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

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

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

Satisfaction in surgically treated patients with degenerative cervical myelopathy: an observational study from the canadian spine outcomes and research network

BACKGROUND CONTEXT

Healthcare reimbursement is evolving towards a value-based model, entwined and emphasizing patient satisfaction. Factors associated with satisfaction after degenerative cervical myelopathy (DCM) surgery have not been previously established.

PURPOSE

Our primary objective was to ascertain satisfaction rates and satisfaction predictors at 3 and 12 months following surgical treatment for DCM.

DESIGN

This is a prospective cohort study within Canadian Spine Outcomes and Research Network (CSORN).

PATIENT SAMPLE

Patients in the study were surgically treated for DCM patients who completed 3-month and 12-month follow-ups within CSORN between 2015 and 2021.

OUTCOME MEASURES

Data analyzed included patient demographic, surgical variables, patient-reported outcomes (NDI, NRS-NP, NRS-AP, SF-12-MCS, SF-12-PCS, ED-5Q, PHQ-8), MJOA and self-reported satisfaction on a Likert scale.

METHODS

Multivariable regression analysis was conducted to identify significant factors associated with satisfaction, address multicollinearity and ensure predictive accuracy. This process was conducted separately for the 3-month and 12-month follow-ups.

RESULTS

Six hundred and sixty-three patients were included, with an average age of 60, and an even distribution across MJOA scores (mild, moderate, severe). At 3-month and 12-month follow-up, satisfaction rates were 86% and 82%, respectively. At 12 months, logistic regression showed the odds of being satisfied varied by +24%, -3%, -10%, -14%, +3%, and +12% for each 1-point change between baseline and 12 months in MJOA, NDI, NRS-NP, NRS-AP, SF-12-MCS, SF-12-PCS. Satisfaction increased 11-fold for each 0.1-point increased in ED-5Q from baseline to 12 months. At baseline, for every 1-point increase in SF-12-MCS, the odds of being satisfied increased by 7%. At 3 months, all PROs (except for NRS-AP change and baseline SF-12-MCS) predicted satisfaction. All logistic regression analyses demonstrated excellent predictive accuracy, with the highest 12-month AUC of 0.86 (95%CI = 0.81-0.90). No patient demographic or surgical factors influenced satisfaction.

CONCLUSION

Improvement in Patient Reported Outcomes and MJOA are strongly associated with patient satisfaction after surgery for DCM. The only baseline PRO associated with 12-months satisfaction was SF-12-MCS. No modifiable patient baseline characteristic or surgical variables were associated with satisfaction.

Scoping Review with Topic Modeling on the Diagnostic Criteria for Degenerative Cervical Myelopathy

STUDY DESIGN

This study is a scoping review.

OBJECTIVE

There is a broad variability in the definition of degenerative cervical myelopathy (DCM) and no standardized set of diagnostic criteria to date.

METHODS

We interrogated the Myelopathy.org database, a hand-indexed database of primary clinical studies conducted exclusively on DCM in humans between 2005-2021. The DCM inclusion criteria used in these studies were inputted into 3 topic modeling algorithms: Hierarchical Dirichlet Process (HDP), Latent Dirichlet Allocation (LDA), and BERtopic. The emerging topics were subjected to manual labeling and interpretation.

RESULTS

Of 1676 reports, 120 papers (7.16%) had well-defined inclusion criteria and were subjected to topic modeling. Four topics emerged from the HDP model: disturbance from extremity weakness and motor signs; fine-motor and sensory disturbance of upper extremity; a combination of imaging and clinical findings is required for the diagnosis; and "reinforcing" (or modifying) factors that can aid in the diagnosis in borderline cases. The LDA model showed the following topics: disturbance to the patient is required for the diagnosis; reinforcing factors can aid in the diagnosis in borderline cases; clinical findings from the extremities; and a combination of imaging and clinical findings is required for the diagnosis. BERTopic identified the following topics: imaging abnormality, typical clinical features, range of objective criteria, and presence of clinical findings.

CONCLUSIONS

This review provides quantifiable data that only a minority of past studies in DCM provided meaningful inclusion criteria. The items and patterns found here are very useful for the development of diagnostic criteria for DCM.

Magnetic Resonance Imaging-CCCFLS Scoring System: Toward Predicting Clinical Symptoms and C5 Paralysis

STUDY DESIGN

A retrospective study.

OBJECTIVE

To develop a new MRI scoring system to assess patients' clinical characteristics, outcomes and complications.

METHODS

A retrospective 1-year follow-up study of 366 patients with cervical spondylosis from 2017 to 2021. The CCCFLS scores (cervical curvature and balance (CC), spinal cord curvature (SC), spinal cord compression ratio (CR), cerebrospinal fluid space (CFS). Spinal cord and lesion location (SL). Increased Signal Intensity (ISI) were divided into Mild group (0-6), Moderate group (6-12), and Severe group (12-18) for comparison, and the Japanese Orthopaedic Association (JOA) scores, visual analog scale (VAS), numerical rating scale (NRS), Neck Disability Index (NDI) and Nurick scores were evaluated. Correlation and regression analyses were performed between each variable and the total model in relation to clinical symptoms and C5 palsy.

RESULTS

The CCCFLS scoring system was linearly correlated with JOA, NRS, Nurick and NDI scores, with significant differences in JOA scores among patients with different CC, CR, CFS, ISI scores, with a predictive model (R2 = 69.3%), and significant differences in preoperative and final follow-up clinical scores among the 3 groups, with a higher rate of improvement in JOA in the severe group (P < .05), while patients with and without C5 paralysis had significant differences in preoperative SC and SL (P < .05).

