A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression

Study Design: Guideline development. Objectives: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM). Results: Our recommendations were as follows: (1) “We recommend surgical intervention for patients with moderate and severe DCM.” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve.” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.” Conclusions: These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

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Change in Functional Impairment, Disability, and Quality of Life Following Operative Treatment for Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis

Global Spine Journal ◽

10.1177/2192568217710137 ◽

2017 ◽

Vol 7 (3_suppl) ◽

pp. 53S-69S ◽

Cited By ~ 21

Author(s):

Michael G. Fehlings ◽

Lindsay A. Tetreault ◽

Shekar Kurpad ◽

Darrel S. Brodke ◽

Jefferson R. Wilson ◽

...

Keyword(s):

Systematic Review ◽

Operative Treatment ◽

Functional Impairment ◽

Cervical Myelopathy ◽

Surgical Intervention ◽

Japanese Orthopaedic Association ◽

Duration Of Symptoms ◽

Degenerative Cervical Myelopathy ◽

The Impact

Study Design: Systematic review. Objectives: The primary objective of this systematic review was to define the change in impairment, disability, and pain following surgical intervention in patients with degenerative cervical myelopathy (DCM). Secondary objectives included to assess the impact of preoperative disease severity and duration of symptoms on outcomes and to summarize complications associated with surgery. Methods: A systematic literature search was conducted to identify prospective studies evaluating the effectiveness and safety of operative treatment in patients with DCM. Outcomes of interest were functional status, disability, pain, and complications. The quality of each study was evaluated using the Newcastle-Ottawa Scale, and the strength of the overall body of evidence was rated using guidelines outlined by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. Results: Of the 385 retrieved citations, 32 met inclusion criteria and are summarized in this review. Based on our results, pooled standard mean differences showed a large effect for improvement in Japanese Orthopaedic Association or modified Japanese Orthopaedic Association score from baseline at short-, medium-, and long-term follow-up: 6 to 12 months (1.92; 95% confidence interval [CI] = 1.41 to 2.43), 13 to 36 months (1.40; 95% CI = 1.12 to 1.67), and ≥36 months (1.92; 95% CI = 1.14 to 2.69) (moderate evidence). Surgery also resulted in significant improvements in Nurick, Neck Disability Index, and Visual Analogue Scale scores (low to very low evidence). The cumulative incidence of complications was low (14.1%; 95% CI = 10.1% to 18.2%). Conclusion: Surgical intervention for DCM results in significant improvements in functional impairment, disability, and pain and is associated with an acceptably low rate of complications.

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Route to diagnosis of degenerative cervical myelopathy in a UK healthcare system: a retrospective cohort study

BMJ Open ◽

10.1136/bmjopen-2018-027000 ◽

2019 ◽

Vol 9 (5) ◽

pp. e027000 ◽

Cited By ~ 7

Author(s):

Bryn Hilton ◽

Jennifer Tempest-Mitchell ◽

Benjamin Davies ◽

Mark Kotter

Keyword(s):

