Anterior Cervical Foraminotomy: 2-Dimensional Operative Video

We provide a step-by-step technique guide for performing anterior cervical foraminotomy in this video. An illustrative case was presented with detailed narration and a discussion of surgical nuances. Anterior cervical foraminotomy can be an effective treatment strategy for patients with unilateral cervical radiculopathy without the need for cervical spine fusion. Spine surgeons should be familiar with technique and use it as a motion-preserving surgical option in treating isolated cervical radiculopathy. There is no identifying information in this video. A patient consent was obtained for publishing of the material included in the video.

Opioid use following cervical spine surgery: trends and factors associated with long-term use

BACKGROUND CONTEXT

Limited or no data exist evaluating risk factors associated with prolonged opioid use following cervical arthrodesis.

PURPOSE

The objectives of this study were to assess trends in postoperative narcotic use among preoperative opioid users (OUs) versus non-opioid users (NOUs) and to identify factors associated with postoperative narcotic use at 1 year following cervical arthrodesis.

STUDY DESIGN/SETTING

This is a retrospective observational study.

PATIENT SAMPLE

The patient sample included 17,391 patients (OU: 52.4%) registered in the Humana Inc claims dataset who underwent anterior cervical fusion (ACF) or posterior cervical fusion (PCF) between 2007 and 2015.

OUTCOME MEASURES

Prolonged opioid usage was defined as narcotic prescription filling at 1 year following cervical arthrodesis.

METHODS

Based on preoperative opioid use, patients were identified as an OU (history of narcotic prescription filled within 3 months before surgery) or a NOU (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and trended for 1 year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at 1 year following ACF and PCF. Based on the model findings, a web-based interactive app was developed to estimate 1-year postoperative risk of using narcotics following cervical arthrodesis (http://neuro-risk.com/opiod-use/ or https://www.neurosurgerycost.com/opioid/opioid_use).

RESULTS

Overall, 87.4% of the patients (n=15,204) underwent ACF, whereas 12.6% (n=2187) underwent PCF. At 1 month following surgery, 47.7% of NOUs and 82% of OUs had a filled opioid prescription. Rates of prescription opioids declined significantly to 7.8% in NOUs versus 50.5% in OUs at 3 months, but plateaued at the 6- to 12-month postoperative period (NOU: 5.7%-6.7%, OU: 44.9%-46.9%). At 1 year, significantly higher narcotic prescription filling rates were observed in OUs compared with NOUs (45.3% vs. 6.3%, p<.001). Preoperative opioid use was a significant driver of 1-year narcotic use following ACF (odds ratio [OR]: 7.02, p<.001) and PCF (OR: 6.98, p<.001), along with younger age (≤50 years), history of drug dependence, and lower back pain.

CONCLUSIONS

Over 50% of the patients used opioids before cervical arthrodesis. Postoperative opioid use fell dramatically during the first 3 months in NOU, but nearly half of the preoperative OUs will remain on narcotics at 1 year postoperatively. Our findings serve as a baseline in identifying patients at risk of chronic use and encourage discontinuation of opioids before cervical spine surgery.

Utility of Oblique Sagittal Reformatted and Three-dimensional Surface Reconstruction Computed Tomography in Foraminal Stenosis Decompression

Determining the responsible level of cervical radiculopathy can be difficult. Because asymptomatic findings are common in cervical radiculopathy, diagnoses based on imaging studies can be inaccurate. Therefore, we investigated whether the application of oblique sagittal reformatted computed tomography (oblique sagittal CT) and three-dimensional surface reconstruction CT (3DCT) affects surgical plans for patients with cervical foraminal stenosis and whether it assists diagnosis of foraminal stenosis. Accordingly, four reviewers, with office notes, observed the CT and magnetic resonance imaging (MRI) images of 18 patients undergoing surgical treatment for cervical radiculopathy. After reviewing the MRI and sagittal, coronal, and axial CT images, the reviewers recorded the operation to be performed; they examined oblique sagittal CT and 3DCT images of the same patients and noted any differences from their surgical plans. Consequently, we analyzed these changes in the decompressed foramina in the surgical plan; mean percent change in the plan was 18.1%. Inter-rater reliability improved from κ - 0.194 to κ - 0.240. Therefore, the addition of oblique and 3DCT images improves inter-rater reliability owing to changes in a part of decompressed foramina. The addition of oblique sagittal CT and 3DCT is helpful in evaluating the foramen and planning surgical treatment of cervical radiculopathy.

