Comparing Quality of Life in Cervical Spondylotic Myelopathy with Other Chronic Debilitating Diseases Using the Short Form Survey 36-Health Survey

Neuromotor decline is associated with gut dysbiosis following surgical decompression for Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) describes a spectrum of disorders that cause progressive and chronic cervical spinal cord compression. The clinical presentation can be complex and can include locomotor impairment, hand and upper extremity dysfunction, pain, loss of bladder and bowel function, as well as gastrointestinal dysfunction. Once diagnosed, surgical decompression is the recommended treatment for DCM patients with moderate to severe impairment. Our body is composed of a large community of microorganisms, known as the microbiota. Traumatic and non-traumatic spinal cord injuries (SCIs) can induce changes in the gut microbiota and gut microbiota derived metabolites. These changes have been reported as important disease-modifying factors after injury. However, whether gut dysbiosis is associated with functional neurological recovery after surgical decompression has not been examined to date. Here, DCM was induced in C57BL/6 mice by implanting an aromatic polyether material underneath the C5-6 laminae. The extent of gut dysbiosis was assessed by gas chromatography and 16S rRNA sequencing from fecal samples before and after decompression. Neuromotor activity was assessed using the Catwalk test. Our results show that DCM pre- and post- surgical decompression is associated with gut dysbiosis, without altering short chain fatty acids (SCFAs) levels. Significant differences in Clostridia, Verrumicrobiae, Lachnospiracea, Firmicutes, Bacteroidales, and Clostridiaceae were observed between the DCM group (before decompression) and after surgical decompression (2 and 5 weeks). The changes in gut microbiota composition correlated with locomotor features of the Catwalk. For example, a longer duration of ground contact and dysfunctional swing in the forelimbs, were positively correlated with gut dysbiosis. These results show for the first time an association between gut dysbiosis and locomotor deterioration after delayed surgical decompression. Thus, providing a better understanding of the extent of changes in microbiota composition in the setting of DCM pre- and post- surgical decompression.

Degenerative Cervical Myelopathy Awareness in Primary Care: UK National Cross-Sectional Survey of General Practitioners

BACKGROUND

Degenerative cervical myelopathy (DCM) is a progressive neurological condition, characterized by spinal cord injury secondary to degenerative changes in the spine. Misdiagnosis in primary care forms part of a complex picture leading to an average diagnostic delay of 2 years. This leads to potentially preventable and permanent disability. A lack of awareness secondary to deficits in postgraduate education may contribute to these delays.

OBJECTIVE

This study aims to assess the awareness of DCM in the setting of general practice.

METHODS

General practitioners completed a quantitative web-based cross-sectional questionnaire. The 17-item questionnaire captured data regarding demographics, subjective awareness, and objective knowledge. The questionnaire was disseminated via professional networks, including via practice managers and senior practice partners. Incentivization was provided via a bespoke DCM fact sheet for those that completed the survey.

RESULTS

A total of 54 general practitioners representing all 4 UK nations responded to the survey. General practitioners most commonly self-assessed that they had "limited awareness" of DCM (n=24, 51%). General practitioners felt most commonly "moderately able" to recognize a case of DCM (n=21, 46%). In total, 13% (n=6) of respondents reported that they would not be at all able to recognize a patient with DCM. Respondents most commonly reported that they were "moderately confident" in their ability to triage a patient with DCM (n=19, 41%). A quarter of respondents reported no prior introduction to DCM throughout their medical training (n=13, 25%). The mean score for knowledge-based questions was 42.6% (SD 3.96%) with the lowest performance observed in patient demographic and clinical recognition items.

CONCLUSIONS

General practitioners lack confidence in the recognition and management of DCM. These findings are consistent with the diagnostic delays previously described in the literature at the primary care level. Further work to develop and implement educational interventions to general practitioner practices is a crucial step to improving patient outcomes in DCM.

Machine learning-based cluster analysis identifies four unique phenotypes of patients with degenerative cervical myelopathy with distinct clinical profiles and long-term functional and neurological outcomes

BACKGROUND

Degenerative cervical myelopathy (DCM), the predominant cause of spinal cord dysfunction among adults, exhibits diverse interrelated symptoms and significant heterogeneity in clinical presentation. This study sought to use machine learning-based clustering algorithms to identify distinct patient clinical profiles and functional trajectories following surgical intervention.

METHODS

In this study, we applied k-means and latent profile analysis (LPA) to identify patient phenotypes, using aggregated data from three major DCM trials. The combination of Nurick score, NDI (neck disability index), neck pain, as well as motor and sensory scores facilitated clustering. Goodness-of-fit indices were used to determine the optimal cluster number. ANOVA and post hoc Tukey's test assessed outcome differences, while multinomial logistic regression identified significant predictors of group membership.

FINDINGS

A total of 1047 patients with DCM (mean [SD] age: 56.80 [11.39] years, 411 [39%] females) had complete one year outcome assessment post-surgery. Latent profile analysis identified four DCM phenotypes: "severe multimodal impairment" (n = 286), "minimal impairment" (n = 116), "motor-dominant" (n = 88) and "pain-dominant" (n = 557) groups. Each phenotype exhibited a unique symptom profile and distinct functional recovery trajectories. The "severe multimodal impairment group", comprising frail elderly patients, demonstrated the worst overall outcomes at one year (SF-36 PCS mean [SD]: 40.01 [9.75]; SF-36 MCS mean [SD], 46.08 [11.50]) but experienced substantial neurological recovery post-surgery (ΔmJOA mean [SD]: 3.83 [2.98]). Applying the k-means algorithm yielded a similar four-class solution. A higher frailty score and positive smoking status predicted membership in the "severe multimodal impairment" group (OR 1.47 [95% CI 1.07-2.02] and 1.58 [95% CI 1.25-1.99, respectively]), while undergoing anterior surgery and a longer symptom duration were associated with the "pain-dominant" group (OR 2.0 [95% CI 1.06-3.80] and 3.1 [95% CI 1.38-6.89], respectively).

INTERPRETATION

Unsupervised learning on multiple clinical metrics predicted distinct patient phenotypes. Symptom clustering offers a valuable framework to identify DCM subpopulations, surpassing single patient reported outcome measures like the mJOA.

FUNDING

No funding was received for the present work. The original studies were funded by AO Spine North America.

A minimum data set-Core outcome set, core data elements, and core measurement set-For degenerative cervical myelopathy research (AO Spine RECODE DCM): A consensus study

BACKGROUND

Degenerative cervical myelopathy (DCM) is a progressive chronic spinal cord injury estimated to affect 1 in 50 adults. Without standardised guidance, clinical research studies have selected outcomes at their discretion, often underrepresenting the disease and limiting comparability between studies. Utilising a standard minimum data set formed via multi-stakeholder consensus can address these issues. This combines processes to define a core outcome set (COS)-a list of key outcomes-and core data elements (CDEs), a list of key sampling characteristics required to interpret the outcomes. Further "how" these outcomes should be measured and/or reported is then defined in a core measurement set (CMS). This can include a recommendation of a standardised time point at which outcome data should be reported. This study defines a COS, CDE, and CMS for DCM research.

METHODS AND FINDINGS

A minimum data set was developed using a series of modified Delphi processes. Phase 1 involved the setup of an international DCM stakeholder group. Phase 2 involved the development of a longlist of outcomes, data elements, and formation into domains. Phase 3 prioritised the outcomes and CDEs using a two-stage Delphi process. Phase 4 determined the final DCM minimal data set using a consensus meeting. Using the COS, Phase 5 finalised definitions of the measurement construct for each outcome. In Phase 6, a systematic review of the literature was performed, to scope and define the psychometric properties of measurement tools. Phase 7 used a modified Delphi process to inform the short-listing of candidate measurement tools. The final measurement set was then formed through a consensus meeting (Phase 8). To support implementation, the data set was then integrated into template clinical research forms (CRFs) for use in future clinical trials (Phase 9). In total, 28 outcomes and 6 domains (Pain, Neurological Function, Life Impact, Radiology, Economic Impact, and Adverse Events) were entered into the final COS. Thirty two outcomes and 4 domains (Individual, Disease, Investigation, and Intervention) were entered into the final CDE. Finally, 4 outcome instruments (mJOA, NDI, SF-36v2, and SAVES2) were identified for the CMS, with a recommendation for trials evaluating outcomes after surgery, to include baseline measurement and at 6 months from surgery.

CONCLUSIONS

The AO Spine RECODE-DCM has produced a minimum data set for use in DCM clinical trials today. These are available at https://myelopathy.org/minimum-dataset/. While it is anticipated the CDE and COS have strong and durable relevance, it is acknowledged that new measurement tools, alongside an increasing transition to study patients not undergoing surgery, may necessitate updates and adaptation, particularly with respect to the CMS.

Flipping the mJOA: Clinical utility of the modified Japanese Orthopaedic Association score as a tool for detecting degenerative cervical myelopathy

Introduction

People with Degenerative Cervical Myelopathy (DCM) often experience diagnostic delay. This could lead to poorer outcomes, including disability.

Research question

Does the modified Japanese Orthopaedic Association scale (mJOA) have clinical utility as an early detection tool for possible DCM?

Materials and methods

This is a prospective study of consecutive adult patients, referred to a National Neurosurgical Centre with a neck problem. Assessing clinicians undertook standard clinical examination and calculated the mJOA score. A consultant radiologist independently reported radiological findings, after which the assessing clinician determined the diagnosis. The sensitivity and specificity of mJOA for DCM at various cut-points was statistically analysed using Receiver Operating Characteristics (ROC) curves.

Results

Of 201 patients (98 male, mean age 52.6 ± 13y) assessed over 13 months, 21 were diagnosed with DCM (prevalence 10.4%). Fifteen (71.4%) had a mJOA score classifying disease severity as mild, 4/21 (19%) had moderate disease and two (9.5%) had severe disease. A mJOA score ≤17 (cutpoint ≥1) showed sensitivity of 95% and specificity of 71% for the clinical diagnosis of DCM. mJOA score ≤16 (cutpoint ≥2) had sensitivity of 62% and specificity of 90%. The ROC area under the curve was 0.885 (95% confidence interval: 0.82 to 0.95). 87% of patients were correctly classified.

Discussion and conclusion

mJOA score ≤16 is 90% specific for a subsequent diagnosis of DCM in people with neck problems and has potential to be used as an early detection tool. Further research is needed to replicate these findings and establish feasibility and acceptability in primary care.

