In order to make a decision regarding treatment, doctors will need to establish:
- to what extent the person’s symptoms are due to Degenerative Cervical Myelopathy (DCM)
- whether the person will benefit from physiotherapy and/or surgical treatment.
In some cases, the surgeon will ask for further tests before making a decision; in other cases, a recommendation for or against surgery can be made during the initial appointment.
People with DCM may benefit from surgery or non-operative therapy, such as physiotherapy. The decision can be made only on the advice of specialist doctors (typically a spine surgeon).
International guidelines involve an assessment scale called the mJOA (modified Japanese Orthopaedic Association) scale to inform the treatment decision. This assessment scale is used to grade the severity of DCM. Guidelines recommend surgery for those with moderate to severe DCM, or any progressive DCM. Surgery is an option in mild and stable forms of the disease. These recommendations are based upon the current evidence base, recognising that the risks of deterioration are high, and therefore the benefits of surgery outweigh its risks.
The role of surgery in mild and stable forms of disease is a research priority. The role of non-operative therapies, such as physiotherapy, is also an important knowledge gap.
People with very mild degenerative changes can benefit from physiotherapy. With special exercises, neck and limb pain can be reduced, the alignment of the neck and its strength can be improved, and neurological symptoms such as numbness can lessen. Such exercises can be effective at reducing pain and symptoms for some time; however, physiotherapy is not likely to fully cure the problem.
For people who have mild DCM, a course of conservative management can help in determining how necessary surgery is.
Unfortunately, DCM is often diagnosed late, at a stage where the role of physiotherapy is limited, and it is not recommended when DCM has become moderate or severe.
Surgery is not without risk, and this can make it difficult to decide whether and when to have surgery. Equally, predicting how an individual will respond to surgery is difficult; this is, therefore, an area of active research.
When to Have Surgery?
International guidelines from AO Spine recommend the use of the mJOA (modified Japanese Orthopaedic Association) Score to support this decision. Surgery is recommended for moderate, severe or progressing DCM. Surgery is an option for mild and stable disease. International guidelines from AO Spine recommend the use of the mJOA (modified Japanese Orthopaedic Association) Score to do this. These recommendations are based upon the current evidence base, recognising that the risks of deterioration are high, and therefore the benefits of surgery outweigh its risks in these instances .
What Type of Surgery to Have?
Many different types of operation may be carried out to treat DCM. Specialist spine surgeons draw from a repertoire of options to decompress, stabilise and/or fortify the spinal column. At present, one technique has not been shown to be superior to any other. See expert recommendations from the World Federation of Neurosurgical Societies (WFNS) on posterior surgical techniques and anterior surgical techniques.
The decision is therefore based on patient-specific factors (e.g. location of compression, nature of the pathology causing compression and alignment of the spine), the different risk profiles of each type of surgery (e.g. chance of complications), and the competencies or experience of the surgeon. The decision should also involve the perspective of the individual with DCM themselves. Surgeons may have different views on the preferred strategy, and it is always worth considering a second opinion.
Surgery is a very important decision point for people with DCM. Whilst the evidence base has significantly improved, there remain many uncertainties around which operation to perform and when to perform it. This was recognised through our research priority ‘Individualising Surgery’, and more specifically through trials we are supporting. You can read about our research projects in the Research section of our website.
Types of Operation
There are several different types of operation used to treat DCM but the aim of each is to decompress the spinal cord. In addition, it may be necessary to stabilise the spine to prevent further progression of degenerative changes. The exact type of procedure offered varies from country to country and from surgeon to surgeon. At present, there is no clear evidence that one type of operation is better than another, although we are working with the DCM community to clarify these questions.
You can hear more these questions and individualising surgery in our podcast.
This page aims to give an overview of surgical options and may be useful when discussing potential treatments with a surgeon. However, the information provided is by no means complete, and it is the responsibility of the patient and the surgeon to cover all aspects required to make a sound decision.
The British Association of Spine Surgeons (BASS) has produced an information booklet for those considering surgery for DCM. It provides a particularly detailed description, including illustrations, for the different procedures which may be helpful.
Surgery from the Front
This patient has had an Anterior Cervical Discectomy and Fusion operation. The surgeon has removed the degenerative discs and/or other structures that were compressing the spinal cord, and used an implant to add strength and stability to the spinal column. This is an X-ray image, post-operatively, showing the adequate position of the implant (cage) and spine alignment.
Surgery from the front (anterior) is often considered when the spinal cord is primarily compressed from the front. These anterior procedures include:
- Anterior Cervical Discectomy and Fusion (ACDF): Where one or more discs are excised and, in modern practice, the space filled with an implant to preserve the disc space height (to reduce neck pain) and support bony fusion between the adjacent vertebrae.
