Cervical Spondylotic Myelopathy: Pathophysiology, Diagnosis, and Emerging Therapies

Abstract

Cervical spondylotic myelopathy (CSM) represents the commonest cause of non-traumatic spinal cord dysfunction in adults and is increasingly encountered in ageing populations. Contemporary literature often frames CSM within the broader construct of degenerative cervical myelopathy (DCM), encompassing compressive myelopathy arising from disc degeneration, osteophyte formation, facet arthropathy, ligamentous hypertrophy, and related degenerative pathologies. The clinical impact of CSM extends beyond gait impairment and hand dysfunction to include pain, falls, loss of independence, and diminished health-related quality of life. Pathophysiology is multifactorial and reflects an interaction between chronic static compression, repetitive dynamic injury, microvascular compromise, neuroinflammation, and progressive cellular and tract-level damage within the spinal cord. Diagnosis remains fundamentally clinical, supported by imaging—particularly magnetic resonance imaging—yet conventional measures incompletely characterise microstructural injury, disease activity, and prognostic potential. Advanced quantitative imaging and fluid biomarkers are increasingly investigated to address these gaps and to support earlier diagnosis and more reliable monitoring. Surgical decompression is the cornerstone of disease-modifying management, but heterogeneous outcomes and persistent disability in a subset of patients highlight the need for adjunctive neuroprotective and restorative strategies. Recent trials and secondary analyses of riluzole, alongside expanding work in biomarkers and quantitative MRI, exemplify the movement towards mechanism-informed therapeutics and precision stratification. This review synthesises current understanding of CSM/DCM pathobiology, diagnostic approaches, contemporary management paradigms, and emerging therapeutic horizons that may reshape care across the next decade.