Priority 24 from the Degenerative Cervical Myelopathy PSP

UNCERTAINTY: What is the role of surgery in the management of non-myelopathic patients with imaging evidence of cord compression? Is this decision impacted by signal change on T2-weighted MRI images or the presence of neck pain? (JLA PSP Priority 24)
Overall ranking 24
JLA question ID 0097/24
Explanatory note In a systematic review by Wilson et al (2013), low level evidence suggested that, in non-myelopathic patients with cervical canal stenosis and cord compression, approximately 8% at 1-year and 23% at 44-months will develop clinical evidence of myelopathy. Important predictors of disease development included presence of symptomatic radiculopathy, prolonged SEPs and MEPs and EMG signs of anterior horn cell lesion (low to moderate evidence). There was no consensus with respect to whether the presence of T2 signal changes impacts te development of myelopathy. A recent clinical practice guideline aimed to address the following questions: should operative management be used to treat non-myelopathic patients with evidence of cord compression (i) without signs or symptoms of radiculopathy or (ii) and clinically/electrophysiological diagnosed radiculopathy. Two recommendations were developed; however, both were based on low quality evidence and were considered weak. Further research is required in order to better address these questions.

A systematic review on the topic rated the level of evidence as insufficient to moderate. Strength was weak for all recommendations developed in the clinical practice guideline.
Wilson JR, Barry S, Fischer DJ, Skelly AC, Arnold PM, Riew KD, Shaffrey CI, Traynelis VC, Fehlings MG. Frequency, timing, and predictors of neurological dysfunction in the nonmyelopathic patient with cervical spinal cord compression, canal stenosis, and/or ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S37-54.
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

Is there any benefit of surgically treating patients with cord compression but no/mild signs/symptoms of myelopathy?
Is surgery indicated in asymptomatic DCM (MRI showing compressive changes?) ~ Role of surgery in patients with radiologically severe cervical spinal stenosis with MR signs of myelopathy, but without clinical evident myelopathy
What is the risk of an asymptomatic patient with severe stenosis to deteriorate in comparison to prophylactic decompression? ~ Is surgery warranted in (neurological) asymptomatic stenosis and neck pain?

Submitted by Spinal Surgeons x 27, Other healthcare professionals x  7, 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