- Cervical Corpectomy: Where as well as the adjacent intervertebral discs, the vertebral body is also excised, to enable decompression of the spinal cord. This gap is typically replaced with an implant, or by taking a piece of bone from elsewhere in the body (e.g. the hip crest).
- Arthroplasty: This procedure is similar to an ACDF, but instead of a fixed or semi-fixed implant, a ‘disc replacement’ is inserted. The aim of this procedure is therefore to retain normal motion of the vertebrae. The use of cervical arthroplasty in treatment of DCM is very controversial, with many feeling it inappropriate or ‘contraindicated’, as unnecessary movement may be driving spinal cord injury and should therefore be reduced not maintained. A detailed description of the procedure can be found in the following British Association of Spine Surgeons (BASS) information leaflets: 1) Cervical Disc Protrusion and Radiculopathy Surgical Options and 2) Cervical Stenosis and Myelopathy. Note these leaflets are not for DCM. If this has been proposed to you for your DCM, or you wish to consider it, careful discussion should follow.
The anterior approach to the spine usually entails a 3cm incision in the front of the neck. The spine can be reached leaving the main arteries of the neck on one side and the trachea and oesophagus on the other side. Space around the spinal cord is created by removing the compressing discs, or, in some cases, by also removing the front of the vertebrae. The space is usually filled with a graft, which can include bone or a metallic or plastic implant.
These operations are usually well tolerated by patients. Transient side effects can include hoarseness and difficulties swallowing. Some surgeons may support recovery after surgery with a hard collar, particularly in the case of Corpectomy. However, there is no consensus on this, and it is at the discretion of your surgeon.
For further information, see our Anterior Cervical Discectomy and Fusion Patient Information Sheet.
Surgery from the Back
This patient has had a Posterior Cervical Decompression operation. The surgeon has made space around the spinal cord by removing parts of the vertebrae behind the spinal cord. This is a postoperative MRI image. Signal intensity changes within the cord are still visible, and may persist despite surgery, but these are rarely a sign of ongoing injury.
In some cases, compression occurs mainly from behind, or it extends over multiple levels as in the image shown. In these cases, a surgeon will often choose a posterior approach, operating on the spine from behind. Although this might seem a less invasive procedure than the anterior approach, it can cause more post-operative discomfort because of the many muscles at the back of the neck that need to heal. Furthermore, a posterior approach may require reconstruction, such as laminoplasty (reconstruction by refashioning the removed bones at the back) or instrumentation and fusion (insertion of metal rods) to support the spine.
The main advantage is that surgery from behind can deal with multiple levels of spinal cord compression. It is often preferred in such cases.
More information can be found on our Posterior Cervical Decompression Patient Information Sheet.
There is considerable regional variation in the use of reconstruction after posterior decompression. In North America, instrumentation and fusion is normally offered as standard. In continental Europe and Asia, a laminoplasty is often preferred. In the UK, decompression alone is the most common strategy.
Reconstruction aims to prevent problems with alignment of the cervical spine after surgery, which may be associated with neck pain and potentially a poorer recovery. However, these techniques restrict the mobility of the spine, and therefore carry other problems such as making the neck stiff and less flexible. They also increase the complexity and cost of the procedure.
At present, the relative merits of each procedure are not well defined; therefore, this remains an area of active research, including through research projects by Myelopathy.org.
Instrumentation and Fusion
This is a post-operative X-ray of a patient who has had an Instrumentation and Fusion operation. The surgeon has added strength and stability to the spinal column, to keep the cervical spine upright (i.e. prevent any deformity of the cervical spine), and potentially reduce any injury to the spinal cord that could occur through abnormal movement of spine level(s). Although this rationale seems logical, it remains unproven and is an active area of research.
In some cases, it is necessary to fortify the spine to reduce compression of the spinal cord. This is often achieved using titanium screws that are inserted into parts of the vertebrae adjacent to the spinal cord. Connecting the screws with metal rods on each side adds strength and stability to the spine. The rods and screws themselves are often a short-term measure (‘instrumentation’), with the ultimate aim that this stability allows bone to grow between the vertebrae and provide long-term stability (‘fusion’). This operation is technically challenging and commonly only performed by dedicated spine surgeons. The risks of inserting the screws include injury to the spinal cord or nerves and important arteries leading up to the brain.
An alternative technique, often preferred in continental Europe and Asia, is laminoplasty. Here, the bone behind the spinal cord is reshaped to relieve compression of the spinal cord. There are a variety of different techniques used to do this, but a common example is ‘open door’ laminoplasty, where the bones behind your spine are wedged open slightly, via a small metal implant, to create more space for your spinal cord.
