Assessment of degenerative cervical myelopathy differs between specialists and may influence time to diagnosis and clinical outcomes

Outcomes for Degenerative Cervical Myelopathy Following Implementation of the AO Spine International Guidelines: A Single-Centre Service Evaluation

IntroductionDegenerative cervical myelopathy (DCM) is a syndrome of symptomatic cervical spinal cord compression due to degenerative spinal changes. Until recently there was no formal consensus on exactly which patients are suitable for surgical or conservative management. The AO Spine international guidelines were introduced to address this issue, based on the best available current evidence. However, their implementation into routine clinical practice has not yet been reported. The objective was to evaluate surgical outcomes following the implementation of the AO Spine guidelines at our spinal neurosurgical centre.MethodsA service evaluation was conducted using data collected from electronic healthcare records for 259 patients, with outcomes of interest including change in mJOA score and complications. Data from 193 patients were included in the final analysis.ResultsThere was a mean improvement of the mJOA score by 1.53 points, 1.44 point and 1.92 points at post-operative intervals of 3 months (P < .001), 6 months (P < .001) and 12 months (P < .001). The percentage (number) of patients whose increase in mJOA score was greater than or equal to the minimal clinically importance difference (MCID) was 41% (44/107), 34% (33/96) and 43% (49/114) at these respective time intervals. Intraoperative complications occurred in 28 patients (11.7%). No association was found between BMI and postoperative change in mJOA score.ConclusionOur results are comparable to those from best practice data and suggest adherence to international guidelines provides a service that promotes meaningful recovery for patients with DCM. Therefore, our results offer support for implementation of the AO Spine international guidelines in clinical practice.

Duration of symptoms before diagnosis in degenerative cervical myelopathy: A systematic review and meta-analysis

Introduction

Degenerative cervical myelopathy (DCM), the commonest cause of spinal cord injury, can lead to progressive disability. Due to overlapping symptoms with other conditions and low awareness among healthcare professionals, many patients experience delayed diagnosis.

Research question

What is the typical duration of symptoms of DCM before diagnosis?

Materials and methods

We searched multiple databases for primary studies reporting duration of symptoms in people with confirmed diagnosis of DCM. Two independent reviewers screened titles, abstracts, full-text articles, extracted data and appraised study quality. We performed random-effects meta-analyses to pool duration of symptoms to presentation, diagnosis, and intervention.

Results

We identified 78 studies from 18 countries, with 12,450 participants. Time from symptom onset to first clinical presentation (two studies, n = 232 participants) was 3.3 (95 % confidence interval, -0.3-6.8) months. Time from symptom onset to diagnosis (five studies, n = 897) was 15.0 (5.0-25.0) months. In 29 studies (n = 3052) that measured from symptom onset to surgery/pre-operative assessment the duration was 14.5 (12.1-17.0) months. Thirty-seven studies had an undefined endpoint, in which when pooled, duration of symptoms was 15.2 (12.4-18.0) months. Most studies did not define the symptoms at onset, however when onset was defined as first occurrence of myelopathic (upper motor neurone) symptoms (five studies, n = 1006), time to surgery was 10.7 (2.3-18.5) months.

Discussion and conclusion

Most people with DCM experience symptoms for more than one year before diagnosis. These data may be useful to inform initiatives to promote early diagnosis. Standardised methodology would improve further research in this area.

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.

Is Upper Extremity or Lower Extremity Function More Important for Patient Satisfaction? An Analysis of 24-Month Outcomes from the QOD Cervical Spondylotic Myelopathy Cohort

STUDY DESIGN

Retrospective analysis of a prospective, multicenter registry.

OBJECTIVE

To assess whether upper or lower limb mJOA improvement more strongly associates with patient satisfaction after surgery for cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

The modified Japanese Orthopaedic Association (mJOA) is commonly used to assess functional status in patients with CSM. Patients present with upper and/or lower extremity dysfunction, and it is unclear whether improvement in one and/or both symptoms drives postoperative patient satisfaction.

METHODS

This study utilizes the prospective Quality Outcomes Database (QOD) CSM data set. Clinical outcomes included mJOA and North American Spine Society (NASS) satisfaction. The upper limb mJOA score was defined as upper motor plus sensory mJOA, and the lower limb mJOA as lower motor plus sensory mJOA. Ordered logistic regression was used to determine whether upper or lower limb mJOA was more closely associated with NASS satisfaction, adjusting for other covariates.

RESULTS

Overall, 1141 patients were enrolled in the QOD CSM cohort. In all, 780 had both preoperative and 24-month mJOA scores, met inclusion criteria, and were included for analysis. The baseline mJOA was 12.1±2.7, and postoperatively, 85.6% would undergo surgery again (NASS 1 or 2, satisfied). Patients exhibited mean improvement in both upper (baseline:3.9±1.4 vs. 24 mo:5.0±1.1, P<0.001) and lower limb mJOA (baseline:3.9±1.4 vs. 24 mon:4.5±1.5, P<0.001); however, the 24-month change in the upper limb mJOA was greater (upper:1.1±1.6 vs. lower:0.6±1.6, P<0.001). Across 24-month NASS satisfaction, the baseline upper and lower limb mJOA scores were similar (pupper=0.28, plower=0.092). However, as satisfaction decreased, the 24-month change in upper and lower limb mJOA decreased as well (pupper<0.001, plower<0.001). Patients with NASS scores of 4 (lowest satisfaction) did not demonstrate significant differences from baseline in upper or lower limb mJOA (P>0.05). In ordered logistic regression, NASS satisfaction was independently associated with upper limb mJOA improvement (OR=0.81; 95% CI: 0.68-0.97; P=0.019) but not lower limb mJOA improvement (OR=0.84; 95% CI: 0.70-1.0; P=0.054).