Dynamic changes in the reflex exam of patients with sub-axial cervical stenosis

Though dynamic changes in the physical exam of patients being evaluated for cervical spine pathology have been reported, there is limited information on the prevalence and clinical features associated with reflex changes in a population undergoing surgical evaluation for cervical spine pathology. Fifty-one patients with at least grade 1 cervical stenosis on MRI underwent initial surgical evaluation for cervical spine pathology. All patients received complete neurologic examinations including dynamic reflex testing in three positions (neck neutral, extended, and flexed) by 2 spine surgeons. The average age was 58.7 years (range, 34-80), with 28 (55%) patients being male. Stenosis at the symptomatic levels was grade 1 in 18 patients (35%), grade 2 in 11 (21%), and grade 3 in 22 (43%). Twenty-one patients (41%) had a dynamic change in reflex exam. The most common change in reflex exam was seen in the Hoffman's reflex with 14 patients (28%). Patients with grade 3 stenosis were more likely to have a static Hoffman's reflex (64%) compared with grade 1 (17%) and grade 2 (18%) (p < 0.05). Patients with grade 3 stenosis had a higher rate of either a static or dynamic Hoffman's reflex (82%) compared with grade 1 (44%) (p < 0.05), but there was no difference between grade 3 and grade 2 (64%) (Table 2). Dynamic changes in reflex exam are commonly seen in patients being evaluated for symptomatic cervical stenosis. The routine neurologic exam can be supplemented with dynamic reflex testing, especially in cases where clinical history or imaging is concerning for cervical myelopathy.

Posterior Subaxial Cervical Spine Screw Fixation: A Review of Techniques

STUDY DESIGN

A narrative literature review.

OBJECTIVES

To review the surgical techniques of posterior screw fixation in the subaxial cervical spine.

METHODS

A broad literature review on the most common screw fixation techniques including lateral mass, pedicle, intralaminar and transfacet screws was performed on PubMed. The techniques and surgical nuances are summarized.

RESULTS

The following techniques were described in detail and presented with illustrative figures, including (1) lateral mass screw insertion: by Roy-Camille, Louis, Magerl, Anderson, An, Riew techniques and also a modified technique for C7 lateral mass fixation; (2) pedicle screw fixation technique as described by Abumi and also a freehand technique description; (3) intralaminar screw fixation; and finally, (4) transfacet screw fixation, as described by Takayasu, DalCanto, Klekamp, and Miyanji.

CONCLUSIONS

Many different techniques of subaxial screw fixation were described and are available. To know the nuances of each one allows surgeons to choose the best option for each patient, improving the success of the fixation and decrease complications.

Radiological Fusion Criteria of Postoperative Anterior Cervical Discectomy and Fusion: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Diagnosis of pseudarthrosis after anterior cervical fusion is difficult, and often depends on the surgeon's subjective assessment because recommended radiographic criteria are lacking. This review evaluated the available evidence for confirming fusion after anterior cervical surgery.

METHODS

Articles describing assessment of anterior cervical fusion were retrieved from MEDLINE and SCOPUS. The assessment methods and fusion rates at 1 and 2 years were evaluated to identify reliable radiographical criteria.

RESULTS

Ten fusion criteria were described. The 4 most common were presence of bridging trabecular bone between the endplates, absence of a radiolucent gap between the graft and endplate, absence of or minimal motion between adjacent vertebral bodies on flexion-extension radiographs, and absence of or minimal motion between the spinous processes on flexion-extension radiographs. The mean fusion rates were 90.2% at 1 year and 94.7% at 2 years. The fusion rate at 2 years had significant independence (P = .048).

CONCLUSIONS

The most common fusion criteria, bridging trabecular bone between the endplates and absence of a radiolucent gap between the graft and endplate, are subjective. We recommend using <1 mm of motion between spinous processes on extension and flexion to confirm fusion.

