BMJ 2018;360:k186 doi: 10.1136/bmj.

k186 (Published 22 February 2018) Page 1 of 4

Practice

PRACTICE

EASILY MISSED?

Degenerative cervical myelopathy

1
Benjamin M Davies academic clinical fellow and specialist registrar neurosurgery , Oliver D Mowforth
1 2
medical student, , Emma K Smith specialist registrar general practice, , Mark RN Kotter clinician
1 1
scientist and consultant neurosurgeon
1
Academic neurosurgery unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK; 2School of General Practice, NHS
Health Education East of England, UK

1box 1) and are often collectively termed spondylosis (fig

What you need to know 1⇓).3
Consider degenerative cervical myelopathy in
patients over 50 with progressive neurological
symptoms, such as pain and stiffness in the neck Box 1How common is it?
or limbs, imbalance, numbness, loss of dexterity, The epidemiology of DCM is poorly understood, in
frequent falls, and/or incontinence part because of the difficulties in diagnosis.3
• The prevalence of surgically treated DCM is
Perform a full neurological assessment as early estimated as 1.6 per 100 000 inhabitants.4 The
symptoms are subtle and non-specific actual prevalence is likely to be much higher
A magnetic resonance imaging (MRI) scan is • The incidence of DCM is expected to rise with
essential to detect degenerative changes in the an ageing population.2 3 Most patients are first
cervical spine and cord compression diagnosed in their 50s; DCM is uncommon
Time is Spine: Refer patients with suspected before the age of 40
DCM promptly to a specialist for consideration • Studies in healthy volunteers have shown that
of spinal surgery, as delayed diagnosis can lead incidental cervical cord compression is
to residual symptoms and functional disability commonly detected on MRI, and becomes
more common with age.5 6 In a series of
randomly selected volunteers aged 40-80,
A 54 year old man presents with neck stiffness for about a year. incidental cervical cord compression was
detected on MRI in 59% of individuals
He complains of numbness in his fingers and difficulty buttoning (108/183, ranging from 31.6% in the fifth
up his shirt, which has not improved following surgery for carpal decade to 66.8% in the eighth decade). Only
tunnel syndrome. Of late, he has experienced unsteadiness and two individuals reported related symptoms2

has started to use a walking stick after sustaining falls. He sees • A proportion of individuals with asymptomatic
cord compression will go on to develop DCM.
a neurologist who identifies hyperreflexia in his arms and legs. The exact figure is unknown. The only
An MRI scan shows multilevel cervical spondylosis and disc prospective study to consider this (n=199)
found that 8% of individuals with asymptomatic
herniation causing cord compression. He is diagnosed with cord compression will develop DCM after one
degenerative cervical myelopathy and referred to spinal surgery year and 22% in total over the observation
period (median follow-up 44 months, range
for operative decompression. 2-12 years)7
What is degenerative cervical • Many patients with DCM remain undiagnosed.
A small study in 66 patients with hip fracture
myelopathy? found 18% of patients who were previously
undiagnosed to have clinical findings
Degenerative cervical myelopathy (DCM), earlier referred to suggestive of DCM8
as cervical spondylotic myelopathy, involves spinal cord
dysfunction from compression in the neck.1 Patients report
neurological symptoms such as pain and numbness in limbs,
poor coordination, imbalance, and bladder problems. Owing to
Why is it missed?
its mobility, the vertebral column of the neck is particularly Non-specific and subtle early features that overlap with other
prone to degenerative changes such as disc herniation, ligament neurological conditions can delay the diagnosis.9 Incomplete
hypertrophy or ossification, and osteophyte formation. These neurological assessment by professionals10 with a poor awareness
changes are more common with age2 (Boxed Text on page of the disease11 further contributes to delay. A retrospective

Correspondence to MRN Kotter [email protected]

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BMJ 2018;360:k186 doi: 10.1136/bmj.k186 (Published 22 February 2018) Page 2 of 4

