title: Nonoperative management of cervical myelopathy: a systematic review.
abstract: METHODS
  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.
  
  
  BACKGROUND
  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.
  
  
  CONCLUSIONS
  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:
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Low.
  
  
  METHODS
  Strong.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Low.
  
  
  METHODS
  Weak.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Low.
  
  
  METHODS
  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.
  
  
  METHODS
  Low.
  
  
  METHODS
  Weak.
authors: *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.
authors: John M
authors: JM
authors: Rhee
authors: Mohammed F
authors: MF
authors: Shamji
authors: W Mark
authors: WM
authors: Erwin
authors: Richard J
authors: RJ
authors: Bransford
authors: S Tim
authors: ST
authors: Yoon
authors: Justin S
authors: JS
authors: Smith
authors: Han Jo
authors: HJ
authors: Kim
authors: Claire G
authors: CG
authors: Ely
authors: Joseph R
authors: JR
authors: Dettori
authors: Alpesh A
authors: AA
authors: Patel
authors: Sukhvinder
authors: S
authors: Kalsi-Ryan
mesh_terms: D002574:Cervical Vertebrae / Q000473:pathology* / Q000503:physiopathology / Q000601:surgery; D018450:Disease Progression; D019317:Evidence-Based Medicine / Q000379:methods; D006801:Humans; D013117:Spinal Cord Compression / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D013118:Spinal Cord Diseases / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D055009:Spondylosis / Q000503:physiopathology / Q000601:surgery / Q000628:therapy; D016896:Treatment Outcome