CONCLUSIONS

As the magnitude of upper and lower mJOA improvement decreased postoperatively, so too did patient satisfaction with surgical intervention. Upper limb mJOA improvement was a significant independent predictor of patient satisfaction, whereas lower limb mJOA improvement was not. These findings may aid preoperative counseling, stratified by patients' upper and lower extremity treatment expectations.

LEVEL OF EVIDENCE

Level-III.

The significance of metabolic disease in degenerative cervical myelopathy: a systematic review

Introduction

Degenerative cervical myelopathy (DCM) is a form of chronic spinal cord injury, with a natural history of potential for progression over time. Whilst driven by mechanical stress on the spinal cord from degenerative and congenital pathology, the neurological phenotype of DCM is likely to be modified by multiple systemic factors. The role of metabolic factors is therefore of interest, particularly given that ischaemia is considered a key pathological mechanism of spinal cord injury. The objective was therefore to synthesise current evidence on the effect of metabolism on DCM susceptibility, severity, and surgical outcomes.

Methods

A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English, with a focus on DCM and metabolism, including diabetes, cardiovascular disease, anaemia, and lipid profile, were eligible for inclusion. Risk of methodological bias was assessed using the Joanna Briggs Institute (JBI) critical assessment tools. Quality assessments were performed using the GRADE assessment tool. Patient demographics, metabolic factors and the relationships between metabolism and spinal cord disease, spinal column disease and post-operative outcomes were assessed.

Results

In total, 8,523 papers were identified, of which 57 met criteria for inclusion in the final analysis. A total of 91% (52/57) of included papers assessed the effects of diabetes in relation to DCM, of which 85% (44/52) reported an association with poor surgical outcomes; 42% of papers (24/57) discussed the association between cardiovascular health and DCM, of which 88% (21/24) reported a significant association. Overall, DCM patients with diabetes or cardiovascular disease experienced greater perioperative morbidity and poorer neurological recovery. They were also more likely to have comorbidities such as obesity and hyperlipidaemia.

Conclusion

Metabolic factors appear to be associated with surgical outcomes in DCM. However, evidence for a more specific role in DCM susceptibility and severity is uncertain. The pathophysiology and natural history of DCM are critical research priorities; the role of metabolism is therefore a key area for future research focus.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268814.

Structural Myelopathies

OBJECTIVE

This article illustrates the clinical importance, diagnosis, and management of degenerative and nondegenerative structural myelopathies. It also aims to create a diagnostic approach for the evaluation of patients with suspected degenerative myelopathies.

LATEST DEVELOPMENTS

There is considerable interest in developing diagnostic methods that can assist in deciding if surgery is indicated in patients with structural myelopathy and the optimal timing for surgery. Diffusion tensor imaging has emerged as a promising imaging modality although it is not used routinely in clinical practice. Neuroprotective medications and interventions are being studied in patients with degenerative myelopathies.

ESSENTIAL POINTS

Structural myelopathies and particularly degenerative myelopathies are common disorders that are routinely encountered in clinical practice, with symptoms that frequently overlap with other neurologic disorders. The prompt diagnosis and treatment of patients are essential in achieving good functional outcomes.

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.

Degenerative Cervical Myelopathy: A Concept Review and Clinical Approach

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide an overview of the evaluation and diagnosis of degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM describes several etiologies of degenerative, nontraumatic spinal cord impairment. Early diagnosis and intervention can decrease neurological decline.

METHODS

An extensive literature review was conducted.

RESULTS

The incidence and prevalence of DCM are increasing worldwide. Asymptomatic spinal cord compression can progress to cervical myelopathy. Static and dynamic factors contribute to spinal cord compression. Patients frequently present with decreased manual dexterity, gait instability, and neck pain. On physical exam, patients frequently present with upper motor neuron signs, a Lhermitte sign, a failed Romberg test, global proprioceptive dysfunction, and decreased pain sensation. Anatomic variation may complicate physical exam interpretation. The modified Japanese Orthopaedic Association Scale and Nurick Classification, based on functional impairment, provide diagnostic utility. Magnetic Resonance Imaging imaging is useful in narrowing the differential diagnosis, evaluating the severity of neurological impairment, and predicting disease progression.

CONCLUSIONS

Understanding the pathophysiology of DCM and the diagnostic utility of the signs and symptoms of DCM is critical. The decision for anterior cervical discectomy and fusion (ACDF), laminoplasty, or combined ACDF and posterior cervical fusion is individualized for each patient.

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.

