Degenerative cervical myelopathy: Diagnosis and management in primary care

Abstract

Objective: To raise awareness about degenerative cervical myelopathy (DCM) and to help family physicians identify, diagnose, and manage DCM more effectively.

Sources of information: A PubMed search was conducted for articles published between 1970 and October 2017, using the terms cervical myelopathy and degenerative spinal cord injury with family medicine or primary care.

Main message: Owing to limited knowledge of DCM in primary care, along with the large variability of the disease, the diagnosis of DCM is often missed or delayed. The natural course of DCM presents as a stepwise decline, with symptoms ranging from muscle weakness to complete paralysis. All individuals with signs and symptoms should be referred to a spine surgeon for consideration of surgery; those with mild DCM might be offered conservative treatment but should receive a surgical evaluation and opinion nonetheless. Asymptomatic patients with evidence of cord compression on magnetic resonance imaging might need to be referred for assessment; however, surgery is not advised. It is critical to closely monitor asymptomatic individuals or those with mild DCM for neurologic deterioration.

Conclusion: Degenerative cervical myelopathy is the most common cause of spinal cord dysfunction in adults. This review helps streamline its diagnosis in primary care, allowing for improved chances of early diagnosis and prevention of further neurologic decline among patients.

Figure 1.

Pathophysiology of DCM: Examples of potential pathologic changes that can occur in the development of DCM. DCM—degenerative cervical myelopathy, PLL—posterior longitudinal ligament. Adapted with permission from Davies et al.

Figure 2.

T2-weighted MRI of a cervical spine: Red arrow indicates disk herniation causing spinal cord compression. MRI—magnetic resonance imaging.

Figure 3.

Office management of DCM: Patients with DCM can be categorized as mild, moderate, or severe. DCM—degenerative cervical myelopathy, mJOA—modified Japanese Orthopedic Association, MRI—magnetic resonance imaging. ^*Proportions given indicate the proportion of patients with DCM for whom the signs and symptoms are present. Data from Martin et al, Behrbalk et al, Kato et al, Tetreault et al, and Fehlings et al.