CONCLUSION

CCCFLS scoring system can be divided into mild (0-6). moderate (6-12), severe (12-18) groups. It can effectively reflect the severity of clinical symptoms, and the improvement rate of JOA is better in the severe group, while the preoperative SC and SL scores are closely related to C5 palsy.

LEVEL OF EVIDENCE

III.

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.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

Radiological Progression of Degenerative Cervical Myelopathy in a Clinically Stable Patient: Case Report

Degenerative cervical myelopathy (DCM) is a common neurological condition, with disease progression that is both variable and difficult to predict. Here, we present a case of DCM in a gentleman in his late 60s with significant radiological disease progression without consequent change in clinical symptoms. The case serves as a reminder of an enduring medical aphorism that clinical history and examination should be prioritized above more complex data, such as imaging investigations. In addition, the case also highlights that guidelines should be contextualized within individual clinical circumstances.

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

Introduction

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

Research question

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

Materials and methods

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

Results

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

Discussion and conclusion

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

Resting-state brain plasticity is associated with the severity in cervical spondylotic myelopathy

OBJECTIVE

To investigate the brain mechanism of non-correspondence between imaging presentations and clinical symptoms in cervical spondylotic myelopathy (CSM) patients and to test the utility of brain imaging biomarkers for predicting prognosis of CSM.

METHODS

Forty patients with CSM (22 mild-moderate CSM, 18 severe CSM) and 25 healthy controls (HCs) were recruited for rs-fMRI and cervical spinal cord diffusion tensor imaging (DTI) scans. DTI at the spinal cord (level C2/3) with fractional anisotropy (FA) and degree centrality (DC) were recorded. Then one-way analysis of covariance (ANCOVA) was conducted to detect the group differences in the DC and FA values across the three groups. Pearson correlation analysis was then separately performed between JOA with FA and DC.

RESULTS

Among them, degree centrality value of left middle temporal gyrus exhibited a progressive increase in CSM groups compared with HCs, the DC value in severe CSM group was higher compared with mild-moderate CSM group. (P < 0.05), and the DC values of the right superior temporal gyrus and precuneus showed a decrease after increase. Among them, DC values in the area of precuneus in severe CSM group were significantly lower than those in mild-moderate CSM and HCs. (P < 0.05). The fractional anisotropy (FA) values of the level C2/3 showed a progressive decrease in different clinical stages, that severe CSM group was the lowest, significantly lower than those in mild-moderate CSM and HCs (P < 0.05). There was negative correlation between DC value of left middle temporal gyrus and JOA scores (P < 0.001), and the FA values of dorsal column in the level C2/3 positively correlated with the JOA scores (P < 0.001).

CONCLUSION

Structural and functional changes have taken place in the cervical spinal cord and brain of CSM patients. The Brain reorganization plays an important role in maintaining the symptoms and signs of CSM, aberrant DC values in the left middle temporal gyrus may be the possible mechanism of inconsistency between imaging findings and clinical symptoms. Degree centrality is a potentially useful prognostic functional biomarker in cervical spondylotic myelopathy.

Early neurological changes in aging cervical spine: insights from PROMIS mobility assessment

Many studies have shown that the prevalence of degenerative spinal cord compression increases with age. However, most cases at early stages are asymptomatic, and their diagnosis remains challenging. Asymptomatic cervical spinal cord compression (ASCC) patients are more likely to experience annular tears, herniated disks, and later develop symptomatic compression. Asymptomatic individuals do not typically undergo spinal cord imaging; therefore, an assessment test that is both sensitive and specific in diagnosing ASCC may be helpful. It has been demonstrated that the Patient Reported Outcome Measure Information System (PROMIS) mobility test is sensitive in detecting degenerative cervical myelopathy (DCM) symptoms. We investigated the use of the PROMIS mobility test in assessing clinical dysfunction in ASCC. In this study, 51 DCM patients and 42 age-matched healthy control (HC) were enrolled. The degree of cervical spinal cord compression was assessed using the high-resolution cervical spinal cord T2 Weighted (T2w) MRIs, which were available for 14 DCM patients. Measurements of the spinal cords anterior-posterior (AP) diameter at the region(s) that were visibly compressed as well as at different cervical spine levels were used to determine the degree of compression. The age-matched HC cohort had a similar MRI to establish the normal range for AP diameter. Twelve (12) participants in the HC cohort had MRI evidence of cervical spinal cord compression; these individuals were designated as the ASCC cohort. All participants completed the PROMIS mobility, PROMIS pain interference (PI), PROMIS upper extremity (UE), modified Japanese orthopedic association (mJOA), and neck disability index (NDI) scoring scales. We examined the correlation between the AP diameter measurements and the clinical assessment scores to determine their usefulness in the diagnosis of ASCC. Furthermore, we examine the sensitivity and specificity of PROMIS mobility test and mJOA. Compared to the HC group, the participants in the ASCC and DCM cohorts were significantly older (p = 0.006 and p < 0.0001, respectively). Age differences were not observed between ASCC and DCM (p > 0.999). Clinical scores between the ASCC and the HC group were not significantly different using the mJOA (p > 0.99), NDI (p > 0.99), PROMIS UE (p = 0.23), and PROMIS PI (p = 0.82). However, there were significant differences between the ASCC and HC in the PROMIS mobility score (p = 0.01). The spinal cord AP diameter and the PROMIS mobility score showed a significant correlation (r = 0.44, p = 0.002). Decreasing PROMIS mobility was significantly associated with a decrease in cervical spinal cord AP diameter independent of other assessment measures. PROMIS mobility score had a sensitivity of 77.3% and specificity of 79.4% compared to 59.1% and 88.2%, respectively, for mJOA in detecting cervical spinal cord compression. Certain elements of ASCC are not adequately captured with the traditional mJOA and NDI scales used in DCM evaluation. In contrast to other evaluation scales utilized in this investigation, PROMIS mobility score shows a significant association with the AP diameter of the cervical spinal cord, suggesting that it is a sensitive tool for identifying early disability associated with degenerative change in the aging spine. In a comparative analysis of PROMIS mobility test against the standard mJOA, the PROMIS mobility demonstrated higher sensitivity for detecting cervical spinal cord compression. These findings underscore the potential use of PROMIS mobility score in clinical evaluation of the aging spine.

