Podcast Episode 2: Natural history
In Episode 2, Michelle Starkey and Benjamin Davies examine our understanding of the natural history, development and progression of Degenerative Cervical Myelopathy. With Jefferson Wilson, Brian Kwon, and Julia Carter who lives with cervical myelopathy, they highlight the key knowledge gaps and how to rectify these.
Current evidence and reason for uncertainties
Systematic reviews on the topic rated the level of evidence as low to moderate.
Systematic reviews that need updating or extending
Tetreault LA, Karadimas S, Wilson JR, Arnold PM, Kurpad S, Dettori JR, Fehlings MG. The Natural History of Degenerative Cervical Myelopathy and the Rate of Hospitalization Following Spinal Cord Injury: An Updated Systematic Review. Global Spine J. 2017 Sep;7(3 Suppl):28S-34S.
Karadimas SK, Erwin WM, Ely CG, Dettori JR, Fehlings MG. Pathophysiology and natural history of cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S21-36.
Wilson JR, Barry S, Fischer DJ, Skelly AC, Arnold PM, Riew KD, Shaffrey CI, Traynelis VC, Fehlings MG. Frequency, timing, and predictors of neurological dysfunction in the nonmyelopathic patient with cervical spinal cord compression, canal stenosis, and/or ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976). 2013 Oct 15;38(22 Suppl 1):S37-54.
Evidence from other reliable sources
Fehlings MG, Tetreault LA, Riew KD, Middleton JW, Aarabi B, Arnold PM, Brodke DS, Burns AS, Carette S, Chen R, Chiba K, Dettori JR, Furlan JC, Harrop JS, Holly LT, Kalsi-Ryan S, Kotter M, Kwon BK, Martin AR, Milligan J, Nakashima H, Nagoshi N, Rhee J, Singh A, Skelly AC, Sodhi S, Wilson JR, Yee A, Wang JC. A Clinical Practice Guideline for the Management of Patients With Degenerative CervicalMyelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression. Global Spine J. 2017 Sep;7(3 Suppl):70S-83S.
Source of uncertainty
* This list shows the original survey submission(s) that informed the indicative uncertainties and the resulting priority question.
What are the chances statistically of ending up wheelchair bound with double incontinence?
Is it necessary that DCM only occurs in old age? If the symptoms of DCM occurs in young then how to reach a diagnosis?
Does degenerative term as we think , which occurs in old age correlate with the age of patient , as we are seeing cases even in 4th to 5th decade
What is the natural history of cases with spinal cord compression without clinical myelopathy?
How long is the neurological plateau after an exacerbation of DCM?
At what stage the patients with cervical spondylosis develop myelopathy.
How much time in the evolution of the disease takes the development of a real disability for the patient?
What are the outcomes of unsymptomatic stenosis
Radiologically narrow spinal canal in MRI, how high risk of progressive myelopathy there is and at What rate
What proportion with asymptomatic cervical cord compression develops DCM? Why do some asymptomatic cervical cord compressions never develop DCM?
Natural History of desease.
Establish a natural history (is it really stepwise progression with time)?
What are the true odds of becoming paralyzed.
What happens to Nurick grade 1 patients ? Do they progress ??
What is the natural history of DCM?
More insight about natural history in nontreated patients
What is the mean rate of progression of the stepwise decline seen in DCM? Is there a way to quantify the stepwise decline in a manner patients can understand (instead of the mJOA or nurrick?)
Are we happy that the natural history of DCM is deterioration therefore intervention is warranted in all cases
What is the natural history of DCM without surgical intervention?
Is DCM always a progressive disease?
How many patients with mild and stable symptoms go on to develop progressive symptoms if they do not have surgery?
Is it reversible?
What is the natural history of DCM
Can we map the unpredictable course of DCM and it’s created uncertainty in patients balancing between hope and fear to guide the during the early treatment and post-surgical process ?
1.) Natural history: Are we over treating DCM?
What is the incidence of MRI C-spine stenosis with relevant spinal cord compression in elderly without neurological complaints ?
What is the rate of deterioration with patients with DCM?
paralysis risk and recovering
Duration of symptom and natural disease course need to be explored.
Do trivial trauma affect the natural history of myelopathy?
What are the average chance of paralysis?
What is the natural course of untreated DCM?
Are there any difference between symptomatic patinets with DCM and asymptomatic patinets with radiological cord compression by cervical degenerative diseases?
Time line of the progress and degeneration
Trauma in degenerative cervical spine. How to prevent DCM?
What is the natural history, based on clinical and imaging entry criteria?
The actual rate of progression
Natural history of this condition
Characterisation of natural history. Most of our current knowledge dates from historical studies
How can we predict the speed of the degenerescence?
Natural history with or without decompression.
What is the natural history of cervical myelopathy?
What is the general natural progression - eve how quickly would one typically expect to see progression into severe disease?
What is the natural course of DCM?
What is the typical course of the disease?
Is there a typical progressive time line on how this processes
What is the Natural history in terms of increasing burden of disability
What is the natural history of DCM is black patients?
How many people experience acute worsening of DCM with minor trauma?
What is the natural history of DCM without surgical treatment?
Natural history of untreated DCM
What complications can I have if I do not take care of myself?
How long does it take to get disability if ever lose function?
How much regenerative potential exists and at what point is it too late to operate?
I would like to know the prognosis and quality of life for the DCM patient who doesn't take the regular treatment?
What are the risks of tetraparesis or quadriplegia when DCM is left untreated?
What is the natural course of DCM?
What is the natural history of non surgical patients
What is the natural history of patients who are recommended surgery but opt for watchful waiting?
Effects of DCM progression on postural control and falls efficacy.
What is the natural history of progression in myelopathy
Evolution/natural history of DCM
How long the progression of dcm can take .
Do all patients with cervical stenosis and mild symptoms of myelopathy show progression of the disease process?
When does myelopathy progress?
At what level is the most frequent cause of DCM
What are tge chances ofe being paralyzed?