Learning objectives
1. To describe the epidemiology and assessment of patients with suspected degenerative cervical myelopathy (DCM)
2. To describe the management and outcomes of patients with DCM
3. To learn from a patient’s experience of being diagnosed and living with DCM
Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults with an estimated prevalence of 2%.(1) DCM is most often caused by degenerative cervical stenosis, which can lead to chronic, non-traumatic spinal cord compression.(1) Degenerative cervical stenosis may be the result of degenerative disc disease (including disc herniation or spondylosis), facet joint degeneration (either arthropathy or instability), hypermobility or ligamentous degeneration.(2–4) DCM is a progressive condition, and if not diagnosed or treated timeously, can result in an incomplete spinal cord injury and neurological loss. DCM patients’ symptoms are thought to deteriorate over time,(5) therefore prompt recognition of any early decline in function is crucial for optimal treatment.
The incidence of DCM appears to rise with an ageing population, with most patients diagnosed in their 50s.(6) The global population is ageing, and therefore the rates of DCM are likely to be increasing. However, awareness of this condition in primary and secondary care specialties appears to vary with numerous case reports documenting delays to diagnosis and treatment.(1) Recent international guidance has recommended a treatment algorithm according to the severity of DCM, as judged by the Modified Japanese Orthopedic Score.(3,8) However, many of the initial presenting symptoms are subtle, and may not be identified without comprehensive neurological testing.(1,3,6) Further, patients may present with symptoms that do not fit neatly into the International Guidance algorithm.(7) Further, older age often results in overlapping symptoms such as peripheral joint osteoarthritis, age-related decline, lumbar spine pathology, as well as cardiovascular conditions. There is no consensus to date on the diagnostic criteria for DCM, which further challenges the management of these patients.(1,7,9) Awareness of this condition as a differential cause of spinal pathology appears to be lacking in primary care, with limited coverage in the UK and US medical curriculum.(10) It is unknown the degree to which physiotherapists screen for this condition, and there are no agreed pathways in place for physiotherapists managing this patient subgroup.
Early diagnosis of DCM is important as most cases appear to progress with time.(5) It is imperative to make every effort to reduce time to diagnosis by ensuring timely assessment, such as upper motor neurone sign assessment, and, where relevant, appropriate investigations, such as cervical spine imaging.(3) Timely treatment is therefore critical to preserving function. Surgical decompression is recommended for moderate and severe classifications of DCM,(7) and aims to prevent further deterioration of symptoms. Delays to diagnosis and treatment are common in this patient group and may have significant long-term impacts on future function and prognosis, especially when younger patients are affected. Myelopathy is an important differential diagnosis to consider in primary and secondary care, irrespective of age, given the potential impact on future productive working years. (1)
During this symposium, we will describe the epidemiology of DCM, and explore the possible initial presentations of patients in primary and secondary care. We will provide clear assessment guidance regarding differential or early diagnosis and management of DCM, using the international guidance for recommended management and triage. We will present and discuss pathways for the management of DCM (and results from an audit of our local pathway) and discuss surgical treatment, outcomes and prognosis. We will also learn from a patient’s experience, and reflect on their journey to diagnosis and treatment. We will engage attendees with a pre-symposium survey of understanding of the condition, assessment tools and current practice, to assess their understanding and current management of DCM. We will also explore current myelopathy pathways in place for attendees.
The planned impact is that all attendees will gain an increased awareness of DCM and the potential consequences of delayed diagnosis and treatment. The symposium will aim to educate physiotherapists on assessment and management of this condition, as well as reviewing current pathways in primary and secondary care for the management of suspected and confirmed DCM. This will hopefully provide improved pathways for future management of suspected and confirmed DCM, and reduce both time to diagnosis and to treatment. We will share current pathways implemented at NUH, discuss learning and future directions for improved management of this condition.