Mapping the Degenerative Cervical Myelopathy Research Landscape: Topic Modeling of the Literature

STUDY DESIGN

Topic modeling of literature.

OBJECTIVES

Our study has 2 goals: (i) to clarify key themes in degenerative cervical myelopathy (DCM) research, and (ii) to evaluate the current trends in the popularity or decline of these topics. Additionally, we aim to highlight the potential of natural language processing (NLP) in facilitating research syntheses.

METHODS

Documents were retrieved from Scopus, preprocessed, and modeled using BERTopic, an NLP-based topic modeling method. We specified a minimum topic size of 25 documents and 50 words per topic. After the models were trained, they generated a list of topics and corresponding representative documents. We utilized linear regression models to examine trends within the identified topics. In this context, topics exhibiting increasing linear slopes were categorized as "hot topics," while those with decreasing slopes were categorized as "cold topics".

RESULTS

Our analysis retrieved 3510 documents that were classified into 21 different topics. The 3 most frequently occurring topics were "OPLL" (ossification of the posterior longitudinal ligament), "Anterior Fusion," and "Surgical Outcomes." Trend analysis revealed the hottest topics of the decade to be "Animal Models," "DCM in the Elderly," and "Posterior Decompression" while "Morphometric Analyses," "Questionnaires," and "MEP and SSEP" were identified as being the coldest topics.

CONCLUSIONS

Our NLP methodology conducted a thorough and detailed analysis of DCM research, uncovering valuable insights into research trends that were otherwise difficult to discern using traditional techniques. The results provide valuable guidance for future research directions, policy considerations, and identification of emerging trends.

Beyond the aging spine - a systematic review of functional changes in the human brain in cervical spondylotic myelopathy

Cervical Spondylotic Myelopathy (CSM) is a degenerative condition that leads to loss of cervical spinal cord integrity, typically affecting the aged population. Emerging fMRI-based evidence suggests that the brain is also affected by CSM. This systematic review aimed to understand the usefulness of brain fMRI in CSM. A comprehensive literature search was conducted until March 2023 according to PRISMA guidelines. The inclusion criteria included original research articles in English, primarily studying the human brain's functional changes in CSM using fMRI with at least 5 participants. The extracted data from each study included demographics, disease severity, MRI machine characteristics, affected brain areas, functional changes, and clinical utilities. A total of 30 studies met the inclusion criteria. Among the fMRI methods, resting-state fMRI was the most widely used experimental paradigm, followed by motor tasks. The brain areas associated with motor control were most affected in CSM, followed by the superior frontal gyrus and occipital cortex. Functional changes in the brain were correlated to clinical metrics showing clinical utility. However, the evidence that a specific fMRI metric correlating with a clinical metric was "very low" to "insufficient" due to a low number of studies and negative results. In conclusion, fMRI can potentially facilitate the diagnosis of CSM by quantitatively interrogating the functional changes of the brain, particularly areas of the brain associated with motor control. However, this field is in its early stages, and more studies are needed to establish the usefulness of brain fMRI in CSM.

A Comparison of Short-Term Outcomes after Surgical Treatment of Multilevel Degenerative Cervical Myelopathy in the Geriatric Patient Population: An Analysis of the National Surgical Quality Improvement Program Database 2010-2020

STUDY DESIGN

Retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program database from 2010 to 2020.

PURPOSE

To compare the short-term complication rates of anterior cervical decompression and fusion (ACDF), posterior cervical laminoplasty (LP), and posterior cervical laminectomy and fusion (PCF) in a geriatric population.

OVERVIEW OF LITERATURE

The geriatric population in the United States has increased significantly. Degenerative cervical myelopathy (DCM) is caused by cervical spinal stenosis, and its prevalence increases with age. Therefore, the incidence of multilevel DCM requiring surgical intervention is likely to increase. ACDF, LP, and PCF are the most commonly used surgical techniques for treating multilevel DCM. However, there is uncertainty regarding the optimal surgical technique for the decompression of DCM in geriatric patients.

METHODS

Patients aged 65 years who had undergone either multilevel ACDF, LP, or PCF for the treatment of DCM were analyzed. Additional analysis was performed by standardizing the data for the American Society of Anesthesiologists classification scores and preoperative functional status.

RESULTS

A total of 23,129 patients were identified. Patients with ACDF were younger, more often female, and preoperatively healthier than those in the other two groups. The estimated postoperative mortality and morbidity, mean operation time, and length of hospital stay were the lowest for ACDF, second lowest for LP, and highest for PCF. The readmission and reoperation rates were comparable between ACDF and LP; however, both were significantly lower than PCF.

CONCLUSIONS

PCF is associated with the highest risk of mortality, morbidity, unplanned reoperation, and unplanned readmission in the short-term postoperative period in patients aged 65 years. In contrast, ACDF carries the lowest risk. However, some disease-specific factors may require posterior treatment. For these cases, LP should be included in the preoperative discussion when determining the ideal surgical approach for geriatric patients.

Dynamic Flexion-Extension Magnetic Resonance Imaging of the Cervical Spine: An Evolutionary Tool for Diagnosis and Management of Cervical Spondylotic Myelopathy

Dynamic problems need dynamic solutions. High motility of the cervical spine causes a common age-related degenerative condition called cervical spondylotic myelopathy (CSM), manifested by neurological impairments. An accurate and reliable diagnosis of CSM is crucial for determining appropriate management strategies. Traditional static magnetic resonance imaging (MRI) has been the gold standard for imaging CSM; however, it may not fully capture dynamic changes during neck movement. Dynamic flexion-extension (DFE) MRI is an innovative imaging technique that allows for real-time visualization of cervical spine motion. This review article aims to scrutinize the role of DFE MRI in assessing CSM, its added value to clinical implementations, and its limitations. Finally, by addressing the knowledge gaps, this survey sheds light on the road ahead to incorporate DFE MRI into a standard version of the practice.

Finite Element Analysis for Degenerative Cervical Myelopathy: Scoping Review of the Current Findings and Design Approaches, Including Recommendations on the Choice of Material Properties

BACKGROUND

Degenerative cervical myelopathy (DCM) is a slow-motion spinal cord injury caused via chronic mechanical loading by spinal degenerative changes. A range of different degenerative changes can occur. Finite element analysis (FEA) can predict the distribution of mechanical stress and strain on the spinal cord to help understand the implications of any mechanical loading. One of the critical assumptions for FEA is the behavior of each anatomical element under loading (ie, its material properties).

OBJECTIVE

This scoping review aims to undertake a structured process to select the most appropriate material properties for use in DCM FEA. In doing so, it also provides an overview of existing modeling approaches in spinal cord disease and clinical insights into DCM.

METHODS

We conducted a scoping review using qualitative synthesis. Observational studies that discussed the use of FEA models involving the spinal cord in either health or disease (including DCM) were eligible for inclusion in the review. We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The MEDLINE and Embase databases were searched to September 1, 2021. This was supplemented with citation searching to retrieve the literature used to define material properties. Duplicate title and abstract screening and data extraction were performed. The quality of evidence was appraised using the quality assessment tool we developed, adapted from the Newcastle-Ottawa Scale, and shortlisted with respect to DCM material properties, with a final recommendation provided. A qualitative synthesis of the literature is presented according to the Synthesis Without Meta-Analysis reporting guidelines.

RESULTS

A total of 60 papers were included: 41 (68%) "FEA articles" and 19 (32%) "source articles." Most FEA articles (33/41, 80%) modeled the gray matter and white matter separately, with models typically based on tabulated data or, less frequently, a hyperelastic Ogden variant or linear elastic function. Of the 19 source articles, 14 (74%) were identified as describing the material properties of the spinal cord, of which 3 (21%) were considered most relevant to DCM. Of the 41 FEA articles, 15 (37%) focused on DCM, of which 9 (60%) focused on ossification of the posterior longitudinal ligament. Our aggregated results of DCM FEA indicate that spinal cord loading is influenced by the pattern of degenerative changes, with decompression alone (eg, laminectomy) sufficient to address this as opposed to decompression combined with other procedures (eg, laminectomy and fusion).

CONCLUSIONS

FEA is a promising technique for exploring the pathobiology of DCM and informing clinical care. This review describes a structured approach to help future investigators deploy FEA for DCM. However, there are limitations to these recommendations and wider uncertainties. It is likely that these will need to be overcome to support the clinical translation of FEA to DCM.

Cervical Spondylotic Myelopathy-Diagnostics and Clinimetrics

Cervical myelopathy is referred to in many ways in the English literature, for example, as cervical spondylotic myelopathy (CSM), spondylotic radiculomyelopathy (SRM) or degenerative cervical myelopathy (DCM). In addition, more frequent occurrences are noted in older adults and to a greater extent in men. The causes of the effects of cervical myelopathy may be the appearance of lesions on the spinal cord, ischemia due to compression of the vertebral artery and repeated micro-injuries during maximal movements-hyperflexion or hyperextension. It is well known that lesions on the spinal cord may occur in a quarter of the population, and this problem is clearly noted in people over 60 years old. The symptoms of SCM develop insidiously, and their severity and side (unilateral or bilateral) are associated with the location and extent of spinal cord compression. Neurological examination most often diagnoses problems in the upper limbs (most often paresis with developing hand muscle atrophy), pyramidal paralysis in one or both lower limbs and disorders in the urinary system. To make a diagnosis of CSM, it is necessary to perform MRI and neurophysiological tests (such as EMG or sensory and/or motor-evoked potentials). The use of appropriately selected scales and specific tests in diagnostics is also crucial. This narrative review article describes the latest knowledge on the diagnosis and clinimetrics of cervical spondylotic myelopathy in adults and provides future directions.

Predictors of Outcome After Surgical Decompression for mild degenerative Cervical Myelopathy -A Systematic Review

STUDY DESIGN

Systematic Reviews.

OBJECTIVES

To investigate predictors of surgical outcomes for mild Degenerative Cervical Myelopathy (DCM) by reviewing all related studies conducted at this point.

METHODS

An electronic search was carried out in PubMed, EMBASE, Scopus, and Web of Science until June 23, 2021. Full-text articles reporting surgical outcome predictors of mild DCM cases were eligible. We included studies with mild DCM which was defined as a modified Japanese Orthopaedic Association score of 15 to 17 or a Japanese Orthopaedic Association score of 13 to 16. Independent reviewers screened all the records, and discrepancies between the reviewers were solved in a session with the senior author. For risk of bias assessment, RoB 2 tool was used for randomized clinical trials and ROBINS-I for non-randomized studies.

