Priority 19 from the Degenerative Cervical Myelopathy PSP

UNCERTAINTY: What is the efficacy and safety of non-operative treatment in the management of DCM compared with surgical treatment? Can non-operative treatment avoid the need for surgery long-term? When can a “watch and wait” approach be adopted? (JLA PSP Priority 19)
Overall ranking	19
JLA question ID	0097/19
Explanatory note	Two systematic reviews have been conducted to (i) evaluate the efficacy and safety of nonoperative versus surgical treatment; and (ii) assess the change in function, pain, and quality of life following nonoperative management. Based on a small randomized control trial by Kadanka et al, there is no difference in mJOA or patient-reported daily activity scores between patients with DCM (mJOA ≥12) treated conservatively versus surgically. Furthermore, this trial concluded that surgical patients had a slower 10-meter walk test than those treated nonoperatively. Finally, a single retrospective cohort study indicated that the incidence of hospitalization for spinal cord injury is higher in DCM patients treated conservatively compared to those managed surgically. The main conclusion from the second systematic review was based on very low evidence: there were no clinically meaningful or statistically significant differences between mJOA scores at baseline and follow-up following structured nonoperative treatment. The role of nonoperative treatment in patients with DCM is largely unknown, especially for individuals with milder forms of myelopathy.
Evidence	Evid Based Spine Care J. 2012 Aug;3(3):35-42.
Health Research Classification System category	Neurological

Extra information provided by this PSP
Original uncertainty examples	Any effective conservative treatment? ~ When is conservative treatment in patients with DCM an option? ~ To what extent can non-operative treatment improve or slow progression of DCM? ~ Is conservative treatment acceptable in early stages? Is it acceptable in late stages? ~ Which treatment modalities are safe? Traction? ~ When is it appropriate to manage a DCM non-operatively? ~ What factors predict a patient that should be treated non-operatively (medically)? ~ What are patient perceptions about operative and non operative treatment?
Submitted by	Spinal Surgeons x 66, Other healthcare professionals x 27 , People with DCM and their supporters x 23

Extra information provided by this PSP

Original uncertainty examples

Any effective conservative treatment? ~ When is conservative treatment in patients with DCM an option? ~ To what extent can non-operative treatment improve or slow progression of DCM? ~ Is conservative treatment acceptable in early stages? Is it acceptable in late stages? ~ Which treatment modalities are safe? Traction? ~ When is it appropriate to manage a DCM non-operatively? ~ What factors predict a patient that should be treated non-operatively (medically)? ~ What are patient perceptions about operative and non operative treatment?

Submitted by

Spinal Surgeons x 66, Other healthcare professionals x 27 , People with DCM and their supporters x 23

PSP information
PSP unique ID	0097
PSP name	Degenerative Cervical Myelopathy
Total number of uncertainties identified by this PSP.	76 (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop	20 November 2019