Surgical Management of Cervical Degenerative Disease
1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?
The authors want to assess the most current and clinically relevant evidence for the surgical management of patients with cervical degenerative disease. Authors published guidelines in 2009 including evidence published from 1966–2007. Fortunately, new research is has been published on this topic, and these guidelines are meant to be updated as new evidence emerges. The authors will develop a new guideline based on a new systematic review based on more recently published literature on this topic.
2. Why are you struggling with this issue?
Cervical degenerative disease is the most common cause of acquired disability in patients over the age of 50. Cervical spondylotic myelopathy is a challenging condition. A large number of patients are severely, and in our opinion, unnecessarily disabled by this preventable condition. Since the publication of the 2009 guideline, new technologies in arthrodesis and biological agents remain areas of intense investigation.
This systematic review would help inform a clinical practice guideline to synthesize new evidence on this topic to help inform decision-making for providers and better patient outcomes.
3. What do you want to see changed? How will you know that your issue is improving or has been addressed?
We would like to explore the following questions related to this topic:
Prognosis of cervical degenerative conditions
1. Does surgical treatment compared to non-operative treatment improve neurologic outcomes in patients with mild or no cervical spondylotic myelopathy?
2. Do patients with mild myelopathy have better neurologic recovery after surgery compared to those with moderate or severe myelopathy? (*Note: this is the "timing of surgery" question, which I think will be difficult to study, i.e. how do you define early surgery? Does this essentially boil down to operating when someone has mild myelopathy versus when it progresses to moderate?)
3. Do preoperative MRI findings predict likelihood of neurologic recovery
after surgical treatment for cervical spondylotic myelopathy?
Surgical treatment
1. For patients with cervical radiculopathy, does anterior surgery result in improved outcomes compared to posterior surgery?
2. For patients with ≥3 levels of disease, is posterior surgery associated with better outcome and fewer approach-related complications than anterior surgery?
3. For patients with cervical spondylotic myelopathy, does cervical laminectomy and fusion improve neurologic recovery and/ or neck pain compared to cervical laminoplasty?
4. Does the use of intraoperative neuromonitoring improve clinical outcomes in patients undergoing surgery for cervical spondylotic myelopathy?
Adjacent segment disease and pseudarthrosis
1. Does the choice of interbody graft or device type effect radiologic fusion rates in patients undergoing anterior cervical discectomy and fusion?
2. In patients with cervical spondylotic radiculopathy or myelopathy at 1 or 2 levels, does cervical arthroplasty decrease the risk of symptomatic adjacent segment disease and/ or reoperation rates compared to anterior cervical discectomy and fusion?
3. What imaging assessment provides greatest sensitivity and specificity for symptomatic pseudarthrosis after prior cervical fusion surgery?
4. In patients with pseudarthrosis after prior anterior cervical fusion surgery, do posterior approaches for arthrodesis improve clinical outcomes and/or fusion rates compared to revision anterior arthrodesis?
4. When do you need the evidence report?
Wed, 03/01/2023
5. What will you do with the evidence report?
The purpose of this topic nomination is to evaluate all available evidence, from which, the Congress of Neurological Surgeons (CNS) will develop a guideline to aid clinicians and guide clinical practice by determining the best options for the surgical management of cervical degenerative disease.
The CNS maintains in-house infrastructure to lead, promote, and support the creation and methodological processes to produce evidence-based guidelines, which are critical tools to confront a rapidly changing health care environment. Using the CNS's high quality, rigorous methodological process, a multidisciplinary task force will develop recommendations based on the available evidence provided by the Evidence Based Practice Center. Throughout development, the task force will use evidence-based methodologies and strictly adhere to a priori defined criteria as defined by the Institute of Medicine's (IOM) standards for conducting systematic reviews and clinical evidence-based guidelines.
This topic was initiated by the Spine and Peripheral Nerves of the American Academy of Neurological Surgeons (AANS)/CNS. The CNS also recruited from a variety of institutions and subspecialty disciplines in an effort to have as broad a representation of opinions and expertise as possible. It is CNS's goal to follow the IOM recommendations to be inclusive and inter-disciplinary when constructing our guidelines and subsequent recommendations. A conscientious effort will also be made to be sure that any conflict of interest is fully disclosed and avoided. Participants who have published extensively in certain areas will be asked to recuse themselves from voting and will be assigned to evaluate evidence in other topics. Every effort will be made to ensure that the guideline is accurate, reliable, and non-biased.
The CNS guidelines attempt to provide essential information for clinicians, globally, helping to improve patient care and outcomes. In addition to developing high quality guidelines, CNS is also committed to dissemination of guidelines in multiple, open access formats, such as publication in peer-reviewed journals, publication on the CNS webpage, webinars, conference seminars and courses, as well as other promotional efforts.
(Optional) About You
What is your role or perspective? Professional Society
If you are you making a suggestion on behalf of an organization, please state the name of the organization: Congress of Neurological Surgeons
May we contact you if we have questions about your nomination? Yes