RESULTS

After screening 6 087 manuscripts, only 8 studies met the inclusion criteria. Lower pre-operative mJOA scores and quality-of-life measurement scores were reported by multiple studies to predict better surgical outcomes compared to other groups. High-intensity pre-operative T2 magnetic resonance imaging (MRI) was also reported to predict poor outcomes. Neck pain before intervention resulted in improved patient-reported outcomes. Two studies also reported motor symptoms prior to surgery as outcome predictors.

CONCLUSION

Lower quality of life before surgery, neck pain, lower pre-operative mJOA scores, motor symptoms before surgery, female gender, gastrointestinal comorbidities, surgical procedure and surgeon's experience with specific techniques, and high signal intensity of cord in T2 MRI were the surgical outcome predictors reported in the literature. Lower Quality of Life (QoL) score and neck prior to surgery were reported as predictors of the more improved outcome, but high cord signal intensity in T2 MRI was reported as an unfavorable outcome predictor.

Translation, Adaptation, and Validation of a Spanish Version of the Japanese Orthopaedic Association Cervical Myelopathy Questionnaire

STUDY DESIGN

Translation and psychometric testing of a questionnaire.

OBJECTIVE

Translation, adaptation, and validation of the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) to the Spanish language.

SUMMARY OF BACKGROUND DATA

Degenerative cervical myelopathy (DCM) has a clear impact on quality of life (QoL). The JOACMEQ is a self-administered questionnaire used to assess DCM-related disability and its impact on QoL. It is compound of five domains: Cervical Function, Upper Extremity Function, Lower Extremity Function, Blader Function, and QoL. Despite its increasing use, the JOACMEQ has not yet been translated and validated for Spanish-speaking patients.

METHODS

A total of 180 patients completed the Spanish version. Of these, 145 (80%) had DCM (mean age: 62.53; SD: 9.92), while 35 had neck pain without DCM (age: 52.71; SD: 10.29). The psychometric properties measured were construct validity, internal consistency, reproducibility, concurrent validity, and discriminatory ability.

RESULTS

We recruited 145 patients with DCM (mean age: 62.5) and 35 with cervical pain (mean age: 52.7). After factor analysis, our data showed very strong construct validity, with questions strongly loaded and clustered for five factors. Internal consistency proved high (Cronbach's α coefficient of 0.912). The intraclass correlation coefficient showed very good reproducibility for all domain (intraclass correlation coefficient range between 0.85 and 0.95). A high correlation between the JOACMEQ QoL domain and neck disability index was also found (Spearman's ρ=-0.847, P <0.01) confirming concurrent validity. The receiver operating characteristic curves proved to be significant in the upper (area under the curve=0.65, P =0.006) and lower (area under the curve=0.661, P =0.003) extremities, confirming discriminatory ability.

CONCLUSIONS

Our proposed Spanish version of the JOACMEQ retains the psychometric characteristics of the original JOACMEQ and could prove useful for the evaluation of patients with DCM in Spanish-speaking countries.

We Choose to Call it 'Degenerative Cervical Myelopathy': Findings of AO Spine RECODE-DCM, an International and Multi-Stakeholder Partnership to Agree a Standard Unifying Term and Definition for a Disease

STUDY DESIGN

Modified DELPHI Consensus Process.

OBJECTIVE

To agree a single unifying term and definition. Globally, cervical myelopathy caused by degenerative changes to the spine is known by over 11 different names. This inconsistency contributes to many clinical and research challenges, including a lack of awareness.

METHOD

AO Spine RECODE-DCM (Research objectives and Common Data Elements Degenerative Cervical Myelopathy). To determine the index term, a longlist of candidate terms and their rationale, was created using a literature review and interviews. This was shared with the community, to select their preferred terms (248 members (58%) including 149 (60%) surgeons, 45 (18%) other healthcare professionals and 54 (22%) People with DCM or their supporters) and finalized using a consensus meeting. To determine a definition, a medical definition framework was created using inductive thematic analysis of selected International Classification of Disease definitions. Separately, stakeholders submitted their suggested definition which also underwent inductive thematic analysis (317 members (76%), 190 (59%) surgeons, 62 (20%) other healthcare professionals and 72 (23%) persons living with DCM or their supporters). Using this definition framework, a working definition was created based on submitted content, and finalized using consensus meetings.

RESULTS

Degenerative Cervical Myelopathy was selected as the unifying term, defined in short, as a progressive spinal cord injury caused by narrowing of the cervical spinal canal.

CONCLUSION

A consistent term and definition can support education and research initiatives. This was selected using a structured and iterative methodology, which may serve as an exemplar for others in the future.

Patient Characteristics Associated With Worsening of Neck Pain-Related Disability After Surgery for Degenerative Cervical Myelopathy: A Nationwide Study of 1508 Patients

BACKGROUND AND OBJECTIVES

Functional status, pain, and quality of life usually improve after surgery for degenerative cervical myelopathy (DCM), but a subset of patients report worsening. The objective was to define cutoff values for worsening on the Neck Disability Index (NDI) and identify prognostic factors associated with worsening of pain-related disability 12 months after DCM surgery.

METHODS

In this prognostic study based on prospectively collected data from the Norwegian Registry for Spine Surgery, the NDI was the primary outcome. Receiver operating characteristics curve analyses were used to obtain cutoff values, using the global perceived effect scale as an external anchor. Univariable and multivariable analyses were performed using mixed logistic regression to evaluate the relationship between potential prognostic factors and the NDI.

RESULTS

Among the 1508 patients undergoing surgery for myelopathy, 1248 (82.7%) were followed for either 3 or 12 months. Of these, 317 (25.4%) were classified to belong to the worsening group according to the mean NDI percentage change cutoff of 3.3. Multivariable analyses showed that smoking (odds ratio [OR] 3.4: 95% CI 1.2-9.5: P < .001), low educational level (OR 2.5: 95% CI 1.0-6.5: P < .001), and American Society of Anesthesiologists grade >II (OR 2.2: 95% CI 0.7-5.6: P = .004) were associated with worsening. Patients with more severe neck pain (OR 0.8: 95% CI 0.7-1.0: P = .003) and arm pain (OR 0.8: 95% CI 0.7-1.0; P = .007) at baseline were less likely to report worsening.

CONCLUSION

We defined a cutoff value of 3.3 for worsening after DCM surgery using the mean NDI percentage change. The independent prognostic factors associated with worsening of pain-related disability were smoking, low educational level, and American Society of Anesthesiologists grade >II. Patients with more severe neck and arm pain at baseline were less likely to report worsening at 12 months.

Management of mild degenerative cervical myelopathy and asymptomatic spinal cord compression: an international survey

STUDY DESIGN

Cross-sectional survey.

OBJECTIVE

Currently there is limited evidence and guidance on the management of mild degenerative cervical myelopathy (DCM) and asymptomatic spinal cord compression (ASCC). Anecdotal evidence suggest variance in clinical practice. The objectives of this study were to assess current practice and to quantify the variability in clinical practice.

METHODS

Spinal surgeons and some additional health professionals completed a web-based survey distributed by email to members of AO Spine and the Cervical Spine Research Society (CSRS) North American Society. Questions captured experience with DCM, frequency of DCM patient encounters, and standard of practice in the assessment of DCM. Further questions assessed the definition and management of mild DCM, and the management of ASCC.

RESULTS

A total of 699 respondents, mostly surgeons, completed the survey. Every world region was represented in the responses. Half (50.1%, n = 359) had greater than 10 years of professional experience with DCM. For mild DCM, standardised follow-up for non-operative patients was reported by 488 respondents (69.5%). Follow-up included a heterogeneous mix of investigations, most often at 6-month intervals (32.9%, n = 158). There was some inconsistency regarding which clinical features would cause a surgeon to counsel a patient towards surgery. Practice for ASCC aligned closely with mild DCM. Finally, there were some contradictory definitions of mild DCM provided in the form of free text.

CONCLUSIONS

Professionals typically offer outpatient follow up for patients with mild DCM and/or asymptomatic ASCC. However, what this constitutes varies widely. Further research is needed to define best practice and support patient care.

Elderly Patients Show Substantial Improvement in Health-Related Quality of Life After Surgery for Degenerative Cervical Myelopathy Despite Medical Frailty: An Ambispective Analysis of a Multicenter, International Data Set

BACKGROUND AND OBJECTIVES

We assessed the relationship between Modified Frailty Index-5 (mFI-5) and neurological outcomes, as well as health-related quality of life (HRQoL) measures, in elderly patients with degenerative cervical myelopathy (DCM) after surgery.

METHODS

Data from 3 major DCM trials (the Arbeitsgemeinschaft für Osteosynthesefragen Spine Cervical Spondylotic Myelopathy-North America, Cervical Spondylotic Myelopathy-International, and CSM-PROTECT studies) were combined, involving 1047 subjects with moderate to severe myelopathy. Patients older than 60 years with 6-month and 1-year postoperative data were analyzed. Neurological outcome was assessed using the modified Japanese Orthopaedic Association score, while HRQoL was measured using the 36-Item Short Form Health Survey (SF-36) (both Physical Component Summary [SF-36 PCS] and Mental Component Summary [SF-36 MCS] scores) and the Neck Disability Index. Frail (mFI ≥2) and nonfrail (mFI = 0-1) cohorts were compared using univariate paired statistics.

RESULTS

The final analysis included 261 patients (62.5% male), with a mean age of 71 years (95% CI 70.7-72). Frail patients (mFI ≥2) had lower baseline modified Japanese Orthopaedic Association scores (10.45 vs 11.96, P < .001), SF-36 PCS scores (32.01 vs 36.51, P < .001), and SF-36 MCS scores (39.32 vs 45.24, P < .001). At 6-month follow-up, SF-36 MCS improved by a mean (SD) of 7.19 (12.89) points in frail vs 2.91 (11.11) points in the nonfrail group (P = .016). At 1 year after surgery, frail patients showed greater improvement in both SF-36 PCS and SF-36 MCS composite scores compared with nonfrail patients (7.81 vs 4.49, P = .038, and 7.93 vs 3.01, P = .007, respectively). Bivariate regression analysis revealed that higher mFI-5 scores correlated with more substantial improvement in overall mental status at 6 months and 1 year (P = .024 and P = .009, respectively).

