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

Michael G. Fehlings, Lindsay A. Tetreault, K. Daniel Riew, James W. Middleton, Bizhan Aarabi, Paul M. Arnold, Darrel S. Brodke, Anthony S. Burns, Simon Carette, Robert Chen, Kazuhiro Chiba, Joseph R. Dettori, Julio C. Furlan, James S. Harrop, Langston T. Holly, Sukhvinder Kalsi-Ryan, Mark Kotter, Brian K. Kwon, Allan R. Martin, James MilliganHiroaki Nakashima, Narihito Nagoshi, John Rhee, Anoushka Singh, Andrea C. Skelly, Sumeet Sodhi, Jefferson R. Wilson, Albert Yee, Jeffrey C. Wang

Research output: Contribution to journalArticle

45 Citations (Scopus)

Abstract

Study Design: Guideline development. Objectives: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM). Results: Our recommendations were as follows: (1) “We recommend surgical intervention for patients with moderate and severe DCM.” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve.” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.” Conclusions: These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

Original languageEnglish
Pages (from-to)70S-83S
JournalGlobal Spine Journal
Volume7
Issue number3_supplement
DOIs
Publication statusPublished - 2017 Sep 1

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Spinal Cord Diseases
Practice Management
Practice Guidelines
Radiculopathy
Guidelines
Signs and Symptoms
Rehabilitation
Natural History
Disease Progression
Patient Care
Safety

Keywords

  • cervical spondylotic myelopathy
  • degenerative cervical myelopathy
  • guidelines
  • spinal cord compression

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine
  • Clinical Neurology

Cite this

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. / Fehlings, Michael G.; Tetreault, Lindsay A.; Riew, K. Daniel; Middleton, James W.; Aarabi, Bizhan; Arnold, Paul M.; Brodke, Darrel S.; Burns, Anthony S.; Carette, Simon; Chen, Robert; Chiba, Kazuhiro; Dettori, Joseph R.; Furlan, Julio C.; Harrop, James S.; Holly, Langston T.; Kalsi-Ryan, Sukhvinder; Kotter, Mark; Kwon, Brian K.; Martin, Allan R.; Milligan, James; Nakashima, Hiroaki; Nagoshi, Narihito; Rhee, John; Singh, Anoushka; Skelly, Andrea C.; Sodhi, Sumeet; Wilson, Jefferson R.; Yee, Albert; Wang, Jeffrey C.

In: Global Spine Journal, Vol. 7, No. 3_supplement, 01.09.2017, p. 70S-83S.

Research output: Contribution to journalArticle

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 2017, '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 Journal, vol. 7, no. 3_supplement, pp. 70S-83S. https://doi.org/10.1177/2192568217701914
Fehlings, Michael G. ; Tetreault, Lindsay A. ; Riew, K. Daniel ; Middleton, James W. ; Aarabi, Bizhan ; Arnold, Paul M. ; Brodke, Darrel S. ; Burns, Anthony S. ; Carette, Simon ; Chen, Robert ; Chiba, Kazuhiro ; Dettori, Joseph R. ; Furlan, Julio C. ; Harrop, James S. ; Holly, Langston T. ; Kalsi-Ryan, Sukhvinder ; Kotter, Mark ; Kwon, Brian K. ; Martin, Allan R. ; Milligan, James ; Nakashima, Hiroaki ; Nagoshi, Narihito ; Rhee, John ; Singh, Anoushka ; Skelly, Andrea C. ; Sodhi, Sumeet ; Wilson, Jefferson R. ; Yee, Albert ; Wang, Jeffrey C. / 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. In: Global Spine Journal. 2017 ; Vol. 7, No. 3_supplement. pp. 70S-83S.
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abstract = "Study Design: Guideline development. Objectives: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM). Results: Our recommendations were as follows: (1) “We recommend surgical intervention for patients with moderate and severe DCM.” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve.” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.” Conclusions: These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.",
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AU - Fehlings, Michael G.

AU - Tetreault, Lindsay A.

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AU - Middleton, James W.

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AU - Arnold, Paul M.

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AU - Kwon, Brian K.

AU - Martin, Allan R.

AU - Milligan, James

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AU - Nagoshi, Narihito

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AU - Singh, Anoushka

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