Evidence-based commentary on the diagnosis, management, and further research of degenerative cervical spinal cord compression in the absence of clinical symptoms of myelopathy

Degenerative cervical myelopathy (DCM) represents the final consequence of a series of degenerative changes in the cervical spine, resulting in cervical spinal canal stenosis and mechanical stress on the cervical spinal cord. This process leads to subsequent pathophysiological processes in the spinal cord tissues. The primary mechanism of injury is degenerative compression of the cervical spinal cord, detectable by magnetic resonance imaging (MRI), serving as a hallmark for diagnosing DCM. However, the relative resilience of the cervical spinal cord to mechanical compression leads to clinical-radiological discordance, i.e., some individuals may exhibit MRI findings of DCC without the clinical signs and symptoms of myelopathy. This degenerative compression of the cervical spinal cord without clinical signs of myelopathy, potentially serving as a precursor to the development of DCM, remains a somewhat controversial topic. In this review article, we elaborate on and provide commentary on the terminology, epidemiology, natural course, diagnosis, predictive value, risks, and practical management of this condition-all of which are subjects of ongoing debate.

The Prevalence of Asymptomatic Cervical Spinal Cord Compression in Individuals Presenting With Symptomatic Lumbar Spinal Stenosis: A Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to determine the prevalence of asymptomatic cervical spinal cord compression (CSCC) in individuals with lumbar spinal stenosis (LSS).

METHODS

A systematic electronic search was conducted in Medline, EMBASE, Scopus, and Web of Science without language restriction, with no starting date limit to June 8, 2023, to define the prevalence of asymptomatic CSCC in symptomatic LSS patients. Asymptomatic CSCC was defined based on radiographic studies. All types of studies were included in the review. Meta-analysis was performed on the reported prevalence of asymptomatic CSCC in LSS.

RESULTS

The database search yielded 10,272 articles. After a full-text review, five studies were included in the final review, comprising a total of 1043 cases. Two studies had a low risk for bias, two moderate, and one estimated to be high risk. The range of prevalence of asymptomatic CSCC in LSS in the five included studies was between 24% and 61%. Meta-analysis on the reported prevalence of asymptomatic CSCC patients with symptomatic LSS demonstrated that the random pooled prevalence was 35% (95% CI: 23 to 48).

CONCLUSIONS

Asymptomatic CSCC appears to occur in a high number of patients, with this study noting its presence in one-third of patients with LSS. Based on these findings, we strongly recommend that spine surgeons exercise particular caution during the positioning of patients who are undergoing surgery for lumbar stenosis. Furthermore, it is imperative to monitor individuals with symptomatic LSS closely for any potential signs of emerging myelopathy.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality Assessment of Degenerative Cervical Myelopathy Information on the Internet

BACKGROUND

Patient education is a key element of spinal surgery informed consent. Patients frequently access health information online, yet this information is unregulated and of variable quality. We aimed to assess the quality of information available on degenerative cervical myelopathy (DCM) websites with a focus on identifying high-quality information websites.

METHODS

We performed a Google search using keywords pertaining to DCM. The top 50 websites returned were classified based on their publication source, intended audience, and country of origin. The quality of these websites was assessed using both the DISCERN instrument and Journal of the American Medical Association (JAMA) benchmark criteria. We also utilized a novel Myelopathy Information Scoring Tool (MIST) to assess the comprehensiveness, accuracy, and detail of online DCM information.

RESULTS

The mean DISCERN score was 39.9 out of 80. Only one-quarter of these websites were rated "good" or "excellent" using DISCERN, and the remaining were rated "very poor," "poor," and "fair." The mean JAMA benchmark score was 1.6 out of 4, with 23 out of 50 websites scoring 0. Evaluation using MIST found a mean score of 25.6 out of 50. Using 30 points as a satisfactory MIST cutoff, 72% of DCM websites were deemed critically deficient and unsatisfactory for comprehensive patient education. Both DISCERN and MIST indicated poorest information pertaining to surgical risks and complications as well as treatment outcomes. Websites such as Orthoinfo.aaos.org and Myelopathy.org provided reliable, trustworthy, and comprehensive patient education.

CONCLUSIONS

Information available on almost three-quarters of DCM websites was of poor quality, with information regarding complications and treatment outcomes most deficient. Clinicians should be aware of quality sites where patients may be directed to augment patient education and surgical counseling.

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

STUDY DESIGN

Systematic Reviews.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

STUDY DESIGN

Modified DELPHI Consensus Process.