CONCLUSION

mFI-5 is a clinically helpful signature to reflect the HRQoL status among elderly patients with DCM. Despite preoperative medical frailty, elderly patients with DCM experience significant HRQoL improvement after surgery. These findings enable clinicians to identify elderly patients with modifiable comorbidities and provide informed counseling on anticipated outcomes.

LEVEL OF EVIDENCE

II.

Characterizing mJOA-defined post-surgical recovery patterns in patients with degenerative cervical myelopathy

Background

Degenerative cervical myelopathy is a spinal disorder resulting in progressive cord compression and neurological deficits that are assessed using the modified Japanese Orthopedic Association (mJOA) questionnaire. It is difficult to predict which patients will recover neurological function after surgery, making it challenging for clinicians to set postoperative patient expectations. In this study, we used mJOA subscores to identify patterns of recovery and recovery timelines in patients with moderate and severe myelopathy.

Methods

Fifty-three myelopathy patients were enrolled and completed the mJOA questionnaire both pre-surgery, and six weeks and six months post-surgery. Pearson chi-square tests were performed to assess relationships of both recovery patterns and recovery timelines with severity of disease.

Results

Moderate myelopathy patients were significantly more likely than severe myelopathy patients to experience full recovery of upper extremity, lower extremity, and sensory domains. Disease severity did not significantly impact the timeline during which recovery occurs. Overall, >90% of patients experienced at least partial recovery by six months post surgery, 80% of which demonstrated it within the first six weeks.

Conclusions

This study shows the more severe the disease experienced by myelopathy patients, the more likely they will be left with permanent disabilities despite surgery. Early identification and treatment are therefore necessary to prevent worsening quality of life and increased costs of functional dependence. The recovery timelines for each subscore are similar and provide new values to guide patient expectations in their potential post-operative recovery. The overall recovery timeline is more generalizable though potentially lacking the specificity patients seek.

Validating the preoperative Japanese Core Outcome Measures Index for the Neck and comparing quality of life in patients with cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament by the patient-reported outcome measures

PURPOSE

This cross-sectional study serves two main purposes. Firstly, it aims to validate the preoperative Japanese Core Outcome Measures Index for the Neck (COMI-Neck) in patients with cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL). Secondly, it seeks to elucidate differences in preoperative quality of life (QOL) between these two cervical pathologies using patient-reported outcome measures (PROMs).

METHODS

A total of 103 preoperative patients (86 with CSM and 17 with OPLL) scheduled for cervical spine surgery were included in the study. Validated PROMs, including the Japanese COMI-Neck, Neck Disability Index (NDI), EuroQol-5 Dimension-3 level (EQ-5D-3L), and SF-12v2, were used to assess QOL. Baseline demographic and clinical data were collected, and statistical analyses were performed to compare the PROMs between CSM and OPLL groups.

RESULTS

The Japanese COMI-Neck demonstrated good construct validity, with positive correlations with NDI and negative correlations with EQ-5D-3L and SF-12v2. Comparison of preoperative PROMs between CSM and OPLL groups revealed differences in age, body mass index, and EQ-5D-3L scores. The CSM group had higher NDI scores for concentration and lower EQ-5D-3L scores for self-care compared to the OPLL group.

CONCLUSIONS

This study validated the preoperative Japanese COMI-Neck in CSM and OPLL patients and identified specific QOL issues associated with each condition. The findings highlight the importance of considering disease-specific QOL and tailoring treatment plans accordingly. Further research should include postoperative assessments and a more diverse population to enhance generalizability.

Is the type and/or co-existence of degenerative spinal pathology associated with the occurrence of degenerative cervical myelopathy? A single centre retrospective analysis of individuals with MRI defined cervical cord compression

BACKGROUND

Degenerative cervical myelopathy (DCM) arises from spinal degenerative changes injuring the cervical spinal cord. Most cord compression is incidental, referred to as asymptomatic spinal cord compression (ASCC). How and why ASCC differs from DCM is poorly understood. In this paper, we study a local cohort to identify specific types and groups of degenerative pathology more likely associated with DCM than ASCC.

METHODS

This study was a retrospective cohort analysis (IRB Approval ID: PRN10455). The frequency of degenerative findings between those with ASCC and DCM patients were compared using network analysis, hierarchical clustering, and comparison to existing literature to identify potential subgroups in a local cohort (N = 155) with MRI-defined cervical spinal cord compression. Quantitative measures of spinal cord compression (MSCC and MCC) were used to confirm their relevance.

RESULTS

ELF (8.7 %, 95 % CI 3.8-13.6 % vs 35.7 %, 95 % CI 27.4-44.0 %) Congenital Stenosis (3.9 %, 95 % CI 0.6-7.3 % vs 25.0 %, 95 % CI 17.5-32.5 %), and OPLL (0.0 %, 95 % CI 0.0-0.0 % vs 3.6 %, 95 % CI 0.3-6.8 %) were more likely in patients with DCM. Comparative network analysis indicated loss of lordosis was associated with ASCC, whilst ELF with DCM. Hierarchical Cluster Analysis indicated four sub-groups: multi-level disc disease with ELF, single-level disc disease without loss of lordosis and OPLL with DCM, and single-level disc disease with loss of lordosis with ASCC. Quantitative measures of cord compression were higher in groups associated with DCM, but similar in patients with single-level disc disease and loss of lordosis.

CONCLUSIONS

This study identified four subgroups based on degenerative pathology requiring further investigation.

Toward Shared Decision-Making in Degenerative Cervical Myelopathy: Protocol for a Mixed Methods Study

BACKGROUND

Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this.

OBJECTIVE

The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes.

METHODS

Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders.

RESULTS

Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway.

CONCLUSIONS

This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46809.

Factors Influencing Surgical Decision-Making in the Posterior Laminectomy With Fixation for Degenerative Cervical Myelopathy (POLYFIX-DCM) Trial: Survey Study

BACKGROUND

Degenerative cervical myelopathy (DCM) is estimated to affect 2% of the adult population. DCM occurs when degenerative processes cause compression and injure the spinal cord. Surgery to remove the stress caused by the compression of the spinal cord is the mainstay of treatment, with a range of techniques in use. Although various factors are described to inform the selection of these techniques, there needs to be more consensus and limited comparative evidence.

OBJECTIVE

The main objective of this survey was to explore the variation of practice and decision-making, with a focus on laminectomy versus laminectomy and fusion in posterior surgery of the cervical spine. We present the results of a survey conducted among the principal investigators (PIs) of the National Institute for Health and Care Research (NIHR) randomized controlled trial on posterior laminectomy with fixation for degenerative cervical myelopathy (POLYFIX-DCM).

METHODS

A series of 7 cases were shared with 24 PIs using SurveyMonkey. Each case consisted of a midsagittal T2-weighted magnetic resonance imaging and lateral cervical x-rays in flexion and extension. Surgeons were asked if their preferred approach was anterior or posterior. If posterior, they were asked whether they preferred to instrument and whether they had the equipoise to randomize in the NIHR POLYFIX-DCM trial. Variability in decision-making was then explored using factors reported to inform decision-making, such as alignment, location of compression, number of levels operated, presence of mobile spondylolisthesis, and patient age.

RESULTS

The majority of PIs (16/30, 53%) completed the survey. Overall, PIs favored a posterior approach (12/16, 75%) with instrumentation (75/112, average 66%) and would randomize (67/112, average 62%) most cases. Factors reported to inform decision-making poorly explained variability in responses in both univariate testing and with a multivariate model (R2=0.1). Only surgeon experience of more than 5 years and orthopedic specialty training background were significant predictors, both associated with an anterior approach (odds ratio [OR] 1.255; P=.02 and OR 1.344; P=.007, respectively) and fusion for posterior procedures (OR 0.628; P<.001 and OR 1.344; P<.001, respectively). Surgeon experience also significantly affected the openness to randomize, with those with more than 5 years of experience less likely to randomize (OR -0.68; P<.001).

CONCLUSIONS

In this representative sample of spine surgeons participating in the POLYFIX-DCM trial as investigators, there is no consensus on surgical strategy, including the role of instrumented fusion following posterior decompression. Overall, this study supports the view that there appears to be a clinical equipoise, and conceptually, a randomized controlled trial appears feasible, which sets the scene for the NIHR POLYFIX-DCM trial.

Secondary analysis of a James Lind Alliance priority setting partnership to facilitate knowledge translation in degenerative cervical myelopathy (DCM): insights from AO Spine RECODE-DCM

OBJECTIVES

To explore whether a James Lind Alliance Priority Setting Partnership could provide insights on knowledge translation within the field of degenerative cervical myelopathy (DCM).

DESIGN

Secondary analysis of a James Lind Alliance Priority Setting Partnership process for DCM.

PARTICIPANTS AND SETTING

DCM stake holders, including spinal surgeons, people with myelopathy and other healthcare professionals, were surveyed internationally. Research suggestions submitted by stakeholders but considered answered were identified. Sampling characteristics of respondents were compared with the overall cohort to identify subgroups underserved by current knowledge translation.

RESULTS

The survey was completed by 423 individuals from 68 different countries. A total of 22% of participants submitted research suggestions that were considered 'answered'. There was a significant difference between responses from different stakeholder groups (p<0.005). Spinal surgeons were the group which was most likely to submit an 'answered' research question. Respondents from South America were also most likely to submit 'answered' questions, when compared with other regions. However, there was no significant difference between responses from different stakeholder regions (p=0.4).

CONCLUSIONS

Knowledge translation challenges exist within DCM. This practical approach to measuring knowledge translation may offer a more responsive assessment to guide interventions, complementing existing metrics.

Osteopathy in the Early Diagnosis and Management of Degenerative Cervical Myelopathy: National Survey

BACKGROUND

Degenerative cervical myelopathy (DCM) is a common and disabling neurodegenerative condition. Surgical decompression is the only evidence-based treatment to halt disease progression; however, diagnosis and access to timely treatment are often delayed, which contribute to significant disability and dependence. Supporting early diagnosis and access to timely treatment is a critical priority. Exploring these challenges, Myelopathy.org has observed that people with DCM may seek osteopathy care for their symptoms, both before and after diagnosis.

OBJECTIVE

This study aimed to describe the current interaction between osteopaths and people with DCM and understand how this may be targeted to enhance the DCM diagnostic pathway.

