Practitioners participating in patient rehabilitation should be aware of the signs and symptoms of myelopathy in order to help identify early signs of newly diagnosed or (in the case of a surgical complication) recurrent myelopathy. The difficulty in recognizing myelopathy lies within its breadth of clinical complaints, with no single pathognomonic finding. Often, patients will complain of balance or coordination problems, difficulties with fine motor control of the hands, progressive weakness, numbness or tingling of the hands, issues with dropping items, or problems controlling bowel or bladder function. Pain, either in the neck or arms, may or may not be present. Patients may display a wide-based unstable gait, weakness (particularly of the hands), numbness, hyperreflexia or other provocative signs (Hoffman, Babinski, clonus, inverted radial reflex). However, because approximately 20% of patients with cervical myelopathy may not demonstrate any focal findings on physical examination, it is important to understand that the absence of physical findings does not rule out the diagnosis. Imaging studies such as MRI or CT-myelograms should demonstrate correlative compression of the spinal cord. The primary indication for surgery is symptomatic myelopathy.

In appropriate circumstances, the spinal cord can be decompressed either anteriorly or posteriorly. In patients with anterior compressive lesions—such as disc herniations, spondylotic bone spurs, or OPLL—performing a posterior decompression requires a neutral or lordotic alignment such that the cord can drift posteriorly away from the anterior lesions following
removal or opening of the lamina. If the alignment is kyphotic and the impinging structures are anterior, a posterior approach may not afford a satisfactory decompressive effect. Relative contraindications that are procedure specific are debatable. Smoking may hinder a patient’s ability to heal a fusion mass and thus favor a nonfusion approach. Axial neck pain arising from spondylosis may be better treated by a stabilizing procedure such as fusion rather than a motion-preserving operation such as laminoplasty, although there is no conclusive data to substantiate this notion, and proponents of either method would argue that both are equally viable treatment options for cervical myelopathy.

In all cases of cervical myelopathy, the primary goal of surgical treatment is to prevent progression. Although, as a general rule, approximately 50% improvement in myelopathic symptoms may be anticipated postoperatively, improvement in myelopathic symptoms or pain may not occur in any given patient depending on a number of factors, including the severity of underlying spinal cord damage. As such, patients must be extensively counseled that arrest of progression constitutes surgical success even in the absence of any symptomatic improvement.

Laminectomy is the complete removal of the lamina from the cervical canal. Historically, multilevel laminectomy was
commonly used as a stand-alone decompressive procedure. However, due to substantial limitations associated with multilevel laminectomy alone—namely, postlaminectomy kyphosis and spondylolisthesis, both of which can lead to pain and/or recurrent spinal cord compression—instrumentation and fusion are currently performed in conjunction with laminectomy. Fusion procedures require bony healing for a successful outcome, whether in the cervical spine or anywhere in the body. Similar to casting a broken arm, immobilization is critical to providing the environment amendable to fusion healing. This is the rationale behind instrumentation with screws and rods to provide structural stability to the cervical spine, allowing the bone graft to heal into a solid fusion mass (Figure 66.3).