Priority 21 from the Degenerative Cervical Myelopathy PSP

UNCERTAINTY: What is the preferred management strategy for patients with mild DCM? What is the most cost-effective management strategy in this cohort of patients? Are there clinical and imaging features that predict who should undergo surgical decompression and/or when? (JLA PSP Priority 21)
Overall ranking 21
JLA question ID 0097/21
Explanatory note A recent clinical practice guideline aimed to address whether nonoperative or operative management should be used to treat patients with mild DCM. Although several studies have assessed the efficacy of surgery, only a single study stratified their sample based on preoperative myelopathy severity. Based on the results from Fehlings et al (2013), patients with mild DCM demonstrate significant improvements in functional impairment, disability and quality of life following surgical intervention. Unfortunately, there were no studies that focused solely on mild patients when addressing disease natural history, important predictors of treatment outcomes, efficacy and safety of nonoperative management and rates of traumatic spinal cord injury. As a result of limited evidence, it was suggested that either surgical intervention or a supervised trial of structured rehabiliation be offered to patients with mild DCM.  The strength of this recommendation was weak. This topic remains to be an important knowledge gap in the field. 

Systematic reviews evaluating the efficacy of surgery and nonoperative treatment did not differentiate among patients with mild, moderate or severe preoperative disease. The strength of the guideline developed for the management of mild myelopathy was weak and was based on very low to low level of evidence. Furthermore, the recommendation suggested either surgical intervention or a supervised trial of structured rehabilitation.
Fehlings MG, Tetreault LA, Kurpad S, Brodke DS, Wilson JR, Smith JS, Arnold PM, Brodt ED, Dettori JR. Change in Functional Impairment, Disability, and Quality of Life Following Operative Treatment for Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis. Global Spine J. 2017 Sep;7(3Suppl):53S-69S.
Fehlings MG, Tetreault LA, Riew KD, Middleton JW, Aarabi B, Arnold PM, Brodke DS, Burns AS, Carette S, Chen R, Chiba K, Dettori JR, Furlan JC, Harrop JS, Holly LT, Kalsi-Ryan S, Kotter M, Kwon BK, Martin AR, Milligan J, Nakashima H, Nagoshi N, Rhee J, Singh A, Skelly AC, Sodhi S, Wilson JR, Yee A, Wang JC. A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression. Global Spine J. 2017 Sep;7(3 Suppl):70S-83S.

Health Research Classification System category Neurological
Extra information provided by this PSP
Original uncertainty examples

When should patients with mild symptoms and signs of DCM (that are seen in the initial assessment) be referred for a surgical consultation? ~ Are there clear indications for surgery in oligosymptomatic DCM patients? ~ Is early surgery for mild myelopathy of potential clinical benefit? ~ When does an individual with mild myelopathy need an operation?  ~ Cost analysis for early operations versus late operations in patients with newly diagnosed symptomatic cervical degenerative myelopathy.

Submitted by Spinal Surgeons x 27, Other healthcare professionals x  3, People with DCM and their supporters x  1
PSP information
PSP unique ID 0097
PSP name Degenerative Cervical Myelopathy
Total number of uncertainties identified by this PSP. 76  (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop 20 November 2019