NARRATIVE REVIEWS
Cervical Spondylotic Myelopathy
Aditya Iyer, MD, MS,* Tej D. Azad, BA,* and Suzanne Tharin, MD, PhD*w
Abstract: Cervical spondylotic myelopathy (CSM) is a degen-
erative disease that represents the most common spinal cord
disorder in adults. The natural history of the disease can be
insidious, and patients often develop debilitating spasticity and
weakness. Diagnosis includes a combination of physical ex-
amination and various imaging modalities. There are various
surgical options for CSM, consisting of anterior and posterior
procedures. This article summarizes the literature regarding the
pathophysiology, natural history, and diagnosis of CSM, as well
as the various treatment options and their associated risks and
indications.
Key Words: cervical myelopathy, spondylosis, ACDF, lam-
inectomy, corpectomy
(Clin Spine Surg 2016;29:408–414)
EPIDEMIOLOGY AND PATHOPHYSIOLOGY
Cervical spondylotic myelopathy (CSM) is the most
common form of spinal cord injury in adults. Degener-
ative spine disease accounts for 54% of nontraumatic
spinal cord injury in North America with an incidence of
76 per million.1 Approximately 10% of all patients age 55
and over demonstrate clinical CSM, although 50% of
patients in this age group demonstrate radiographic evi-
dence of cervical spondylosis on magnetic resonance
imaging (MRI).2
The pathophysiology of CSM is multifactorial.
Cervical spondylosis is degenerative osteoarthritis of the
cervical spine and is accelerated by excessive motion and
repetitive trauma. Spondylosis generally begins with de-
generative changes in the disk space causing secondary
changes in surrounding soft tissue and bony structures.
Affected structures include the intervertebral disks, facet
joints, uncovertebral joints, posterior longitudinal liga-
ment, and the ligamentum flavum. When patients with
cervical spondylosis develop spinal cord compression
and clinical myelopathy, a diagnosis of CSM is made.
Received for publication February 16, 2016; accepted May 25, 2016.
From the *Department of Neurosurgery, Stanford University School of
Medicine; and wDivision of Neurosurgery, Palo Alto VA, Palo Alto,
CA.
The authors declare no conflict of interest.
Reprints: Suzanne Tharin, MD, PhD, Department of Neurosurgery,
Stanford University, 300 Pasteur Drive, Stanford, CA 94305
(e-mail: stharin@stanford.edu).
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Narrower baseline cervical canal diameters predispose
patients to an earlier onset of CSM.3
NATURAL HISTORY AND PROGNOSTIC
INDICATORS
The natural history of CSM is varied—certain pa-
tients experience a gradual, stepwise decline whereas
others demonstrate a long quiescent period.4 Retro-
spective studies show that 75% of patients with CSM
experience episodic changes in symptoms with stable pe-
riods often lasting months to years.5 Up to 80% of pa-
tients remain stable over a 3-year follow-up period.6 The
fraction of patients who convert to surgery following
failed nonoperative management ranges from 4% to
40%, during a period ranging from 3 to 7 years.7
Although it is not uncommon for patients with
CSM who sustain minor trauma to present with neuro-
logical symptoms such as central cord syndrome, there is
no evidence that minor trauma is a risk factor for neu-
rological deterioration in asymptomatic patients with
radiographic evidence of spondylotic cord compression.8
Bednarik and colleagues studied 199 asymptomatic pa-
tients with radiographic evidence of spondylotic cord
compression for 3.7 years. Only 1 of the 14 patients (7%)
who suffered a minor trauma developed clinical myelop-
athy compared with 24% who developed myelopathy
without any associated trauma. This study concluded that
in asymptomatic patients, trauma was not associated with
the development of clinical myelopathy.9
Age, symptom duration, and preoperative neuro-
logical function have been identified as important prog-
nostic indicators of surgical outcome. For patients in
whom these clinical indicators do not provide adequate
guidance, there is evidence that preoperative sensory
evoked potentials have prognostic utility.10
DIAGNOSIS
The onset of CSM is most often insidious. The
spinocerebellar and corticospinal tracts are generally af-
fected first, and patients often present with gait un-
steadiness and fine motor deficits.11 Patients may
additionally report nonspecific neck and shoulder pain,
with or without radiculopathy. Physical examination
demonstrates lower motor neuron signs at the level of
greatest pathology and upper motor neuron signs at the
levels below. Positive Hoffman’s sign and Babinski re-
flexes are frequently encountered, in addition to hyper-
active reflexes, including clonus. Patients have hand
numbness and hand fine motor deficits, a wide based,
Clin Spine Surg  Volume 29, Number 10, December 2016
Clin Spine Surg  Volume 29, Number 10, December 2016
ataxic gait, and difficulty performing tandem gait. A
prospective study by Rhee et al12 found that 79% of CSM
patients have an objective exam finding, relative to 57%
of healthy, normal patients.