METHODS

Registered osteopaths in the United Kingdom completed a web-based survey hosted by the Institute of Osteopathy, as part of their institute's 2021 census. Responses were collected from February to May 2021. Demographic information about the respondents was captured, including age, gender, and ethnicity. Professional information captured included the year of qualification; region of practice; type of practice; and number of undiagnosed, operated diagnosed, and unoperated diagnosed DCM cases encountered per year. The completion of the survey was voluntary; however, a prize draw incentive was offered to participants.

RESULTS

The demographics were heterogenous for the 547 practitioners who completed the survey. There was representation from a wide range of demographic groups, including the level of experience, gender, age, and the region of United Kingdom. At least 68.9% (377/547) of osteopaths reported encounters with DCM each year. Osteopaths most frequently encountered patients with undiagnosed DCM, with a mean of 3 patient encounters per year. This compares to 2 encounters per year with patients with diagnosed DCM. The level of practitioner experience was positively correlated with the detection of undiagnosed DCM (P<.005). The influence of practitioner experience was corroborated by a subgroup analysis looking at the relationship between practitioner age on the detection of undiagnosed DCM. Osteopaths older than 54 years encountered an average of 4.2 cases per year, whereas those younger than 35 years detected 2.9 cases per year. Osteopaths in private clinics reported encounters with a greater mean number (4.4) of undiagnosed DCM cases per year than osteopaths in other clinic types (3.0).

CONCLUSIONS

Osteopaths reported that they frequently consult people with DCM, including those suspected to have undiagnosed or presurgical DCM. Given this concentrated presentation of early DCM and a workforce professionally trained to examine musculoskeletal disease, osteopaths could have an important role in accelerating access to timely treatment. We included a decision support tool and specialist referral template as a tool to support onward care.

Utility of MRI in Quantifying Tissue Injury in Cervical Spondylotic Myelopathy

Cervical spondylotic myelopathy (CSM) is a progressive disease that worsens over time if untreated. However, the rate of progression can vary among individuals and may be influenced by various factors, such as the age of the patients, underlying conditions, and the severity and location of the spinal cord compression. Early diagnosis and prompt treatment can help slow the progression of CSM and improve symptoms. There has been an increased use of magnetic resonance imaging (MRI) methods in diagnosing and managing CSM. MRI methods provide detailed images and quantitative structural and functional data of the cervical spinal cord and brain, allowing for an accurate evaluation of the extent and location of tissue injury. This review aims to provide an understanding of the use of MRI methods in interrogating functional and structural changes in the central nervous system in CSM. Further, we identified several challenges hindering the clinical utility of these neuroimaging methods.

Degenerative cervical myelopathy: Where have we been? Where are we now? Where are we going?

Degenerative cervical myelopathy (DCM), a recently coined term, encompasses a group of age-related and genetically associated pathologies that affect the cervical spine, including cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL). Given the significant contribution of DCM to global disease and disability, there are worldwide efforts to promote research and innovation in this area. An AO Spine effort termed 'RECODE-DCM' was initiated to create an international multistakeholder consensus group, involving patients, caregivers, physicians and researchers, to focus on launching actionable discourse on DCM. In order to improve the management, treatment and results for DCM, the RECODE-DCM consensus group recently identified ten priority areas for translational research. The current article summarizes recent advancements in the field of DCM. We first discuss the comprehensive definition recently refined by the RECODE-DCM group, including steps taken to arrive at this definition and the supporting rationale. We then provide an overview of the recent advancements in our understanding of the pathophysiology of DCM and modalities to clinically assess and diagnose DCM. A focus will be set on advanced imaging techniques that may offer the opportunity to improve characterization and diagnosis of DCM. A summary of treatment modalities, including surgical and nonoperative options, is then provided along with future neuroprotective and neuroregenerative strategies. This review concludes with final remarks pertaining to the genetics involved in DCM and the opportunity to leverage this knowledge toward a personalized medicine approach.

Lived experience-centred word clouds may improve research uncertainty gathering in priority setting partnerships

INTRODUCTION

AO Spine RECODE-DCM was a multi-stakeholder priority setting partnership (PSP) to define the top ten research priorities for degenerative cervical myelopathy (DCM). Priorities were generated and iteratively refined using a series of surveys administered to surgeons, other healthcare professionals (oHCP) and people with DCM (PwDCM). The aim of this work was to utilise word clouds to enable the perspectives of people with the condition to be heard earlier in the PSP process than is traditionally the case. The objective was to evaluate the added value of word clouds in the process of defining research uncertainties in National Institute for Health Research (NIHR) James Lind Alliance (JLA) Priority Setting Partnerships.

METHODS

Patient-generated word clouds were created for the four survey subsections of the AO Spine RECODE-DCM PSP: diagnosis, treatment, long-term management and other issues. These were then evaluated as a nested methodological study. Word-clouds were created and iteratively refined by an online support group of people with DCM, before being curated by the RECODE-DCM management committee and expert healthcare professional representatives. The final word clouds were embedded within the surveys administered at random to 50% of participants. DCM research uncertainties suggested by participants were compared pre- and post-word cloud presentation.

RESULTS

A total of 215 (50.9%) participants were randomised to the word cloud stream, including 118 (55%) spinal surgeons, 52 (24%) PwDCM and 45 (21%) oHCP. Participants submitted 434 additional uncertainties after word cloud review: word count was lower and more uniform across each survey subsections compared to pre-word cloud uncertainties. Twenty-three (32%) of the final 74 PSP summary questions did not have a post-word cloud contribution and no summary question was formed exclusively on post-word cloud uncertainties. There were differences in mapping of pre- and post-word cloud uncertainties to summary questions, with greater mapping of post-word cloud uncertainties to the number 1 research question priority: raising awareness. Five of the final summary questions were more likely to map to the research uncertainties suggested by participants after having reviewed the word clouds.

CONCLUSIONS

Word clouds may increase the perspective of underrepresented stakeholders in the research question gathering stage of priority setting partnerships. This may help steer the process towards research questions that are of highest priority for people with the condition.

Predictors of Quality of Life in Patients With Degenerative Cervical Myelopathy Receiving Nonsurgical Management Due to Chronic Pain

BACKGROUND

Most patients with degenerative cervical myelopathy (DCM) experience pain, and their quality of life (QoL) is poor.

AIMS

This study aimed to identify predictors of QoL, including demographic, clinical, physical, and psychosocial characteristics, in chronic pain patients with DCM receiving non-surgical management.

DESIGN

A descriptive study design was used.

SETTING

Participants were recruited at the pain clinic at a university hospital in Seoul, South Korea.

PARTICIPANTS/SUBJECTS

The subjects included 157 inpatients and outpatients with DCM receiving non-surgical management.

METHODS

We administered a written, structured, self-reported questionnaire, which included standard validated measures for the main variables of interest.

RESULTS

The median number of pain sites was two, and the average and most pain severities were 4.63 ± 2.35 and 5.71 ± 2.32 out of 10 within one month, respectively. Stepwise multiple regression analysis revealed that depression, education level, and headache were factors influencing physical QoL. Depression, education level, and marital status were factors influencing psychological QoL, whereas depression and education level were factors influencing social relationships QoL. Finally, the factors influencing environmental QoL were depression, educational level, and marital status.

CONCLUSIONS

Demographic characteristics, including educational level and marital status, clinical characteristics, including pain site, and psychological characteristics, including depression, were identified as factors influencing QoL in chronic pain patients with DCM receiving non-surgical management.

CLINICAL IMPLICATIONS

Healthcare professionals should consider demographic, clinical, and psychological characteristics when evaluating patients... QoL. In addition, it is necessary to pay attention to the QoL of participants who are single and have lower levels of education, headache pain, and high levels of depression. These patients are likely to have low QoL and strategies to improve their QoL should be developed.

Targeting patient recovery priorities in degenerative cervical myelopathy: design and rationale for the RECEDE-Myelopathy trial-study protocol

INTRODUCTION

Degenerative cervical myelopathy (DCM) is a common and disabling condition of symptomatic cervical spinal cord compression secondary to degenerative changes in spinal structures leading to a mechanical stress injury of the spinal cord. RECEDE-Myelopathy aims to test the disease-modulating activity of the phosphodiesterase 3/phosphodiesterase 4 inhibitor Ibudilast as an adjuvant to surgical decompression in DCM.

METHODS AND ANALYSIS

RECEDE-Myelopathy is a multicentre, double-blind, randomised, placebo-controlled trial. Participants will be randomised to receive either 60-100 mg Ibudilast or placebo starting within 10 weeks prior to surgery and continuing for 24 weeks after surgery for a maximum of 34 weeks. Adults with DCM, who have a modified Japanese Orthopaedic Association (mJOA) score 8-14 inclusive and are scheduled for their first decompressive surgery are eligible for inclusion. The coprimary endpoints are pain measured on a visual analogue scale and physical function measured by the mJOA score at 6 months after surgery. Clinical assessments will be undertaken preoperatively, postoperatively and 3, 6 and 12 months after surgery. We hypothesise that adjuvant therapy with Ibudilast leads to a meaningful and additional improvement in either pain or function, as compared with standard routine care.

STUDY DESIGN

Clinical trial protocol V.2.2 October 2020.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from HRA-Wales.The results will be presented at an international and national scientific conferences and in a peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ISRCTN Number: ISRCTN16682024.

Return to work after surgery for degenerative cervical myelopathy: a nationwide registry-based observational study

BACKGROUND

Few studies of high quality exist on return to work (RTW) rate after surgery for degenerative cervical myelopathy (DCM). This study aims to examine the RTW rate in patients undergoing surgery for DCM.

METHODS

Nationwide prospectively collected data were obtained from the Norwegian Registry for Spine Surgery and the Norwegian Labour and Welfare Administration. The primary outcome was return to work, defined as being at work at a given time postoperatively without any medical income-compensation benefits. Secondary endpoints included the neck disability index (NDI) and quality of life measured by EuroQol-5D (EQ-5D).

RESULTS

Among 439 patients operated for DCM between 2012 and 2018, 20% of the patients received a medical income-compensation benefit one year before surgery. This number increased steadily towards the operation at which timepoint 100% received benefits. By 12 months after surgery, 65% had returned to work. By 36 months, 75% had returned to work. Patients that returned to work were more likely to be non-smokers and to have a college education. They had less comorbidity, more were without benefit 1-year pre-surgery, and significantly more patients were employed at operation date. Average days of sick leave in the year before surgery were significantly less in the RTW group, and they had a significantly lower baseline NDI and EQ-5D All PROMs reached statistical significance at 12 months, in favor of the group that achieved RTW.