Diagnosing Pseudoarthrosis After Anterior Cervical Discectomy and Fusion

Radiographic confirmation of fusion after anterior cervical discectomy and fusion (ACDF) surgery is a critical aspect of determining surgical success. However, there is a lack of established diagnostic radiographic parameters for pseudoarthrosis. The purpose of this study is to summarize the findings of previous studies, review the advantages and disadvantages of frequently employed diagnostic criteria, and present our recommended protocol of fusion assessment. This study identified randomized controlled trials, case-control studies, and prospective and retrospective cohort studies reporting on spinal fusion and how successful fusion after ACDF. Among the 39 articles reviewed, bridging bone across the operated levels on static radiographs was the most commonly used criteria to confirm fusion (31 of 39, 79%). Dynamic flexion-extension radiographs were used to assess for interspinous movement (ISM) (22 of 39, 56.4%) and change in Cobb angle (12 of 39, 30.8%). Computed tomography (CT) based findings (21 of 39, 53.8%) were employed in ambiguous cases with improved sensitivity and specificity. Reconstructed CT scans were used to assess for intragraft bridging bone and extragraft bridging bone (ExGBB). ExGBB were proved to have the highest diagnostic sensitivity and specificity for pseudoarthrosis detection when compared to all other radiographic criteria. The ISM <1 mm on dynamic flexion-extension radiographs had high diagnostic sensitivity and specificity as well. After our reviewing, we recommend using dynamic lateral flexion-extension cervical spine radiographs at 150% magnificationin which the interspinous motion <1 mm and superjacent interspinous motion ≥4 mm confirms fusion. In ambiguous cases, we recommend using reconstructed CT scans to evaluate for ExGBB.

Freehand technique for C2 pedicle and pars screw placement: is it safe?

BACKGROUND CONTEXT

During placement of C2 pedicle and pars screws, intraoperative fluoroscopy is used so that neurovascular complications can be avoided, and screws can be placed in the proper position. However, this method is time consuming and increases radiation exposure. Furthermore, it does not guarantee a completely safe and accurate screw placement.

PURPOSE

The objective of this study was to evaluate the safety of the C2 pedicle and pars screw placement without fluoroscopic or other guidance methods.

STUDY DESIGN

This is a retrospective comparative study.

PATIENT SAMPLE

One hundred ninety-eight patients who underwent placement of C2 pedicle or pars screws without any intraoperative radiographic guidance were included in the study.

OUTCOME MEASURES

Medical records and postoperative computed tomography (CT) scans were evaluated.

MATERIALS AND METHODS

Clinical data were reviewed for intraoperative and postoperative complications. The accuracy of screw placement was evaluated with postop CT scans using a previously published cortical-breach grading system (described by the location and the percentage of the screw diameter over the cortical edge [0=none, Grade I≤25% of the screw diameter, Grade II=26%-50%, Grade III=51%-75%, and Grade IV=76%-100%]).

RESULTS

A total of 148 pedicle screws and 219 pars screws were inserted by two experienced surgeons. There were no cases of cerebral spinal fluid leakage and no neurovascular complications during screw placement. Postoperative CT scans were available for 76 patients, which included 52 pedicle screws and 87 pars screws. For cases with C2 pedicle screws, there were 12 breaches (23%); these included 10 screws with a Grade I breach (19%), 1 screw with a Grade II breach (2%), and 1 screw with a Grade IV breach (2%). Lateral breaches occurred in seven screws (13%), inferior breaches occurred in three screws (6%), and superior breaches occurred in two screws (4%). For cases with C2 pars screws, there were 10 breaches (11%); these included 6 screws with a Grade I breach (7%), 2 screws with a Grade II breach (2%), and 2 screws with a Grade IV breach (2%). Medial breaches were found in four (5%), lateral breaches in two (2%), inferior breaches in two (2%), and superior breaches in two (2%). Two of the cases with superior breaches (one for pedicle and one for pars) experienced occipital neuralgia months after surgery. There was no statistically significant difference in the incidence of overall and high-grade breaches between the groups (p=.07 and 1.0, respectively).

CONCLUSIONS

Although even in experienced hands up to 23% of C2 pedicle screws and 11% of C2 pars screws placed using a freehand technique without guidance may be malpositioned, a clear majority of malpositioned screws demonstrated a low-grade breach, and only 2 of 198 patients (1%) experienced complications related to screw placement.