Imaging that assists with the diagnosis of CSM in-
cludes MRI, flexion-extension radiographs, and computed
tomography (CT) scans. MRI demonstrates disk bulges,
disk-osteophyte complexes, facet and ligamentous hyper-
trophy, as well as possible listhesis, all of which contribute
to spinal canal stenosis and spinal cord compression. In-
creased T2 signal is sometimes seen in the spinal cord,
suggesting spinal cord injury, including myelomalacia,
from either cord compression or repetitive trauma. Pa-
tients presenting with multisegmental T2 changes on MRI
often have longstanding CSM.13 An important under-
recognized radiographic feature of CSM is gadolinium
enhancement associated with the site of maximal stenosis.
Enhancement has been reported to persist for months to
years following decompressive surgery.14
Weight-bearing films, including flexion-extension
radiographs, are the definitive study for the assessment of
cervical lordosis and loss thereof. These will also identify
kyphosis and demonstrate whether it is rigid or flexible.
Plain radiographs are also useful in assessing whether
there is any evidence of instability that may predispose to
a repetitive trauma mechanism underlying CSM and will
better demonstrate spondylolisthesis than supine MRI.
CT scans are best for identifying bony and calcific
changes, including calcified disks, ossification of the
posterior longitudinal ligament, and facet hypertrophy.
CT may also demonstrate ankylosis of the uncovertebral
and/or facet joints, important considerations for the re-
storation of lordosis. Finally, noncontrast CT suggests
the course of the vertebral arteries, potentially revealing
anomalies such as tortuous vertebral artery15 or ponti-
culus posticus16 that must be considered before corpec-
tomy and placement of C1 screws, respectively.
All 3 imaging modalities can be used to measure the
canal diameter. The extent of developmental stenosis can
be determined by measuring the Torg-Pavlov ratio, which
is the width of the canal divided by the width of the
vertebral body as measured on a lateral radiograph. A
normal ratio is 1.0, with ratios of <0.8 being indicative of
congenitally narrow canals.17 On axial MRIs and CT
myelograms, it is possible to measure the compression
ratio, which is the narrowest anteroposterior diameter
divided by the broadest transverse diameter of the cer-
vical cord at a single level. A transverse area of <40 mm2
or a ratio of <0.4 correlates strongly with both clinical
and histopathologic evidence of myelopathy.18
Radiographic imaging further provides an oppor-
tunity to assess cervical alignment. Until recently, in-
dications for surgical correction of cervical alignment
were not well-established. Ames et al19 outlined a com-
prehensive assessment framework and normative values
from an asymptomatic population by which to analyze
cervical alignment. An accompanying study correlated
C2–C7 sagittal vertical axis with modified Japanese
Orthopedic Association scores and suggested a relation-
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Cervical Spondylotic Myelopathy
ship between cord volume and myelopathy, on the basis of
sagittal alignment,20 contributing to evidence supporting the
role of cervical alignment in cervical surgery outcomes.21
NONOPERATIVE TREATMENT
Nonoperative interventions, including medications,
immobilization with orthotics, physical therapy, and
spinal injections are sometimes recommended for patients
with mild symptoms, however this is little data to support
this.8 Several retrospective studies have demonstrated no
benefit to rigid immobilization in the absence of surgery
in the treatment of CSM.22–24 Sampath and colleagues
prospectively studied 62 patients with cervical myelop-
athy for 1 year and compared surgery to nonoperative
management, including a combination of orthotics,
physical therapy, and medications. Patients in the surgery
group had improvement in pain and functional status.
