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Nonoperative Management of Cervical Myelopathy: A Systematic Review

Rhee, John M. MD*; Shamji, Mohammed F. MD, PhD, FRCSC; Erwin, W. Mark DC, PhD; Bransford, Richard J. MD§; Yoon, S. Tim MD, PhD*; Smith, Justin S. MD, PhD; Kim, Han Jo MD; Ely, Claire G. BS**; Dettori, Joseph R. MPH, PhD**; Patel, Alpesh A. MD, FACS††; Kalsi-Ryan, Sukhvinder BScPT, MSc, PhD‡‡

doi: 10.1097/BRS.0b013e3182a7f41d
Role of Non-Surgical Management in Cervical Spondylotic Myelopathy

Study Design. Systematic review.

Objective. To conduct a systematic review investigating the evidence of (1) efficacy, effectiveness, and safety of nonoperative treatment of patients with cervical myelopathy; (2) whether the severity of myelopathy affects outcomes of nonoperative treatment; and (3) whether specific activities or minor injuries are associated with neurological deterioration in patients with myelopathy or asymptomatic stenosis being treated nonoperatively.

Summary of Background Data. Little is known about the appropriate role of nonoperative treatment in the management of cervical myelopathy, which is typically considered a surgical disorder.

Methods. A systematic search was conducted in PubMed and the Cochrane Collaboration Library for articles published between January 1, 1956, and November 20, 2012. We included all articles that compared nonoperative treatments or observation with surgery for patients with cervical myelopathy or asymptomatic cervical cord compression to determine their effects on clinical outcomes, including myelopathy scales (Japanese Orthopaedic Association, Nurick), general health scores (36-Item Short Form Health Survey), and pain (neck and arm). Nonoperative treatments included physical therapy, medications, injections, orthoses, and traction. We also searched for articles evaluating the effect of specific activities or minor trauma in neurological outcomes. Case reports and studies with less than 10 patients in the exposure group were excluded.

Results. Of 54 citations identified from our search, 5 studies reported in 6 articles met inclusion criteria. In 1 randomized controlled study, there was low evidence that nonoperative treatment may yield equivalent or better outcomes than surgery in those with mild myelopathy. For moderate to severe myelopathy, nonoperative treatment had inferior outcomes versus surgery in 2 cohort studies, despite the fact that surgically treated patients were worse at baseline. There was insufficient evidence to determine whether specific activities or minor trauma is a risk factor for neurological deterioration in those with myelopathy or asymptomatic cord compression.

Conclusion. There is a paucity of evidence for nonoperative treatment of cervical myelopathy, and further studies are needed to determine its role more definitively. In particular, for the patient with milder degrees of myelopathy, randomized studies comparing nonoperative with surgical treatment would be particularly helpful, as would trials comparing specific types of nonoperative treatments with the natural history of myelopathy.

Evidence-Based Clinical Recommendations.

Recommendation 1. Because myelopathy is known to be a typically progressive disorder and there is little evidence that nonoperative treatment halts or reverses its progression, we recommend not routinely prescribing nonoperative treatment as the primary modality in patients with moderate to severe myelopathy.

Overall Strength of Evidence. Low

Strength of Recommendation. Strong

Recommendation 2. 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 compared with the natural history. If nonoperative treatment is selected, we suggest care be taken to observe for neurological deterioration.

Overall Strength of Evidence. Low

Strength of Recommendation. Weak

Recommendation 3. In those 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 neurological deterioration. We suggest that patients should be counseled about this uncertainty.

Overall Strength of Evidence. Low

Strength of Recommendation. Weak

Recommendation 4. In those with a clinical diagnosis of cervical spondylotic myelopathy but no ossification of the posterior longitudinal ligament, the available studies did not specifically address the issue of neurological deterioration secondary to minor trauma. However, in those with underlying ossification of the posterior longitudinal ligament, trauma may be more likely to cause worsening of existing myelopathy or even initiate symptoms in those who were previously asymptomatic. We suggest that patients should be counseled about these possibilities.

Overall Strength of Evidence. Low

Strength of Recommendation. Weak

Supplemental Digital Content is Available in the Text.In a systematic review, there was a paucity of evidence supporting the use of nonoperative treatment in cervical myelopathy. Given the progressive nature of myelopathy, nonoperative treatment should not be routinely recommended.

*Emory Spine Center, Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA

Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada

Division of Orthopaedic Surgery, The Spine Programme, Toronto Western Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada

§Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA

Department of Neurosurgery, University of Virginia, Charlottesville, VA

Hospital for Special Surgery, Spine and Scoliosis Service, New York, NY

**Spectrum Research, Inc., Tacoma, WA

††Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; and

‡‡Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.

Address correspondence and reprint requests to John M. Rhee, MD, Emory Spine Center, Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park South #3000, Atlanta, GA 30329; E-mail:

Acknowledgment date: March 4, 2013. First revision date: May 19, 2013. Second revision date: July 25, 2013. Third revision date: July 31, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Supported by AOSpine North America, Inc. Analytic support for this work was provided by Spectrum Research, Inc., with funding from the AOSpine North America.

Relevant financial activities outside the submitted work: board membership, consultancy, royalties, stock/stock options, support for travel, fees for participation in review activities, payment for writing or reviewing the manuscript, expert testimony, grants/grants pending, payment for lectures, patents, payment for development of educational presentations, provision of writing assistance, medicines, equipment, or administrative support, and travel/accommodations/meeting expenses.

© 2013 by Lippincott Williams & Wilkins