PRACTICE

study of medical records of 42 patients in Israel who underwent Box 2Commonly reported symptoms and
surgery for DCM noted an average delay of 2.2 years (range examination findings in DCM9
1.7 months to 8.9 years) from initiation of symptoms to Symptoms
diagnosis. On average, 5.2 ±3.6 consultations were required
• Neck pain/stiffness
before a diagnosis was made.10 Forty three per cent of these
• Unilateral or bilateral limb/body pain
patients had symptoms of numbness and pain in hands, and
• Upper limb weakness, numbness, or loss of
were initially diagnosed and sometimes treated for carpal tunnel dexterity
syndrome.10 In our clinical experience, the diagnosis of carpal
• Lower limb stiffness, weakness, or sensory
tunnel syndrome, especially when diagnosed bilaterally, is often loss
incorrect and DCM usually accounts for these symptoms. • Paraesthesia (tingling or pins and needles
sensations)

Why does this matter? • Autonomic symptoms such as bowel or

bladder incontinence, erectile dysfunction, or
difficulty passing urine
Spinal cord compression results in progressive neurological
• Imbalance/unsteadiness
decline and affects quality of life.12 Left untreated, it can lead
• Falls
to tetraplegia and wheelchair dependence (data on how many
patients with DCM progress in this way are unavailable). Examination findings
Surgical decompression can halt the disease progression,
• Motor signs
however, the regenerative capacity of the spinal cord is limited o Pyramidal weakness (Upper limb; extensors
and any damage is often permanent. Delayed treatment leads more than flexors. Lower limb: flexors more
than extensors)
to poorer outcomes and lifelong disability. Findings from the
o Limb hyperreflexia
AOSpine series (746 patients with DCM) indicate that treatment
within six months of symptoms offers the best chance of o Spasticity (eg, clasp knife sign)

recovery,13 but this time frame is some way from current average o Clonus, especially Achilles tendon
diagnosis times.10 o Hoffman’s sign (thumb adduction/flexion +/−
finger flexion after forced flexion and sudden
release of a finger, distally)
How is it diagnosed? o Babinski’s sign (upgoing plantar)
o Segmental weakness (corresponding to the
Detecting early DCM can be challenging. A high index of level of compression)
suspicion, alongside a comprehensive neurological examination
• Sensory loss (limb and/or trunk)
is advised. Boxed Text on page 2Box 2 outlines common
• Lhermitte’s sign (electric shock sensation
symptoms and examination findings in DCM. down the spine, or into the limbs, on neck
flexion or extension, present in severe cases)
• Gait disturbance

Clinical
Pain is a common reason to seek treatment. Musculoskeletal
pain might be present in the neck, while neuropathic pain can
affect upper and lower limbs and occasionally the trunk. Patients
often report neck stiffness, at times without pain. A textbook
case would describe gait dysfunction and bilateral hand
impairment. Frequently not all symptoms are present. For
example, pain might be absent and symptoms can be unilateral
and vary in severity, even on a daily basis.9 Atypical symptoms
such as headaches and muscle cramps are also reported.9
The more consistent feature of DCM is the evolution of
symptoms. Most patients describe symptoms that have been
ongoing for months and getting worse.9 The rate of progression
varies; in some individuals symptoms remain mild over extended
periods of time, while in others disease progression accelerates.
Functional decline can be insidious, and patients might
mistakenly attribute these symptoms to “getting older.” Typical
features include loss of dexterity (difficulty doing up buttons,
using keys, mobile phones, or writing) or mobility (use of
walking aids or frequent falls).
Symptoms might precede objective examination findings.9 14 As
in focal central nervous system disorders, examination features
in DCM have a low sensitivity—that is, a normal finding does
not exclude the disease— but high specificity—that is, an
abnormal finding is highly suggestive of the disease.5 14 Features
can be mild and difficult to elicit in the initial stages of disease.