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Development of the cervical myelopathy severity index: a new patient reported outcome measure to quantify impairments and functional limitations

BACKGROUND CONTEXT

Existing degenerative cervical myelopathy (DCM) severity scales have significant shortcomings, creating a strong impetus for the development of a practical measurement tool with sound psychometric properties.

PURPOSE

This work reports the item generation and reduction of the Cervical Myelopathy Severity Index (CMSI), a new DCM patient-reported outcome measure of symptoms and functional limitations.

DESIGN

Prospective observational study.

PATIENT SAMPLE

Adult DCM patients belonging to one of three distinct treatment groups: (1) observation cohort, (2) preoperative surgical cohort, (3) 6 to 12 months postoperative cohort.

OUTCOME MEASURES

Patient-reported outcome measure of symptoms and functional limitations.

METHODS

Item generation was performed using semi-structured patient focus groups emphasizing symptoms experienced and functional limitations. Readability was assessed through think-aloud patient interviews. Item reduction involved surveys of DCM patients with a spectrum of disease severity and board-certified spine surgeons experienced in the treatment of DCM. A priori criteria for item removal included: patient median importance/severity <2 (of 4), 30% or more no severity (response of zero), item severity correlations ≤ 0.80 (Spearman), item severity reliability (weighted kappa <0.60) based on a 2-week interval and clinician median importance <2 with retention of items with very high clinical importance.

RESULTS

There were 42 items generated from a combination of specialist input and patient focus groups. Items captured sensorimotor symptoms and limitations related to upper and lower extremities as well as sphincter dysfunction. Ninety-eight patients (43, 30, 25 observation, pre- and postsurgery respectively) and 51 surgeons completed the assessment. Twenty-three items remained after application of median importance and severity thresholds and weighted kappa cutoffs. After elimination of highly correlated (>0.80) items and combining two similar items, the final CMSI questionnaire list included 14 items.

CONCLUSIONS

The CMSI is a new DCM patient-reported clinical measurement tool developed using patient and clinician input to inform item generation and reduction. Future work will evaluate the reliability, validity, and responsiveness of the CMSI in relation to existing myelopathy measurement indices.

The "Bevel drilling" for degenerative cervical myelopathy: A technical note with illustrative video

Degenerative cervical myelopathy is a pathology frequently encounterd in the neurosurgical practice. Posterior ostophytes located at the posterior part of the vertebral endplate are frequently involved in the reduction of the cervical canal. We propose a description of the technique used in our department to drill this posterior part of the endplate safely with the help of modern instruments and microscope magnification.The bony resection being performed with diamond burr, we believe this technique less traumatic on the spinal cord than repeated insertions of rongeur. Radiological result shows a nice enlargment of the cervical canal. This technique offers a less invasive alternative to corporectomy in cases of two-level stenosis.

Automated Detection of Cervical Spinal Stenosis and Cord Compression via Vision Transformer and Rules-Based Classification

BACKGROUND AND PURPOSE

Cervical spinal cord compression, defined as spinal cord deformity and severe narrowing of the spinal canal in the cervical region, can lead to severe clinical consequences, including intractable pain, sensory disturbance, paralysis, and even death, and may require emergent intervention to prevent negative outcomes. Despite the critical nature of cord compression, no automated tool is available to alert clinical radiologists to the presence of such findings. This study aims to demonstrate the ability of a vision transformer (ViT) model for the accurate detection of cervical cord compression.

MATERIALS AND METHODS

A clinically diverse cohort of 142 cervical spine MRIs was identified, 34% of which were normal or had mild stenosis, 31% with moderate stenosis, and 35% with cord compression. Utilizing gradient-echo images, slices were labeled as no cord compression/mild stenosis, moderate stenosis, or severe stenosis/cord compression. Segmentation of the spinal canal was performed and confirmed by neuroradiology faculty. A pretrained ViT model was fine-tuned to predict section-level severity by using a train:validation:test split of 60:20:20. Each examination was assigned an overall severity based on the highest level of section severity, with an examination labeled as positive for cord compression if ≥1 section was predicted in the severe category. Additionally, 2 convolutional neural network (CNN) models (ResNet50, DenseNet121) were tested in the same manner.

RESULTS

The ViT model outperformed both CNN models at the section level, achieving section-level accuracy of 82%, compared with 72% and 78% for ResNet and DenseNet121, respectively. ViT patient-level classification achieved accuracy of 93%, sensitivity of 0.90, positive predictive value of 0.90, specificity of 0.95, and negative predictive value of 0.95. Receiver operating characteristic area under the curve was greater for ViT than either CNN.

CONCLUSIONS

This classification approach using a ViT model and rules-based classification accurately detects the presence of cervical spinal cord compression at the patient level. In this study, the ViT model outperformed both conventional CNN approaches at the section and patient levels. If implemented into the clinical setting, such a tool may streamline neuroradiology workflow, improving efficiency and consistency.

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.

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.

Respiratory dysfunction in degenerative cervical myelopathy: A systematic review

INTRODUCTION

Degenerative cervical myelopathy is a condition of symptomatic cervical spinal cord compression secondary to a range of degenerative spinal pathology. Respiratory symptoms such as shortness of breath are not uncommonly reported by people with DCM and respiratory dysfunction has been described in several DCM studies. The objective of this review was therefore to systematically synthesise the current evidence on the relationship between DCM and respiratory function.