CONCLUSION

At 12 months following surgery, 65% had returned to work. At the end of the 36-month follow-up period, 75% had returned to work, 5% less than the working percentage in the beginning of the follow-up period. This study demonstrates that a large percentage of patients return to work after surgical treatment for DCM.

Prevalence and risk factors for anxiety and depression among community dwelling patients with cervical spondylosis during the COVID-19 pandemic

Background

The emergence of COVID-19 and its unfavorable consequences lead to disease fear and other related mental health problems for individuals worldwide. This study aimed to analyze the prevalence and relevant factors of anxiety and depression among community dwelling cervical spondylosis (CS) patients, and to explore the relationship between fear of COVID-19 and anxiety and depression, so as to provide scientific basis for improving their mental health.

Methods

A community-based cross-sectional study was conducted among a cohort of 556 CS patients by using convenient sampling. These participants were asked to complete a demographic questionnaire, the Hospital Anxiety and Depression Scale (HADS), and the Fear of COVID-19 Scale (FCV-19S). The Chi-square test was used to determine the differences among categorical variables. Binary stepwise logistic regression was used to determine predictors of anxiety and depression.

Results

The median HADS-A score was 5 (interquartile interval 2-7), and the median HADS-D score was 4 (interquartile interval 2-8). In this study, the prevalence of anxiety and depression was 25.0% and 26.6%, respectively. Gender and comorbid chronic diseases were predictors of depressive symptoms. In addition, fear of COVID-19 was related to depression and anxiety among community dwelling CS patients.

Conclusion

Approximately one quarter of community dwelling CS patients were suffering depression or anxiety. Our findings could provide a basis for the development of psychological crisis intervention strategies for CS patients under public health emergencies in the future.

Determinants of quality of life in degenerative cervical myelopathy: a systematic review

BACKGROUND

Degenerative cervical myelopathy (DCM) is the most common cause of chronic, progressive spinal cord impairment worldwide. Patients experience substantial pain, functional neurological decline and disability. Health-related quality of life (HRQoL) appears to be particularly poor, even when compared to other chronic diseases. However, the determinants of HRQoL are poorly understood. The objective was to perform a systematic review of the determinants of quality of life of people with DCM.

METHODS

A systematic search was conducted in MEDLINE and Embase following PRISMA 2020 guidelines (PROSPERO CRD42018115675). Full-text papers in English, exclusively studying DCM, published before 26 March 2020 were eligible for inclusion and were assessed using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias 2 (RoB 2) tool. Study sample characteristics, patient demographics, cohort type, HRQoL instrument utilised, HRQoL score, and relationships of HRQoL with other variables were qualitatively synthesised.

RESULTS

A total of 1176 papers were identified; 77 papers and 13,572 patients were included in the final analysis. A total of 96% of papers studied surgical cohorts and 86% utilised the 36-Item Short Form Survey (SF-36) as a measure of HRQoL. HRQoL determinants were grouped into nine themes. The most common determinant to be assessed was surgical technique (38/77, 49%) and patient satisfaction and experience of pain (10/77, 13%). HRQoL appeared to improve after surgery. Pain was a negative predictor of HRQoL.

CONCLUSION

Current data on the determinants of HRQoL in DCM are limited, contradictory and heterogeneous. Limitations of this systematic review include lack of distinction between DCM subtypes and heterogenous findings amongst the papers in which HRQoL is measured postoperatively or post-diagnosis. This highlights the need for greater standardisation in DCM research to allow further synthesis. Studies of greater precision are necessary to account for HRQoL being complex, multi-factorial and both time and context dependent.

The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND

Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations.

RESEARCH QUESTION

Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease?

MATERIALS AND METHODS

Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses.

RESULTS

47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m²). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001).

DISCUSSION AND CONCLUSION

Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated.

LEVEL OF EVIDENCE

Level III.

Most degenerative cervical myelopathy remains undiagnosed, particularly amongst the elderly: modelling the prevalence of degenerative cervical myelopathy in the United Kingdom

BACKGROUND

Degenerative cervical myelopathy (DCM) is a poorly recognised form of spinal cord injury which arises when degenerative changes in the cervical spine injure the spinal cord. Timely surgical intervention is critical to preventing disability. Despite this, DCM is frequently undiagnosed, and may be misconstrued as normal ageing. For a disease associated with age, we hypothesised that the elderly may represent an underdiagnosed population. This study aimed to evaluate this hypothesis by comparing age-stratified estimates of DCM prevalence based on spinal cord compression (SCC) data with hospital-diagnosed prevalence in the UK.

METHODS

We queried the UK Hospital Episode Statistics database for admissions with a primary diagnosis of DCM. Age-stratified incidence rates were calculated and extrapolated to prevalence by adjusting population-level life expectancy to the standardised mortality ratio of DCM. We compared these figures to estimates of DCM prevalence based on the published conversion rate of asymptomatic SCC to DCM.

RESULTS

The mean prevalence of DCM across all age groups was 0.19% (0.17, 0.21), with a peak prevalence of 0.42% at age 50-54 years. This contrasts with estimates from SCC data which suggest a mean prevalence of 2.22% (0.436, 2.68) and a peak prevalence of 4.16% at age > 79 years.

CONCLUSIONS

To our knowledge, this is the first study to estimate the age-stratified prevalence of DCM and estimate underdiagnosis. There is a substantial difference between estimates of DCM prevalence derived from SCC data and UK hospital activity data. This is greatest amongst elderly populations, indicating a potential health inequality.

The Natural History of Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is the most frequent cause of spinal cord dysfunction and injury in the adult population and leads to significant loss of quality of life and economic impact from its associated medical care expenditures and loss of work. Surgical intervention is recommended for patients manifesting progressing neurological signs and symptoms of myelopathy, but the optimal management in individuals who have mild and clinically stable disease manifestations is controversial. Understanding the natural history of DCM is, thus, important in assessing patients and identifying those most appropriately indicated for surgical management. Despite the attempts to rigorously perform studies of the natural history of these patients, most published investigations suffer from methodological weaknesses or are underpowered to provide definitive answers. Investigations of particular patient subsets, however, provide some clinical guidance as to which patients stand most to benefit from surgery, and these may include those with lower baseline mJOA scores, evidence of segmental hypermobility, cord signal changes on MRI, abnormal somatosensory or motor-evoked potentials, or the presence of certain inflammatory markers. Clinicians should assess patients with mild myelopathy and those harboring asymptomatic cervical spinal cord compression individually when making treatment decisions and an understanding of the various factors that may influence natural history may aid in identifying those best indicated for surgery. Further investigations will likely identify how variables that affect natural history can be used in devising more precise treatment algorithms.

Degenerative cervical myelopathy education in UK medical schools: a national cross-sectional survey of medical students

INTRODUCTION

Degenerative cervical myelopathy (DCM) is a common and progressive neurological condition caused by injury of the cervical spinal cord by degenerative spinal pathology. Delayed diagnosis leading to avoidable and irreversible disability is a major current problem limiting patient outcomes. Lack of sufficient representation of DCM in undergraduate and postgraduate medical curricula may contribute to poor recognition of DCM by non-specialist doctors. The objective of this study was to assess the DCM teaching provision in UK medical schools and the DCM knowledge of UK medical students.

METHODS

UK medical students completed a web-based survey distributed nationally through university social media pages, university email bulletins and the national student network of Myelopathy.org. The survey comprised a 19-item questionnaire capturing data on student demographics, myelopathy teaching and myelopathy knowledge. Advertisements were repeated monthly over a 12-month recruitment period and participation was incentivised by entry into an Amazon voucher prize draw. Ethical approval for the study was granted by the Psychology Research Ethics Committee, University of Cambridge (PRE.2018.099).

RESULTS

A total of 751 medical students from 32 British medical schools completed the survey. Medical students from all year groups participated. Most students (520; 72%) had not received any medical school teaching about DCM. When students had received DCM teaching, the duration of teaching was minimal (75% < 1 h). A total of 350 students (47%) reported conducting private study on DCM. Modal student self-rating of their own knowledge of DCM was 'terrible' (356; 47%). There was no correlation between a student's subjective rating of their knowledge and their answers to objective questions. A total of 723 (96%) of students expressed interest in learning more about DCM, with lectures the preferred format.

CONCLUSIONS

DCM appears to be a neglected condition in medical education which has implications for clinical practice. However, student enthusiasm to undertake private study suggests future teaching interventions will be well-received. Future work is necessary to characterise the format of DCM teaching that is most effective and to subsequently measure how educational interventions translate into clinical benefits.

Moving Beyond the Neck and Arm: The Pain Experience of People With Degenerative Cervical Myelopathy Who Have Pain

STUDY DESIGN

Cross-sectional internet survey of people living with degenerative cervical myelopathy.

OBJECTIVE

The purpose of this study was to quantify pain distribution, severity, and interference in persons with degenerative cervical myelopathy.

METHODS

Eighty-two participants with degenerative cervical myelopathy were recruited for this internet survey. This survey utilized the Michigan Body Map and brief pain inventory (BPI) to assess anatomical distribution and severity of pain as well as the patient derived modified Japanese Orthopedic Association scale (p-mJOA) for myelopathic severity and SF-36 for measures of health-related quality of life. Internal consistency was evaluated with Cronbach's alpha. Pearson's correlations were assessed with p-mJOA and SF-36. Multivariate analysis of variance was used to determine if history of prior surgery or concomitant pain diagnosis impacted experience of pain.

RESULTS

Michigan body map distribution and brief pain inventory severity and interference were correlated with p-mJOA and SF-36 scores (p < 0.05). Pain was moderate to severe in 78% of participants. Pain was commonly widespread. Pain scales were sufficiently internally consistent (α > 0.9). History of surgery or other pain diagnosis did not impact experience of pain in myelopathy.

CONCLUSIONS

Pain is commonly identifiable in large areas of the body, is frequently moderate to severe in intensity and impacts quality of life and severity of myelopathy in a cohort of individuals with myelopathy who have pain.