Whereas, conservatively managed patients were able to
perform fewer activities of daily living and had pro-
gressive worsening of neurological symptoms.24 Although
degenerative instability may contribute to spondylotic
myelopathy, in the authors’ experience rigid cervical
orthoses tend to hold the patient in relative cervical ex-
tension, a position in which cord trauma from anterior
osteophytes is relatively maximized. For this reason, they
are not part of our management plan.
A new medical treatment option under investigation
is riluzole, an Food and Drug Administration-approved
drug for the treatment of amyotrophic lateral sclerosis.
Currently, a phase III clinical trial (NCT01257828) in-
vestigating the efficacy of riluzole, in addition to surgical
decompression, for CSM is underway.25
SURGICAL TREATMENT OPTIONS AND
OUTCOMES
The goals of surgery for patients with CSM include
decompression of the spinal cord, restoration of cervical
alignment, and treatment of instability if present.26 The
prospective AOSpine CSM North America study in-
dicated that cervical decompression arrests deterioration
and improves neurological outcomes, functional status,
and quality of life (QOL) in patients, regardless of disease
severity.27
Several surgical approaches have been developed to
treat CSM and controversy exists regarding which oper-
ation offers the best clinical outcome with the fewest com-
plications. Common anterior techniques include discectomy
and/or corpectomy and fusion. Posterior operations include
laminectomy and fusion and laminoplasty. It is now be-
coming clear that the complex presentation and pathology
of patients with CSM call for treatments tailored to specific
anatomic and pathologic factors.26
Anterior Techniques—Anterior Cervical
Discectomy and Fusion (ACDF) and Corpectomy
Initially described by Robinson and Smith28 in 1955
and Cloward29 in 1958, the ACDF has become one of the
most common operations for both CSM and cervical
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Iyer et al
radiculopathy. The operation has remained relatively
unchanged, with removal of cervical disk material and
fusion across the disk space through the placement of an
interbody graft.23 The goals of ACDF are direct decom-
pression of the cervical spinal cord from its ventral
pathology, direct and indirect foraminal decompression,
and restoration of cervical lordosis.
ACDF is considered the gold standard treatment
for single-level to 2-level disease and is indicated for an-
terior pathology particularly in the setting of cervical
kyphosis. However, ACDF is relatively contraindicated
in patients with stenosis from primarily posterior path-
ology, with pathology that is primarily located behind the
vertebral body rather than the disk space or with ossifi-
cation of the posterior longitudinal ligament. ACDF is
less commonly performed in patients with >3 levels of
disease.30
Although ACDF is an effective method to decom-
press the anterior spinal cord, restore lordosis, and pre-
serve spinal stability, it has been argued that ACDF is not
optimal for multilevel CSM. Commonly cited reasons
include an inability to achieve complete decompression
behind the midvertebral body, and a greater risk of
pseudarthrosis due to a greater number of graft-host
interfaces.31
An alternative anterior procedure, corpectomy, can
limit the number of graft-host interfaces, facilitate more
extensive decompression including posterior to the ver-
tebral body, and provide abundant local autograft.32
Shortcomings of corpectomy include a slightly higher
incidence of complications, including possible graft ex-
trusion due to the fewer points for ventral plate screw
fixation.33 A meta-analysis by Xiao et al34 found that
ACDF, relative to corpectomy, showed no significant
differences in terms of postoperative Japanese Orthopedic
Association score and fusion rate, but better improved
cervical lordosis and lower complication rate.
Posterior Techniques—Laminectomy and Fusion
and Laminoplasty
The objective of both laminectomy and fusion and
laminoplasty is to decompress the spinal cord. The pri-
mary indication for both procedures is multilevel cord
compression in the absence of kyphosis. Posterior ap-
proaches are contraindicated for patients with irreducible
kyphosis, due to the sagittal bowstring effect,35 whereby
tethering of the spinal cord over the kyphosis causes
neural injury that may be exacerbated by posterior de-
compression.
