Skip to main content
NCBI home page
The Yale Journal of Biology and Medicine logoLink to The Yale Journal of Biology and Medicine
. 1993 May-Jun;66(3):165–177.

Cervical spondylotic myelopathy: a review of surgical indications and decision making.

M D Law Jr 1, M Bernhardt 1, A A White 3rd 1
PMCID: PMC2588867  PMID: 8209553

Abstract

Cervical spondylotic myelopathy (CSM) is frequently underdiagnosed and undertreated. The key to the initial diagnosis is a careful neurologic examination. The physical findings may be subtle, thus a high index of suspicion is helpful. Poor prognostic indicators and, therefore, absolute indications for surgery are: 1. Progression of signs and symptoms. 2. Presence of myelopathy for six months or longer. 3. Compression ratio approaching 0.4 or transverse area of the spinal cord of 40 square millimeters or less. Improvement is unusual with nonoperative treatment and almost all patients progressively worsen. Surgical intervention is the most predictable way to prevent neurologic deterioration. The recommended decompression is anterior when there is anterior compression at one or two levels and no significant developmental narrowing of the canal. For compression at more than two levels, developmental narrowing of the canal, posterior compression, and ossification of the posterior longitudinal ligament, we recommend posterior decompression. In order for posterior decompression to be effective there must be lordosis of the cervical spine. If kyphosis is present, anterior decompression is needed. Kyphosis associated with a developmentally narrow canal or posterior compression may require combined anterior and posterior approaches. Fusion is required for instability.