Establishing mild, moderate and severe criteria for the myelopathy disability index in cervical spondylotic myelopathy

AIM

Cervical Spondylotic Myelopathy (CSM) is a disabling condition arising from arthritic compression and consequent injury of the cervical spinal cord. Stratification of CSM severity has been useful to inform clinical practice and research analysis. In the UK the Myelopathy Disability Index (MDI) is a popular assessment tool and has been adopted by the British Spinal Registry. However, no categories of severity exist. Therefore, the aim of this study was to define categories of mild, moderate and severe.

METHOD

An anchor-based analysis was carried out on previously collected data from a prospective observational cohort (N = 404) of patients with CSM scheduled for surgery and assessed pre-operatively and at 3, 12, 24 and 60 months post-operatively. Outcomes collected included the SF-36 version-1 quality of life measure, visual analogue scales for neck/arm/hand pain, MDI and Neck Disability Index (NDI). A Receiver Operating Curve (ROC) analysis, using the NDI for an anchor-based approach, was performed to identify MDI thresholds.

RESULTS

Complete data was available for 404 patients (219 Men, 185 Women). The majority of patients underwent anterior surgery (284, 70.3%). ROC curves plotted to identify the thresholds from mild to moderate to severe disease, selected optimal thresholds of 4-5 (AUC 0.83) and 8-9 (AUC 0.87). These MDI categories were validated against domains of the SF36 and VAS scores with expected positive linear correlations.

CONCLUSION

Categories of mild, moderate and severe CSM according to the MDI of 4-5 and 8-9 were established based on the NDI.

The information needs of people with degenerative cervical myelopathy: A qualitative study to inform patient education in clinical practice

BACKGROUND

Individuals with lifelong illnesses need access to adequate information about their condition to make optimal health decisions. Degenerative Cervical Myelopathy (DCM) is the most common form of spinal cord dysfunction in adults worldwide. Its chronic and debilitating nature, varied impact, clinical trajectory, and management options necessitate appropriate informational support to sustain effective clinical and self-directed care strategies. However, before clinicians can meet patients' information needs, they must first have an understanding of their baseline requirements. This study explores the information needs of people with DCM (PwCM). In doing so, it provides a starting point for the development of patient education and knowledge management strategies in clinical practice.

METHODS

Semi-structured interviews with PwCM were conducted using an interview guide. Interviews were audio-recorded and transcribed verbatim. Thematic analysis according to Braun and Clarke's six-phase approach was used to analyse the data. Findings were reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

RESULTS

Twenty PwCM (65% female, 35% male), with ages ranging from 39 to 74 years old participated in the interviews. The findings indicated that the provision of information to PwCM during clinical interactions varies. Accordingly, PwCM's information needs were broad-ranging, as was the nature of the information they found useful. Three main themes were identified (1) Variation in the provision of information to PwCM during clinical interactions, (2) Variations in the information needs of PwCM, and (3) Information that PwCM find useful.

CONCLUSION

Efforts must turn to adequately educating patients at the time of the clinical encounter. A comprehensive and consistent patient-centered information exchange in DCM is necessary to achieve this.

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.

Targeting earlier diagnosis: What symptoms come first in Degenerative Cervical Myelopathy?

BACKGROUND

Degenerative cervical myelopathy (DCM) is a common and disabling condition. Early effective treatment is limited by late diagnosis. Conventional descriptions of DCM focus on motor and sensory limb disability, however, recent work suggests the true impact is much broader. This study aimed to characterise the symptomatic presentation of DCM from the perspective of people with DCM and determine whether any of the reported symptoms, or groups of symptoms, were associated with early diagnosis.

METHODS

An internet survey was developed, using an established list of patient-reported effects. Participants (N = 171) were recruited from an online community of people with DCM. Respondents selected their current symptoms and primary presenting symptom. The relationship of symptoms and their relationship to time to diagnosis were explored. This included symptoms not commonly measured today, termed 'non-conventional' symptoms.

RESULTS

All listed symptoms were experienced by >10% of respondents, with poor balance being the most commonly reported (84.2%). Non-conventional symptoms accounted for 39.7% of symptomatic burden. 55.4% of the symptoms were reported as an initial symptom, with neck pain the most common (13.5%). Non-conventional symptoms accounted for 11.1% of initial symptoms. 79.5% of the respondents were diagnosed late (>6 months). Heavy legs was the only initial symptom associated with early diagnosis.

CONCLUSIONS

A comprehensive description of the self-reported effects of DCM has been established, including the prevalence of symptoms at disease presentation. The experience of DCM is broader than suggested by conventional descriptions and further exploration of non-conventional symptoms may support earlier diagnosis.

Life expectancy in patients with degenerative cervical myelopathy is currently reduced but can be restored with timely treatment

PURPOSE

Degenerative cervical myelopathy is a progressive slow-motion spinal cord injury. Surgery is the mainstay of treatment. Baseline disability predicts surgical recovery; therefore, timely treatment is critical to restoring function. However, current challenges mean most patients present with advanced disease and are instead left with life changing disabilities. While short-term mortality is rarely reported, the long-term effects of this on life expectancy are unknown, including whether function could be modifiable with timely treatment. This article investigates the effect of DCM on life expectancy.