Primary Care ◽

Cohort Study ◽

Symptom Onset ◽

Cervical Myelopathy ◽

Secondary Care ◽

Primary Outcome ◽

Cord Compression ◽

Cervical Cord ◽

Clinical Documentation ◽

Degenerative Cervical Myelopathy

ObjectivesDegenerative cervical myelopathy (DCM) presents insidiously, making initial diagnosis challenging. Surgery has been shown to prevent further disability but existing spinal cord damage may be permanent. Delays in surgery lead to increased disability and reduced postoperative improvements. Therefore, rapid surgical assessment is key to improving patient outcomes. Unfortunately, diagnosis of DCM in primary care is often delayed. This study aimed to characterise patients with DCM route to diagnosis and surgical assessment as well as to plot disease progression over time.DesignRetrospective, observational cohort study.SettingSingle, tertiary centre using additional clinical records from primary and secondary care centres.ParticipantsOne year of cervical MRI scans conducted at a tertiary neurosciences centre (n=1123) were screened for cervical cord compression, a corresponding clinical diagnosis of myelopathy and sufficient clinical documentation to plot a route to diagnosis (n=43).Primary outcome measuresTime to diagnosis from symptom onset, route to diagnosis and disease progression were the primary outcome measures in this study. Disease severity was approximated using a prospectively validated method for inferring modified Japanese Orthopaedic Association (i-mJOA) functional scoring from clinical documentation.ResultsPatients received a referral to secondary care 6.4±7.7 months after symptom onset. Cervical MRI scanning and neurosurgical review occurred 12.5±13.0 and 15.8±13.5 months after symptom onset, respectively. i-mJOA was 16.0±1.7 at primary care assessment and 14.8±2.5 at surgical assessment. 61.0% of patients were offered operations. For those who received surgery, time between onset and surgery was 22.1±13.2 months.ConclusionsRoute to surgical assessment was heterogeneous and lengthy. Some patients deteriorated during this period. This study highlights the need for a streamlined pathway by which patients with cervical cord compression can receive timely assessment and treatment by a specialist. This would improve outcomes for patients using existing treatments.

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Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy

Neurosurgery ◽

10.1093/neuros/nyz325 ◽

2019 ◽

Vol 86 (6) ◽

pp. 763-768

Author(s):

Inamullah Khan ◽

Kristin R Archer ◽

John Paul Wanner ◽

Mohamad Bydon ◽

Jacquelyn S Pennings ◽

...

Keyword(s):

Cervical Myelopathy ◽

Elective Surgery ◽

Japanese Orthopaedic Association ◽

Cord Compression ◽

Cervical Cord ◽

Multivariable Logistic Regression Model ◽

Quality Outcomes ◽

Degenerative Cervical Myelopathy ◽

Postoperative Improvement

Abstract BACKGROUND Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored. OBJECTIVE To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM. METHODS This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest. RESULTS A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in their myelopathic symptoms, compared to patients with mild mJOA score in. CONCLUSION Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.

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Tracking white and grey matter degeneration along the spinal cord axis in degenerative cervical myelopathy

10.1101/2021.04.18.21255238 ◽

2021 ◽

Author(s):

Kevin Vallotton ◽

Gergely David ◽

Markus Hupp ◽

Nikolai Pfender ◽

Julien Cohen-Adad ◽

...

Keyword(s):

Spinal Cord ◽

Cervical Myelopathy ◽

Grey Matter ◽

Cord Compression ◽

Cervical Cord ◽

Tissue Specific ◽

Microstructural Changes ◽

Diffusion Weighted ◽

Degenerative Cervical Myelopathy ◽

Lumbar Cord

AbstractObjectiveTo determine tissue-specific neurodegeneration across the spinal cord in patients with mild-moderate degenerative cervical myelopathy (DCM).MethodsTwenty-four mild-moderate DCM and 24 healthy subjects were recruited. In patients, a T2-weighted scan was acquired at the compression site, while in all participants a T2*-weighted and diffusion-weighted scan was acquired at the cervical level (C2-C3) and in the lumbar enlargement (i.e. rostral and caudal to the site of compression). We quantified intramedullary signal changes, maximal canal and cord compression, white (WM) and grey matter (GM) atrophy, and microstructural indices from diffusion-weighted scans. All patients underwent clinical (modified Japanese Orthopaedic Association (mJOA)) and electrophysiological assessments. Regression analysis assessed associations between MRI readouts and electrophysiological and clinical outcomes.ResultsTwenty patients were classified with mild and four with moderate DCM using the mJOA scale. The most frequent site of compression was at C5-C6 level with maximum cord compression of 4.68±0.83 mm. Ten patients showed imaging evidence of cervical myelopathy. In the cervical cord, WM and GM atrophy and WM microstructural changes were evident, while in the lumbar cord only WM showed atrophy and microstructural changes. Remote cervical cord WM microstructural changes were pronounced in patients with radiological myelopathy and associated with impaired electrophysiology. Lumbar cord WM atrophy was associated with lower limb sensory impairments.ConclusionTissue-specific neurodegeneration revealed by quantitative MRI, already apparent across the spinal cord in mild-moderate DCM prior to the onset of severe clinical impairments. WM microstructural changes are particularly sensitive to remote pathologically and clinically eloquent changes in DCM.