Full text

PDF
165

Images in this article

166Figure 1
on p.166

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Adams C. B., Logue V. Studies in cervical spondylotic myelopathy. 3. Some functional effects of operations for cervical spondylotic myelopathy. Brain. 1971;94(3):587–594. doi: 10.1093/brain/94.3.587. [DOI] [PubMed] [Google Scholar]
  2. Adams C. B., Logue V. Studies in cervical spondylotic myelopathy. I. Movement of the cervical roots, dura and cord, and their relation to the course of the extrathecal roots. Brain. 1971;94(3):557–568. doi: 10.1093/brain/94.3.557. [DOI] [PubMed] [Google Scholar]
  3. Adams C. B., Logue V. Studies in cervical spondylotic myelopathy. II. The movement and contour of the spine in relation to the neural complications of cervical spondylosis. Brain. 1971;94(3):568–586. [PubMed] [Google Scholar]
  4. Aebi M., Zuber K., Marchesi D. Treatment of cervical spine injuries with anterior plating. Indications, techniques, and results. Spine (Phila Pa 1976) 1991 Mar;16(3 Suppl):S38–S45. doi: 10.1097/00007632-199103001-00008. [DOI] [PubMed] [Google Scholar]
  5. Alker G. Neuroradiology of cervical spondylotic myelopathy. Spine (Phila Pa 1976) 1988 Jul;13(7):850–853. doi: 10.1097/00007632-198807000-00027. [DOI] [PubMed] [Google Scholar]
  6. Anderson P. A., Henley M. B., Grady M. S., Montesano P. X., Winn H. R. Posterior cervical arthrodesis with AO reconstruction plates and bone graft. Spine (Phila Pa 1976) 1991 Mar;16(3 Suppl):S72–S79. doi: 10.1097/00007632-199103001-00012. [DOI] [PubMed] [Google Scholar]
  7. Bernard T. N., Jr, Whitecloud T. S., 3rd Cervical spondylotic myelopathy and myeloradiculopathy. Anterior decompression and stabilization with autogenous fibula strut graft. Clin Orthop Relat Res. 1987 Aug;(221):149–160. [PubMed] [Google Scholar]
  8. Bernhardt M., Hynes R. A., Blume H. W., White A. A., 3rd Cervical spondylotic myelopathy. J Bone Joint Surg Am. 1993 Jan;75(1):119–128. doi: 10.2106/00004623-199301000-00016. [DOI] [PubMed] [Google Scholar]
  9. Breig A., el-Nadi A. F. Biomechanics of the cervical spinal cord. Relief of contact pressure on and overstretching of the spinal cord. Acta Radiol Diagn (Stockh) 1966 Nov;4(6):602–624. doi: 10.1177/028418516600400602. [DOI] [PubMed] [Google Scholar]
  10. Brown B. M., Schwartz R. H., Frank E., Blank N. K. Preoperative evaluation of cervical radiculopathy and myelopathy by surface-coil MR imaging. AJR Am J Roentgenol. 1988 Dec;151(6):1205–1212. doi: 10.2214/ajr.151.6.1205. [DOI] [PubMed] [Google Scholar]
  11. Brown M. D., Malinin T. I., Davis P. B. A roentgenographic evaluation of frozen allografts versus autografts in anterior cervical spine fusions. Clin Orthop Relat Res. 1976 Sep;(119):231–236. [PubMed] [Google Scholar]
  12. CLARKE E., ROBINSON P. K. Cervical myelopathy: a complication of cervical spondylosis. Brain. 1956 Sep;79(3):483–510. doi: 10.1093/brain/79.3.483. [DOI] [PubMed] [Google Scholar]
  13. CLOWARD R. B. The anterior approach for removal of ruptured cervical disks. J Neurosurg. 1958 Nov;15(6):602–617. doi: 10.3171/jns.1958.15.6.0602. [DOI] [PubMed] [Google Scholar]
  14. Cusick J. F. Monitoring of cervical spondylotic myelopathy. Spine (Phila Pa 1976) 1988 Jul;13(7):877–880. doi: 10.1097/00007632-198807000-00033. [DOI] [PubMed] [Google Scholar]
  15. Cusick J. F. Pathophysiology and treatment of cervical spondylotic myelopathy. Clin Neurosurg. 1991;37:661–681. [PubMed] [Google Scholar]
  16. Denno J. J., Meadows G. R. Early diagnosis of cervical spondylotic myelopathy. A useful clinical sign. Spine (Phila Pa 1976) 1991 Dec;16(12):1353–1355. doi: 10.1097/00007632-199112000-00001. [DOI] [PubMed] [Google Scholar]
  17. Epstein J. A., Janin Y., Carras R., Lavine L. S. A comparative study of the treatment of cervical spondylotic myeloradiculopathy. Experience with 50 cases treated by means of extensive laminectomy, foraminotomy, and excision of osteophytes during the past 10 years. Acta Neurochir (Wien) 1982;61(1-3):89–104. doi: 10.1007/BF01740074. [DOI] [PubMed] [Google Scholar]
  18. Epstein J. A. The surgical management of cervical spinal stenosis, spondylosis, and myeloradiculopathy by means of the posterior approach. Spine (Phila Pa 1976) 1988 Jul;13(7):864–869. doi: 10.1097/00007632-198807000-00031. [DOI] [PubMed] [Google Scholar]
