Degenerative Cervical Myelopathy Management Recommendations for Mild, Moderate or Severe DCM

Guidelines are intended to promote standardization of care for patients with DCM and eliminate the wide variation in management strategies in current practice.

New guidelines provide the first ever recommendations for management of mild, moderate, or severe degenerative cervical myelopathy (DCM), a common cause of neck pain, numbness/tingling in the arms, and problems with balance in the legs (Table). The guidelines are intended to promote standardization of care for patients with DCM and eliminate the wide variation in management strategies in current practice, explained Michael G. Fehlings, MD, PhD, FRCSC, FACS, who led the multidisciplinary guidelines' development group.

The guidelines were developed under the guidance of AOSpine North America, AOSpine International, the Cervical Spine Research Society, and the American Association and Congress of Neurological Surgeons. The findings were published in a special focus issue of the open-access Global Spine Journal.

Table: Management of mild, moderate and severe degenerative cervical myelopathyTable: Management of Mild, Moderate and Severe Degenerative Cervical Myelopathy (DCM)

Key Findings From the Literature
Over the past decade, several prospective clinical studies have “shed considerable light on optimal management of this condition,” Dr. Fehlings said. The two most important studies—conducted by AOSpine North America and AOSpine International—found that patients with mild, moderate, and severe DCM showed substantial improvement following decompression surgery, resulting in significant improvements in quality of life.1,2

Patients left untreated deteriorate given the natural history of this condition,” Dr. Fehlings said. “In general, the data found little evidence that non-operative management of DCM was effective.”

Guideline Recommendations on DCM
For patients with moderate or severe DCM “a clear and strong recommendation was made to counsel patients for surgical management,” Dr. Fehlings said, adding that clinical judgment always is required to determine whether the patient is medically fit for surgery (Table).

“For patients with mild DCM, there is a bit more equipoise between watchful waiting/non-operative management and the recommendation for surgery, which should be based on clinical judgment,” Dr. Fehlings said. “Surgical management could still be a reasonable option, but depending on the physician and patient preference, it is also a reasonable option to consider an initial trial of non-operative management with a medically-supervised structured rehabilitation program and careful follow-up. If the patient fails to improve or shows clinical deterioration, they should be counseled to have surgical management.”

Management is less clear for patients with neck pain with or without arm pain (radiculopathy) who undergo MRI and are found to have evidence of spinal cord compression, Dr. Fehlings said.

“Patients who have clinical evidence of radiculopathy (ie, arm pain and clinical signs of radiculopathy plus or minus confirmatory electrophysiology) should be counseled toward having surgery because those patients are at a high risk of developing myelopathy,” Dr. Fehlings explained. “It is felt that they are best managed preemptively, because outcomes are much better with early surgical management for myelopathy.”

However, patients with neck pain alone (ie, no arm pain/radiculopathy) who have evidence of spinal cord compression on MRI should not undergo prophylactic surgery, but should be counseled about the symptoms of myelopathy. If the patient reports back with symptoms of myelopathy, then physicians should refer to the guidelines for mild, moderate, and severe DCM, Dr. Fehlings said.

older woman with neck painDegenerative cervical myelopathy is a common cause of neck pain, numbness/tingling in the arms, and problems with balance in the legs.

Low Incidence of Complications From DCM Surgery
The incidence of complications from surgery for DCM is generally low. The most common complication is delayed C5 palsy, in which patients develop weakness of the biceps and deltoid muscles. The incidence of this complication is approximately 2% to 3%, and can be managed by steroid injection. Patients with OPLL (ossification of the posterior lateral ligament) who are undergoing multilevel posterior decompression are at a higher risk for this complication, Dr. Fehlings explained.

The anticonvulsant riluzole, a sodium-glutamate antagonist, is currently being investigated to help prevent delayed C5 palsy following decompression surgery for DCM. Dr. Fehlings, who is an investigator in this trial, said that results should be available in 2018.

The other important complication is worsening spinal cord function, which occurs in approximately 1% of patients, and typically resolves over time.

A Call for Greater Public Awareness of DCM Symptoms
“Degenerative cervical myelopathy is the most common cause of spinal cord impairment among adults worldwide, and can be thought of as the most serious complication of arthritis,” explained Dr. Fehlings. DCM is an overarching term that encompasses a number of degenerative and congenital conditions that result in extradural compression of the cervical spinal cord and progressive impairment; the most common of which are cervical spondylotic myelopathy (CSM) and OPLL, he explained.

Despite how common this condition is, patients are often not aware of DCM symptoms, Dr. Fehlings said. “The main symptom of DCM is unsteadiness when walking, with patients compensating by widening their gate. Patients often think this is just a symptom of old age,” he told SpineUniverse.

“Patients often have weakness/numbness in their hands that is sometimes misdiagnosed as carpal tunnel syndrome,” Dr. Fehlings said. “However, if patients have symptoms in both hands, problems with the cervical spinal cord, including DCM need to be ruled out.”

Gaps in Knowledge
Dr. Fehlings said that more research is needed to delineate the optimal management of patients with mild DCM. “My own gestalt is that these patients should be offered surgical management up front,“ Dr. Fehlings said. “This partly reflects that, as a surgeon, most patients will generally have completed a trial of non-operative management by the time they come to me.”

In addition, he said that more research is needed to guide treatment for patients who are minimally symptomatic but have evidence of cord compression on MRI.

Disclosure
Dr. Fehlings disclosed no relevant financial relationships.

Updated on: 11/03/17
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Summary of the Clinical Practice Guidelines for the Management of Degenerative Cervical Myelopathy and Traumatic Spinal Cord Injury
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