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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 ; [et al.]

SAGE Publications ; 2017

In: Global Spine Journal Vol. 7, No. 3_suppl ( 2017-09), p. 70S-83S

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In: Global Spine Journal, SAGE Publications, Vol. 7, No. 3_suppl ( 2017-09), p. 70S-83S

Abstract: 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.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/2192568217701914

Language: English

Publisher: SAGE Publications

Publication Date: 2017

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2

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Use of Methylprednisolone Sodium Succinate

Fehlings, Michael G. ; Wilson, Jefferson R. ; Tetreault, Lindsay A. ; [et al.]

SAGE Publications ; 2017

In: Global Spine Journal Vol. 7, No. 3_suppl ( 2017-09), p. 203S-211S

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In: Global Spine Journal, SAGE Publications, Vol. 7, No. 3_suppl ( 2017-09), p. 203S-211S

Abstract: The objective of this guideline is to outline the appropriate use of methylprednisolone sodium succinate (MPSS) in patients with acute spinal cord injury (SCI). Methods: A systematic review of the literature was conducted to address key questions related to the use of MPSS in acute SCI. A multidisciplinary Guideline Development Group used this information, in combination with their clinical expertise, to develop recommendations for the use of MPSS. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.” Results: The main conclusions from the systematic review included the following: (1) there were no differences in motor score change at any time point in patients treated with MPSS compared to those not receiving steroids; (2) when MPSS was administered within 8 hours of injury, pooled results at 6- and 12-months indicated modest improvements in mean motor scores in the MPSS group compared with the control group; and (3) there was no statistical difference between treatment groups in the risk of complications. Our recommendations were: (1) “We suggest not offering a 24-hour infusion of high-dose MPSS to adult patients who present after 8 hours with acute SCI”; (2) “We suggest a 24-hour infusion of high-dose MPSS be offered to adult patients within 8 hours of acute SCI as a treatment option”; and (3) “We suggest not offering a 48-hour infusion of high-dose MPSS to adult patients with acute SCI.” Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in SCI patients.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/2192568217703085

Language: English

Publisher: SAGE Publications

Publication Date: 2017

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3

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury and Central Cord Syndrome: Recommendations on the Timing (≤24 Hours Versus 〉24 Hours) of Decompressive Surgery

Fehlings, Michael G. ; Tetreault, Lindsay A. ; Wilson, Jefferson R. ; [et al.]

SAGE Publications ; 2017

In: Global Spine Journal Vol. 7, No. 3_suppl ( 2017-09), p. 195S-202S

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In: Global Spine Journal, SAGE Publications, Vol. 7, No. 3_suppl ( 2017-09), p. 195S-202S

Abstract: To develop recommendations on the timing of surgical decompression in patients with traumatic spinal cord injury (SCI) and central cord syndrome. Methods: A systematic review of the literature was conducted to address key relevant questions. A multidisciplinary guideline development group used this information, along with their clinical expertise, to develop recommendations for the timing of surgical decompression in patients with SCI and central cord syndrome. Based on GRADE, a strong recommendation is worded as “we recommend,” whereas a weak recommendation is presented as “we suggest.” Results: Conclusions from the systematic review included (1) isolated studies reported statistically significant and clinically important improvements following early decompression at 6 months and following discharge from inpatient rehabilitation; (2) in one study on acute central cord syndrome without instability, a marginally significant improvement in total motor scores was reported at 6 and 12 months in patients managed with early versus late surgery; and (3) there were no significant differences in length of acute care/rehabilitation stay or in rates of complications between treatment groups. Our recommendations were: “We suggest that early surgery be considered as a treatment option in adult patients with traumatic central cord syndrome” and “We suggest that early surgery be offered as an option for adult acute SCI patients regardless of level.” Quality of evidence for both recommendations was considered low. Conclusions: These guidelines should be implemented into clinical practice to improve outcomes in patients with acute SCI and central cord syndrome by promoting standardization of care, decreasing the heterogeneity of management strategies, and encouraging clinicians to make evidence-informed decisions.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/2192568217706367

Language: English

Publisher: SAGE Publications

Publication Date: 2017

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4

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Anticoagulant Thromboprophylaxis

Fehlings, Michael G. ; Tetreault, Lindsay A. ; Aarabi, Bizhan ; [et al.]