Laminoplasty is also indicated for multilevel com-
pression but preserves motion and avoids fusion-related
complications. However, it is contraindicated for patients
with neck pain, marked kyphosis (> 13 deg.), and in-
stability resulting from trauma or rheumatoid arthritis.30
The relative effectiveness of these 2 posterior tech-
niques has been extensively studied. The prospective
AOSpine CSM North America study confirmed findings
from retrospective studies, reporting no significant differ-
ences in postoperative functional status and QOL between
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Clin Spine Surg  Volume 29, Number 10, December 2016
patients treated by laminectomy and fusion and those
treated by laminoplasty when treatment choice is left to
the surgeon.36
Combined Approach
Combined (or circumferential) approaches to CSM
are less commonly indicated than pure anterior or pos-
terior operations. Indications include patients with fixed
kyphosis, instability and poor bone quality. A combined
approach may also be considered for patients with severe
kyphotic angulation necessitating decompression of 3 or
more levels to minimize the failure rate.37
Anterior Versus Posterior Approaches
A systematic review by Lawrence et al38 found that
posterior approaches produced a greater increase in sag-
ittal spinal canal diameter and lower rates of dysphagia,
but also greater postoperative axial neck pain rates when
compared with anterior approaches.
A prospective trial by Ghogawala et al39 (n = 50)
found an anterior approach (ACDF) provided patients
with greater improvement in health-related QOL, shorter
length of stay, and lower hospital costs relative to a
posterior approach (laminectomy and fusion). However,
a more recent prospective study (n = 264) reported that
baseline characteristics of patients receiving anterior
(ACDF) or posterior (laminectomy and fusion or lam-
inoplasty) approaches differed: patients receiving anterior
approaches tended to have more focal pathology, be
younger, and have less severe myelopathy than patients
receiving posterior approaches.40 When the authors ad-
justed for baseline differences, they found no significant
differences in functional and QOL outcomes between
anterior or posterior surgical approaches.40 A large pro-
spective, multicenter trial comparing dorsal and ventral
surgical approaches for patients with multilevel CSM is
currently underway (NCT02076113). This study is the
most recent trial to investigate the optimal surgical
treatment of CSM (Table 1).
Electrophysiological (EP) Monitoring
Although EP monitoring is a sensitive tool to assess
potential neurological injury, intraoperative EP worsen-
ing is not specific. EP changes may not represent clinical
worsening and recognition of these changes does not
necessarily prevent neurological injury.41
Complications
Adverse events following surgical management for
CSM range from 6.5% to 16.6%, with rates and specific
complications differing between anterior and posterior
approaches.42 The prospective AOSpine study of CSM
reported a perioperative complication rate (within 30 d of
surgery) of 15.6% and an overall delayed complication
rate (31 d to 2 y following surgery) of 4.4%.43 Occurrence
of perioperative complications has been associated with
increased age, combined procedures, increased operative
time, and greater operative blood loss.
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Clin Spine Surg  Volume 29, Number 10, December 2016
TABLE 1. Current and Completed CSM Trials
Trial ID Title
NCT00876603 Anterior vs. posterior procedures for cervical spondylotic myelopathy:
prospective randomized clinical trial (CSM)
NCT02076113 Cervical spondylotic myelopathy surgical trial
NCT00506558 The CSM trial: a multicenter study comparing ventral to dorsal surgery
for cervical spondylotic myelopathy
NCT00565734 Surgical treatment of cervical spondylotic myelopathy
NCT00285337 Assessment of surgical techniques for treating cervical spondylotic
myelopathy
CSM indicates cervical spondylotic myelopathy.