METHODS

The review was registered on PROSPERO and adhered to PRISMA guidelines. Ovid MEDLINE and Embase were searched from inception to 14th March 2023. DCM studies reporting on any measure or outcome relating to respiratory function or disease were eligible. Reference lists of included studies and relevant reviews articles were hand searched. Title, abstract and full text screening, risk of bias and GRADE assessments were completed in duplicate. A quantitative synthesis is presented.

RESULTS

Of 1991 studies identified by literature searching, 13 met inclusion criteria: 3 cohort studies, 5 case-control studies, 1 case series and 4 case studies. Forced vital capacity (FVC), peak expiratory flow rate (PEFR) and maximal voluntary ventilation (MVV) were reported to be lower in DCM patients than controls; there was inconsistency in comparisons of forced expiratory volume in 1 s (FEV1). There was conflicting evidence on whether surgical decompression was associated with improvements in respiratory parameters and on the relationship between level of spinal cord compression and respiratory dysfunction.

CONCLUSION

DCM may be associated with respiratory dysfunction. However, consistency and quality of evidence is currently low. Further work should characterise respiratory dysfunction in DCM patients more rigorously and investigate putative mechanisms such as disruption to cervical nerve roots responsible for diaphragmatic innervation and damage to descending spinal projections from brainstem respiratory centres.

Age and flexors as risk factors for cervical radiculopathy: A new machine learning method

This study aimed to investigate the risk factors for cervical radiculopathy (CR) along with identifying the relationships between age, cervical flexors, and CR. This was a retrospective cohort study, including 60 patients with CR enrolled between December 2018 and June 2020. In this study, we measured C2 to C7 Cobb angle, disc degeneration, endplate degeneration, and morphology of paraspinal muscles and evaluated the value of predictive methods using receiver operating characteristic curves. Next, we established a diagnostic model for CR using Fisher discriminant model and compared different models by calculating the kappa value. Age and cervical flexor factors were used to construct clinical predictive models, which were further evaluated by C-index, receiver operating characteristic curve, calibration curve, and decision curve analysis. Multivariate analysis showed that age and cervical flexors were potential risk factors for CR, while the diagnostic model indicated that both exerted the best diagnostic effect. The obtained diagnostic equation was as follows: y1 = 0.33 × 1 + 10.302 × 2-24.139; y2 = 0.259 × 1 + 13.605 × 2-32.579. Both the C-index and AUC in the training set reached 0.939. Moreover, the C-index and AUC values in the external validation set reached 0.961. We developed 2 models for predicting CR and also confirmed their validity. Age and cervical flexors were considered potential risk factors for CR. Our noninvasive inspection method could provide clinicians with a more potential diagnostic value to detect CR accurately.

Machine Learning and Symptom Patterns in Degenerative Cervical Myelopathy: Web-Based Survey Study

BACKGROUND

Degenerative cervical myelopathy (DCM), a progressive spinal cord injury caused by spinal cord compression from degenerative pathology, often presents with neck pain, sensorimotor dysfunction in the upper or lower limbs, gait disturbance, and bladder or bowel dysfunction. Its symptomatology is very heterogeneous, making early detection as well as the measurement or understanding of the underlying factors and their consequences challenging. Increasingly, evidence suggests that DCM may consist of subgroups of the disease, which are yet to be defined.

OBJECTIVE

This study aimed to explore whether machine learning can identify clinically meaningful groups of patients based solely on clinical features.

METHODS

A survey was conducted wherein participants were asked to specify the clinical features they had experienced, their principal presenting complaint, and time to diagnosis as well as demographic information, including disease severity, age, and sex. K-means clustering was used to divide respondents into clusters according to their clinical features using the Euclidean distance measure and the Hartigan-Wong algorithm. The clinical significance of groups was subsequently explored by comparing their time to presentation, time with disease severity, and other demographics.

RESULTS

After a review of both ancillary and cluster data, it was determined by consensus that the optimal number of DCM response groups was 3. In Cluster 1, there were 40 respondents, and the ratio of male to female participants was 13:21. In Cluster 2, there were 92 respondents, with a male to female participant ratio of 27:65. Cluster 3 had 57 respondents, with a male to female participant ratio of 9:48. A total of 6 people did not report biological sex in Cluster 1. The mean age in this Cluster was 56.2 (SD 10.5) years; in Cluster 2, it was 54.7 (SD 9.63) years; and in Cluster 3, it was 51.8 (SD 8.4) years. Patients across clusters significantly differed in the total number of clinical features reported, with more clinical features in Cluster 3 and the least clinical features in Cluster 1 (Kruskal-Wallis rank sum test: χ22=159.46; P<.001). There was no relationship between the pattern of clinical features and severity. There were also no differences between clusters regarding time since diagnosis and time with DCM.

CONCLUSIONS

Using machine learning and patient-reported experience, 3 groups of patients with DCM were defined, which were different in the number of clinical features but not in the severity of DCM or time with DCM. Although a clearer biological basis for the clusters may have been missed, the findings are consistent with the emerging observation that DCM is a heterogeneous disease, difficult to diagnose or stratify. There is a place for machine learning methods to efficiently assist with pattern recognition. However, the challenge lies in creating quality data sets necessary to derive benefit from such approaches.

Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF)

BACKGROUND

For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation.

METHODS

The present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups.

RESULTS

We analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12-30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001).

CONCLUSIONS

Osteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46809.