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Walk and Run Test in Patients with Degenerative Compression of the Cervical Spinal Cord

Journal of Clinical Medicine ◽

10.3390/jcm10050927 ◽

2021 ◽

Vol 10 (5) ◽

pp. 927

Author(s):

Zdenek Kadanka ◽

Tomas Skutil ◽

Eva Vlckova ◽

Josef Bednarik

Keyword(s):

Cervical Spinal Cord ◽

Japanese Orthopaedic Association ◽

Cord Compression ◽

Cervical Cord ◽

Cross Sectional ◽

Severity Of Disability ◽

Degree Of Disability ◽

Degenerative Cervical Myelopathy ◽

Cardinal Symptoms ◽

Run Test

Impaired gait is one of the cardinal symptoms of degenerative cervical myelopathy (DCM) and frequently its initial presentation. Quantitative gait analysis is therefore a promising objective tool in the disclosure of early cervical cord impairment in patients with degenerative cervical compression. The aim of this cross-sectional observational cohort study was to verify whether an objective and easily-used walk and run test is capable of detecting early gait impairment in a practical proportion of non-myelopathic degenerative cervical cord compression (NMDCC) patients and of revealing any correlation with severity of disability in DCM. The study group consisted of 45 DCM patients (median age 58 years), 126 NMDCC subjects (59 years), and 100 healthy controls (HC) (55.5 years), all of whom performed a standardized 10-m walk and run test. Walking/running time/velocity, number of steps and cadence of walking/running were recorded; analysis disclosed abnormalities in 66.7% of NMDCC subjects. The DCM group exhibited significantly more pronounced abnormalities in all walk/run parameters when compared with the NMDCC group. These were apparent in 84.4% of the DCM group and correlated closely with disability as quantified by the modified Japanese Orthopaedic Association scale. A standardized 10-m walk/run test has the capacity to disclose locomotion abnormalities in NMDCC subjects who lack other clear myelopathic signs and may provide a means of classifying DCM patients according to their degree of disability.

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Functional outcome of posterior laminectomy in case of cervical myelopathy with multilevel cervical cord compression

International Journal of Orthopaedics Sciences ◽

10.22271/ortho.2018.v4.i4f.56 ◽

2018 ◽

Vol 4 (4) ◽

pp. 510-514

Author(s):

Dr. Siddharth D Parekh ◽

Dr. Arvind B Goregaonkar ◽

Dr. Anoop Dhamangaokar ◽

Dr. Apratim R Deekshit ◽

Dr. Umesh P Kanade

Keyword(s):

Functional Outcome ◽

Cervical Myelopathy ◽

Cord Compression ◽

Cervical Cord ◽

Cervical Cord Compression ◽

Posterior Laminectomy

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The effect of ageing on presentation, management and outcomes in degenerative cervical myelopathy: a systematic review

Age and Ageing ◽

10.1093/ageing/afaa236 ◽

2020 ◽

Author(s):

Ben Grodzinski ◽

Rory Durham ◽

Oliver Mowforth ◽

Daniel Stubbs ◽

Mark R N Kotter ◽

...

