Clinical outcomes of nonoperatively managed degenerative cervical myelopathy: an ambispective longitudinal cohort study in 117 patients

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  • 1 Division of Neurosurgery, Department of Surgery, University of Toronto;
  • 2 Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto;
  • 3 KITE Research Institute, University Health Network, Toronto;
  • 4 Department of Physical Therapy, University of Toronto, Ontario, Canada;
  • 5 Graduate Entry Medicine, University College Cork, Ireland; and
  • 6 Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
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OBJECTIVE

Degenerative cervical myelopathy (DCM) is among the most common pathologies affecting the spinal cord but its natural history is poorly characterized. The purpose of this study was to investigate functional outcomes in patients with DCM who were managed nonoperatively as well as the utility of quantitative clinical measures and MRI to detect deterioration.

METHODS

Patients with newly diagnosed DCM or recurrent myelopathic symptoms after previous surgery who were initially managed nonoperatively were included. Retrospective chart reviews were performed to analyze clinical outcomes and anatomical MRI scans for worsening compression or increased signal change. Quantitative neurological assessments were collected prospectively, including modified Japanese Orthopaedic Association (mJOA) score; Quick-DASH; graded redefined assessment of strength, sensation, and prehension–myelopathy version (GRASSP–M: motor, sensory, and dexterity); grip dynamometer; Berg balance scale score; gait stability ratio; and gait variability index. A deterioration of 10% was considered significant (e.g., a 2-point decrease in mJOA score).

RESULTS

A total of 117 patients were included (95 newly diagnosed, 22 recurrent myelopathy), including 74 mild, 28 moderate, and 15 severe cases. Over a mean follow-up of 2.5 years, 57% (95% CI 46%–67%) of newly diagnosed patients and 73% (95% CI 50%–88%) of patients with recurrent DCM deteriorated neurologically. Deterioration was best detected with grip strength (60%), GRASSP dexterity (60%), and gait stability ratio (50%), whereas the mJOA score had low sensitivity (33%) in 50 patients. A composite score had a sensitivity of 81% and a specificity of 82%. The sensitivity of anatomical MRI was 28% (83 patients).

CONCLUSIONS

DCM appears to have a poor natural history; however, prospective studies are needed for validation. Serial assessments should include mJOA score, grip strength, dexterity, balance, and gait analysis. The absence of worsening on anatomical MRI or in mJOA scores is not sufficient to determine clinical stability.

ABBREVIATIONS CPGs = clinical practice guidelines; DCM = degenerative cervical myelopathy; eGVI = enhanced gait variability index; GRASSP-M = graded redefined assessment of strength, sensation, and prehension–myelopathy version; MDD = mean detectible difference; mJOA = modified Japanese Orthopaedic Association; SR = stability ratio.

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Contributor Notes

Correspondence Michael G. Fehlings: University of Toronto, Toronto Western Hospital, Toronto, ON, Canada. michael.fehlings@uhn.ca.

INCLUDE WHEN CITING Published online April 9, 2021; DOI: 10.3171/2020.9.SPINE201395.

A.R.M. and S.K.R. share first authorship of this work.

Disclosures Dr. Kalsi-Ryan owns Neural Outcomes Consulting, Inc., which manufactures and distributes GRASSP products, and she is also the inventor who collects royalties (with University Health Network as the licensing body). Dr. Wilson is a consultant for Stryker Canada.

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