Cervical Spine Deformity-Part 3: Posterior Techniques, Clinical Outcome, and Complications

The goals of cervical deformity surgery include deformity correction, restoration of horizontal gaze, decompression of neural elements, spinal stabilization with a biomechanically sound construct, and meticulous arthrodesis technique to prevent pseudoarthrosis and minimizing surgical complications. Many different surgical options exist, but selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In this last part of the cervical deformity review series, various posterior deformity correction techniques are discussed in detail, along with an overview of surgical outcome and postoperative complications.

Trends in resource utilization and rate of cervical disc arthroplasty and anterior cervical discectomy and fusion throughout the United States from 2006 to 2013

BACKGROUND CONTEXT

The typically accepted surgical procedure for cervical disc pathology has been the anterior cervical discectomy and fusion (ACDF), although recent trials have demonstrated equivalent or improved outcomes with cervical disc arthroplasty (CDA). Trends for these two procedures regarding utilization, revision procedures, and other demographic information have not been sufficiently explored.

PURPOSE

The present study aims to provide data regarding ACDF and CDA from 2006 to 2013 in the United States.

DESIGN

The present study is a retrospective national database analysis.

PATIENT SAMPLE

The present study included 20% sample of discharges from US hospitals, which is weighted to provide national estimates.

OUTCOME MEASURES

Functional measures such as national incidence, hospital costs, length of stay (LOS), routine discharge, revision burden, and patient characteristics were used in the present study.

METHODS

Patients from the National Inpatient Sample (NIS) database who underwent primary ACDF, revision ACDF, primary CDA, and revision CDA from 2006 to 2013 were included. Demographic and economic data for the procedures' respective International Classification of Diseases, Ninth Revision, Clinical Modification codes were collected.

RESULTS

A total of 1,059,403 ACDF and 13,099 CDA surgeries were performed in the United States from 2006 to 2013. The annual number of ACDF increased by 5.7% nonlinearly from 120,617 in 2006 to 127,500 in 2013 (mean per year 132,425; range 120,617-147,966); CDA increased by 190% nonlinearly from 540 in 2006 to 1,565 in 2013 (mean per year 1,637; range 540-2,381). Cervical disc arthroplasty patients were younger and had more private or "other" insurance, including worker's compensation (p<.0001). Mean LOS was longer for ACDF (ACDF 2.3 days vs. CDA 1.5; p<.0001). Routine discharge was higher in the CDA group (CDA 96% vs. ACDF 89%; p-value<.0001). The mean hospital-related cost was more expensive for ACDF (ACDF $16,178 vs. CDA $13,197; p-value=.0007). Cervical disc arthroplasty mean revision burden, defined as the ratio of revision procedures to the sum of primary and revision procedures, was greater (CDA 5.9% vs. ACDF 2.3%, p-value=.01).

CONCLUSIONS

Nationally approximately 132,000 ACDFs are done each year compared with only 1,600 CDAs. The number of ACDF surgeries performed far outpaces CDA by a ratio of 81:1 in the United States without a clear direction in the trend for utilization given recent fluctuations. Cervical disc arthroplasty revision burden was more than double compared with the ACDF revision burden (5.9% vs. 2.3%), which was not accounted for by patient baseline demographics. The etiologies of these findings are likely multifactorial and require further research.

Worldwide Steroid Prescription for Acute Spinal Cord Injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To continue the line of a previous publication using steroid for acute spinal cord injury (SCI) by spine surgeons from Latin America (LA) and assess the current status of methylprednisolone (MP) prescription in Europe (EU), Asia Pacific (AP), North America (NA), and Middle East (ME) to determine targets for educational activities suitable for each region.

METHODS

The English version of a previously published questionnaire was used to evaluate opinions about MP administration in acute SCI in LA, EU, AP, NA, and ME. This Internet-based survey was conducted by members of AOSpine. The questionnaire asked about demographic features, background with management of spine trauma patients, routine administration of MP in acute SCI, and reasons for MP administration.

RESULTS

A total of 2659 responses were obtained for the electronic questionnaire from LA, EU, AP, NA, and ME. The number of spine surgeons that treat SCI was 2206 (83%). The steroid was used by 1198 (52.9%) surgeons. The uses of MP were based predominantly on the National Acute Spinal Cord Injury Study III study (n = 595, 50%). The answers were most frequently given by spine surgeons from AP, ME, and LA. These regions presented a statistically significant difference from North America (P < .001). The number of SCI patients treated per year inversely influenced the use of MP. The higher the number of patients treated, the lower the administration rates of MP observed.