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BMJ 2018;360:k186 doi: 10.1136/bmj.k186 (Published 22 February 2018) Page 3 of 4

PRACTICE

Investigations How patients were involved in the creation of this

article
Request an MRI scan of the cervical spine to detect cord This article was reviewed and endorsed by
compression (fig 1⇓) in suspected DCM. An urgent MRI is individuals experiencing DCM who were part of a
required for patients with progressive disease and/or symptoms committee at Myelopathy.org. The committee was
keen to emphasise the possible prevalence of DCM
that substantially affect quality of life. In patients with mild and its long term effects, even after surgery. More
symptoms, a non-urgent MRI might be requested. Bear in mind specifically, it was involved in shaping the paragraph
“What is DCM?”
that the extent of spinal cord compression and signal changes
Myelopathy.org (www.myelopathy.org) is the first
in the cord on the MRI scan do not correlate well with the organisation dedicated to raising awareness,
severity of symptoms.3 Even mild compression can account for providing information, and supporting research for
DCM. It provides a forum for individuals to
severe disease. communicate their experiences of DCM and offers
The pathway to diagnosis varies depending on local services. peer to peer support to patients. Reports of delayed
and/or misdiagnosis are common, which result from
In the UK, for example, many primary care physicians do not a lack of awareness among frontline medical
have direct access to MRI imaging and referral to neurology specialties, particularly primary care. The committee
proposed an educational initiative, which included
might be warranted. this article.