METHODS

The survival of patients from an observational study of patients undergoing surgery from 1994 to 2007 was compared to their expected survival using a gender- and aged -matched cohort. Comparisons were made by one sample log-rank test and standardised mortality ratios. Factors associated with survival were explored using a Cox regression analysis, including disease severity.

RESULTS

A total of 357 patients were included in the analysis. After a median follow-up of 15.3 years, 135 of 349 patients had died; 114.7 deaths would have been expected. The DCM cohort had an increased risk of death compared to the non-DCM cohort (standardised mortality ratio 1.18 [95% CI: 1.02-1.34]. Age at operation 1.08 (95% CI: 1.07 to 1.1, p < 0.001) and severe DCM 1.6 (95% CI: 1.06 to 2.3, p = 0.02) were associated with worse survival (N = 287). In those surviving at least 2 years after surgery, only severe DCM was associated with conditional survival (HR 1.6, 95% CI 1.04 2.4, p = 0.03).

CONCLUSION

Life expectancy is reduced in those undergoing surgery for DCM. This is driven by premature mortality among those left with severe disability. As disability can be reduced with timely treatment, these findings reinforce the need for collective and global action to raise awareness of DCM and enable early diagnosis.

Myelopathy disability index: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy

PURPOSE

To find the cut-off values in the Myelopathy Disability Index (MDI) that will allow us to classify the severity of Degenerative Cervical Myelopathy (DCM) into mild, moderate and severe.

METHODS

Cross-sectional study with prospective data collection, with a total of 64 patients diagnosed with Degenerative Cervical Myelopathy (DCM). Anthropometric, diagnostic, neurological, functional and quality of life variables were collected. A Receiver Operating Curve (ROC) was performed. The cut-off points were validated by comparing the functional status of patients in the 3 groups and their Nurick scores.

RESULTS

Sixty-four patients (23 women) with a mean age of 61.97 (SD 11.57) participated in this study. The majority of patients were Nurick I (28.13%) and Nurick II (32.81%). The medium MDI was 7.36 (SD 6.66) and the mJOA was 14.08 (SD 2.57). The mild-moderate cut-off value was between 4 and 5, with an Area Under the Curve (AUC) of 0.805, sensitivity of 0.853 and specificity of 0.6. For moderate-severe, the cut-off value obtained was between 7 and 8, with an AUC of 0.862, sensitivity of 0.857 and specificity of 0.684. Patients with greater severity had significantly lower functionality, with a P-value of 0.004 in the 30 Metre Walking Test and 0.005 in the Nine-Hole Peg Test. Established severity groups were also significantly related to the different categories of the Nurick score (P-value = 0.000).

CONCLUSION

MDI values between 0 and 4 correspond to mild DCM, between 5 and 7 would be moderate DCM and from 8 to 30 indicate severe DCM.

Degenerative Cervical Myelopathy: Evaluation and Management

Degenerative cervical myelopathy is most commonly caused by cervical spondylosis, with a predominant elderly population, and is the most common cause of spinal cord impairment. Patients typically present with gait dysfunction, hand impairment, and/or the presence of long tract signs: clonus, Hoffman sign, Babinski sign, or inverted radial reflexes. One of the key surgical strategies is deciding an approach, which is based on patient characteristics and cause of pathologic condition. Without operative intervention, there is a high rate of neurological decline. Most surgeons recommended surgical treatment given the favorable outcomes and well understood natural history of disease.

Identification of Degenerative Cervical Myelopathy in the Chiropractic Office: Case Report and a Review of the Literature

Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction, yet it may be challenging to identify as it presents with variable symptoms. A 62-year-old woman presented to a chiropractor with a three-month exacerbation of neck pain, hand/finger numbness, and torso dysesthesia. She had previously seen primary care, physical therapy, rheumatology, and pain management. Previous cervical magnetic resonance imaging showed moderate cervical canal stenosis; however, previous providers had diagnosed her with radiculopathy and possible carpal tunnel syndrome yet had not requested neurosurgical consultation. On examination, the chiropractor identified sensorimotor deficits, hyperreflexia, and bilateral Hoffman reflexes, and referred the patient to a neurosurgeon for suspected DCM. The neurosurgeon performed an anterior cervical discectomy and fusion from C4-7. The patient's symptoms and disability level improved within two months of follow-up. We identified 11 previous cases in which a chiropractor suspected DCM which was then confirmed by a surgeon. Including the current case (i.e., 12 total), patients were older and mostly male; 50% had neck pain, 92% had hyperreflexia. Chiropractors referred each patient to a surgeon; 83% underwent cervical spine surgery. This case highlights the identification of DCM by a chiropractor and referral for neurosurgical evaluation with a positive outcome. Patients with previously undiagnosed DCM may present to chiropractors with varied symptoms and examination findings. DCM may contraindicate spinal manipulation and instead warrant surgery. Accordingly, chiropractors play a key role in the detection and referral of patients with misdiagnosed or overlooked DCM.

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.

Hospitalisation for degenerative cervical myelopathy in England: insights from the National Health Service Hospital Episode Statistics 2012 to 2019

PURPOSE

Degenerative cervical myelopathy (DCM) is the most common cause of adult spinal cord dysfunction worldwide. However, the current incidence of DCM is poorly understood. The Hospital Episode Statistics (HES) database contains details of all secondary care admissions across NHS hospitals in England. This study aimed to use HES data to characterise surgical activity for DCM in England.