CONCLUSIONS

The study identified potential targets for educational campaigns, aiming to reduce inappropriate practices of MP administration.

Cervical Spine Deformity-Part 2: Management Algorithm and Anterior Techniques

A sound operative plan based on solid understanding of the pathology and biomechanics is the most important part of cervical deformity correction. Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In Part 2 of this three-part review series, we discuss the pre-operative planning, management algorithm, and anterior surgical techniques for cervical deformity correction.

Cervical Spine Deformity-Part 1: Biomechanics, Radiographic Parameters, and Classification

Cervical spine deformities can have a significant negative impact on the quality of life by causing pain, myelopathy, radiculopathy, sensorimotor deficits, as well as inability to maintain horizontal gaze in severe cases. Many different surgical options exist for operative management of cervical spine deformities. However, selecting the correct approach that ensures the optimal clinical outcome can be challenging and is often controversial. We aim to provide an overview of cervical spine deformity in a 3-part series covering topics including the biomechanics, radiographic parameters, classification, treatment algorithms, surgical techniques, clinical outcome, and complication avoidance with a review of pertinent literature.

Cervical Disc Arthroplasty: A Comprehensive Review of Single-Level, Multilevel, and Hybrid Procedures

STUDY DESIGN

Systematic review.

OBJECTIVES

Degenerative disc disease and spondylosis resulting in radiculopathy and retrodiscal myelopathy are among the most frequently encountered cervical spinal disorders. Traditionally, anterior cervical discectomy and fusion (ACDF) has successfully achieved neural decompression and restored intradiscal height in these conditions. Unfortunately, nonunion and iatrogenic adjacent segment pathology associated with fusion procedures in the cervical spine has led to an interest in motion-preserving procedures. Cervical disc arthroplasty (CDA) was developed in hopes of preserving cervical biomechanics while mitigating the complications associated with ACDF. Through a systematic review of both published and ongoing studies on single- and multilevel CDA, and hybrid surgeries, we aim to provide evidence for their safety and efficacy in the treatment of various cervical pathologies.

METHODS

A systematic search of several large databases, including Cochrane Central, PubMed, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry was conducted to identify published studies and ongoing clinical trials on CDA and hybrid surgery.

RESULTS

Among the relevant studies reviewed, 3 were randomized controlled trials, 2 systematic reviews, as well as multiple prospective case series, biomechanical studies, and meta-analyses.

CONCLUSION

Over the past decade, multiple high-quality studies have shown that single-level CDA can offer equivalent clinical outcomes with a reduction in secondary procedures and total cost when compared to ACDF. However, more recently there has been an increasing prevalence of 2-level CDA and hybrid surgery. Although the data regarding these multilevel procedures is less robust, it appears that they may be as effective as their single-level counterparts.

Inflammatory biomarkers of low back pain and disc degeneration: a review

Biomarkers are biological characteristics that can be used to indicate health or disease. This paper reviews studies on biomarkers of low back pain (LBP) in human subjects. LBP is the leading cause of disability, caused by various spine-related disorders, including intervertebral disc degeneration, disc herniation, spinal stenosis, and facet arthritis. The focus of these studies is inflammatory mediators, because inflammation contributes to the pathogenesis of disc degeneration and associated pain mechanisms. Increasingly, studies suggest that the presence of inflammatory mediators can be measured systemically in the blood. These biomarkers may serve as novel tools for directing patient care. Currently, patient response to treatment is unpredictable with a significant rate of recurrence, and, while surgical treatments may provide anatomical correction and pain relief, they are invasive and costly. The review covers studies performed on populations with specific diagnoses and undefined origins of LBP. Since the natural history of LBP is progressive, the temporal nature of studies is categorized by duration of symptomology/disease. Related studies on changes in biomarkers with treatment are also reviewed. Ultimately, diagnostic biomarkers of LBP and spinal degeneration have the potential to shepherd an era of individualized spine medicine for personalized therapeutics in the treatment of LBP.

National outcomes following single-level cervical disc arthroplasty versus anterior cervical discectomy and fusion

Background

To compare the differences in the thirty-day postoperative outcomes between cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF).