Determining the relationship between preoperative mental health scores and postoperative outcomes in adult spinal deformity surgeries

OBJECTIVE

The objective of this study was to examine the relationship between the mental health domain of the refined 22-item Scoliosis Research Society Outcome Questionnaire (SRS) and various postoperative outcome measures in the adult spinal deformity (ASD) population. Given the scale and involved nature of deformity surgery, some surgeons have proposed that preoperative mental health scores (MHSs) may assist in screening out poor surgical candidates. In this study, the authors aimed to further assess the SRS MHS as a preoperative metric and its association with postoperative outcomes and to comment on its potential use in patient selection and optimization for ASD surgery.

METHODS

The authors conducted a retrospective study of 100 consecutive patients who had undergone primary or revision ASD surgery at a single academic institution between 2015 and 2019. Each patient had a minimum 2-year follow-up. Patients were categorized on the basis of their baseline mental health per the SRS mental health domain, with a score < 4 indicating low baseline mental health (LMH) and a score ≥ 4 indicating high baseline mental health (HMH). Baseline and follow-up SRS and Oswestry Disability Index scores, surgical procedures, lengths of stay, discharge locations, intraoperative or postoperative complications, and other outcome metrics were then compared between the HMH and LMH groups, as well as these groups stratified by an age ≤ 45 and > 45 years.

RESULTS

Among patients aged ≤ 45 and those aged > 45, the LMH group had significantly worse baseline health-related quality-of-life (HRQOL) metrics in nearly all domains. The LMH group also had an increased median estimated blood loss (EBL; 1200 vs 800 ml, p = 0.0026) and longer average surgical duration (8.3 ± 2.8 vs 6.9 ± 2.6 hours, p = 0.014). Both LMH and HMH groups had significant improvements in nearly all HRQOL measures postoperatively. Despite their worse preoperative HRQOL baseline, patients in the LMH group actually improved the most and reached the same HRQOL endpoints as those in the HMH group.

CONCLUSIONS

While patients with lower baseline MHSs may require slightly longer hospital courses or more frequent discharges to rehabilitation facilities, these patients actually attain greater absolute improvements from their preoperative baseline and surprisingly have the same postoperative HRQOL metrics as the patients with high MHSs, despite their poorer starting point. This finding suggests that patients with LMH may be uniquely positioned to substantially benefit from surgical intervention and improve their HRQOL scores and thus should be considered for ASD surgery to an extent similar to patients with HMH.

Cervical cord reperfusion injury: a rare complication of spine surgery

BACKGROUND

Anterior cervical discectomy and fusion procedure has been considered the surgical procedure of choice for the management of degenerative cervical myelopathy. Postoperative paresis is one of the most serious and concerning complications. The occurrence of such complications without any clear anatomic explanation (e.g., epidural hematoma) is unusual.

CASE PRESENTATION

A 62-year-old man underwent cervical spine decompression via the anterior approach for marked central canal stenosis and spinal cord compression due to degenerative changes. The operation was performed under neuromonitoring, and a complete discectomy for the levels C3/C4, C5/C6, and C6/C7 was performed. Fluoroscopy confirmed the correct placement of the inserted plates and screws. No motor or sensory deficits were evident after postoperative recovery. However, 1 day later, the patient experienced progressive weakness in his both upper and lower extremities. A whole spine MRI study was performed to exclude epidural hematoma as the possible etiology. Although no localized fluid collection or hematoma was observed, the study demonstrated abnormal signal intensity in the spinal cord on T2-weighted images at the levels C5 to C7. Such findings were consistent with changes in cord reperfusion syndrome. The patient was administered intravenous methylprednisolone therapy. Gradual improvement in the muscle power in his both extremities was noted, and the patient was discharged with a satisfactory outcome. One month later, the MRI study was repeated and showed regression of the previously seen high T2 signal intensity in the cervical spine.

CONCLUSION

Cervical cord reperfusion injury is an extremely rare etiology of neurological deterioration following spinal cord decompressive surgeries. Clinicians need to maintain a high index of suspicion for this complication and should be familiar with its imaging appearance.

Evidence of impaired macroautophagy in human degenerative cervical myelopathy

Degenerative cervical myelopathy (DCM) is a common progressive disease of the spinal cord which can cause tetraplegia. Despite its prevalence, few studies have investigated the pathophysiology of DCM. Macroautophagy is a cellular process which degrades intracellular contents and its disruption is thought to contribute to many neurodegenerative diseases. The present study tests the hypothesis that macroautophagy is impaired in DCM. To address this, we utilised a collection of post-mortem cervical spinal cord samples and investigated seven DCM cases and five human controls. Immunohistochemical staining was used to visualise proteins involved in autophagy. This demonstrated significantly reduced numbers of LC3 puncta in cases versus controls (p = 0.0424). Consistent with reduced autophagy, we identified large aggregates of p62 in four of seven cases and no controls. Tau was increased in two of five cases compared to controls. BCL-2 was significantly increased in cases versus controls (p = 0.0133) and may explain this reduction in autophagy. Increased BCL-2 (p = 0.0369) and p62 bodies (p = 0.055) were seen in more severe cases of DCM. This is the first evidence that autophagy is impaired in DCM; the impairment appears greater in more severe cases. Further research is necessary to investigate whether macroautophagy has potential as a therapeutic target in DCM.

Development of a core measurement set for research in degenerative cervical myelopathy: a study protocol (AO Spine RECODE-DCM CMS)

INTRODUCTION

Progress in degenerative cervical myelopathy (DCM) is hindered by inconsistent measurement and reporting. This impedes data aggregation and outcome comparison across studies. This limitation can be reversed by developing a core measurement set (CMS) for DCM research. Previously, the AO Spine Research Objectives and Common Data Elements for DCM (AO Spine RECODE-DCM) defined 'what' should be measured in DCM: the next step of this initiative is to determine 'how' to measure these features. This protocol outlines the steps necessary for the development of a CMS for DCM research and audit.

METHODS AND ANALYSIS

The CMS will be developed in accordance with the guidance developed by the Core Outcome Measures in Effectiveness Trials and the Consensus-based Standards for the selection of health Measurement Instruments. The process involves five phases. In phase 1, the steering committee agreed on the constructs to be measured by sourcing consensus definitions from patients, professionals and the literature. In phases 2 and 3, systematic reviews were conducted to identify tools for each construct and aggregate their evidence. Constructs with and without tools were identified, and scoping reviews were conducted for constructs without tools. Evidence on measurement properties, as well as on timing of assessments, are currently being aggregated. These will be presented in phase 4: a consensus meeting where a multi-disciplinary panel of experts will select the instruments that will form the CMS. Following selection, guidance on the implementation of the CMS will be developed and disseminated (phase 5). A preliminary CMS review scheduled at 4 years from release.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Cambridge (HBREC2019.14). Dissemination strategies will include peer-reviewed scientific publications; conference presentations; podcasts; the identification of AO Spine RECODE-DCM ambassadors; and engagement with relevant journals, funders and the DCM community.

Tremor as a symptom of degenerative cervical myelopathy: a systematic review

BACKGROUND

AO Spine RECODE-DCM (Research objectives and common data elements for degenerative cervical myelopathy) has highlighted that the subjective disability reported by people living with DCM is much broader than routinely considered today by most professionals. This includes a description of tremor. The objective of this review was to study the incidence and possible aetiology of tremor in degenerative cervical myelopathy (DCM).

METHODS

A systematic review registered in PROSPERO (CRD42020176905) was conducted in Embase and MEDLINE for papers studying tremor and DCM published on or before the 20^th of July 2020. All manuscripts describing an association between tremor and DCM in humans were included. Articles relating to non-human animals, and those not available in English were excluded. An analysis was conducted in accordance with PRISMA and SWiM guidelines for systematic reviews.

RESULTS

Out of a total of 4402 screened abstracts, we identified 7 case reports and series describing tremor in 9 DCM patients. Papers were divided into three groups for the discussion. The first group includes DCM correctly identified on presentation, with tremor as a described symptom. The second group includes cases where DCM was misdiagnosed, often as Parkinson's disease. The third group includes a single case with a previous history of DCM, presenting with an otherwise unexplained tremor. This grouping allows for the clustering of cases supporting various arguments for the association between tremor and DCM.

CONCLUSION

DCM can be associated with tremor. The current evidence is restricted to case series. Further study is warranted to establish tremor prevalence, and its significance to assessment and management.

A scoping review of information provided within degenerative cervical myelopathy education resources: Towards enhancing shared decision making

BACKGROUND

Degenerative cervical myelopathy (DCM) is a chronic neurological condition estimated to affect 1 in 50 adults. Due to its diverse impact, trajectory and management options, patient-centred care and shared decision making are essential. In this scoping review, we aim to explore whether information needs in DCM are currently being met in available DCM educational resources. This forms part of a larger Myelopathy.org project to promote shared decision making in DCM.

METHODS

A search was completed encompassing MEDLINE, Embase and grey literature. Resources relevant to DCM were compiled for analysis. Resources were grouped into 5 information types: scientific literature, videos, organisations, health education websites and patient information leaflets. Resources were then further arranged into a hierarchical framework of domains and subdomains, formed through inductive analysis. Frequency statistics were employed to capture relative popularity as a surrogate marker of potential significance.

RESULTS

Of 2674 resources, 150 information resources addressing DCM were identified: 115 scientific literature resources, 28 videos, 5 resources from health organisations and 2 resources from health education websites. Surgical management was the domain with the largest number of resources (66.7%, 100/150). The domain with the second largest number of resources was clinical presentation and natural history (28.7%, 43/150). Most resources (83.3%, 125/150) were designed for professionals. A minority (11.3% 17/150) were written for a lay audience or for a combined audience (3.3%, 5/150).

CONCLUSION

Educational resources for DCM are largely directed at professionals and focus on surgical management. This is at odds with the needs of stakeholders in a lifelong condition that is often managed without surgery, highlighting an unmet educational need.

Provision and Perception of Physiotherapy in the Nonoperative Management of Degenerative Cervical Myelopathy (DCM): A Cross-Sectional Questionnaire of People Living With DCM

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

Degenerative cervical myelopathy (DCM) is a common syndrome of acquired spinal cord impairment caused by canal stenosis secondary to arthritic changes of the spine. International guidelines consider physiotherapy an option for mild, stable DCM; however, few studies have been conducted on nonoperative management. The objective was to determine current usage and perceptions of nonoperative physiotherapy for DCM.

METHODS

Persons with DCM were recruited to a web-based survey. Participants with complete responses that had not received surgery were included (n = 167). Variables included symptom duration, treatment history, current disability, and demographic characteristics.