  19. Epstein N. E., Hyman R. A., Epstein J. A., Rosenthal A. D. "Dynamic" MRI scanning of the cervical spine. Spine (Phila Pa 1976) 1988 Aug;13(8):937–938. doi: 10.1097/00007632-198808000-00015. [DOI] [PubMed] [Google Scholar]
  20. Fujiwara K., Yonenobu K., Ebara S., Yamashita K., Ono K. The prognosis of surgery for cervical compression myelopathy. An analysis of the factors involved. J Bone Joint Surg Br. 1989 May;71(3):393–398. doi: 10.1302/0301-620X.71B3.2722928. [DOI] [PubMed] [Google Scholar]
  21. Gregorius F. K., Estrin T., Crandall P. H. Cervical spondylotic radiculopathy and myelopathy. A long-term follow-up study. Arch Neurol. 1976 Sep;33(9):618–625. doi: 10.1001/archneur.1976.00500090024005. [DOI] [PubMed] [Google Scholar]
  22. Grüninger W., Gruss P. Stenosis and movement of the cervical spine in cervical myelopathy. Paraplegia. 1982 Jun;20(3):121–130. doi: 10.1038/sc.1982.24. [DOI] [PubMed] [Google Scholar]
  23. Hall D. J., Webb J. K. Anterior plate fixation in spine tumor surgery. Indications, technique, and results. Spine (Phila Pa 1976) 1991 Mar;16(3 Suppl):S80–S83. doi: 10.1097/00007632-199103001-00013. [DOI] [PubMed] [Google Scholar]
  24. Herkowitz H. N. A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine (Phila Pa 1976) 1988 Jul;13(7):774–780. doi: 10.1097/00007632-198807000-00011. [DOI] [PubMed] [Google Scholar]
  25. Herkowitz H. N. A comparison of anterior cervical fusion, cervical laminectomy, and cervical laminoplasty for the surgical management of multiple level spondylotic radiculopathy. Spine (Phila Pa 1976) 1988 Jul;13(7):774–780. doi: 10.1097/00007632-198807000-00011. [DOI] [PubMed] [Google Scholar]
  26. Herkowitz H. N. The surgical management of cervical spondylotic radiculopathy and myelopathy. Clin Orthop Relat Res. 1989 Feb;(239):94–108. [PubMed] [Google Scholar]
  27. Hirabayashi K., Miyakawa J., Satomi K., Maruyama T., Wakano K. Operative results and postoperative progression of ossification among patients with ossification of cervical posterior longitudinal ligament. Spine (Phila Pa 1976) 1981 Jul-Aug;6(4):354–364. doi: 10.1097/00007632-198107000-00005. [DOI] [PubMed] [Google Scholar]
  28. Hukuda S., Ogata M., Mochizuki T., Shichikawa K. Laminectomy versus laminoplasty for cervical myelopathy: brief report. J Bone Joint Surg Br. 1988 Mar;70(2):325–326. doi: 10.1302/0301-620X.70B2.3346317. [DOI] [PubMed] [Google Scholar]
  29. Jamjoom A., Williams C., Cummins B. The treatment of spondylotic cervical myelopathy by multiple subtotal vertebrectomy and fusion. Br J Neurosurg. 1991;5(3):249–255. doi: 10.3109/02688699109005184. [DOI] [PubMed] [Google Scholar]
  30. Jenkins D. H. Extensive cervical laminectomy. Long-term results. Br J Surg. 1973 Nov;60(11):852–854. doi: 10.1002/bjs.1800601105. [DOI] [PubMed] [Google Scholar]
  31. Kamikozuru M. [Significance of the anterior floating method for cervical myelopathy due to the ossification of the posterior longitudinal ligament]. Nihon Seikeigeka Gakkai Zasshi. 1991 Aug;65(8):431–440. [PubMed] [Google Scholar]
  32. LEES F., TURNER J. W. NATURAL HISTORY AND PROGNOSIS OF CERVICAL SPONDYLOSIS. Br Med J. 1963 Dec 28;2(5373):1607–1610. doi: 10.1136/bmj.2.5373.1607. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. LaRocca H. Cervical spondylotic myelopathy: natural history. Spine (Phila Pa 1976) 1988 Jul;13(7):854–855. doi: 10.1097/00007632-198807000-00028. [DOI] [PubMed] [Google Scholar]
  34. Lesoin F., Bouasakao N., Clarisse J., Rousseaux M., Jomin M. Results of surgical treatment of radiculomyelopathy caused by cervical arthrosis based on 1000 operations. Surg Neurol. 1985 Apr;23(4):350–355. doi: 10.1016/0090-3019(85)90205-8. [DOI] [PubMed] [Google Scholar]
  35. McAfee P. C., Regan J. J., Bohlman H. H. Cervical cord compression from ossification of the posterior longitudinal ligament in non-orientals. J Bone Joint Surg Br. 1987 Aug;69(4):569–575. doi: 10.1302/0301-620X.69B4.3112161. [DOI] [PubMed] [Google Scholar]
  36. Montesano P. X., Juach E. C., Anderson P. A., Benson D. R., Hanson P. B. Biomechanics of cervical spine internal fixation. Spine (Phila Pa 1976) 1991 Mar;16(3 Suppl):S10–S16. doi: 10.1097/00007632-199103001-00004. [DOI] [PubMed] [Google Scholar]