Anterior Complications
Dysphagia
Rates of dysphagia following anterior cervical sur-
gery have been shown to vary from 0% to 24% and are
contingent upon patient-specific characteristics (eg, mag-
nitude and duration of symptoms).44 Dysphagia has been
reported at higher rates following combined approaches
(21.1%), relative to either anterior (2.3%) or posterior
approaches (0.9%), alone.43 A systematic review by
Lawrence et al38 identified dysphagia rates ranging from
7.1% to 30.8% in anterior groups, relative to no reported
dysphagia in the posterior groups. The risk of dysphagia
following anterior surgery has been associated with older
age, female sex, multilevel surgery, revision procedures,
and involvement of the C4–C5 and C5–C6 levels.44
Recurrent Laryngeal Nerve Palsy (RLNP)
Injury to the recurrent laryngeal nerve during an-
terior spine surgery is a well-documented risk and can
produce hoarseness following surgery by denervation of
the vocal cords. RLNP with vocal cord paralysis may be
asymptomatic. In the setting of revision anterior cervical
surgery, one is obliged to either approach from the same
side as the prior approach or confirm intact vocal cord
function before contralateral approach. A prospective
study reported the incidence of clinically symptomatic
RLNP to be 8.3% following anterior cervical surgery.45
Although there is a theoretical decreased risk of RLNP by
using a left-sided approach, evidence has shown that
RLNP is unrelated to the side of approach.46
Additional Anterior Complications
Additional complications of anterior cervical sur-
gery include vertebral artery injury,47 Horner syndrome,48
postoperative hematoma,49 esophageal injury,50 and
hardware complications.51
Anterior and Posterior Complications
Pseudarthrosis
Pseudarthrosis can produce persistent neck pain
and radicular symptoms. Rates of pseudarthrosis fol-
lowing ACDF range from 1% to 20% for single-level
fusions and up to 50% for multilevel fusions.52 After
single-level corpectomy, the rate of pseudarthrosis has
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Cervical Spondylotic Myelopathy
Phase Intervention Status
— ACDF vs. laminoplasty Recruiting
— ACDF vs. dorsal decompression with Recruiting
fusion or laminoplasty
III ACDF vs. posterior decompression with Completed
or without fusion
IV Anterior vs. posterior approaches Completed
IV Anterior vs. posterior approaches Completed
(laminoplasty or laminectomy)
been reported as be 5.1%, with a 15.2% rate following
2-level corpectomy.53 Rates after posterior laminectomy
and fusion range from 1% to 38%.54 A systematic review
of anterior versus posterior approaches for multilevel
CSM identified 3 studies that analyzed pseudarthrosis.
Among these studies, pseudarthrosis was reported with
postoperative rates of 4%, 7.7%, and 17.6%, in anterior
procedures.38
C5 Palsy
C5 palsy is an established neurological complication
of cervical decompression and generally manifests as de-
layed-onset painful deltoid and biceps weakness, either
unilateral or bilateral, on postoperative day 1 or 2.55
Although its precise etiology remains unknown, pre-
operative spinal cord rotation has been shown to be a
significant predictor of C5 palsy development post-
operatively.56 Furthermore, preexisting formaminal
stenosis increases risk of C5 nerve root palsy,57 which can
be mediated with prophylactic C5 foraminotomy.58
There is ongoing debate regarding the role of width
of laminectomy in the risk of C5 palsy.59 Studies have
identified laminectomy width as a correlative factor for
development of C5 palsy,55 while a study by Klement
et al59 found no association between risk of C5 palsy and
laminectomy width.
No statistically significant difference in the rates of
C5 palsy between anterior and posterior approaches have
been reported.43 A retrospective review of 1001 cases by
Bydon et al60 found that in anterior surgeries, older age
most strongly predicted development of C5 palsy while in
posterior operations, C4–C5 foraminotomy correlated
most strongly. The authors also reported a higher in-
cidence of C5 palsy in corpectomies versus ACDF.
