Individualizing surgery

Are there clinical and imaging factors that can help a surgeon select who should undergo surgical decompression in the setting of DCM? At what stage of the disease is surgery the preferred management strategy?

Podcast Episode 10: Individualizing surgery

Episode 10 of the AO Spine RECODE-DCM podcast series focuses on Individualizing Surgery in the setting of Degenerative Cervical Myelopathy! Are there clinical and imaging factors that can help select who should undergo surgical decompression? At what stage of the disease is surgery the preferred management strategy? Ben Davies and Michelle Starkey put the questions to Daniel Simpson, James Harrop, and Lindsay Tetreault.

Current evidence and reason for uncertainties

No systematic reviews, scoping reviews or guidelines identified.

Source of uncertainty

  • Spinal surgeons


  • Other healthcare professionals


  • People with DCM and their supporters


  • Original suggestions*

    * This list shows the original survey submission(s) that informed the indicative uncertainties and the resulting priority question.

    Who are eligible for surgical treatment for DCM?

    Is mjoa really effective as criterion to undergo sugery

    When is decompression necessary/not necessary definitively

    Which signs are important for choosing surgical decompression of the spinal cord?

    Operative indications

    In addition to progressive neurological deficit, who has to be operated surgically? Acute signal changes in MRI? Is there any definite evidence for measurement (mm) of anteroposterior diameter of cervical spine in subaxial area indicated for prophylactic indication for surgery according to CT? What about square of spine in CT? Does CT scan a necessity for evaluation and treatment? What about lateral dynamic (flexion extension) cervical x-ray? 

    When should patients have decompressive surgery--once hyperreflexia? sensory symptoms? weakness? gait dysfunction and/or dropping items? or based on MRI findings?

    What are the indicators that surgery is the best option?

    Factors that predict the need for surgery in early DCM

    Surgical indication for signal changes on MRI

    What are the clear indications for surgical intervention?

    Who are eligible for surgical treatment for DCM?

    What are the contraindications for surgery?

    What is the ideal threshold for deciding to do surgery on a patient with DCM?

    Would like to find out if there is … stage where surgery may not help?

    How could we decide for early treatments with other MRI sequences? Only clinical factors? 

    What are the key imaging (MRI) findings (canal stenosis, cord signal changes...) that predict need for surgical treatment of DCM?

    In stable DCM are there any clear cut indicators which will prompt us to opt for surgery?

    Does the 'signal change' on preoperative MRI scan poses the certainty to proceed with decompressive surgery for the DCM patients?

    2. Who has to be included in the treatment for DCM and what is the evidence for inclusion criteria?   

    Are the subtle signs of DCM such as brisk reflexes, Hoffman's, etc enough for the early diagnosis and should treatment be instituted prophylacdtically

    In which way do neurophysiological examsn might help therapeutic decisions in oligosymptomatic DCM

    In stable DCM are there any clear cut indicators which will prompt us to opt for surgery?

    In the absence of significant compression, can signal changes be considered as an indication for surgery?

    Is it possible to develop a prognostic screening tool ( like the STartback for LBP ) which will help clinicians to make decisions about who requires surgical intervention?

    What clinical signs and symptoms could be considered definite indications for surgery in DCM?

    Is Radiological diagnosis final for taking decision about surgery of DCM?

    Which are the most important diagnostic item to decide surgical treatment in paucisimptomatic patients?

    In the presence of myelomalacia, which clinical signs should prompt a quicker surgical treatment?

    What is the value of functional MRI (flexion and extension) in predicting need for surgical treatment in patients with DCM

    Decision making for the timing of operative intervention. 

    How degree of clinical severity is appropriate to consider surgical indication for DCM?

    At which stage- especially if signs are mild- is it necessary to treat DCM

    At what stage does it become clear that surgical intervention is the preferred/desired treatment? 

    How can we best choose surgical candidates?  

    When is surgery indicated, and when can we simply observe?  

    What are the indications of surgical treatment? 

    What level of severity do you offer surgical treatment ie mild moderate severe

    Are there clinical factors that are predictive of which patients will require a surgical intervention versus conservative management?  

    Which symptoms and/or signs and/or imaging features should trigger surgical treatment?

    Who is an appropriate surgical candidate and is there a subset of people we can/should monitor?

    When should the patient go under surgery? 

    What are the clinical findings  (symptoms/ signs) that necessitate surgery?  What are the MRI , nerve conduction or EMG signs that mandate surgical intervention? Is presence of pain matter in decision -making?

    Are there clinical signs that help me with my surgical decision-making?  

    Which symptoms should lead to surgery?  Are there patients that should not be treated with surgery since they are not expected to recover?  

    What are the clinical criteria for surgical treatment of DCM?  

    Classification of levels of DCM which will help determine when surgery can be conducted

    What is the clinic finding that is indicative that surgical intervention should be completed?

    Can we use neurophysiology (SSEP, CMAP) to prognosticate and help in treatment decision analysis ?

    When to 'definitely' declare non-operative care unsuccessful with a view to proceeding to surgery

    More definitive indications for surgical intervention

    3. How quickly after signal change in the cord is seen should surgery be offered? 

    Should patients with hyperintense cord lesions always be offered surgical decompression? Are there imaging features that can reliably detect significant cord change that renders surgery useless prior to it being done?  

    Are there any clinical/physical exam findings that can help us to better select surgical candidates on an early stage (diagnose DCM in patients with no or mild complaints related to DCM)?

    What factors make patients decide surgical treatment in moderate DCM?  Surgeon's explanation? What kind of DCM symptom? MRI pictures?

    How important is spinal cord signal change in defining the need for surgical treatment?  

    Are Evoked potentials (and EMG) necessary to decide for surgical treatment?

    Which symptom should be given primacy while deciding to operate on a patient of DCM.

    Are there any prognostic factors that could facilitate to select patients for surgery?

    Surgical indiction for signal changes on MRI

    The assessment of the Cortocopinal Reserve Capacity as a new means to identify patients with presymptomatic and mild myelopathy that would benefit from surgery

    What is the first sign that would indicate the necessity of surgical intervention

    Is the medication ( only) effectiv?   What is the red flag of symptoms and sign..make the decision of surgery?

    Would babinski or ankle clonus be a good guide for more severe cases requiring surgical management

    What are de early signs and symptoms of DCM that can help to early surgery? 

    Does neck pain influence the surgical decision