How is it managed?
Often cord compression is an incidental finding and at least Acknowledgments: MRNK is supported by a National Institute of Health Research
initially does not cause symptoms.2 Reassure the patient that no Clinician Scientist Award.
further management is required at this stage but advise them to I confirm that we, the authors, have read and understood the BMJ policy on
report any symptoms promptly in the future. declaration of interests and have no competing interests to declare.
1
Guidelines from AOSpine an international community of spine All authors have contributed to the development, drafting and revision of this article
surgeons advise that all patients with DCM should be assessed and agree to its submission.
by a specialist surgeon, who might fall under the remit of Provenance and peer review: commissioned; externally peer reviewed.
neurosurgery or orthopaedics. The guidelines use the modified
Japanese Orthopaedic Association score, which classifies 1 Fehlings MG, Tetreault LA, Riew KD, etal . A clinical practice guideline for the management
of patients with degenerative cervical myelopathy: recommendations for patients with
patients as having mild or severe symptoms based on arm, leg, mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord
and bladder function.1 Surgery is recommended in patients with compression. Global Spine J 2017;7(Suppl):70S-83S.
moderate or severe DCM and in those with disease progression. 10.1177/2192568217701914 29164035
2 Kovalova I, Kerkovsky M, Kadanka Z, etal . Prevalence and imaging characteristics of
Treatment of symptoms (for pain, for example) and regular non-myelopathic and myelopathic spondylotic cervical cord compression. Spine (Phila
follow-up might be offered for patients with mild, stable DCM. Pa 1976) 2016;41:1908-16. 10.1097/BRS.0000000000001842 27509189
3 Nouri A, Tetreault L, Singh A, Karadimas SK, Fehlings MG. Degenerative cervical
The AOSpine series showed that decompressive surgery can myelopathy: epidemiology, genetics, and pathogenesis. Spine (Phila Pa 1976)
2015;40:E675-93. 10.1097/BRS.0000000000000913 25839387
halt disease progression and enable meaningful, albeit limited, 4 Boogaarts HD, Bartels RHMA. Prevalence of cervical spondylotic myelopathy. Eur Spine
recovery across a range of measures including pain, function, J 2015;24(Suppl 2):139-41. 10.1007/s00586-013-2781-x 23616201
and quality of life.15 The optimal timing of surgery is debatable 5 Nagata K, Yoshimura N, Muraki S, etal . Prevalence of cervical cord compression and its
association with physical performance in a population-based cohort in Japan: the
because the progression of disease is poorly understood.9 Wakayama Spine Study. Spine (Phila Pa 1976) 2012;37:1892-8.
Preoperative physiotherapy should only be advised by specialist 10.1097/BRS.0b013e31825a2619 22565382
6 Okada E, Matsumoto M, Ichihara D, etal . Aging of the cervical spine in healthy volunteers:
services1; neck manipulation is strictly contraindicated as it a 10-year longitudinal magnetic resonance imaging study. Spine (Phila Pa 1976)
might cause further damage.16 2009;34:706-12. 10.1097/BRS.0b013e31819c2003 19333104
7 Bednarik J, Kadanka Z, Dusek L, etal . Presymptomatic spondylotic cervical myelopathy:
It is not possible to predict the long term outcome of surgery. an updated predictive model. Eur Spine J 2008;17:421-31.
Maximal recovery occurs at around 6-12 months. Residual 10.1007/s00586-008-0585-1 18193301
8 Radcliff KE, Curry EP, Trimba R, etal . High incidence of undiagnosed cervical myelopathy
symptoms beyond this are likely to be permanent and should in patients with hip fracture compared to controls. J Orthop Trauma 2016;30:189-93.
be managed appropriately. Functional deficits are common, and 10.1097/BOT.0000000000000485 26562581
9 Tracy JA, Bartleson JD. Cervical spondylotic myelopathy. Neurologist 2010;16:176-87.
include falls and reduced mobility, incontinence, depression, 10.1097/NRL.0b013e3181da3a29 20445427
sleep deficits, and struggles with self-care, and often the most 10 Behrbalk E, Salame K, Regev GJ, Keynan O, Boszczyk B, Lidar Z. Delayed diagnosis of
cervical spondylotic myelopathy by primary care physicians. Neurosurg Focus 2013;35:E1.
troublesome symptom is pain. Discuss with your patient that 10.3171/2013.3.FOCUS1374 23815245
complete resolution of pain is unlikely. Neuropathic analgesia 11 Roberts E. Elemental ideas: cervical spondylotic myelopathy. www.myelopathy.org
12 Oh T, Lafage R, Lafage V, etal . Comparing quality of life in cervical spondylotic myelopathy
and anti-spasticity medication can be offered to manage the with other chronic debilitating diseases using the SF-36 survey. World Neurosurg
pain. Early referral to specialist pain clinics is often helpful. 2017;106:699-706. 10.1016/j.wneu.2016.12.124 28065875
13 Tetreault LA, Côté P, Kopjar B, Arnold P, Fehlings MGAOSpine North America and
Ask patients to report any worsening or new symptoms or signs International Clinical Trial Research Network. A clinical prediction model to assess surgical
as untreated levels of the cervical spine might further degenerate outcome in patients with cervical spondylotic myelopathy: internal and external validations
using the prospective multicenter AOSpine North American and international datasets of
and cause spinal cord compression. 743 patients. Spine J 2015;15:388-97. 10.1016/j.spinee.2014.12.145 25549860
14 Nicholl DJ, Appleton JP. Clinical neurology: why this still matters in the 21st century. J
Education into practice Neurol Neurosurg Psychiatry 2015;86:229-33. 10.1136/jnnp-2013-306881 24879832
What features would prompt you to suspect DCM in 15 Fehlings MG, Ibrahim A, Tetreault L, etal . A global perspective on the outcomes of surgical
a patient? decompression in patients with cervical spondylotic myelopathy: results from the
prospective multicenter AOSpine international study on 479 patients. Spine (Phila Pa
How would you explain a diagnosis of DCM to your 1976) 2015;40:1322-8. 10.1097/BRS.0000000000000988 26020847
patient? 16 Rhee JM, Shamji MF, Erwin WM, etal . Nonoperative management of cervical myelopathy:
Are you aware of the appropriate local pathways for a systematic review. Spine (Phila Pa 1976) 2013;38(Suppl 1):S55-67.
arranging an urgent MRI scan for patients with 10.1097/BRS.0b013e3182a7f41d 23963006
suspected DCM? Published by the BMJ Publishing Group Limited. For permission to use (where not already
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PRACTICE

Figure

Fig 1 Pathology of DCM. (A) Anatomy of an initially healthy spine (C2 level), with examples of the potential pathological
changes that can occur and cause DCM (shown at lower spinal levels; C3-7).1 (B) Sagittal section from a T2-weighted
MRI scan showing multilevel degenerative changes in the cervical spine. The spinal cord is compressed at C3/4 by
a disc prolapse (white arrow) and at C5/6 by spondylosis, thickening of the posterior longitudinal ligament, and a
disc-osteophyte complex (white star). However, this is not associated with high signal changes in the cord on MRI
(Figure reproduced with permission from Michael G Fehlings, University of Toronto)3

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