Future perspectives after the guidelines of degenerative cervical myelopathy: A narrative review

Abstract

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults, often resulting from cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL). As the aging population increases, the prevalence of DCM is expected to rise, making the optimization of treatment strategies crucial. While surgical decompression is widely accepted for moderate to severe cases, the management of mild DCM remains controversial. Some studies report significant neurological improvement with surgery, while others find no difference between surgical and conservative approaches. Current guidelines suggest conservative management may be considered for mild cases, with surgical intervention recommended if symptoms progress or do not respond to non-operative treatment.

Non-surgical approaches such as cervical traction therapy and orthotic treatment have been explored, though their long-term effectiveness remains unclear. Pharmacological treatments, including NSAIDs, muscle relaxants, and corticosteroids, are commonly prescribed for symptomatic relief, yet their effectiveness in treating myelopathy-specific symptoms has not been established. According to current guidelines, patients with a modified Japanese Orthopaedic Association (mJOA) score of 15 or higher are considered suitable candidates for conservative management. However, surgical intervention should be considered if there is evidence of symptom progression.

Surgical strategies for DCM vary based on the severity and location of spinal cord compression. The Japanese CSM and OPLL guidelines have extensively compared different surgical approaches. For CSM treatment, while anterior cervical discectomy and fusion (ACDF) and laminoplasty provide similar neurological recovery, ACDF offers better sagittal alignment but carries a higher risk of reoperation. Comparisons between ACDF and posterior decompression and fusion (PDF) indicate that both procedures yield comparable neurological outcomes, though ACDF has been associated with better patient-reported quality of life. In OPLL patients, anterior surgery may be preferable for those with severe kyphosis and extensive anterior compression, despite an increased risk of complications.

Future research should focus on refining diagnostic tools, optimizing surgical decision-making, and assessing the effectiveness of conservative management strategies. Standardizing intraoperative ultrasonography criteria, evaluating the role of postoperative cervical collar immobilization, and investigating rehabilitation protocols are key areas requiring further study.