug treatment for degenerative cervical myelopathy

Abstract

Degenerative cervical myelopathy (DCM) is the most common cause of non-traumatic spinal cord dysfunction in adults worldwide. Conservative treatments, such as physical therapy, activity modification, cervical traction, and the use of cervical collars, have been employed primarily for symptomatic relief in mild cases or for patients deemed unfit for surgery. Advances in our understanding of the molecular pathways involved in neuroinflammation and neuronal injury in DCM have spurred the development of newer pharmacological treatments aimed at neuroprotection and inflammation control. We found limited evidence that conservative treatment enhances functional recovery in patients with DCM. Patients with mild DCM who opt for conservative therapy should be aware of likely neurological deterioration and higher spinal cord injury risk following neck trauma. Nonoperative management could benefit patients with mild DCM who presented early (at least less than a year), have soft disc herniation as the cause of the myelopathy, have one level of myelopathic compression, and whose MRI does not show circumferential compression of the spinal cord. Riluzole did not replicate its promising animal results in human trials, using the modified Japanese Orthopaedic Association (mJOA) score as an outcome measure. Cerebrolysin is promising but needs more RCTs to define its role in the management algorithm. Limaprost Alfadex provided inconclusive evidence, however, is in an ongoing phase III trial. Erythropoietin showed benefit in animal and human trials but concerns over side effects may limit use. G-CSF demonstrated evidence of preserved neurological function in mice but needs human studies. Steroids did not show benefit and are likely deleterious to tissue healing and can increase infection risk. Anti-Fas ligand antibody has not been studied in humans but demonstrated benefit in animal models. Research should focus on large-scale RCTs for these drugs with careful attention to long-term effects, side effects, and finding the most effective doses.