RESULTS

Disease and demographic characteristics were equivalent between those who did and did not receive physiotherapy. In all, 19.5% of physiotherapy recipients reported subjective benefit from physiotherapy. Those perceiving benefit had significantly higher mJOA (modified Japanese Orthopaedic Association) scores, lower neck pain scores, and shorter symptom duration. In multivariate logistic regression analysis, those with mild DCM were more likely to perceive benefit than those with severe DCM, as were those with moderate DCM (to a lesser extent). Individuals whose diagnosis was delayed 1 to 2 years were less likely to perceive benefit than those that waited 0 to 6 months.

CONCLUSIONS

The provision of nonoperative physiotherapy in the management of DCM is inconsistent and appears to differ from international guidelines. Few patients perceived benefit from physiotherapy; however, this was more likely in those with mild DCM and in those with shorter symptom durations. Further work is needed to establish the appropriate role of physiotherapy for this population.

Quantitative MR Markers in Non-Myelopathic Spinal Cord Compression: A Narrative Review

Degenerative spinal cord compression is a frequent pathological condition with increasing prevalence throughout aging. Initial non-myelopathic cervical spinal cord compression (NMDC) might progress over time into potentially irreversible degenerative cervical myelopathy (DCM). While quantitative MRI (qMRI) techniques demonstrated the ability to depict intrinsic tissue properties, longitudinal in-vivo biomarkers to identify NMDC patients who will eventually develop DCM are still missing. Thus, we aim to review the ability of qMRI techniques (such as diffusion MRI, diffusion tensor imaging (DTI), magnetization transfer (MT) imaging, and magnetic resonance spectroscopy (1H-MRS)) to serve as prognostic markers in NMDC. While DTI in NMDC patients consistently detected lower fractional anisotropy and higher mean diffusivity at compressed levels, caused by demyelination and axonal injury, MT and 1H-MRS, along with advanced and tract-specific diffusion MRI, recently revealed microstructural alterations, also rostrally pointing to Wallerian degeneration. Recent studies also disclosed a significant relationship between microstructural damage and functional deficits, as assessed by qMRI and electrophysiology, respectively. Thus, tract-specific qMRI, in combination with electrophysiology, critically extends our understanding of the underlying pathophysiology of degenerative spinal cord compression and may provide predictive markers of DCM development for accurate patient management. However, the prognostic value must be validated in longitudinal studies.

The Prevalence of Degenerative Cervical Myelopathy-Related Pathologies on Magnetic Resonance Imaging in Healthy/Asymptomatic Individuals: A Meta-Analysis of Published Studies and Comparison to a Symptomatic Cohort

Degenerative cervical myelopathy (DCM) is a progressive cervical spinal cord injury brought about by mechanical stress from degenerative changes in the cervical spine. It is typically diagnosed on clinical symptoms and examination findings together with MRI findings. In this study, we explore the significance of these degenerative pathology to onset of DCM by performing the first meta-analysis on the prevalence of degenerative features reported on MRI amongst healthy and asymptomatic populations and compare this to the prevalence of degenerative features reported on MRI amongst a symptomatic population calculated in a previous review. We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines, cognizant of their adaptation for epidemiological studies. A search strategy was used to identify original research carrying out MRI screening of cervical spines of asymptomatic patients in MEDLINE and Embase from 1985 to present day. The search yielded a total of 1098 studies of which 17 were included in this meta-analysis covering a total of 5059 patients. Ossification of posterior longitudinal ligament (pooled asymptomatic prevalence of 0.4%, 95% Confidence Interval [0.1%, 0.8%]), enlargement of ligamentum flavum (pooled asymptomatic prevalence of 11.8%, 95% Confidence Interval [5.3%, 18.4%]) and degenerative multilevel disc pathology (pooled asymptomatic prevalence of 64.5%, 95% Confidence Interval [48.3%, 80.8%], I² 100%) were found to be significantly lower in asymptomatic populations. Symptomatic populations have a prevalence of 10.5% (95% Confidence Interval [7.7%, 13.3%]) for ossification of posterior longitudinal ligament, 56.8% (95% Confidence Interval [52.3%, 61.3%]) for enlargement of ligamentum flavum and 89.7% (95% Confidence Interval [86.9%, 92.5%]) for degenerative multilevel disc pathology [18]. Understanding the natural history of DCM is a recognised research priority, and whilst these perspectives require further evaluation, they may be of significant relevance to the evolving biomechanical understanding of the disease.

Establishing the Socio-Economic Impact of Degenerative Cervical Myelopathy Is Fundamental to Improving Outcomes [AO Spine RECODE-DCM Research Priority Number 8]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To contextualize AO Spine RECODE-DCM research priority number 5: What is the socio-economic impact of DCM? (The financial impact of living with DCM to the individual, their supporters, and society as a whole).

METHODS

In this review, we introduce the methodology of health-economic investigation, including potential techniques and approaches. We summarize the current health-economic evidence within DCM, so far focused on surgical treatment. We also cover the first national estimate, in partnership with Myelopathy.org from the United Kingdom, of the cost of DCM to society. We then demonstrate the significance of this question to advancing care and outcomes in the field.

RESULTS

DCM is a common and often disabling condition, with a significant lack of recognition. While evidence demonstrates the cost-effectives of surgery, even among higher income countries, health inequalities exist. Further the prevalent residual disability in myelopathy, despite treatment affects both the individual and society as a whole. A report from the United Kingdom provides the first cost-estimate to their society; an annual cost of ∼£681.6 million per year, but this is likely a significant underestimate.

CONCLUSION

A clear quantification of the impact of DCM is needed to raise the profile of a common and disabling condition. Current evidence suggests this is likely to be globally substantial.

Developing Peri-Operative Rehabilitation in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 6]: An Unexplored Opportunity?

STUDY DESIGN

Narrative review.

OBJECTIVE

Degenerative cervical myelopathy is one of the most frequent impairments of the spinal cord encountered internationally in adults. Currently, surgical decompression is the recommended treatment for people with DCM (PwCM) presenting with moderate to severe symptoms or neurological deficits. However, despite surgical intervention, not all patients make a complete recovery due to the irreversible tissue damage within the spinal cord. The objective of this review is to describe the state and gaps in the current literature on rehabilitation for PwCM and possible innovative rehabilitation strategies.

METHODS

Literature search.

RESULTS

In other neurological disorders such as stroke and acute traumatic spinal cord injury (SCI), timely and strategic rehabilitation has been shown to be indispensable for maximizing functional outcomes, and it is imperative that appropriate perioperative rehabilitative interventions accompany surgical approaches in order to enable the best outcomes. In this review, the current state of knowledge regarding rehabilitation for PwCM is described. Additionally, various therapies that have shown to improve outcomes in comparable neurological conditions such as stroke and SCI which may be translated to DCM will be reviewed.

CONCLUSIONS

We conclude that locomotor training and arm/hand therapy may benefit PwCM. Further, we conclude that body weight support, robotic assistance, and virtual/augmented reality therapies may be beneficial therapeutic analogs to locomotor and hand therapies.

Gathering Global Perspectives to Establish the Research Priorities and Minimum Data Sets for Degenerative Cervical Myelopathy: Sampling Strategy of the First Round Consensus Surveys of AO Spine RECODE-DCM

STUDY DESIGN

Survey.

INTRODUCTION

AO Spine Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy (AO Spine RECODE-DCM) is an international initiative that aims to accelerate knowledge discovery and improve outcomes by developing a consensus framework for research. This includes defining the top research priorities, an index term and a minimum data set (core outcome set and core data elements set - core outcome set (COS)/core data elements (CDE)).

OBJECTIVE

To describe how perspectives were gathered and report the detailed sampling characteristics.

METHODS

A two-stage, electronic survey was used to gather and seek initial consensus. Perspectives were sought from spinal surgeons, other healthcare professionals and people with degenerative cervical myelopathy (DCM). Participants were allocated to one of two parallel streams: (1) priority setting or (2) minimum dataset. An email campaign was developed to advertise the survey to relevant global stakeholder individuals and organisations. People with DCM were recruited using the international DCM charity Myelopathy.org and its social media channels. A network of global partners was recruited to act as project ambassadors. Data from Google Analytics, MailChimp and Calibrum helped optimise survey dissemination.

RESULTS

Survey engagement was high amongst the three stakeholder groups: 208 people with DCM, 389 spinal surgeons and 157 other healthcare professionals. Individuals from 76 different countries participated; the United States, United Kingdom and Canada were the most common countries of participants.

CONCLUSION

AO Spine RECODE-DCM recruited a diverse and sufficient number of participants for an international PSP and COS/CDE process. Whilst PSP and COS/CDE have been undertaken in other fields, to our knowledge, this is the first time they have been combined in one process.

Developing Novel Therapies for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 7]: Opportunities From Restorative Neurobiology

STUDY DESIGN

Narrative review.

OBJECTIVES

To provide an overview of contemporary therapies for the James Lind Alliance priority setting partnership for degenerative cervical myelopathy (DCM) question: 'Can novel therapies, including stem-cell, gene, pharmacological and neuroprotective therapies, be identified to improve the health and wellbeing of people living with DCM and slow down disease progression?'

METHODS

A review of the literature was conducted to outline the pathophysiology of DCM and present contemporary therapies that may hold therapeutic value in 3 broad categories of neuroprotection, neuroregeneration, and neuromodulation.

RESULTS

Chronic spinal cord compression leads to ischaemia, neuroinflammation, demyelination, and neuronal loss. Surgical intervention may halt progression and improve symptoms, though the majority do not make a full recovery leading to lifelong disability. Neuroprotective agents disrupt deleterious secondary injury pathways, and one agent, Riluzole, has undergone Phase-III investigation in DCM. Although it did not show efficacy on the primary outcome modified Japanese Orthopaedic Association scale, it showed promising results in pain reduction. Regenerative approaches are in the early stage, with one agent, Ibudilast, currently in a phase-III investigation. Neuromodulation approaches aim to therapeutically alter the state of spinal cord excitation by electrical stimulation with a variety of approaches. Case studies using electrical neuromuscular and spinal cord stimulation have shown positive therapeutic utility.

CONCLUSION

There is limited research into interventions in the 3 broad areas of neuroprotection, neuroregeneration, and neuromodulation for DCM. Contemporary and novel therapies for DCM are now a top 10 priority, and whilst research in these areas is limited in DCM, it is hoped that this review will encourage research into this priority.