METHODS

The HES database was interrogated for all cases of DCM between 2012 and 2019. DCM cases were identified from 5 ICD-10 codes. Age-stratified values were collected for 'Finished Consultant Episodes' (FCEs), which correspond to a patient's hospital admission under a lead clinician. Data was analysed to explore current annual activity and longitudinal change.

RESULTS

34,903 FCEs with one or more of the five ICD-10 codes were identified, of which 18,733 (53.6%) were of working age (18-64 years). Mean incidence of DCM was 7.44 per 100,000 (SD ± 0.32). Overall incidence of DCM rose from 6.94 per 100,000 in 2012-2013 to 7.54 per 100,000 in 2018-2019. The highest incidence was seen in 2016-2017 (7.94 per 100,000). The median male number of FCEs per year (2919, IQR: 228) was consistently higher than the median female number of FCEs per year (2216, IQR: 326). The rates of both emergency admissions and planned admissions are rising.

CONCLUSIONS

The incidence of hospitalisation for DCM in England is rising. Health care policymakers and providers must recognise the increasing burden of DCM and act to address both early diagnoses and access to treatment in future service provision plans.

Outcomes of Degenerative Cervical Myelopathy From The Perspective of Persons Living With the Condition: Findings of a Semistructured Interview Process With Partnered Internet Survey

STUDY DESIGN

Mixed-methods cross-sectional study.

OBJECTIVES

Degenerative cervical myelopathy (DCM) is a common and disabling condition. While classically, assessment and diagnosis has focused on neuromuscular symptoms, many other disabilities have been linked. The aim of this study was to explore the consequences of DCM for those with lived experience, producing a long list to inform the development of a core outcome set for DCM research.

METHODS

A 2-stage process was used: a focus group session of people with DCM (PwCM) and their supporters (n = 8) discussed the impact of DCM. This was used to develop a preliminary list of consequences, which were then placed into a survey of an online community of DCM sufferers (n = 224). Survey participants were asked to tick the consequences that they had experienced and given the opportunity to submit additional. Additional consequences were reviewed by a group of healthcare professionals and PwCM and included if not already represented. Demographic information including disease severity, age, and sex were captured for sampling comparison.

RESULTS

A total of 52 outcomes were identified from the focus group and nominally divided into 2 categories; symptoms (36 outcomes) and handicaps (18 outcomes), and further evaluated using a survey. All outcomes were recognized by at least 5% of respondents. A further 16 outcomes were added following the survey.

CONCLUSIONS

A list of DCM consequences has been defined from the perspective of PwCM. This will now be evaluated as part of AO Spine RECODE-DCM, an international multistakeholder collaboration to establish a core outcome set for research.

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.

Cervical Myelopathy: An Update on Posterior Decompression

STUDY DESIGN

This was a narrative review.

OBJECTIVE

The aim was to discuss current methods and review updated outcome studies regarding posterior decompression in the management of cervical myelopathy.

SUMMARY OF BACKGROUND DATA

Progressive myelopathy in the cervical segments is an indication for urgent surgical management. Although nonoperative treatment is an option in mild to moderate cases, the majority of patients will experience deterioration in neurological function requiring surgical decompression.

METHODS

A review of the literature was performed using PubMed to provide updated information regarding posterior cervical decompression in the management of myelopathy.

RESULTS

There are numerous studies comparing outcome data between cervical laminectomy and fusion with laminoplasty. While each technique has advantages and disadvantages, both provide adequate decompression and good long-term outcomes in patients meeting appropriate criteria.

CONCLUSIONS

Posterior decompression is an important approach for spine surgeons to have in their toolkits when treating cervical myelopathy.

Improving Awareness Could Transform Outcomes in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 1]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness.

METHODS

Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM.

RESULTS

DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness.

CONCLUSION

Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.

Improving Assessment of Disease Severity and Strategies for Monitoring Progression in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 4]

STUDY DESIGN

Narrative Review.

OBJECTIVE

To (i) discuss why assessment and monitoring of disease progression is critical in Degenerative cervical myelopathy (DCM); (ii) outline the important features of an ideal assessment tool and (iii) discuss current and novel strategies for detecting subtle deterioration in DCM.

METHODS

Literature review.

RESULTS

Degenerative cervical myelopathy is an overarching term used to describe progressive injury to the cervical spinal cord by age-related changes of the spinal axis. Based on a study by Smith et al (2020), the prevalence of DCM is approximately 2.3% and is expected to rise as the global population ages. Given the global impact of this disease, it is essential to address important knowledge gaps and prioritize areas for future investigation. As part of the AO Spine RECODE-DCM (Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy) project, a priority setting partnership was initiated to increase research efficiency by identifying the top ten research priorities for DCM. One of the top ten priorities for future DCM research was: What assessment tools can be used to evaluate functional impairment, disability and quality of life in people with DCM? What instruments, tools or methods can be used or developed to monitor people with DCM for disease progression or improvement either before or after surgical treatment?

