Spine Surgery Improves Physical Functioning and QOL in Mild Degenerative Cervical Myelopathy

Peer Reviewed

Patients with mild degenerative cervical myelopathy (DCM) reported significant impairment in quality of life (QOL), especially social/physical functioning and mental health, in a large prospective cohort study published in the April 1 issue of Neurosurgery. Surgical decompression of the cervical spine resulted in significant improvements in functional status, disability level, and QOL in this cohort.

Older happy couple out drinking coffee.Cervical decompression to treat mild DCM significantly improved quality of life measures in adults. Photo Source: 123RF.com.“The findings suggest that the modified Japanese Orthopaedic Association (mJOA) score may under-represent the degree of impairment that patients with mild DCM have,” said senior author Michael G. Fehlings, MD, PhD. “I would advise clinicians to examine the impact that DCM has on each patient using the Short Form-36 as well as by asking about pain level and hand or gait dysfunction. If patients report impairment in these areas, it would appear that they would benefit substantially from surgery.”

The Conundrum of Mild Degenerative Cervical Myelopathy

In the latest guidelines on DCM, a strong recommendation was made to counsel patients with moderate or severe DCM for surgical management, Dr. Fehlings explained.1,2 However, clinical evidence on how to guide treatment decisions for mild degenerative cervical myelopathy are less clear, with both surgical management and a medically-supervised structured rehabilitation program being reasonable options.

The present multicenter study included 193 patients who underwent surgical decompression for mild DCM (mean age, 52.4 years; 34.7% women) as part of the AOSpine Cervical Spondylotic Myelopathy (CSM) North America or CSM International trials.2,3 All patients had an mJOA score of 15 to 17 (indicating mild DCM), at least one clinical sign of myelopathy, imaging evidence of cervical cord compression, and had not prior undergone cervical spine surgery.

Common Symptoms of Mild Degenerative Cervical Myelopathy

The most common presenting symptoms of DCM in this group were numb hands (81%), weakness (65%), and clumsy hands (54%). Gait difficulties were also common, and were reported by approximately half of the patients (48%).

As shown in the Table, significant improvements were found in all major outcome measures at 2 years post-operatively, including mJOA score, Nurick grade, Neck Disability Index (NDI), and the following domains on the SF-36v2: Bodily Pain, Emotional Well-Being, Energy/Fatigue, Mental Component Summary, Physical Component Summary, Physical Functioning, Role Limitation Emotional, Role Limitation Physical, and Social Functioning (Table).

Table. Outcomes of Mild DCM at 2 Years Post-operatively Compared With Baseline. Data extracted from Badhiwala et al.Outcomes of Mild DCM at 2 Years Post-operatively Compared With Baseline. Data extracted from Badhiwala et al. Photo Source: SpineUniverse.comThe complication rate was relatively low with 31% of patients reporting at least 1 complication, most commonly progression of myelopathy (6.74%), worsening of axial neck pain (6.22%), and dysphagia (5.7%).

Surgery for Degenerative Cervical Myelopathy Is Best Performed at an Early Stage

Surgical outcomes are best when DCM is treated at an earlier stage, Dr. Fehlings said. “We think that this paper can help guide clinicians on the subset of patients with mild DCM who benefit the most from surgery,” he said.

“Patients with DCM may present with minimal impairment but have magnetic resonance imaging [MRI] scans that show cortical compression. While some of these patients remain stable, many patients go on to develop deterioration,” Dr. Fehlings explained. Based on the study findings, it appears that surgery is beneficial for patients with mild DCM who rate their person health-related QOL as significantly impaired, he said.

“In particular, it appears that the clinical features with the most impact on health-related QOL are pain, hand dysfunction/clumsiness, and gait impairment,” Dr. Fehlings told SpineUniverse. “In contrast, if patients feel well, do not report pain or substantial neurological impairment, and self-report their SF-36 as very good, they likely can be followed clinically,” Dr. Fehlings said.

Better Outcome Measures for DCM Are Needed

Dr. Fehlings called for improved outcomes measures for mild DCM as the mJOA “is not particularly sensitive for patients with mild DCM.” He noted that research is currently underway on more sensitive measures of hand and upper extremity function, including the modified Graded Redefined Assessment of Strength, Sensation and Prehension GRASSP scale.4

In addition, “research is underway on the use of high resolution microstructural MRI to dissect out which patients with DCM may be at greater risk of neurologic deterioration,” Dr. Fehlings said.5 “In fact, our group has recently reported on use of an T2* signaling algorithm to analyze MRI data in spinal cord injury. White matter ratio is a sensitive biomarker that can predict which patients are at higher risk for neurologic impairment. If the data are validated in a larger prospective study, white matter ratio may detect which patients are at higher risk for deterioration and are best treated with surgery earlier in the course of the disease.”

Another knowledge gap is what metric is best for quantifying pain in DCM, Dr. Fehlings said. He added that it is difficult to establish what pain level (on a visual analog scale) may be an appropriate cutoff point indicating that surgery may be the best treatment choice in DCM.

Larger Cohort Studies Are Needed, Experts Say

“The authors are to be complimented on important data strongly suggesting that we should listen to our patients’ complaints, notably about hand function, and offer the consideration of surgical intervention for improving neurologic function,” commented SpineUniverse Editorial Board Member Regis Haid, Jr., MD, in an accompanying editorial. He suggested that future research on this topic should include a larger cohort with more data points (such as alignment).

Dr. Haid emphasized two key takeaway messages from the study by Dr. Fehlings and colleagues: 1) dysfunction was not self-rated as “mild” in these patients, and 2) surgery not only slowed down or stopped the progression of myelopathy, but also resulted in significant functional gains. Dr. Haid is a Neurosurgeon at Atlanta Brain and Spine Care.

Peter G. Angevine, MD, MPH, commented in an editorial that the findings may not necessarily be generalizable to the overall population of patients with mild DCM given that the cohort was relatively young (mean age, 52 years) and had pathology limited to 1 or 2 levels. Dr. Angevine is Associate Professor of Neurological Surgery at The Spine Hospital at The Neurological Institute of New York.

Updated on: 04/17/19
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Summary of the Clinical Practice Guidelines for the Management of Degenerative Cervical Myelopathy and Traumatic Spinal Cord Injury
Michael G. Fehlings, MD, PhD, FRCSC, FACS
Professor of Neurosurgery
Department of Surgery
University of Toronto
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