Diagnosis and Prevalence (1975-2010) of Sudden Death due to Atlantoaxial Subluxation in Cervical Rheumatoid Arthritis: A Literature Review

Rheumatoid arthritis (RA), a chronic inflammatory disease primarily affecting synovial joints and tendons, can potentially impact various organs within the body. One notable complication associated with RA is upper cervical spine instability, medically termed atlantoaxial subluxation (AAS). This condition can lead to adverse consequences, including chronic myelopathy and acute mechanical compression of the medulla oblongata, with the potential for sudden death. While AAS may often remain asymptomatic, some nonspecific symptoms, such as neck pain, have been documented. Severe atlantoaxial subluxation can trigger more distinct symptoms, including delayed occipital pain attributed to the compression of the exiting C2 nerve root. Recent studies have elucidated a spectrum of symptoms preceding sudden death, encompassing vertigo, dizziness, convulsions, dysphagia, disorientation, and seizures. Remarkably, some cases have reported sudden death occurring during sleep. Historical data reveal a fluctuating incidence of this phenomenon, with eleven cases reported between 1969 and 1975 and six cases documented between 1990 and 2010. Notably, one of the most prevalent causes of sudden mortality in individuals with RA is the acute mechanical damage inflicted upon the medulla oblongata due to atlantoaxial subluxation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of Cervical Stenosis and Rate of Impact on Risk of Spinal Cord Injury During Whiplash Injury

STUDY DESIGN

Finite Element Study.

OBJECTIVE

To determine the risk of spinal cord injury with pre-existing cervical stenosis during a whiplash injury.

SUMMARY OF BACKGROUND DATA

Patients with cervical spinal stenosis are often cautioned on the potential increased risk of spinal cord injury (SCI) from minor trauma such as rear impact whiplash injuries. However, there is no consensus on the degree of canal stenosis or the rate of impact that predisposes cervical SCI from minor trauma.

METHODS

A previously validated three-dimensional finite element model of the human head-neck complex with the spinal cord and activated cervical musculature was used. Rear impact acceleration was applied at 1.8 m/s and 2.6 m/s. Progressive spinal stenosis was simulated at the C5 to C6 segment, from 14 mm to 6 mm, at 2 mm intervals of ventral disk protrusion. Spinal cord von Mises stress and maximum principal strain were extracted and normalized with respect to the 14 mm spine at each cervical spine level from C2 to C7.

RESULTS

The mean segmental range of motion was 7.3 degrees at 1.8 m/s and 9.3 degrees at 2.6 m/s. Spinal cord stress above the threshold for SCI was noted at C5 to C6 for 6 mm stenosis at 1.8 m/s and 2.6 m/s. The segment (C6-C7) inferior to the level of maximum stenosis also showed increasing stress and strain with a higher rate of impact. For 8 mm stenosis, spinal cord stress exceeded SCI thresholds only at 2.6 m/s. Spinal cord strain above SCI thresholds were only noted in the 6 mm stenosis model at 2.6 m/s.

CONCLUSION

Increased spinal stenosis and rate of impact are associated with greater magnitude and spatial distribution of spinal cord stress and strain during a whiplash injury. Spinal canal stenosis of 6 mm was associated with consistent elevation of spinal cord stress and strain above SCI thresholds at 2.6 m/s.

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

OBJECTIVES

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

DESIGN

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

PARTICIPANTS AND SETTING

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

RESULTS

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

CONCLUSIONS

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

Assessment of Cervical Myelopathy Risk in Ossification of the Posterior Longitudinal Ligament Patients With Spinal Cord Compression Based on Segmental Dynamic Versus Static Factors

OBJECTIVE

Using segmental dynamic and static factors, we aimed to elucidate the pathogenesis and relationship between ossification of the posterior longitudinal ligament (OPLL) and the severity of cervical myelopathy.

METHODS

Retrospective analysis of 163 OPLL patients' 815 segments. Imaging was used to evaluate each segmental space available for the spinal cord (SAC), OPLL diameter, type, bone space, K-line, the C2-7 Cobb angle, each segmental range of motion (ROM), and total ROM. Magnetic resonance imaging was used to evaluate spinal cord signal intensity. Patients were divided into the myelopathy group (M group) and the without myelopathy group (WM group).

RESULTS

Minimal SAC (p = 0.043), (C2-7) Cobb angle (p = 0.004), total ROM (p = 0.013), and local ROM (p = 0.022) were evaluated as an independent predictor of myelopathy in OPLL. Different from the previous report, the M group had a straighter whole cervical spine (p < 0.001) and poorer cervical mobility (p < 0.001) compared to the WM group. Total ROM was not always a risk factor for myelopathy, as its impact depended on SAC, when SAC > 5 mm, the incidence rate of myelopathy decreased with the increase of total ROM. Lower cervical spine (C5-6, C6-7) showing increased "Bridge-Formation," along with spinal canal stenosis and segmental instability (C2-3, C3-4) in the upper cervical spine, could cause myelopathy in M group (p < 0.05).

CONCLUSION

Cervical myelopathy is linked to the OPLL's narrowest segment and its segmental motion. The hypermobility of the C2-3 and C3-4, contributes significantly to the development of myelopathy in OPLL.

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.

