Journal Article

Natural history of degenerative cervical myelopathy: a meta-analysis and neurologic deterioration survival curve synthesis

Oitment, Colby, Guha, Daipayan, Hache, Philip, Pahuta, Markian, Sarraj, Mohamed

2022

Overview

Background: The aim of this study was to synthesize accurate time-based estimates of meaningful neurologic decline in patients with degenerative cervical myelopathy (DCM) managed conservatively. Methods: Following the Cochrane Prognosis Methods Guidelines, we conducted a broad systematic search of Medline, Embase and CENTRAL. We included English-language studies reporting time-to-event analysis of neurologic deterioration in adult patients with DCM treated without surgery. Title, abstract and full-text screening was done in duplicate. On the basis of the best available evidence, we utilized a change in Modified Japanese Orthopaedic Association (mJOA) score of 2 to signify meaningful neurologic decline. Results: A total of 9570 studies were identified for title and abstract screening, ultimately yielding 6 studies for inclusion. Our final analysis included 2 level-1 prospective randomized control studies, 1 level-2 prospective cohort study, 2 level-3 retrospective cohort studies and 1 level-4 retrospective case series. Overall, 674 patients underwent conservative treatment for cervical myelopathy (range 35-247 per study) with an average mild-moderate initial modified Japanese Orthopaedic Association (mJOA) score of 14.23 (range 8.5-18) among the 5 studies where this was reported. The average reported age among the 6 included studies was 56.88 (range 28-80), with 50% males. Mean final follow-up was 24.5 months (range 5-208 mo). Our survival curves reveal a slow decline in neurologic function in a population of patients with mild-moderate mJOA scores. They show 86% survival at 1 year, 70% survival at 3 years and a slow decline to 48% survivorship with no meaningful neurologic deterioration at 20 years. Conclusion: To our knowledge, this systematic review and meta-analysis is the first synthesis of data on the natural history of DCM. Given the paucity of high-quality evidence supporting surgical intervention in mild-moderate DCM, with the relatively slow progression shown by our pooled survival estimates, longitudinal follow-up of conservatively managed moderate DCM patients is warranted to better understand the natural history of this pathology. Ultimately, a shared patient-centred approach should incorporate a careful review of possible prognostic factors for deterioration including nonremissible factors, and informed decision-making can be guided by the use of our proposed survivorship curves.

• Publisher: CMA Impact, Inc
• Subject: Medical prognosis / Natural history / Orthopedics