CONCLUSIONS

With the increasing prevalence of DCM, effective surveillance of this population will require both the implementation of a monitoring framework as well as the development of new assessment tools.

Establishing Diagnostic Criteria for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 3]

STUDY DESIGN

Narrative review.

OBJECTIVES

To discuss the importance of establishing diagnostic criteria in Degenerative Cervical Myelopathy (DCM), including factors that must be taken into account and challenges that must be overcome in this process.

METHODS

Literature review summarising current evidence of establishing diagnostic criteria for DCM.

RESULTS

Degenerative Cervical Myelopathy (DCM) is characterised by a degenerative process of the cervical spine resulting in chronic spinal cord dysfunction and subsequent neurological disability. Diagnostic delays lead to progressive neurological decline with associated reduction in quality of life for patients. Surgical decompression may halt neurologic worsening and, in many cases, improves function. Therefore, making a prompt diagnosis of DCM in order to facilitate early surgical intervention is a clinical priority in DCM.

CONCLUSION

There are often extensive delays in the diagnosis of DCM. Presently, no single set of diagnostic criteria exists for DCM, making it challenging for clinicians to make the diagnosis. Earlier diagnosis and subsequent specialist referral could lead to improved patient outcomes using existing treatment modalities.

Intraoperative monitoring of CSF pressure in patients with degenerative cervical myelopathy (COMP-CORD Study): a prospective cohort study

Degenerative cervical myelopathy (DCM) is hallmarked by spinal canal narrowing and related cord compression and myelopathy. CSF pressure dynamics are likely disturbed due to spinal canal stenosis. The study aims to investigate the diagnostic value of continuous intraoperative CSF pressure monitoring during surgical decompression. Prospective single center study (NCT02170155) with enrolment of DCM patients that underwent surgical decompression between December 2019 and May 2021. Data from N=17 patients were analyzed, symptom severity graded with the modified Japanese Orthopedic Score (mJOA). CSF pulsations were continuously monitored with a lumbar intrathecal catheter during surgical decompression. Mean patient age was 62±9 years (range 38-73; 8F), symptoms were mild-moderate in most patients (mean mJOA 14±2, range 10-18). Measurements were well tolerated without safety concerns. In 15/16 (94%) CSF pulsations increased at the time of surgical decompression. In one case, responsiveness could not be evaluated for technical reasons. Unexpected CSF pulsation decrease was related to adverse events (i.e., CSF leakage). Median CSF pulsation amplitudes increased from pre-decompression (0.52 mmHg [IQR 0.71]) to post-decompression (0.72 mmHg [IQR 0.96]) (P=0.001). Mean baseline CSF pressure increased with lower magnitude than pulsations, from 9.5±3.5 to 10.3±3.8 mmHg (P=0.003). Systematic relations of CSF pulsations were confined to surgical decompression, independent of arterial blood pressure (P=0.927) or heart rate (P=0.102). Intraoperative CSF pulsation monitoring was sensitive, timely, and specifically related to surgical decompression while in addition adverse events could be discerned. Further investigation of the clinical value of intraoperative guidance for decompression in complex DCM surgery is promising.

The Prevalence of Asymptomatic and Symptomatic Spinal Cord Compression on Magnetic Resonance Imaging: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Cervical spinal cord compression (SCC) due to degenerative changes of the spine is a frequent finding on magnetic resonance imaging (MRI). While most people remain asymptomatic, a proportion develop symptoms of degenerative cervical myelopathy (DCM). DCM is an often-progressive neurological disease that can cause quadriplegia. The epidemiology of SCC and DCM is poorly understood. We sought to estimate the prevalence of degenerative cervical SCC and DCM from cross-sectional cohorts undergoing MRI.

METHODS

We conducted a systematic review and meta-analysis of MRI reports on human subjects older than 16 years with degenerative SCC. A predetermined search strategy was used to identify relevant literature on MEDLINE. Title and abstract screenings were followed by full text screening. Data was extracted and analyzed by fixed or random-effects models.

RESULTS

The present search returned 1506 publications. Following our exclusion criteria, 19 studies were included. Subgroup analysis of 3786 individuals estimated the prevalence of asymptomatic SCC in a healthy population as 24.2% with a significantly higher prevalence of SCC in older populations compared with younger populations and American/European populations compared with Asian populations. Subgroup analysis of 1202 individuals estimated the prevalence of DCM in a healthy population as 2.3%.

CONCLUSIONS

We present the first estimates of the prevalence of asymptomatic SCC and DCM. Studies investigating the epidemiology of SCC are heterogeneous in methodology and results. These data indicate the need for more studies into the epidemiology of SCC and DCM performed with consistent methodologies.

New Method for the Quantitative Assessment of Sensory Disturbances in Cervical Myelopathy: Application for Neurological Level Diagnosis

Introduction

Cervical myelopathy frequently manifests as sensory disturbances, including numbness, and their distribution pattern aids in neurological level diagnosis. However, the objective assessment of sensory disturbances is challenging. In this study, we attempted to quantitatively evaluate sensory symptoms in patients with cervical myelopathy according to lesion level using PainVision^Ⓡ.