Integration of MRI and somatosensory evoked potentials facilitate diagnosis of spinal cord compression

This study aimed to integrate magnetic resonance imaging (MRI) and related somatosensory evoked potential (SSEP) features to assist in the diagnosis of spinal cord compression (SCC). MRI scans were graded from 0 to 3 according to the changes in the subarachnoid space and scan signals to confirm differences in SCC levels. The amplitude, latency, and time-frequency analysis (TFA) power of preoperative SSEP features were extracted and the changes were used as standard judgments to detect neurological function changes. Then the patient distribution was quantified according to the SSEP feature changes under the same and different MRI compression grades. Significant differences were found in the amplitude and TFA power between MRI grades. We estimated three degrees of amplitude anomalies and power loss under each MRI grade and found the presence or absence of power loss occurs after abnormal changes in amplitude only. For SCC, few integrated approach combines the advantages of both MRI and evoked potentials. However, integrating the amplitude and TFA power changes of SSEP features with MRI grading can help in the diagnosis and speculate progression of SCC.

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.

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

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

Human spinal cord tissue is an underutilised resource in degenerative cervical myelopathy: findings from a systematic review of human autopsies

STUDY DESIGN

Systematic review.

BACKGROUND

Although degenerative cervical myelopathy (DCM) is the most prevalent spinal cord condition worldwide, the pathophysiology remains poorly understood. Our objective was to evaluate existing histological findings of DCM on cadaveric human spinal cord tissue and explore their consistency with animal models.

METHODS

MEDLINE and Embase were systematically searched (CRD42021281462) for primary research reporting on histological findings of DCM in human cadaveric spinal cord tissue. Data was extracted using a piloted proforma. Risk of bias was assessed using Joanna Briggs Institute critical appraisal tools. Findings were compared to a systematic review of animal models (Ahkter et al. 2020 Front Neurosci 14).

RESULTS

The search yielded 4127 unique records. After abstract and full-text screening, 19 were included in the final analysis, reporting on 150 autopsies (71% male) with an average age at death of 67.3 years. All findings were based on haematoxylin and eosin (H&E) staining. The most commonly reported grey matter findings included neuronal loss and cavity formation. The most commonly reported white matter finding was demyelination. Axon loss, gliosis, necrosis and Schwann cell proliferation were also reported. Findings were consistent amongst cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. Cavitation was notably more prevalent in human autopsies compared to animal models.

CONCLUSION

Few human spinal cord tissue studies have been performed. Neuronal loss, demyelination and cavitation were common findings. Investigating the biological basis of DCM is a critical research priority. Human spinal cord specimen may be an underutilised but complimentary approach.

Deep Learning Algorithm for Identifying Cervical Cord Compression Due to Degenerative Canal Stenosis on Radiography

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

Validate the diagnostic accuracy of a deep-learning algorithm for cervical cord compression due to degenerative canal stenosis on radiography.

SUMMARY OF BACKGROUND DATA

The diagnosis of degenerative cervical myelopathy is often delayed, resulting in improper management. Screening tools for suspected degenerative cervical myelopathy would help identify patients who require detailed physical evaluation.

MATERIALS AND METHODS

Data from 240 patients (120 with cervical stenosis on magnetic resonance imaging and 120 age and sex-matched controls) were randomly divided into training (n = 198) and test (n = 42) data sets. The deep-learning algorithm, designed to identify the suspected stenosis level on radiography, was constructed using a convolutional neural network model called EfficientNetB2, and radiography and magnetic resonance imaging data from the training data set. The accuracy and area under the curve of the receiver operating characteristic curve were calculated for the independent test data set. Finally, the number of correct diagnoses was compared between the algorithm and 10 physicians using the test cohort.

RESULTS

The diagnostic accuracy and area under the curve of the deep-learning algorithm were 0.81 and 0.81, respectively, in the independent test data set. The rate of correct responses in the test data set was significantly higher for the algorithm than for the physician's consensus (81.0% vs . 66.2%; P = 0.034). Furthermore, the accuracy of the algorithm was greater than that of each individual physician.

CONCLUSIONS

We developed a deep-learning algorithm capable of suggesting the presence of cervical spinal cord compression on cervical radiography and highlighting the suspected levels on radiographic imaging when cord compression is identified. The diagnostic accuracy of the algorithm was greater than that of spine physicians.

LEVEL OF EVIDENCE

Level IV.

Could spinal cord oscillation contribute to spinal cord injury in degenerative cervical myelopathy?

Introduction

Degenerative Cervical Myelopathy [DCM] is a slow-motion spinal cord injury. Compression and dynamic compression have been considered disease hallmarks. However, this is likely an oversimplification, as compression is more commonly incidental and has only modest correlation to disease severity. MRI studies have recently suggested spinal cord oscillation could play a role.

Research question

To determine if spinal cord oscillation could contribute to spinal cord injury in degenerative cervical myelopathy.

Material and methods

A computational model of an oscillating spinal cord was developed from imaging of a healthy volunteer. Using finite element analysis, the observed implications of stress and strain, were measured in the context of a simulated disc herniation. The significance was bench marked by comparison to a more recognised dynamic injury mechanism; a flexion extension model of dynamic compression.

Results

Spinal cord oscillation altered both compressive and shear strain on the spinal cord. Following initial compression, compressive strain moves from within the spinal cord to the spinal cord surface, whilst shear strain is magnified by 0.1-0.2, depending on the amplitude of oscillation. These orders of magnitude are equivalent to a dynamic compression model.

Discussion and conclusion

Spinal cord oscillation could significantly contribute to spinal cord damage across DCM. Its repeated occurrence with every heartbeat, draws parallels to the concept of fatigue damage, which could reconcile differing theories on the origins of DCM. This remains hypothetical at this stage, and further investigations are required.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

STUDY DESIGN

Clinical trial protocol V.2.2 October 2020.

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ISRCTN Number: ISRCTN16682024.

