The natural history of cervical spondylotic myelopathy

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  • 1 Division of Neurological Surgery, University of Alabama, Birmingham, Alabama;
  • | 2 Departments of Orthopaedic Surgery and
  • | 11 Neurological Surgery, University of Wisconsin, Madison, Wisconsin;
  • | 3 Division of Neurosurgery, David Geffen School of Medicine, University of California at Los Angeles, California;
  • | 4 Department of Neurosurgery, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts;
  • | 5 Department of Neurosurgery, University of Medicine and Dentistry of New Jersey—New Jersey Medical School, Newark, New Jersey;
  • | 6 Department of Neurological Surgery, Neurological Institute, Columbia University, New York, New York;
  • | 7 Department of Neurosurgery, University of California at San Francisco, California;
  • | 8 Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa;
  • | 9 Department of Neurosurgery, Mount Sinai School of Medicine, New York, New York; and
  • | 10 Department of Orthopaedic Surgery, Milton S. Hershey Medical Center, Pennsylvania State College of Medicine, Hershey, Pennsylvania
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Object

The objective of this systematic review was to use evidence-based medicine to delineate the natural history of cervical spondylotic myelopathy (CSM) and identify factors associated with clinical deterioration.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the natural history of CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

Results

The natural history of CSM is mixed: it may manifest as a slow, stepwise decline or there may be a long period of quiescence (Class III). Long periods of severe stenosis are associated with demyelination and may result in necrosis of both gray and white matter. With severe and/or long lasting CSM symptoms, the likelihood of improvement with nonoperative measures is low. Objectively measurable deterioration is rarely seen acutely in patients younger than 75 years of age with mild CSM (modified Japanese Orthopaedic Association scale score > 12; Class I). In patients with cervical stenosis without myelopathy, the presence of abnormal electromyography findings or the presence of clinical radiculopathy is associated with the development of symptomatic CSM in this patient population (Class I).

Conclusions

The natural history of CSM is variable, which may affect treatment decisions.

Abbreviations used in this paper:

AP = anteroposterior; ADL = activities of daily living; CSM = cervical spondylotic myelopathy; EMG = electromyography; ISI = increased signal intensity; JOA = Japanese Orthopaedic Association; mJOA = modified JOA; ROM = range of motion; SEP = somatosensory evoked potential.

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