Diagnosis and Management of Degenerative Cervical Myelopathy

The treatment of degenerative cervical myelopathy (DCM), which encompasses cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament, has progressed markedly over the past few decades. The natural history of DCM includes multiple phenotypes: a slow deterioration, a stepwise pattern of decline, and rapidly progressive functional decline. Symptoms include gait disturbance, decreased fine motor abilities, weakness, sensory changes, and neck pain. Classically, those with minimal or early symptoms were treated conservatively with observation; however, newer investigations suggest evidence for early surgical treatment. Those with objective myelopathic symptoms confirmed by imaging demonstrating spinal cord compression are indicated for surgery. Surgical treatment can be accomplished with multiple different technical approaches including anteriorly based surgery, posteriorly based surgery, and combined techniques. Traditionally, anterior surgery included anterior cervical diskectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF), but increasing investigations incorporate cervical disk arthroplasty in this cohort of patients. Historically, laminectomy for posterior decompression was a hallmark of treatment in DCM; however, this led to complications such as postlaminectomy kyphosis and instability which has led to substitution of this treatment by laminoplasty and laminectomy + fusion. Surgical adjuncts such as Riluzole have demonstrated promise in the treatment of DCM patients. Success in surgical treatment is defined by decompression of the spinal cord to halt progression of symptoms and in some patients improve function. Although surgical treatment has yielded success in the treatment of DCM, perioperative complications can be devastating which make surgical technique and patient selection paramount.