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Cervical Degenerative Disease

Key Questions Dec 22, 2021
Male feeling the neck pain

Background 

Cervical degenerative disease results from the dehydration or desiccation of spinal disc material, reducing the flexibility and height of the disc. The prevalence of cervical degeneration increases  with age and is expected to increase as the proportion of the population over the age of 60 increases. About 27 percent of the Medicare population is diagnosed with the condition annually.1 The condition can be associated with pain, and treatment in the U.S. consists of medication and/or surgery. Surgical management is more prevalent with increasing age.2 Due to the potential risks of surgery, it is important to offer evidence-based treatments to improve outcomes and balance the risks of treatment.

The most recent guidelines on the surgical management of cervical degenerative disease from the  Congress of Neurological Surgeons were published in 2009.3 New evidence has been published since that time, warranting a new systematic review that could inform the development of an updated guideline to inform practice.

Draft Key Questions*

* Note that “cervical spondylotic myelopathy” refers to cervical myelopathy due to cervical degenerative disease. There are other causes of myelopathy, but the focus of the key questions is on that caused by cervical degenerative disease.

  1. What is the comparative effectiveness of surgical treatment compared to non-operative treatment on neurologic outcomes in patients with cervical degenerative disease with mild or no cervical spondylotic myelopathy?
  2. In patients with cervical degenerative disease and mild to severe myelopathy, how does the effectiveness of surgery on neurologic outcomes vary by level of severity of myelopathy at the time of surgery?
  3. What is the prognostic utility of preoperative magnetic resonance imaging (MRI) findings for neurologic recovery after surgery in patients with cervical spondylotic myelopathy?
  4. In patients with cervical degenerative disease, what are the comparative effectiveness and harms of: 
    1. Anterior compared to posterior surgery
      1. In patients with cervical radiculopathy?
      2. In patients with ≥3 levels of disease?
    2. What are the comparative effectiveness and harms of cervical laminectomy and fusion compared to cervical laminoplasty in patients with cervical spondylotic myelopathy?
  5. What are the effectiveness and harms of intraoperative neuromonitoring (e.g., with somatosensory or motor evoked potential measurements) on clinical outcomes in patients undergoing surgery for cervical spondylotic myelopathy?
  6. What are the comparative effectiveness and harms of cervical arthroplasty compared to anterior cervical discectomy and fusion in patients with cervical spondylotic radiculopathy or myelopathy at 1 or 2 levels?
    1. In patients undergoing anterior cervical discectomy, how do outcomes vary with choice of interbody graft or device type?
  7. In patients with pseudarthrosis after prior anterior cervical fusion surgery, what are the comparative effectiveness and harms of posterior approaches compared to revision anterior arthrodesis?
  8. What is the sensitivity and specificity of imaging assessment for identifying symptomatic pseudarthrosis after prior cervical fusion surgery?

Draft Analytic Frameworks

Figure 1: This figure depicts key questions 1-6 within the context of the PICO Framework described in Table 1. In general, the figure illustrates how interventions such as surgery or non-surgery treatments, prior imaging, and intraoperative neuromonitoring for patients with cervical degenerative disease may affect in neurologic outcomes, quality of life, fusion and reoperation rates, symptomatic adjacent segment disease, or result in adverse effects.

 

Figure 2: This figure depicts key questions 1-6 within the context of the PICO Framework described in Table 1. In general, the figure illustrates how interventions such as posterior surgery and imaging assessment for patients with cervical degenerative disease who have pseudathrosis after anterior cervical fusion surgery may affect in neurologic outcomes, quality of life, fusion and reoperation rates, or result in adverse effects.

 

PICO (Population, Interventions, Comparators, and Outcome)

Table 1. PICO for KQs

Questions

KQ1: Surgical vs. non-operative treatment

KQ2: By myelopathy severity

KQ3: MRI for prognosis

KQ4: Comparative effectiveness and harms of:
KQ4a: Anterior vs. posterior surgery
KQ4ai: in cervical radiculopathy
KQ4aii: in >3 levels of disease
KQ4b: Laminectomy and fusion vs. laminoplasty

KQ5: Effectiveness and harms of intraoperative neuromonitoring

KQ6: Arthroplasty vs. anterior cervical discectomy and fusion
KQ6a. By interbody graft or device type

Population

Patients with cervical degenerative disease who have mild or no cervical spondylotic myelopathy

Patients with cervical degenerative disease who have mild to severe cervical spondylotic myelopathy

Patients with cervical degenerative disease who have cervical spondylotic myelopathy

