Choosing the right treatment for degenerative cervical myelopathy

Degenerative cervical myelopathy (DCM) is a progressive degenerative disorder of the spinal cord that can lead to significant and irreversible neurological deficits if left untreated. Determining the most appropriate treatment strategy requires a thorough assessment of disease severity, patient-specific factors, and comparative benefits of surgical versus non-surgical interventions. Conservative treatment, including physical therapy, pharmacological treatment, and lifestyle modifications, might be considered for patients with mild symptoms and those deemed unsuitable for surgery. However, for cases with moderate to severe myelopathy or progressive neurological deterioration, surgical treatment remains the gold standard. Surgical options-including anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), laminoplasty, and laminectomy with or without fusion-should be selected based on the pattern of spinal cord compression, sagittal alignment, and patient comorbidities. ACDF and ACCF are preferred for focal anterior compression at limited levels, whereas laminoplasty is generally indicated for multilevel posterior compression in patients with preserved cervical lordosis. For cases with cervical kyphosis or significant instability, laminectomy with fusion is often required. In certain complex cases, a combined anterior-posterior approach may be necessary to achieve adequate decompression, restore spinal alignment, and enhance stability, particularly in patients with severe deformities or multilevel involvement. Recent advances in minimally invasive spine surgery and motion-preserving techniques, such as cervical disc arthroplasty (CDA), have broadened the spectrum of treatment options, offering potential benefits for reducing perioperative morbidity and preserving segmental motion. Additionally, acute spinal cord injury due to trauma in a spondylotic spine, particularly central cord syndrome (CCS), represents a critical consideration in treatment planning. The role of anterior versus posterior surgery, including the rationale for decision-making, has been expanded to highlight key factors such as sagittal vertical axis, T1 slope, and spinal alignment. Moreover, we discuss the role of laminectomy without fusion in DCM management, evaluating its indications and limitations. Decision-making must carefully weigh patient-reported outcomes, complication risks, and long-term functional prognosis. This review provides an expert synthesis of current evidence and guidelines for DCM treatment, integrating the latest surgical innovations and a patient-centered approach to optimize clinical outcomes.