Methods

Dermal sensations were evaluated in patients (n = 158) and healthy volunteers (n = 100) using PainVision^Ⓡ PS-2100, which measured the current perception threshold (CPT). The results were analyzed for their correlation with magnetic resonance imaging (MRI) data, visual analog scale (VAS) scores, and patient functional status assessed by the Japanese Orthopaedic Association (JOA) and JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) scores.

Results

Forearm and palm CPT values were significantly higher in patients with cervical myelopathy (both sites, P < 0.001) and were negatively correlated with the JOA score (forearm, r = −0.33; palm, r = −0.35; P < 0.001) and the JOACMEQ scores for upper extremity function (forearm, r = −0.37; palm, r = −0.39; P < 0.001), lower extremity function (forearm, r = −0.39; palm, r = −0.40; P < 0.001), and quality of life (forearm r = −0.27, P = 0.0025); however, no correlation was observed with the VAS score. Stratification of patients according to their lesion levels determined by MRI revealed that the C3/C4 subgroup had significantly higher forearm CPT values than the C4/C5 (P = 0.024) and C5/C6 (P = 0.0013) subgroups and higher palm CPT values than the C5/C6 subgroup (P = 0.009).

Conclusions

Quantitative measurements of sensory disturbances using the PainVision^Ⓡ device correspond to the degree of patient functional disability and the lesion level. This indicates that both the distribution and intensity of sensory abnormalities are important for neurological level diagnosis in patients with cervical myelopathy.

Degenerative cervical myelopathy - update and future directions

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.

Cord compression defined by MRI is the driving factor behind the decision to operate in Degenerative Cervical Myelopathy despite poor correlation with disease severity

OBJECTIVES

The mainstay treatment for Degenerative Cervical Myelopathy (DCM) is surgical decompression. Not all cases, however, are suitable for surgery. Recent international guidelines advise surgery for moderate to severe disease as well as progressive mild disease. The goal of this study was to examine the factors in current practice that drive the decision to operate in DCM.

STUDY DESIGN

Retrospective cohort study.

METHODS

1 year of cervical spine MRI scans (N = 1123) were reviewed to identify patients with DCM with sufficient clinical documentation (N = 39). Variables at surgical assessment were recorded: age, sex, clinical signs and symptoms of DCM, disease severity, and quantitative MRI measures of cord compression. Bivariate correlations were used to compare each variable with the decision to offer the patient an operation. Subsequent multivariable analysis incorporated all significant bivariate correlations.

RESULTS

Of the 39 patients identified, 25 (64%) were offered an operation. The decision to operate was significantly associated with narrower non-pathological canal and cord diameters as well as cord compression ratio, explaining 50% of the variance. In a multivariable model, only cord compression ratio was significant (p = 0.017). Examination findings, symptoms, functional disability, disease severity, disease progression, and demographic factors were all non-significant.

CONCLUSIONS

Cord compression emerged as the main factor in surgical decision-making prior to the publication of recent guidelines. Newly identified predictors of post-operative outcome were not significantly associated with decision to operate.

Efficacy of Laminoplasty in Improving Sensory Disturbances in Patients with Cervical Spondylotic Myelopathy: A Prospective Study

OBJECTIVE

Upper extremity sensory disturbances are primary symptoms that affect the quality of life (QOL) of patients with cervical spondylotic myelopathy. Although laminoplasty is 1 of the surgical options, its effects on sensory disturbances have remained unclear. We aimed to determine whether surgical intervention would improve the sensory disturbances of patients with cervical spondylotic myelopathy.

METHODS

We conducted a prospective clinical trial of 101 patients who had undergone open door laminoplasty. For an objective sensory assessment, we measured the current perception thresholds (CPTs) in the patients' forearms and palms using PainVision PS-2100. For a subjective sensory assessment, numbness in the upper extremities was rated using a visual analog scale (VAS). Using the VAS scores, the patients were divided into those with improvement and without improvement. Their self-reported 36-item short-form health survey and Japanese Orthopaedic Association cervical myelopathy evaluation questionnaire scores were compared.

RESULTS

The postoperative CPTs in relationship to the preoperative CPTs at 3, 6, and 12 months was 99.3%, 98.1%, and 93.8% in the forearm and 93.6%, 90.6%, and 87.8% in the palm, respectively. The corresponding postoperative numbness VAS scores were 63.8%, 50.5%, and 48.0%. At 12 months postoperatively, the 36-item short-form health survey physical and role component summary scores, cervical spine function effectiveness rates, upper and lower extremity function, and QOL items in the Japanese Orthopaedic Association cervical myelopathy evaluation questionnaire were significantly higher in the improvement group.

CONCLUSIONS

Our findings have indicated that improvement in postoperative subjective sensory disturbances will occur relatively earlier and will be significantly greater than the improvement in objective sensory disturbances. Furthermore, improvement in the subjective sensory disturbances contributes to functional spinal cord recovery and patients' health-related QOL.

Missed thoracic myelopathy: Do not throw the hammer away yet

Background

Spinal stenosis may result in myelopathy, radiculopathy, and neurogenic claudication. It is often difficult to differentiate between these conditions. A comprehensive history and physical examination and a magnetic resonance imaging (MRI) of the entire spine accurately confirm the diagnosis.