Keyword(s):

Systematic Review ◽

Functional Status ◽

Cervical Myelopathy ◽

Older Patients ◽

Meta Analysis ◽

Current Evidence ◽

Clinical Aspects ◽

Similar Amount ◽

Degenerative Cervical Myelopathy ◽

The Impact

Abstract Objective Degenerative cervical myelopathy (DCM) is a disabling neurological condition. The underlying degenerative changes are known to be more common with age, but the impact of age on clinical aspects of DCM has never been synthesised. The objective of this study is to determine whether age is a significant predictor in three domains—clinical presentation, surgical management and post-operative outcomes of DCM. Methods a systematic review of the Medline and Embase databases (inception to 12 December 2019), registered with PROSPERO (CRD42019162077) and reported in accordance with preferred reporting items of systematic reviews and meta-analysis (PRISMA) guidelines, was conducted. The inclusion criteria were full text articles in English, evaluating the impact of age on clinical aspects of DCM. Results the initial search yielded 2,420 citations, of which 206 articles were eventually included. Age was found to be a significant predictor in a variety of measures. Within the presentation domain, older patients have a worse pre-operative functional status. Within the management domain, older patients are more likely to undergo posterior surgery, with more levels decompressed. Within the outcomes domain, older patients have a worse post-operative functional status, but a similar amount of improvement in functional status. Because of heterogenous data reporting, meta-analysis was not possible. Conclusion the current evidence demonstrates that age significantly influences the presentation, management and outcomes of DCM. Although older patients have worse health at all individual timepoints, they experience the same absolute benefit from surgery as younger patients. This finding is of particular relevance when considering the eligibility of older patients for surgery.

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Duration of symptoms in the quantification of upper limb disability and impairment for individuals with mild degenerative cervical myelopathy (DCM)

PLoS ONE ◽

10.1371/journal.pone.0222134 ◽

2019 ◽

Vol 14 (9) ◽

pp. e0222134 ◽

Cited By ~ 2

Author(s):

Sukhvinder Kalsi-Ryan ◽

Jerri Clout ◽

Pouya Rostami ◽

Eric M. Massicotte ◽

Michael G. Fehlings

Keyword(s):

Upper Limb ◽

Cervical Myelopathy ◽

Duration Of Symptoms ◽

Degenerative Cervical Myelopathy

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Cilostazol, a selective Type III phosphodiesterase inhibitor: prevention of cervical myelopathy in a rat chronic compression model

Journal of Neurosurgery Spine ◽

10.3171/2013.9.spine121136 ◽

2014 ◽

Vol 20 (1) ◽

pp. 93-101 ◽

Cited By ~ 17

Author(s):

Shinji Yamamoto ◽

Ryu Kurokawa ◽

Phyo Kim

Keyword(s):

Spinal Cord ◽

Grip Strength ◽

Motor Neurons ◽

Cervical Myelopathy ◽

Cervical Spondylotic Myelopathy ◽

Phosphodiesterase Inhibitor ◽

Cord Compression ◽

Anterior Horn ◽

Cervical Cord ◽

Forced Running

Object Regional blood flow is decreased in experimental models of chronic spinal cord compression, and the alteration presumably contributes to the development of myelopathy. Cilostazol (Otsuka Pharmaceuticals Co.), a selective Type III phosphodiesterase inhibitor, has been shown to be neuroprotective in cerebral hypoperfusion animal models and clinically effective in preventing the recurrence of cerebral infarction. To investigate the neuroprotective effect of cilostazol on cervical spondylotic myelopathy, the preventive effect against progressive motor dysfunction and the loss of anterior horn motor neurons were assessed using a chronic cord compression model in rats. Methods To produce chronic cervical cord compression in male Wistar rats, thin polyurethane sheets (3 × 5 × 0.7 mm) that gradually expand over 48–72 hours by absorbing water were implanted under the C5–6 laminae. In sham operations, the sheets were momentarily placed and then immediately removed. This model has been shown to reproduce characteristic features of clinical cervical myelopathy, with progressive motor disturbances after a latency period and insidious neuronal loss preceding the onset of symptoms. In the treatment group, cilostazol (30 mg/kg/day) was orally administered to the rats once a day, starting the day after surgery and continuing through the entire observation period of 25 weeks. In the control group, vehicle solution was administered under the same protocol. Changes in motor function were monitored by measuring bilateral forepaw grip strength and the duration of forced running on a treadmill. Twenty-five weeks after surgery, cervical spinal cords were examined histopathologically. Results Cilostazol preserved both forepaw grip strength and forced running capability. The drug also preserved anterior horn motor neurons in the C5–6 spinal cord segment, which diminished in number in the untreated chronic compression group. The drug decreased the number of TUNEL-positive apoptotic cells. Conclusions These results indicate that cilostazol is neuroprotective in the chronically compressed cervical cord and is potentially useful in the treatment of cervical spondylotic myelopathy.