  37. Montgomery D. M., Brower R. S. Cervical spondylotic myelopathy. Clinical syndrome and natural history. Orthop Clin North Am. 1992 Jul;23(3):487–493. [PubMed] [Google Scholar]
  38. Morscher E., Sutter F., Jenny H., Olerud S. Die vordere Verplattung der Halswirbelsäule mit dem Hohlschrauben-Plattensystem aus Titanium. Chirurg. 1986 Nov;57(11):702–707. [PubMed] [Google Scholar]
  39. Nakano N., Nakano T., Nakano K. Comparison of the results of laminectomy and open-door laminoplasty for cervical spondylotic myeloradiculopathy and ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976) 1988 Jul;13(7):792–794. doi: 10.1097/00007632-198807000-00014. [DOI] [PubMed] [Google Scholar]
  40. Nurick S. The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain. 1972;95(1):101–108. doi: 10.1093/brain/95.1.101. [DOI] [PubMed] [Google Scholar]
  41. Oiwa T., Hirabayashi K., Uzawa M., Ohira T. Experimental study on postlaminectomy deterioration of cervical spondylotic myelopathy. Influences of intradural surgery and persistent spinal block. Spine (Phila Pa 1976) 1985 Oct;10(8):717–721. doi: 10.1097/00007632-198510000-00005. [DOI] [PubMed] [Google Scholar]
  42. PENNING L. Some aspects of plain radiography of the cervical spine in chronic myelopathy. Neurology. 1962 Aug;12:513–519. doi: 10.1212/wnl.12.8.518. [DOI] [PubMed] [Google Scholar]
  43. Panjabi M., White A., 3rd Biomechanics of nonacute cervical spinal cord trauma. Spine (Phila Pa 1976) 1988 Jul;13(7):838–842. doi: 10.1097/00007632-198807000-00024. [DOI] [PubMed] [Google Scholar]
  44. Parke W. W. Correlative anatomy of cervical spondylotic myelopathy. Spine (Phila Pa 1976) 1988 Jul;13(7):831–837. doi: 10.1097/00007632-198807000-00023. [DOI] [PubMed] [Google Scholar]
  45. Pavlov H., Torg J. S., Robie B., Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method. Radiology. 1987 Sep;164(3):771–775. doi: 10.1148/radiology.164.3.3615879. [DOI] [PubMed] [Google Scholar]
  46. Pouchot J., Watts C. S., Esdaile J. M., Hill R. O. Sudden quadriplegia complicating ossification of the posterior longitudinal ligament and diffuse idiopathic skeletal hyperostosis. Arthritis Rheum. 1987 Sep;30(9):1069–1072. doi: 10.1002/art.1780300917. [DOI] [PubMed] [Google Scholar]
  47. REID J. D. Effects of flexion-extension movements of the head and spine upon the spinal cord and nerve roots. J Neurol Neurosurg Psychiatry. 1960 Aug;23:214–221. doi: 10.1136/jnnp.23.3.214. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. ROBINSON R. A., SOUTHWICK W. O. Surgical approaches to the cervical spine. Instr Course Lect. 1960;17:299–330. [PubMed] [Google Scholar]
  49. Raynor R. B. Anterior or posterior approach to the cervical spine: an anatomical and radiographic evaluation and comparison. Neurosurgery. 1983 Jan;12(1):7–13. doi: 10.1227/00006123-198301000-00002. [DOI] [PubMed] [Google Scholar]
  50. Raynor R. B., Pugh J., Shapiro I. Cervical facetectomy and its effect on spine strength. J Neurosurg. 1985 Aug;63(2):278–282. doi: 10.3171/jns.1985.63.2.0278. [DOI] [PubMed] [Google Scholar]
  51. Ripa D. R., Kowall M. G., Meyer P. R., Jr, Rusin J. J. Series of ninety-two traumatic cervical spine injuries stabilized with anterior ASIF plate fusion technique. Spine (Phila Pa 1976) 1991 Mar;16(3 Suppl):S46–S55. doi: 10.1097/00007632-199103001-00009. [DOI] [PubMed] [Google Scholar]
  52. Rosenørn J., Hansen E. B., Rosenørn M. A. Anterior cervical discectomy with and without fusion. A prospective study. J Neurosurg. 1983 Aug;59(2):252–255. doi: 10.3171/jns.1983.59.2.0252. [DOI] [PubMed] [Google Scholar]
  53. Rowland L. P. Surgical treatment of cervical spondylotic myelopathy: time for a controlled trial. Neurology. 1992 Jan;42(1):5–13. doi: 10.1212/wnl.42.1.5. [DOI] [PubMed] [Google Scholar]
  54. Saunders R. L., Bernini P. M., Shirreffs T. G., Jr, Reeves A. G. Central corpectomy for cervical spondylotic myelopathy: a consecutive series with long-term follow-up evaluation. J Neurosurg. 1991 Feb;74(2):163–170. doi: 10.3171/jns.1991.74.2.0163. [DOI] [PubMed] [Google Scholar]