Vertebral Primary Bone Lesions: Review of Management Options

The assessment and treatment of vertebral primary bone lesions continue to pose a unique yet significant challenge. Indeed, there exists little in the literature in the way of compiling and overviewing the various types of vertebral lesions, which can often have complicated intervention strategies. Given the severe consequences of mismanaged vertebral bone tumors-including the extreme loss of motor function-it is clear that such an overview of spinal lesion care is needed. Thus, in the following paper, we aim to address the assessment of various vertebral primary bone lesions, outlining the relevant nonsurgical and surgical interventional methods. We describe examples of primary benign and malignant tumors, comparing and contrasting their differences. We also highlight emerging treatments and approaches for these tumors, like cryoablation and stereotactic body radiation therapy. Ultimately, we aim to emphasize the need for further guidelines in regard to correlating lesion type with proper therapy, underscoring the innate diversity of vertebral primary bone lesions in the literature.

Update of the Natural History, Pathophysiology, and Treatment Strategies of Degenerative Cervical Myelopathy: A Narrative Review

Cervical myelopathy is a clinical syndrome resulting in symptoms of neurologic deficits due to prolonged spinal cord compression or ischemia in the cervical spine. Spinal cord compression can be caused by ossification of the posterior longitudinal ligament and hypertrophy of ligamentun flavum in addition to degenerative cervical spondylosis, degenerative disc disease, and progressive cervical kyphosis. Degenerative cervical myelopathy (DCM) is a series of disease entities caused by spinal cord compression by various nontraumatic and non-infectious causes. The pathophysiology of DCM includes spinal cord structure and function abnormalities caused by both static and dynamic factors. Surgical decompression for patients with moderate to severe cervical myelopathy not only inhibits the progression of neurological deterioration, but also improves functional status, pain, and quality of life. However, the role of nonsurgical treatment in patients with mild spinal cord compression is controversial. In general, patients with cervical myelopathies who do not undergo surgery have a poor prognosis. Appropriate surgical treatment is recommended when spinal cord compression is confirmed on image study in patients with reasonable symptoms of cervical myelopathy. The patient's overall health, degree of compression, presence of concurrent cervical radiculopathy, and cervical spine alignment, in addition to lesion location and etiology, should be considered when determining an appropriate surgical procedure. This review covers the updated issues, including pathophysiology, clinical manifestations, differential diagnosis, and available treatments for DCM.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

New Imaging Modalities for Degenerative Cervical Myelopathy

INTRODUCTION

Degenerative cervical myelopathy (DCM) is defined as dysfunction of the spinal cord as a result of compression from degenerative changes to surrounding joints, intervertebral disks, or ligaments. Symptoms can include upper extremity numbness and diminished dexterity, difficulty with fine manipulation of objects, gait imbalance, and incoordination, and compromised bowel and bladder function. Accurate diagnosis and evaluation of the degree of impairment due to degenerative cervical myelopathy remain a challenging clinical endeavor requiring a thorough and accurate history, physical examination, and assessment of imaging findings.

METHODS

A narrative review is presented summarizing the current landscape of imaging modalities utilized in DCM diagnostics and the future direction of research for spinal cord imaging.

RESULTS AND DISCUSSION

Current imaging modalities, particularly magnetic resonance imaging and, to a lesser extent, radiographs/CT, offer important information to aid in decision making but are not ideal as stand-alone tools. Newer imaging modalities currently being studied in the literature include diffusion tensor imaging, MR spectroscopy, functional magnetic resonance imaging, perfusion imaging, and positron emission tomography. These newer imaging modalities attempt to more accurately evaluate the physical structure, intrinsic connectivity, biochemical and metabolic function, and perfusion of the spinal cord in DCM. Although there are still substantial limitations to implementation, future clinical practice will likely be revolutionized by these new imaging modalities to diagnose, localize, surgically plan and manage, and follow patients with DCM.

Prognostic Factors Impacting Surgical Outcomes in Patients With Cervical Spondylotic Myelopathy

The purpose of surgical decompression in patients who have CSM is to stop the progression of symptoms and hopefully improve function. It is critical to understand prognostic factors that affect the outcome. Factors intrinsic to the patient that can adversely affect outcomes include diabetes, older age, tobacco use, the presence of mental health disease, and obesity. MRI imaging findings of T2 hyperintensity and clinical duration and severity of symptoms is also associated with poorer outcomes. Patients should be counseled regarding the efficacy of decompressive procedures for CSM and given realistic expectations based on their unique biophysical profiles.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nontraumatic Spinal Cord Injury: Epidemiology, Etiology and Management

The spinal cord is a conduit within the central nervous system (CNS) that provides ongoing communication between the brain and the rest of the body, conveying complex sensory and motor information necessary for safety, movement, reflexes, and optimization of autonomic function. After a traumatic spinal cord injury (SCI), supraspinal influences on the peripheral nervous system and autonomic nervous system (ANS) are disrupted, leading to spastic paralysis, sympathetic blunting, and parasympathetic dominance, resulting in cardiac dysrhythmias, systemic hypotension, bronchoconstriction, copious respiratory secretions, and uncontrolled bowel, bladder, and sexual dysfunction. This article outlines the pathophysiology of the less reported nontraumatic SCI (NTSCI), its classification, its influence on sensory/motor function, and introduces the probable comorbidities associated with SCI that will be discussed in more detail in the accompanying manuscripts of this special issue. Finally, management strategies for NTSCI will be provided.

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.