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Predicting the minimum clinically important difference in patients undergoing surgery for the treatment of degenerative cervical myelopathy

Neurosurgical FOCUS ◽

10.3171/2016.3.focus1665 ◽

2016 ◽

Vol 40 (6) ◽

pp. E14 ◽

Cited By ~ 23

Author(s):

Lindsay Tetreault ◽

Jefferson R. Wilson ◽

Mark R. N. Kotter ◽

Aria Nouri ◽

Pierre Côté ◽

...

Keyword(s):

Relative Risk ◽

Cervical Myelopathy ◽

Univariate Analysis ◽

Japanese Orthopaedic Association ◽

Minimum Clinically Important Difference ◽

Duration Of Symptoms ◽

Clinically Important Difference ◽

Younger Age ◽

Degenerative Cervical Myelopathy ◽

Unstable Gait

OBJECTIVE The minimum clinically important difference (MCID) is defined as the minimum change in a measurement that a patient would identify as beneficial. Before undergoing surgery, patients are likely to inquire about the ultimate goals of the operation and of their chances of experiencing meaningful improvements. The objective of this study was to define significant predictors of achieving an MCID on the modified Japanese Orthopaedic Association (mJOA) scale at 2 years following surgery for the treatment of degenerative cervical myelopathy (DCM). METHODS Seven hundred fifty-seven patients were prospectively enrolled in either the AOSpine North America or International study at 26 global sites. Fourteen patients had a perfect preoperative mJOA score of 18 and were excluded from this analysis (n = 743). Data were collected for each participating subject, including demographic information, symptomatology, medical history, causative pathology, and functional impairment. Univariate log-binominal regression analyses were conducted to evaluate the association between preoperative clinical factors and achieving an MCID on the mJOA scale. Modified Poisson regression using robust error variances was used to create the final multivariate model and compute the relative risk for each predictor. RESULTS The sample consisted of 463 men (62.31%) and 280 women (37.69%), with an average age of 56.48 ± 11.85 years. At 2 years following surgery, patients exhibited a mean change in functional status of 2.71 ± 2.89 points on the mJOA scale. Of the 687 patients with available follow-up data, 481 (70.01%) exhibited meaningful gains on the mJOA scale, whereas 206 (29.98%) failed to achieve an MCID. Based on univariate analysis, significant predictors of achieving the MCID on the mJOA scale were younger age; female sex; shorter duration of symptoms; nonsmoking status; a lower comorbidity score and absence of cardiovascular disease; and absence of upgoing plantar responses, lower-limb spasticity, and broad-based unstable gait. The final model included age (relative risk [RR] 0.924, p < 0.0001), smoking status (RR 0.837, p = 0.0043), broad-based unstable gait (RR 0.869, p = 0.0036), and duration of symptoms (RR 0.943, p = 0.0003). CONCLUSIONS In this large multinational prospective cohort, 70% of patients treated surgically for DCM exhibited a meaningful functional gain on the mJOA scale. The key predictors of achieving an MCID on the mJOA scale were younger age, shorter duration of symptoms, nonsmoking status, and lack of significant gait impairment.

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