  55. Saunders R. L., Bernini P. M., Shirreffs T. G., Jr, Reeves A. G. Central corpectomy for cervical spondylotic myelopathy: a consecutive series with long-term follow-up evaluation. J Neurosurg. 1991 Feb;74(2):163–170. doi: 10.3171/jns.1991.74.2.0163. [DOI] [PubMed] [Google Scholar]
  56. Selladurai B. M. Cervical myelopathy due to nuclear herniations in young adults: clinical and radiological profile, results of microdiscectomy without interbody fusion. J Neurol Neurosurg Psychiatry. 1992 Jul;55(7):604–608. doi: 10.1136/jnnp.55.7.604. [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Smith M. D., Bolesta M. J., Leventhal M., Bohlman H. H. Postoperative cerebrospinal-fluid fistula associated with erosion of the dura. Findings after anterior resection of ossification of the posterior longitudinal ligament in the cervical spine. J Bone Joint Surg Am. 1992 Feb;74(2):270–277. [PubMed] [Google Scholar]
  58. Stauffer E. S., Kelly E. G. Fracture-dislocations of the cervical spine. Instability and recurrent deformity following treatment by anterior interbody fusion. J Bone Joint Surg Am. 1977 Jan;59(1):45–48. [PubMed] [Google Scholar]
  59. Symon L., Lavender P. The surgical treatment of cervical spondylotic myelopathy. Neurology. 1967 Feb;17(2):117–127. doi: 10.1212/wnl.17.2.117. [DOI] [PubMed] [Google Scholar]
  60. Taylor J., Johnston R. A., Caird F. I. Surgical treatment of cervical spondylotic myelopathy in elderly patients. Age Ageing. 1991 Nov;20(6):407–412. doi: 10.1093/ageing/20.6.407. [DOI] [PubMed] [Google Scholar]
  61. Tencer A. F., Allen B. L., Jr, Ferguson R. L. A biomechanical study of thoracolumbar spinal fractures with bone in the canal. Part I. The effect of laminectomy. Spine (Phila Pa 1976) 1985 Jul-Aug;10(6):580–585. doi: 10.1097/00007632-198507000-00013. [DOI] [PubMed] [Google Scholar]
  62. Tsuyama N. Ossification of the posterior longitudinal ligament of the spine. Clin Orthop Relat Res. 1984 Apr;(184):71–84. [PubMed] [Google Scholar]
  63. Ulrich C., Woersdoerfer O., Kalff R., Claes L., Wilke H. J. Biomechanics of fixation systems to the cervical spine. Spine (Phila Pa 1976) 1991 Mar;16(3 Suppl):S4–S9. doi: 10.1097/00007632-199103001-00003. [DOI] [PubMed] [Google Scholar]
  64. Walker J., Gillespie R., Davis J., Dawson W. Water-soluble contrast medium for intraoperative evaluation of anterior cervical discectomy. Technical note. J Neurosurg. 1988 Mar;68(3):491–492. doi: 10.3171/jns.1988.68.3.0491. [DOI] [PubMed] [Google Scholar]
  65. White A. A., 3rd, Jupiter J., Southwick W. O., Panjabi M. M. An experimental study of the immediate load bearing capacity of three surgical constructions for anterior spine fusions. Clin Orthop Relat Res. 1973 Mar-Apr;(91):21–28. doi: 10.1097/00003086-197303000-00005. [DOI] [PubMed] [Google Scholar]
  66. White A. A., 3rd, Panjabi M. M. Biomechanical considerations in the surgical management of cervical spondylotic myelopathy. Spine (Phila Pa 1976) 1988 Jul;13(7):856–860. doi: 10.1097/00007632-198807000-00029. [DOI] [PubMed] [Google Scholar]
  67. White A. A., 3rd, Southwick W. O., Deponte R. J., Gainor J. W., Hardy R. Relief of pain by anterior cervical-spine fusion for spondylosis. A report of sixty-five patients. J Bone Joint Surg Am. 1973 Apr;55(3):525–534. [PubMed] [Google Scholar]
  68. Whitecloud T. S., 3rd Anterior surgery for cervical spondylotic myelopathy. Smith-Robinson, Cloward, and vertebrectomy. Spine (Phila Pa 1976) 1988 Jul;13(7):861–863. doi: 10.1097/00007632-198807000-00030. [DOI] [PubMed] [Google Scholar]
  69. Yoo J. U., Zou D., Edwards W. T., Bayley J., Yuan H. A. Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine. Spine (Phila Pa 1976) 1992 Oct;17(10):1131–1136. doi: 10.1097/00007632-199210000-00001. [DOI] [PubMed] [Google Scholar]
  70. Yoshida M., Otani K., Shibasaki K., Ueda S. Expansive laminoplasty with reattachment of spinous process and extensor musculature for cervical myelopathy. Spine (Phila Pa 1976) 1992 May;17(5):491–497. doi: 10.1097/00007632-199205000-00004. [DOI] [PubMed] [Google Scholar]
  71. Zdeblick T. A., Bohlman H. H. Cervical kyphosis and myelopathy. Treatment by anterior corpectomy and strut-grafting. J Bone Joint Surg Am. 1989 Feb;71(2):170–182. [PubMed] [Google Scholar]

Articles from The Yale Journal of Biology and Medicine are provided here courtesy of Yale Journal of Biology and Medicine

RESOURCES