Treatment/Management

Introduction

To help with decisions regarding management of people with DCM, evidence-based international guidelines have recently been created by AO Spine and the Cervical Spine Research Society [1]. It is recommended to urgently refer anyone with DCM to a spinal specialist for a full assessment [2]. People with moderate (mJOA 12–14) or severe (mJOA ≤11) DCM will likely be offered surgery. People with mild (mJOA 15–17) DCM will be offered either surgery or a supervised trial of structured rehabilitation, with regular follow up and progression to surgery in the event of neurological deterioration or failure to improve [1].

People with asymptomatic spinal cord compression without signs or symptoms of radiculopathy will be counselled on their risk of progression and the symptoms and signs of myelopathy, but will not be offered prophylactic surgery. People with asymptomatic cord compression and evidence of radiculopathy will be offered either surgical or non-surgical intervention. Non-surgical intervention entails a supervised trial of structured rehabilitation, with progression to surgery if the person develops symptoms or signs of myelopathy [1].

Surgical

The aim of surgery is to alleviate the mechanical stress on the spinal cord [1]. There are both anterior approaches, such as anterior cervical discectomy and fusion, and posterior surgical approaches, such as laminectomy. At present there is no clear evidence that one technique is superior to another [2,3]. A posterior approach is often favoured for ossification of the posterior longitudinal ligament or multilevel compression involving mostly posterior pathology, whilst an anterior approach is often favoured for restoring lordosis or for approaching anterior pathology over a limited number of segments [4]. The Cervical Spondylotic Myelopathy Surgical (CSM-S) trial, the first randomised controlled trial of anterior versus posterior surgery for DCM affecting two or more levels, found no difference in function or quality of life outcomes between these approaches [5]. This is discussed in this podcast episode.

The primary aim of surgical intervention is to halt disease progression. However, surgery has also been shown to be effective at improving neurological function, disability, quality of life and pain [6,7]. Nonetheless, recovery is frequently incomplete, and it is not possible to predict the amount or nature of recovery; hence, you should counsel people with DCM that even after surgery they are likely to be left with significant permanent disabilities [1].

Non-Operative Management

This is an option for people with mild DCM or spinal cord compression without myelopathy [1]. Non-surgical management options include bracing, analgesia, therapeutic exercise, manual therapy, bed rest and avoidance of high-risk activities and environments [2]. Whilst there is no clear evidence of harm of structured non-operative treatment, there is little evidence supporting its overall effectiveness or guiding the use of any specific strategy [3–5]. Preoperative physiotherapy should only be advised by specialist spinal services [1]. You should not perform neck manipulation, such as cervical traction, in pre-operative DCM due to the risk of causing further damage to the spinal cord [1]. In a survey of the Myelopathy.org community (n=197), although ~50% of people with DCM had received physiotherapy, only 1 in 5 reported any benefit [6]. A high proportion of people with DCM undergoing non-surgical management will go on to need surgery in the following few years [5].

Electrophysiological Investigations

Clinical electrophysiological studies can be useful adjuncts to MRI imaging both in diagnosing DCM and in ruling out differential diagnoses such as isolated radiculopathy, peripheral neuropathy and motor neurone disease [1–3].

There are many different types of electrophysiological study, including electromyography (EMG), which examines the activity of the muscles, and nerve conduction studies (NCS), which examine the transmission of signals along neural pathways. Mostly these studies are performed only in the periphery, principally to assess for and localise a radiculopathy, or to rule out peripheral neuropathies, brachial plexopathy or peripheral nerve entrapment. Such an examination does not therefore diagnose DCM specifically, but can help by excluding alternative causes or informing the operative strategy [4].

More specialist versions of these tests can be performed, such as somatosensory and motor evoked potentials, which can detect the sensory and motor conduction impairment that occurs in the spinal cord in DCM [3].

Post-Operative Management

Despite surgical treatment, most individuals with DCM will go on to live with lifelong disabilities, including pain [1–3]. The role of post-operative therapies to enhance recovery or manage residual symptoms has not yet been researched [4] and is a recently identified research priority [5].

Once surgical treatment has been completed, healing has taken place (~12 months) and an individual’s recovery has stabilised, it is considered that the risk of manual therapies normalises to that of the general population.

Whilst there is no evidence at this stage, the Myelopathy.org community indicates that a range of different therapies may help, including hydrotherapy, massage, meditation and mindfulness.