SAGE Publications ; 2017

In: Global Spine Journal Vol. 7, No. 3_suppl ( 2017-09), p. 212S-220S

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In: Global Spine Journal, SAGE Publications, Vol. 7, No. 3_suppl ( 2017-09), p. 212S-220S

Abstract: The objective of this study is to develop evidence-based guidelines that recommend effective, safe and cost-effective thromboprophylaxis strategies in patients with spinal cord injury (SCI). Methods: A systematic review of the literature was conducted to address key questions relating to thromboprophylaxis in SCI. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.” Results: Based on conclusions from the systematic review and expert panel opinion, the following recommendations were developed: (1) “We suggest that anticoagulant thromboprophylaxis be offered routinely to reduce the risk of thromboembolic events in the acute period after SCI;” (2) “We suggest that anticoagulant thromboprophylaxis, consisting of either subcutaneous low-molecular-weight heparin or fixed, low-dose unfractionated heparin (UFH) be offered to reduce the risk of thromboembolic events in the acute period after SCI. Given the potential for increased bleeding events with the use of adjusted-dose UFH, we suggest against this option;” (3) “We suggest commencing anticoagulant thromboprophylaxis within the first 72 hours after injury, if possible, in order to minimize the risk of venous thromboembolic complications during the period of acute hospitalization.” Conclusions: These guidelines should be implemented into clinical practice in patients with SCI to promote standardization of care, decrease heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/2192568217702107

Language: English

Publisher: SAGE Publications

Publication Date: 2017

detail.hit.zdb_id: 2648287-3

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5

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Type and Timing of Rehabilitation

Fehlings, Michael G. ; Tetreault, Lindsay A. ; Aarabi, Bizhan ; [et al.]

SAGE Publications ; 2017

In: Global Spine Journal Vol. 7, No. 3_suppl ( 2017-09), p. 231S-238S

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In: Global Spine Journal, SAGE Publications, Vol. 7, No. 3_suppl ( 2017-09), p. 231S-238S

Abstract: The objective of this study is to develop guidelines that outline the appropriate type and timing of rehabilitation in patients with acute spinal cord injury (SCI). Methods: A systematic review of the literature was conducted to address key questions related to rehabilitation in patients with acute SCI. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the type and timing of rehabilitation. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest. Results: Based on the findings from the systematic review, our recommendations were: (1) We suggest rehabilitation be offered to patients with acute spinal cord injury when they are medically stable and can tolerate required rehabilitation intensity (no included studies; expert opinion); (2) We suggest body weight–supported treadmill training as an option for ambulation training in addition to conventional overground walking, dependent on resource availability, context, and local expertise (low evidence); (3) We suggest that individuals with acute and subacute cervical SCI be offered functional electrical stimulation as an option to improve hand and upper extremity function (low evidence); and (4) Based on the absence of any clear benefit, we suggest not offering additional training in unsupported sitting beyond what is currently incorporated in standard rehabilitation (low evidence). Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care, decreasing the heterogeneity of management strategies and encouraging clinicians to make evidence-informed decisions.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/2192568217701910

Language: English

Publisher: SAGE Publications

Publication Date: 2017

detail.hit.zdb_id: 2648287-3

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6

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Degenerative Cervical Myelopathy: Development and Natural History [AO Spine RECODE-DCM Research Priority Number 2]

Nouri, Aria ; Tessitore, Enrico ; Molliqaj, Granit ; [et al.]

