Surgery for cervical radiculomyelopathy

Cervical spondylosis, or degeneration (wear and tear of the bones and discs in the neck), is a very common condition affecting most of us at some point in our lives. It is frequently related to strain of the supporting muscles or wear and tear of the discs that connect the individual bones (vertebrae) that form the spine, resulting in neck pain. Radiculopathy is pain, weakness or reduced reflexes that follow the path of nerves that come from the neck region. Myelopathy is spasticity and weakness in the lower limbs with or without "numb and clumsy" hands.

Most people with degeneration in the neck area may have no symptoms. In 10% to 15% of cases, the condition worsens to the extent that surgery is recommended. Surgery is aimed at improving these problems, but it is unclear which type of surgical procedure is best and how effective it is.

This review of two trials with 149 patients found no conclusive evidence to support surgical treatment for people with degeneration, radiculopathy or myelopathy. Possible limitations of this review include the the lack of large trials and the risk of bias associated with these studies. Further research is very likely to change the estimate of effects and our confidence in the results.

Future large-scale randomised trials with better methods are needed to provide clear evidence on the balance between risk and benefit from surgery for individuals with cervical degeneration with radiculopathy or myelopathy.

Authors' conclusions: 

Both small trials had significant risks of bias and do not provide reliable evidence on the effects of surgery for cervical spondylotic radiculopathy or myelopathy. It is unclear whether the short-term risks of surgery are offset by long-term benefits. Further research is very likely to have an impact on the estimate of effect and our confidence in it.

There is low quality evidence that surgery may provide pain relief faster than physiotherapy or hard collar immobilization in patients with cervical radiculopathy; but there is little or no difference in the long-term.

There is very low quality evidence that patients with mild myelopathy feel subjectively better shortly after surgery, but there is little or no difference in the long-term.

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Background: 

Cervical spondylosis causes pain and disability by compressing the spinal cord or roots. Surgery to relieve the compression may reduce the pain and disability, but is associated with a small but definite risk. .

Objectives: 

To determine whether: 1) surgical treatment of cervical radiculopathy or myelopathy is associated with improved outcome, compared with conservative management and 2) timing of surgery (immediate or delayed pending persistence/progression of relevant symptoms and signs) has an impact on outcome.

Search strategy: 

We searched CENTRAL, MEDLINE, and EMBASE to 1998 for the original review. A revised search was run in CENTRAL (The Cochrane Library 2008, Issue 2), MEDLINE, EMBASE, and CINAHL (January 1998 to June 2008) to update the review.

Authors of the identified randomised controlled trials were contacted for additional published or unpublished data.

Selection criteria: 

All randomised or quasi-randomised controlled trials allocating patients with cervical radiculopathy or myelopathy to 1) "medical management" or "decompressive surgery (with or without fusion) plus medical management" 2) "early decompressive surgery" or "delayed decompressive surgery".

Data collection and analysis: 

Two authors independently selected trials, assessed risk of bias and extracted data.

Main results: 

Two trials (N = 149) were included. In both trials, allocation concealment was inadequate and arrangements for blinding of outcome assessment were unclear.

One trial (81 patients with cervical radiculopathy) found that surgical decompression was superior to physiotherapy or cervical collar immobilization in the short-term for pain, weakness or sensory loss; at one year, there were no significant differences between groups.

One trial (68 patients with mild functional deficit associated with cervical myelopathy) found no significant differences between surgery and conservative treatment in three years following treatment. A substantial proportion of cases were lost to follow-up.

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