Methods

Patients undergoing primary single-level ACDF and CDA from 2010-2014 were identified by unique Current Procedural Terminology (CPT) codes within the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database. Primary outcomes included surgical and medical complications, length of hospital stay (LOS), unplanned readmission, return to operating room, and mortality all occurring within 30 days of the initial procedure. Patients were propensity score-matched to reduce selection bias and differences in preoperative characteristics. Multivariate logistic regression models were utilized to determine associations between covariates and primary outcomes of interest.

Results

Propensity score-matching produced a cohort of 1,305 patients with 652 (50.0%) ACDF and 653 (50.0%) CDA patients. There were no statistically significant differences in the development of major surgical or medical complications between the groups. ACDF patients experienced a significantly longer LOS (2.3±14.8 vs. 1.1±1.0 days, P=0.034) and unplanned hospital readmission (1.8% vs. 0.2%, P=0.002). For ACDF patients, increased LOS [odds ratios (OR), 4.21; 95% confidence interval (CI), 1.29-13.73; P=0.017] and increased readmission (OR, 12.17; 95% CI, 1.16-127.23; P=0.037) persisted in the multivariate model. Elevated ASA classification, preoperative anemia and elevated white blood cell count (WBC) were also associated with a significantly increased LOS.

Conclusions

Although ACDF and CDA can be indicated for similar cervical pathologies, the latter can be performed safely and effectively with comparable perioperative risk of major complications. The increased readmission rate and LOS for patients undergoing ACDF may have significant impact on patient cost and outcomes.

Why Does C5 Palsy Occur After Prophylactic Bilateral C4-5 Foraminotomy in Open-Door Cervical Laminoplasty? A Risk Factor Analysis

STUDY DESIGN

Retrospective study.

OBJECTIVES

To evaluate the efficacy of bilateral C4-5 foraminotomy in preventing occurrence of postoperative C5 palsy and to identify possible risk factors for its development.

METHODS

A total of 70 consecutive patients who underwent open-door laminoplasty with bilateral C4-5 foraminotomy were included. Clinical, radiographic, and operative data was reviewed. Development of postoperative C5 palsy was analyzed.

RESULTS

A total of 54 males and 16 females were reviewed. Mean age was 56 years (range, 30-86 years). The primary pathology was spondylosis in 76% of cases and ossified posterior longitudinal ligament in 21%. Radiographic evidence of C4-5 foraminal stenosis was seen in 81% of the patients. The mean duration of preoperative symptoms was 7 ± 19 months. Four (5.7%) out of 70 patients developed C5 palsy after open-door laminoplasty with bilateral C4-5 foraminotomy. Multivariate analysis showed that a long duration of preoperative symptoms (>12 months) and the presence of preoperative C4-5 T2-MRI cord signal change were statistically significant risk factors for the development of C5 palsy even after bilateral C4-5 foraminotomy in open-door laminoplasty (P < .0001 and P = .036, respectively).

CONCLUSIONS

Prophylactic bilateral C4-5 foraminotomies do not completely eliminate the occurrence of C5 palsy. Prolonged duration of symptoms and presence of preoperative T2-MRI cord signal change increase the risk for developing postoperative C5 palsy despite foraminotomy.

A Clinical Practice Guideline for the Management of Degenerative Cervical Myelopathy: Introduction, Rationale, and Scope

Degenerative cervical myelopathy (DCM) is a progressive spine disease and the most common cause of spinal cord dysfunction in adults worldwide. Patients with DCM may present with common signs and symptoms of neurological dysfunction, such as paresthesia, abnormal gait, decreased hand dexterity, hyperreflexia, increased tone, and sensory dysfunction. Clinicians across several specialties encounter patients with DCM, including primary care physicians, rehabilitation specialists, therapists, rheumatologists, neurologists, and spinal surgeons. Currently, there are no guidelines that outline how to best manage patients with mild (defined as a modified Japanese Orthopedic Association (mJOA) score of 15-17), moderate (mJOA = 12-14), or severe (mJOA ≤ 11) myelopathy, or nonmyelopathic patients with evidence of cord compression. This guideline provides evidence-based recommendations to specify appropriate treatment strategies for these populations. The intent of our recommendations is to (1) help identify patients at high risk of neurological deterioration, (2) define the role of nonoperative and operative management in each patient population, and (3) determine which patients are most likely to benefit from surgical intervention. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with DCM by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.