SAGE Publications ; 2022

In: Global Spine Journal Vol. 12, No. 1_suppl ( 2022-02), p. 39S-54S

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In: Global Spine Journal, SAGE Publications, Vol. 12, No. 1_suppl ( 2022-02), p. 39S-54S

Abstract: Narrative review. Objectives: To discuss the current understanding of the natural history of degenerative cervical myelopathy (DCM). Methods: Literature review summarizing current evidence pertaining to the natural history and risk factors of DCM. Results: DCM is a common condition in which progressive arthritic disease of the cervical spine leads to spinal cord compression resulting in a constellation of neurological symptoms, in particular upper extremity dysfunction and gait impairment. Anatomical factors including cord-canal mismatch, congenitally fused vertebrae and genetic factors may increase individuals’ risk for DCM development. Non-myelopathic spinal cord compression (NMSCC) is a common phenomenon with a prevalence of 24.2% in the healthy population, and 35.3% among individuals 〉 60 years of age. Clinical radiculopathy and/or electrophysiological signs of cervical cord dysfunction appear to be risk factors for myelopathy development. Radiological progression of incidental Ossification of the Posterior Longitudinal Ligament (OPLL) is estimated at 18.3% over 81-months and development of myelopathy ranges between 0-61.5% (follow-up ranging from 40 to 124 months between studies) among studies. In patients with symptomatic DCM undergoing non-operative treatment, 20-62% will experience neurological deterioration within 3-6 years. Conclusion: Current estimates surrounding the natural history of DCM, particularly those individuals with mild or minimal impairment, lack precision. Clear predictors of clinical deterioration for those treated with non-operative care are yet to be identified. Future studies are needed on this topic to help improve treatment counseling and clinical prognostication.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/21925682211036071

Language: English

Publisher: SAGE Publications

Publication Date: 2022

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7

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A Clinical Practice Guideline for the Management of Patients With Acute Spinal Cord Injury: Recommendations on the Role of Baseline Magnetic Resonance Imaging in Clinical Decision Making and Outcome Prediction

Fehlings, Michael G. ; Martin, Allan R. ; Tetreault, Lindsay A. ; [et al.]

SAGE Publications ; 2017

In: Global Spine Journal Vol. 7, No. 3_suppl ( 2017-09), p. 221S-230S

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In: Global Spine Journal, SAGE Publications, Vol. 7, No. 3_suppl ( 2017-09), p. 221S-230S

Abstract: The objective of this guideline is to outline the role of magnetic resonance imaging (MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury (SCI). Methods: A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI. This review focused on longitudinal studies that controlled for baseline neurologic status. A multidisciplinary Guideline Development Group (GDG) used this information, their clinical expertise, and patient input to develop recommendations on the use of MRI for SCI patients. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as “we recommend,” whereas a weaker recommendation is indicated by “we suggest.” Results: Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) “We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention, when feasible, to facilitate improved clinical decision-making” (quality of evidence, very low) and (2) “We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome” (quality of evidence, low). Conclusions: These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/2192568217703089

Language: English

Publisher: SAGE Publications

Publication Date: 2017

detail.hit.zdb_id: 2648287-3

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8

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A New Framework for Investigating the Biological Basis of Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 5]: Mechanical Stress, Vulnerability and Time

Davies, Benjamin M. ; Mowforth, Oliver ; Gharooni, Aref-Ali ; [et al.]

SAGE Publications ; 2022

In: Global Spine Journal Vol. 12, No. 1_suppl ( 2022-02), p. 78S-96S

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In: Global Spine Journal, SAGE Publications, Vol. 12, No. 1_suppl ( 2022-02), p. 78S-96S

Abstract: Literature Review (Narrative) Objective To propose a new framework, to support the investigation and understanding of the pathobiology of DCM, AO Spine RECODE-DCM research priority number 5. Methods Degenerative cervical myelopathy is a common and disabling spinal cord disorder. In this perspective, we review key knowledge gaps between the clinical phenotype and our biological models. We then propose a reappraisal of the key driving forces behind DCM and an individual’s susceptibility, including the proposal of a new framework. Results Present pathobiological and mechanistic knowledge does not adequately explain the disease phenotype; why only a subset of patients with visualized cord compression show clinical myelopathy, and the amount of cord compression only weakly correlates with disability. We propose that DCM is better represented as a function of several interacting mechanical forces, such as shear, tension and compression, alongside an individual’s vulnerability to spinal cord injury, influenced by factors such as age, genetics, their cardiovascular, gastrointestinal and nervous system status, and time. Conclusion Understanding the disease pathobiology is a fundamental research priority. We believe a framework of mechanical stress, vulnerability, and time may better represent the disease as a whole. Whilst this remains theoretical, we hope that at the very least it will inspire new avenues of research that better encapsulate the full spectrum of disease.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/21925682211057546