Risks and Benefits of Surgery
Weighing Up the Benefits and Risks
Surgery is the only known option to halt disease progression. It aims to resolve the injury mechanism and has been shown to enable at least some recovery.
However, surgery carries risk, and does not benefit all people. International guidelines have helped to advise who should have surgery, but these represent an average. Many individual factors, such as age or general health status, can increase the risks of surgery and need to be factored into decision-making.
Surgery is a major undertaking and it is important to weigh up the risks and benefits. All concerns should be discussed with your surgeon.
What Are the Intended Benefits?
The main objectives of surgery are to stop the worsening of any disability, and to enable at least some recovery.
Of the people who are experiencing pain in their neck and arm, 90–95% can expect relief from their arm pain if they have surgery. Recent analysis from our studies with partners AO Spine also suggest neck pain will improve to some degree.
In people with disability, about 60% can expect improvement, 30% will find that their condition stabilises but does not improve, and less than 10% will find that their condition continues to deteriorate. It is good news that less than 1% will feel worse as a direct consequence of the operation.
What Are the Potential Risks?
With any operation there are risks involved, not only from the surgery itself but also from general anaesthesia. Some of these risks apply to all of the surgical procedures, and some are specific to certain types of surgery. Below, we list the common risks. These are categorised as Common (>1/100), Uncommon (~1/1000) and Rare ~1/10,000.
- Dural tear
- CSF leak
- Epidural haematoma
- Neurological root injury (including C5 Palsy)
- Worsening myelopathy
- Post-operative red eye
- Swallowing difficulties
- Hoarse voice
- Neck pain
- Adjacent segment disease
- Drowsiness, confusion or restlessness
- Nausea and/or vomiting
- Soft tissue infection
- Urinary tract infection
- Respiratory infection
- Inadequate decompression
- Spinal cord injury
- Injury to the mouth or teeth from intubation or the breathing tube
- Myocardial infarction
- Respiratory problems
- Vertebral artery injury
- Wrong level surgery
- Cardiac arrest
Preparing for DCM Surgery
Make sure to follow your doctors’ advice regarding pre-operative assessment, which is an important opportunity to discuss the risks and benefits of the planned operation. You may also be referred for further review by an anaesthetist (the doctor who performs the general anaesthetic). Their assessments will explore in detail any other health problems you have, record any medication you take, perform an examination of your heart and lungs, and complete some baseline investigations such as blood and heart tests. A degree of bleeding is unavoidable with surgery. If you take a blood-thinning agent, bleeding can be harder to control, therefore you should discuss this with your surgeon.
What Can I Do to Help?
Some aspects can help you through an operation:
- Stop Smoking – smoking damages the lungs (important when having a general anaesthetic) and affects wound healing (important for recovery after surgery). By stopping smoking, you reduce your risks of postoperative infections and complications of general anaesthesia. This should ideally be at least six weeks before your operation.
- Lose Weight – obesity can affect wound healing and increase the risk of postoperative infection.
The Day of Surgery
Be sure to follow your doctors’ advice regarding fasting before surgery. Remember to bring all your regular medication. You will be provided with a hospital gown, and your personal possessions will be collected and locked away. You will be reviewed by your medical team, usually the anaesthetist and surgeon. It is not usually possible to provide an exact operating time, as so many different factors are involved, so bring along something to help pass any waiting time.
Early After Surgery
At this time, the focus is to heal and regain mobility. Your medical team will be on hand to ensure that you are comfortable, that your wounds are healing well, and that no complications have arisen. The most essential professional at this stage is the physiotherapist, who will help you to mobilise safely and improve any deficits that you have developed. An occupational therapist may be required to help with some functional aspects of daily living.
DCM can cause a range of disabilities. Most patients swiftly return home, once their doctors agree that they are mobile and have reached a safe level of independence. However, recovery may be slow and/or incomplete. In these situations, the options include further support at home, rehabilitation as an outpatient, or admission to a rehabilitation unit for inpatient rehabilitation.
Individuals undergoing surgery for DCM can experience significant improvements over a year. However, the extent of improvements is variable, and the factors that influence the recovery are currently poorly understood. The role of dedicated neurorehabilitation in acute spinal cord injury and stroke is well proven and has seen exciting advances over recent years. We are urgently working to import these advances into the less recognised field of ‘slow-motion’ spinal cord injury that we see in DCM. We hope that this work will generate a spectrum of novel rehabilitation strategies.
People with DCM should, therefore, be able to have dedicated rehabilitation in a specialist spine unit. However, the reality is that rehabilitation is often limited to a short course of physiotherapy.
With our global community of experts, we are clarifying optimal rehabilitation strategies for people with DCM.
You can learn more about these strategies and this research in our podcast.