Posterior Complications
Postlaminectomy Kyphosis
Iatrogenic postlaminectomy kyphosis, which can
also be observed following laminoplasty, has been iden-
tified as a cause of progressive myelopathy, postural de-
formity, and intractable pain. The underlying mechanism
is thought to relate to removal of the midline tension
band. In this regard, facet ankylosis, which is part of the
pathology of cervical spondylosis, may actually be pro-
tective. Accordingly, much of the early data regarding
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Iyer et al Clin Spine Surg  Volume 29, Number 10, December 2016

this complication comes from the pediatric literature.61
However, there is increasing evidence identifying post-
laminectomy kyphosis as a significant deleterious com-
plication in adult patients undergoing posterior cervical
surgery for CSM when fusion is not performed.62 The
incidence of postlaminectomy kyphosis in the setting of
CSM in the adult population is approximately 20%.62,63
This is a significant risk and may represent an under-
estimate of the incidence of this complication, as it may
not be seen in short-term follow-up. The cumulative data
suggest that the younger and less spondylotic a patient is,
the more quickly and severely the patient is likely to ky-
phose following cervical laminectomy without fusion.
Authors’ Preferred Treatment
Best treatment practices represent the intersection
of evidence, individual patient characteristics, and the
surgeon’s honest understanding of his own skill set. Di-
agnosis and indications embody the first step in our al-
gorithm (Fig. 1). A partial list of important mimics
includes amyotrophic lateral sclerosis and other motor
neuron diseases, MS, myoclonus and other movement
disorders, and Parsonage-Turner syndrome. All of these
may coexist with some degree of subclinical cervical
spondylosis or degenerative disk disease. A thorough
history and physical examination are the best tools for
distinguishing CSM from myelopathology with incidental

Myelopathic symptoms;
history, physical and
imaging consistent with
CSM

Yes: Diagnosis of CSM. Is No: Full neurologic

patient a surgical medical work up;
candidate? Neurology referral

No: Expectant
Yes: Determine best
management; physical
surgical approach
therapy; No cervical collar

Age >65;
Age <65; no dysphagia; Circumferential
dysphagia/anterior
primarily anterior pathology;kyphosis; poor
scarring; primarily
pathology bone quality
posterior pathology

Lordotic on extension Fixed kyphosis/facet

Posterior decompression:
ACDF/Corpectomy/hybrid films/no facet ankylosis: ankylosis: back-front-back
laminectomy with fusion
construct front-back decompression decompression, deformity
vs. laminoplasty
and fusion correction, fusion

FIGURE 1. Authors’ CSM algorithm. Preferred CSM treatment is determined using a combination of medical and myelopathy
history, physical examination, imaging findings, biomechanical considerations, and specific patient factors. CSM indicates cervical
spondylotic myelopathy.

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Clin Spine Surg  Volume 29, Number 10, December 2016
cervical spondylosis. Once a diagnosis is established, we
determine the patient’s overall surgical candidacy (Fig. 1).
This includes medical fitness for surgery (HbA1c, cardiac
clearance, renal function, anticoagulation and indications,
pulmonary function, life expectancy, etc.) and his informed
consent. We fairly represent the positive and negative as-
pects of the natural history of CSM in the face of which
some patients chose, at least initially, to be managed ex-
pectantly. Once a decision to operate has been made, the
next major question is whether to approach from anterior,
posterior, or both (Fig. 1). In general we favor anterior
procedures in patients younger than 65 without prior neck
irradiation, dysphagia, or significant anterior surgery. Ky-
phosis requires an anterior approach, although in the case
of fixed kyphosis with facet ankylosis the anterior proce-
dure would be part of a more extensive back-front-back
approach. Other advantages of an anterior approach in-
clude more reliable direct and indirect foraminal decom-
pression in our hands, fusion across fewer levels typically,
and the ability to “play (the pathology) as it lays” in cases
of central disk-osteophytes. This tends to be our preferred
approach for disease of up to 3 levels. We favor a posterior
approach in older patients, and in those with a history of
dysphagia, neck irradiation, or extensive prior anterior
cervical spine procedures. Preservation of some lordosis, or
at least an absence of fixed kyphosis on upright dynamic
films, is required for us to approach posteriorly under most
circumstances. We offer, or at least include, posterior de-
compression and fusion for pathology of 4 levels or more.
We tend to offer front-back approaches to patients with a
combination of significant circumferential pathology and
poor bone quality, while we reserve back-front-back pro-
cedures for sagittal deformity correction in patients with
CSM and fixed kyphosis that includes facet ankylosis
(Fig. 1).
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