Language: English

Publisher: SAGE Publications

Publication Date: 2022

detail.hit.zdb_id: 2648287-3

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9

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Degenerative Cervical Myelopathy: A Practical Approach to Diagnosis

Tetreault, Lindsay ; Kalsi-Ryan, Sukhvinder ; Benjamin Davies ; [et al.]

SAGE Publications ; 2022

In: Global Spine Journal Vol. 12, No. 8 ( 2022-10), p. 1881-1893

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In: Global Spine Journal, SAGE Publications, Vol. 12, No. 8 ( 2022-10), p. 1881-1893

Abstract: Narrative Review. Objectives The objective of this review is to provide a stepwise approach to the assessment of patients with potential symptoms of degenerative cervical myelopathy (DCM). Methods N/A Results DCM is an overarching term used to describe progressive compression of the cervical spinal cord by age-related changes to the spinal axis. These alterations to normal anatomy narrow the spinal canal, reduce the space available for the spinal cord, and may ultimately compress the ascending and descending neural tracts. Patients with DCM present with a wide range of symptoms that can significantly impact quality of life, including bilateral hand numbness and paresthesia, gait impairment, motor weakness of the upper and lower extremities, and bladder and bowel dysfunction. Unfortunately, DCM is often misdiagnosed, resulting in delayed assessment and management by the appropriate specialist. The proper evaluation of a patient with suspected DCM includes obtaining a detailed patient history, conducting a comprehensive neurological examination, and ordering appropriate tests to rule in or out other diagnoses. Conclusion This review summarizes a stepwise approach to the diagnosis of patients with DCM.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/21925682211072847

Language: English

Publisher: SAGE Publications

Publication Date: 2022

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Imaging and Electrophysiology for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 9]

Martin, Allan R. ; Tetreault, Lindsay ; Nouri, Aria ; [et al.]

SAGE Publications ; 2022

In: Global Spine Journal Vol. 12, No. 1_suppl ( 2022-02), p. 130S-146S

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In: Global Spine Journal, SAGE Publications, Vol. 12, No. 1_suppl ( 2022-02), p. 130S-146S

Abstract: Narrative review. Objective The current review aimed to describe the role of existing techniques and emerging methods of imaging and electrophysiology for the management of degenerative cervical myelopathy (DCM), a common and often progressive condition that causes spinal cord dysfunction and significant morbidity globally. Methods A narrative review was conducted to summarize the existing literature and highlight future directions. Results Anatomical magnetic resonance imaging (MRI) is well established in the literature as the key imaging tool to identify spinal cord compression, disc herniation/bulging, and inbuckling of the ligamentum flavum, thus facilitating surgical planning, while radiographs and computed tomography (CT) provide complimentary information. Electrophysiology techniques are primarily used to rule out competing diagnoses. However, signal change and measures of cord compression on conventional MRI have limited utility to characterize the degree of tissue injury, which may be helpful for diagnosis, prognostication, and repeated assessments to identify deterioration. Early translational studies of quantitative imaging and electrophysiology techniques show potential of these methods to more accurately reflect changes in spinal cord microstructure and function. Conclusion Currently, clinical management of DCM relies heavily on anatomical MRI, with additional contributions from radiographs, CT, and electrophysiology. Novel quantitative assessments of microstructure, perfusion, and function have the potential to transform clinical practice, but require robust validation, automation, and standardization prior to uptake.

Type of Medium: Online Resource

ISSN: 2192-5682 , 2192-5690

URL: Article

DOI: 10.1177/21925682211057484

Language: English

Publisher: SAGE Publications

Publication Date: 2022

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