Degenerative cervical myelopathy
J.Sales-Llopis
Neurosurgery Service, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL - FISABIO Foundation), Alicante, Spain.
The assessment, diagnosis, operative and nonoperative management of degenerative cervical myelopathy (DCM) have evolved rapidly over the last 20 years. A clearer understanding of the pathobiology of DCM has led to attempts to develop objective measurements of the severity of myelopathy, including technology such as multiparametric magnetic resonance imaging, biomarkers, and ancillary clinical testing. New pharmacological treatments have the potential to alter the course of surgical outcomes, and greater innovation in surgical techniques have made surgery safer, more effective and less invasive. Future developments for the treatment of DCM will seek to improve the diagnostic accuracy of imaging, improve the objectivity of clinical assessment, and increase the use of surgical techniques to ensure the best outcome is achieved for each individual patient 1).
Goel was troubled by the fact that his several PubMed and MEDLINE indexed articles on the subject published in leading journals dedicated to the study of the spine have not found any place in the huge reference list of 137 articles 2)
Definition
Degenerative cervical myelopathy definition.
Epidemiology
Degenerative cervical myelopathy epidemiology.
Etiology
Degenerative cervical myelopathy etiology.
Pathophysiology
A review of Tetreault et al. summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood-spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies 3).
Clinical features
Degenerative cervical myelopathy clinical features
Scales
As a widespread used scale, the Modified Japanese Orthopaedic Association scale (mJOA) should be translated and culturally adapted 4).
see Cervical spine stenosis scales
Diagnosis
Degenerative cervical myelopathy diagnosis.
Differential diagnosis
Degenerative Cervical Myelopathy Differential Diagnosis.
Treatment
Degenerative cervical myelopathy treatment
Outcome
see Degenerative cervical myelopathy outcome.
Systematic reviews
A systematic review of MEDLINE and Embase for “Cervical” AND “Myelopathy” was conducted following PRISMA guidelines. Full-text papers in English, exclusively studying DCM, published between January 1, 1995 and August 08, 2020 were considered eligible. Extracted data for each study included authors, journal, year of publication, location, sample size and study design. Each study was then analysed for alignment to the established research priorities.
Results: In total, 2261 papers with a total of 1,323,979 patients were included. Japan published more papers (625) than any other country. Moreover, 2005 (89%) of 2261 papers were aligned to at least one research priority. The alignment of papers to the different research priorities was unequal, with 1060 papers on the most researched priority alone (#15, predictors of outcome after treatment), but only 64 total papers on the least-researched 10 priorities. The comparative growth of research in the different priorities was also unequal, with some priorities growing and others plateauing over the past 5 years.
Discussion: Research activity in DCM continues to grow, and the focus of this research remains on surgery. The established research priorities therefore represent a new direction for the field 5)
Randomized, controlled trials
A National Institutes of Health-funded (1R13AR065834-01) investigator meeting was held before the initiation of the trial to bring multiple stakeholders together to finalize the study protocol. Study investigators, coordinators, and major stakeholders were able to attend and discuss strengths of, limitations of, and concerns about the study. The final protocol was approved for funding by the Patient-Centered Outcomes Research Institute (CE-1304-6173). The trial began enrollment on April 1, 2014 6).
Case series
see Degenerative cervical myelopathy case series.
Case reports
A 63-year-old male who complained of a four-week-long “tingling and numbness” in his right upper and lower extremities. The sensation worsened over the next couple of days to the point where it affected his gait and led to a subsequent visit to the emergency room. Initial presentation prompted a stroke workup, but further investigation revealed findings suggestive of CSM. This case report highlights the symptomology of cervical spondylotic myelopathy in adults greater than 50 years of age and emphasizes the importance of recognizing the essential markers of this condition 7).