Case Description

Here, we report a patient with low back and progressive bilateral lower extremity pain, numbness, and weakness with bowel incontinence, urinary retention, and gait abnormalities. A lumbar MRI demonstrated multilevel severe spondylosis/stenosis from L3-S1. The patient underwent a decompressive lumbar laminectomy from L3-5. However, the patient continued to experience the same symptoms postoperatively along with flexor spasms of the left leg, dystonic posturing of the left foot, hyperactive bilateral patellar and Achilles deep tendon reflexes, and a Babinski sign. An NCV of the legs revealed no lumbar radiculopathy. The thoracic MRI, however, demonstrated severe spondylosis at the T11-12 level attributed to a large synovial cyst. Following decompression/cyst resection, the patient's symptoms partially resolved within 1 postoperative month.

Conclusion

Spinal surgeons should be alert to the potential for overlapping symptoms/signs of thoracic myelopathy and lumbar myeloradiculopathy. If there are features of upper and lower motor neuron disease, MR scans of the entire spine are necessary before lumbar surgical decompression to identify significant cephalad surgical pathology.

A comparison of radiological descriptions of spinal cord compression with quantitative measures, and their role in non-specialist clinical management

INTRODUCTION

Magnetic resonance imaging (MRI) is gold-standard for investigating Degenerative Cervical Myelopathy (DCM), a disabling disease triggered by compression of the spinal cord following degenerative changes of adjacent structures. Quantifiable compression correlates poorly with disease and language describing compression in radiological reports is un-standardised.

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

1) Identify terminology in radiological reporting of cord compression and elucidate relationships between language and quantitative measures 2) Evaluate language's ability to distinguish myelopathic from asymptomatic compression 3) Explore correlations between quantitative or qualitative features and symptom severity 4) Investigate the influence of quantitative and qualitative measures on surgical referrals.

METHODS

From all cervical spine MRIs conducted during one year at a tertiary centre (N = 1123), 166 patients had reported cord compression. For each spinal level deemed compressed by radiologists (N = 218), four quantitative measurements were calculated: 'Maximum Canal Compromise (MCC); 'Maximum Spinal Cord Compression' (MSCC); 'Spinal Canal Occupation Ratio' (SCOR) and 'Compression Ratio' (CR). These were compared to associated radiological reporting terminology.

RESULTS

1) Terminology in radiological reports was varied. Objective measures of compromise correlated poorly with language. "Compressed" was used for more severe cord compromise as measured by MCC (p<0.001), MSCC (p<0.001), and CR (p = 0.002). 2) Greater compromise was seen in cords with a myelopathy diagnosis across MCC (p<0.001); MSCC (p = 0.002) and CR (p<0.001). "Compress" (p<0.001) and "Flatten" (p<0.001) were used more commonly for myelopathy-diagnosis levels. 3) Measurements of cord compromise (MCC: p = 0.304; MSCC: p = 0.217; SCOR: p = 0.503; CR: p = 0.256) and descriptive terms (p = 0.591) did not correlate with i-mJOA score. 4) The only variables affecting spinal surgery referral were increased MSCC (p = 0.001) and use of 'Compressed' (p = 0.045).

CONCLUSIONS

Radiological reporting in DCM is variable and language is not fully predictive of the degree of quantitative cord compression. Additionally, terminology may influence surgical referrals.

RE-CODE DCM (REsearch Objectives and Common Data Elements for Degenerative Cervical Myelopathy): A Consensus Process to Improve Research Efficiency in DCM, Through Establishment of a Standardized Dataset for Clinical Research and the Definition of the Research Priorities

STUDY DESIGN

Mixed-method consensus process.

OBJECTIVES

Degenerative cervical myelopathy (DCM) is a common and disabling condition that arises when mechanical stress damages the spinal cord as a result of degenerative changes in the surrounding spinal structures. RECODE-DCM (REsearch Objectives and Common Data Elements for Degenerative Cervical Myelopathy) aims to improve efficient use of health care resources within the field of DCM by using a multi-stakeholder partnership to define the DCM research priorities, to develop a minimum dataset for DCM clinical studies, and confirm a definition of DCM.

METHODS

This requires a multi-stakeholder partnership and multiple parallel consensus development processes. It will be conducted via 4 phases, adhering to the guidance set out by the COMET (Core Outcomes in Effectiveness Trials) and JLA (James Lind Alliance) initiatives. Phase 1 will consist of preliminary work to inform online Delphi processes (Phase 2) and a consensus meeting (Phase 3). Following the findings of the consensus meeting, a synthesis of relevant measurement instruments will be compiled and assessed as per the COSMIN (Consensus-based Standards for the Selection of Health Measurement Instruments) criteria, to allow recommendations to be made on how to measure agreed data points. Phase 4 will monitor and promote the use of eventual recommendations.

CONCLUSIONS

RECODE-DCM sets out to establish for the first time an index term, minimum dataset, and research priorities together. Our aim is to reduce waste of health care resources in the future by using patient priorities to inform the scope of future DCM research activities. The consistent use of a standard dataset in DCM clinical studies, audit, and clinical surveillance will facilitate pooled analysis of future data and, ultimately, a deeper understanding of DCM.