KQ4ai: Patients with cervical radiculopathy of any level

KQ4aii: Patients with ≥3 levels of cervical
degenerative disease

KQ4b: Patients with cervical spondylotic myelopathy

Patients with cervical spondylotic myelopathy

Patients with cervical spondylotic radiculopathy or myelopathy at 1 or 2 levels

Subgroup: interbody graft or device type

Interventions

Surgery

Surgery

MRI prior to surgery

KQ4ai. and KQ4aii: Anterior surgery

KQ4b: Cervical laminectomy and fusion

Intraoperative monitoring

Cervical arthroplasty

Comparators

Non-operative treatments (e.g., immobilization, anti-inflammatory medications, physical therapy, cervical traction, epidural steroid injections, clinical observation)

Non-operative treatments (e.g., immobilization, anti- inflammatory medications, physical therapy, cervical traction, epidural steroid injections, clinical observation)

NA

KQ4ai. and KQ4aii: Posterior surgery

KQ4b: Cervical laminoplasty

No intraoperative monitoring

Anterior discectomy and fusion

Outcomes

Neurologic outcomes (e.g., pain [VAS scores, NDI, SF-12, EQ-5D, PROMIS-29],
sensory disturbance, weakness in the dermatomes and myotomes of the affected    nerve root, mJOA score, Nurick scoring system, MDI, SF-36, quantitative gait analysis); QOL; harms (any)

Neurologic outcomes (e.g., pain [VAS scores, NDI, SF-12, EQ-5D, PROMIS-29],
sensory disturbance, weakness in the dermatomes and myotomes of the affected    nerve root, mJOA score, Nurick scoring system, MDI, SF-36, quantitative gait analysis); QOL; harms (any)

Neurologic outcomes (e.g., pain [VAS scores, NDI, SF-12, EQ-5D, PROMIS-29],
sensory disturbance, weakness in the dermatomes and myotomes of the affected nerve root, mJOA score, Nurick scoring system, MDI, SF-36, quantitative gait analysis); QOL

Neurologic outcomes (e.g., pain [VAS scores, NDI, SF-12, EQ-5D, PROMIS-29],
sensory disturbance, weakness in the dermatomes and myotomes of the affected nerve root, mJOA score, Nurick scoring system, MDI, SF-36, quantitative gait analysis); fusion rate; reoperation rate; QOL: harms (any)

Neurologic outcomes (e.g., pain [VAS scores, NDI, SF-12, EQ-5D, PROMIS-29],
sensory disturbance, weakness in the dermatomes and myotomes of the affected nerve root, mJOA score, Nurick scoring system, MDI, SF-36, quantitative gait analysis); fusion rate; reoperation rate; QOL: harms (any)

Neurologic outcomes (e.g., pain [VAS scores, NDI, SF-12, EQ-5D, PROMIS-29],
sensory disturbance, weakness in the dermatomes and myotomes of the affected nerve root, mJOA score, Nurick scoring system, MDI, SF-36, quantitative gait analysis); Symptomatic adjacent segment disease, reoperation rates, radiologic fusion rates, QOL, harms (any)

Abbreviations: EQ-5D=EuroQol-5 dimension instrument; KQ=key question; MDI=myelopathy disability index; MRI=magnetic resonance imaging; mJOA=modified Japanese orthopedic association scale; NDI=neck disability index; PROMIS-29=patient reported outcome measurement information system; QOL=quality of life; SF=short form health survey (12 or 36 items); VAS= visual analogue scale for pain.

References

  1. Parenteau CS, Lau EC, Campbell IC, et al. Prevalence of spine degeneration diagnosis by type, age, gender, and obesity using Medicare data. Sci Rep. 2021 Mar 8;11(1):5389. PMID: 33686128.
  2. Buser Z, Ortega B, D'Oro A, et al. Spine Degenerative Conditions and Their Treatments: National Trends in the United States of America. Global Spine J. 2018 Feb;8(1):57-67. PMID: 29456916.
  3. Matz PG, Anderson PA, Kaiser MG, et al. Introduction and methodology: guidelines for the surgical management of cervical degenerative disease. J Neurosurg Spine. 2009 Aug;11(2):101- 3. PMID: 19769488.

Project Timeline

Cervical Degenerative Disease

Dec 22, 2021
Topic Initiated
Dec 22, 2021
Key Questions
Page last reviewed December 2021
Page originally created December 2021

Internet Citation: Key Questions: Cervical Degenerative Disease. Content last reviewed December 2021. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/cervical-degenerative-disease/draft-comments

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