Nonoperative Management of Cervical Myelopathy

Nonoperative Management of Cervical Myelopathy

The authors conducted this systematic review to examine the evidence of the effectiveness, and safety of nonoperative treatment for individuals with cervical myelopathy, whether the severity of myelopathy affects outcomes of nonoperative treatment, and whether particular activities or minor injuries are associated with neurologic deterioration in patients with myelopathy or asymptomatic stenosis being treated nonoperatively. Not a great deal is known about the appropriate role of nonoperative treatment as applied to cervical myelopathy, which is ordinarily considered a surgical disorder. A systematic search was conducted in PubMed and the Cochrane Collaboration Library for articles published between January 1, 1956 and November 20, 2012. The authors included all articles that compared nonoperative treatments or observation to surgery in patients with cervical myelopathy or asymptomatic cervical cord compression to determine their effects on clinical outcomes, including myelopathy scales (JOA, Nurick), general health scores (SF36), and pain (neck and arm).. Nonoperative treatments included physical therapy, medications, injections, orthoses, and traction. They also searched for articles evaluating the effect of specific activities or minor trauma in neurologic outcomes. Case reports and studies with less than 10 patients in the exposure group were excluded. Of 54 citations identified from their search, 5 studies reported in 6 articles met inclusion criteria. In one randomized controlled study, there was low evidence that nonoperative treatment may yield equivalent or better outcomes versus surgery in those with mild myelopathy. For moderate to severe myelopathy, nonoperative treatment had inferior outcomes versus surgery in two cohort studies, despite the fact that surgically treated patients were worse at baseline. There was not enough evidence to determine whether specific activities or minor trauma are risk factors for neurologic deterioration in those with myelopathy or asymptomatic cord compression.

There is a scarcity of evidence for nonoperative treatment of cervical myelopathy, and additional studies are required to more definitively determine its role. In particular for the patient with milder degrees of myelopathy, randomized studies comparing nonoperative to surgical treatment would be particularly helpful, as would trials comparing specific types of nonoperative treatments to the natural history of myelopathy.Because myelopathy is known to be a typically progressive disorder and there is not much evidence that nonoperative treatment halts or reverses its progression, they recommended not routinely prescribing nonoperative treatment as the primary modality in patients with moderate to severe myelopathy. They also suggested that if there is a role for nonoperative treatment as a primary treatment modality, it may be in the patient with mild myelopathy. However, it is not clear which specific forms of nonoperative treatment provide any benefit over the natural history. The authors suggested that if nonoperative treatment is chosen care be taken to observe for neurological deterioration. They went on to say that in individuals with asymptomatic spondylotic cord compression but no clinical myelopathy, the available literature neither supports nor refutes the notion that minor trauma is a risk factor for neurologic deterioration. They suggested that patients should be counseled about this uncertainty. Finally, the authors added that in those with a clinical diagnosis of CSM but no OPLL, the available studies did not specifically address the issue of neurologic deterioration secondary to minor trauma. However, in those with underlying OPLL, trauma may be more likely to cause worsening of existing myelopathy or even trigger symptoms in those who were previously asymptomatic. It was their recommendation that patients be counseled about these possibilities.

Neck Pain

Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, neck pain ranked 4th highest in terms of disability and 21st in terms of overall burden.

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