Cervical Myelopathy: Symptoms, Tests and When to Operate

Degenerative cervical myelopathy occurs when the spinal cord is compressed in the neck due to wear-and-tear changes (discs, osteophytes, and ligaments). It causes hand clumsiness, gait instability, stiffness, and, in advanced stages, urinary problems. Diagnosis is based on neurological examination and MRI confirmation of compression. In moderate–severe or progressive disease, surgical decompression is the standard treatment; in mild and stable cases, conservative management with close follow-up may be considered.

• Cervical myelopathy is dysfunction of the spinal cord due to compression in the cervical spine.
• Key signs: hand clumsiness, falls, stiffness, hyperreflexia, unsteady gait, sphincter disturbances.
• Diagnosis: neurological examination + MRI; the mJOA scale guides clinical severity.
• When to operate: if there is moderate–severe severity, clinical progression, or objective neurological deficits.
• Emergencies: sudden loss of strength, repeated falls, loss of bladder/bowel control, or fever with severe neck pain.

What is cervical myelopathy?

Degenerative cervical myelopathy (DCM) is a neurological disorder caused by chronic compression of the spinal cord in the cervical region. Degenerative changes of the intervertebral disc, osteophyte formation, thickening of the ligamentum flavum, and ossification of the posterior longitudinal ligament (OPLL) reduce the diameter of the spinal canal and compromise the cord tissue through mechanical, ischemic, and inflammatory mechanisms.

Symptoms and warning signs

• Hand clumsiness: difficulty buttoning, writing, or handling small objects.
• Unsteady gait and imbalance, with risk of falls.
• Hyperreflexia, Hoffmann or Babinski sign, and stiffness.
• Neck pain and stiffness of varying intensity.
• Paresthesias (tingling) and weakness in hands and arms.
• Urinary urgency or incontinence in advanced stages.

The onset of pyramidal signs, falls, or sphincter disturbances warrants prompt evaluation due to the risk of irreversible neurological deterioration.

How it is diagnosed (exam, MRI, mJOA)

Neurological examination

Includes strength, sensation, reflexes, coordination and gait tests, and the search for signs of pyramidal tract involvement (Hoffmann, Babinski, clonus).

Imaging tests

MRI is the test of choice to confirm cord compression and assess cord changes (e.g., hyperintensity compatible with myelomalacia). CT complements bony evaluation, especially in OPLL or marked osteophytes.

mJOA scale

The mJOA scale (0–18) classifies functional severity: mild (15–17), moderate (12–14), and severe (≤11). It helps to objectify symptoms and guide therapeutic and follow-up decisions.

Treatments: conservative vs surgical

Conservative management (mild and stable cases)

• Postural education and cervical protection measures in daily life.
• Physical therapy focused on balance, coordination, and strength; avoid high-velocity manipulations.
• Pain management and, if appropriate, neuromodulators for neuropathic pain.
• Close clinical follow-up and MRI if symptoms change or progress.

Surgical treatment (standard in moderate–severe or progressive cases)

The goal is to decompress the spinal cord and, when indicated, stabilize the spine. Approach choice depends on affected levels, cervical alignment, and presence of OPLL:

• Anterior approaches: discectomy and fusion (ACDF) or arthroplasty in selected cases.
• Posterior approaches: laminoplasty or laminectomy with or without instrumentation.

In general, early intervention is associated with better functional outcomes and less long-term disability.

Benefits and risks of surgery

Expected benefits

• Improvement in gait, balance, and manual dexterity.
• Reduction of paresthesias and/or associated neuropathic pain.
• Stopping the progression of neurological deficit.

Risks and adverse effects

• Infection, hematoma, or neurological injury (uncommon).
• Transient dysphagia or hoarseness in anterior approaches.
• Pseudarthrosis, shoulder/neck pain, or heterotopic ossification (arthroplasty).
• Adjacent segment syndrome in long-term fusions.

Indication should be individualized, explaining options, benefits, and risks in clear informed consent.

Practical referral criteria

• Objective neurological deficit (strength, sensation) or pyramidal signs.
• Gait instability and falls.
• Symptom progression or sphincter involvement.
• Reasonable diagnostic doubt of cervical myelopathy in primary care.

Delays in specialist assessment may worsen functional prognosis.

Realistic recovery times

• Hospital stay: 24–72 hours in many cases, depending on technique and levels.
• Walking: within first 24 hours, with early physical therapy.
• Return to work: 2–6 weeks for office work; 6–12 weeks or more for physical jobs.
• Neurological improvement: can continue for up to 6–12 months, linked to initial severity.

When to go to the ER

• Sudden loss of strength in arms or legs.
• Repeated falls or sudden worsening of gait.
• Loss of bladder or bowel control.
• Fever with severe neck pain.

These scenarios require urgent attention to rule out acute compression or complications.

Myths and realities

• “Physical therapy always cures it” → In moderate–severe DCM, surgery is often the standard to prevent deterioration.
• “If it doesn’t hurt, it’s not serious” → Motor and sensory deficits can occur without severe neck pain.
• “It’s better to wait” → In progressive cases, delaying surgery worsens outcomes; in stable mild cases, conservative management with monitoring may be considered.

Patient checklist

• Record symptoms (onset, progression, falls, sphincters).
• Gather previous tests and a recent MRI if possible.
• Ask for your mJOA score and realistic goals.
• Clarify doubts about anterior or posterior approach, levels, and need for fusion.
• Understand risks, rehab plan, and warning signs.

FAQs

Glossary

DCM: Degenerative cervical myelopathy; spinal cord dysfunction due to chronic compression in the neck.

OPLL: Ossification of the posterior longitudinal ligament; may narrow the spinal canal.

Ligamentum flavum: Elastic posterior band that can thicken and invade the canal with degeneration.

mJOA: Functional scale from 0–18 points that classifies DCM severity.

Decompression: Surgery aimed at relieving spinal cord compression.

ACDF: Anterior cervical discectomy and fusion; technique to decompress and stabilize.

References

• Dr. Vicenç Gilete – Neurosurgeon and Spine Surgeon
• Updates in DCM concepts (Journal of Spine Surgery, 2024).
• Systematic review and meta-analysis of outcomes after DCM surgery (NASS Open Access, 2025).
• WFNS Spine Committee recommendations for cervical spondylotic myelopathy (Neurospine, 2019).
• Guidelines and summaries for primary care on diagnosis and referral in cervical myelopathy.