Chapters Transcript Degenerative Cervical Myelopathy: Updates, Challenges, and Future Directions Dr. Jacob Greenberg, MD provides an overview and history of degenerative cervical myelopathy (DCM), shares recent updates, and challenges in DCM care. That they're due. Doctor Jacob Greenberg earned his medical degree and completed his residency in neurological surgery with the Washi School of Medicine at Barnes Jewish Hospital. He then went to Ohio to complete his fellowship and complex spine orthopedic and neurological surgery at Cleveland Clinic Foundation. He is currently an assistant professor of neurosurgery and co-director of patient safety and quality improvement at Barnes Jewish Hospital. His specialties are cervical myo myelopathy and I, yeah, I'm just gonna mess it up radio copy, um Reno craniovertebral junction disease, spinal stenosis, minimally invasive spine surgery, very vision, spine surgery, robotic spine surgery. So today he is going to talk to us about degenerative cervical. My lot that the updates challenges in future direction. They even pronounce that right at all. And you're on mute. Oh, there you go. That was, that was great. Um Well, thank you. I appreciate the opportunity to be here. It's nice to meet everyone at least to some degree virtually. Um As UN said, I'm gonna be talking about uh degenerative cervical myelopathy. Try to give a bit of an overview, uh talk about some updates um that there have been recent years in terms of progress. We've made some ongoing challenges we've had um in some relatively promising future directions. Um So again, I'm gonna try to give just an overview of degenerative cervical myelopathy or, or DC M for short. Um For those um people that may not be thinking about it as much every day. Um It's clinical presentation, natural history, talk about some of them, the recent updates in terms of where I think we've gained new knowledge. Um in recent years, um talk about some of the ongoing challenges where I think we still have a lot of room to grow and um some emerging directions that may be helpful for tackling some of those pro problems um or challenges in the years ahead. Uh So just to start with um degenerative cervical myelopathy again, or DC M um really refers to a symptomatic chronic compression um of the cervical spinal cord um in the neck. Um So this is very different from an acute spinal cord injury, like from a fall or car crash or a central cord syndrome, which you know, again occurs all of a sudden, this is very much a um degenerative arthritic process um that can have a variety of causes. Um But ultimately, it relates to arthritis in the neck that compresses the spinal cord. I mean, then leads to a variety of sequela as a result. We don't really know how prevalent this disease disease is because we know it's um it's certainly quite underdiagnosed. Um that said, um our best estimates from a series where people have carefully looked um prospectively is that probably about 2% of healthy adults actually have uh cervical myelopathy. Um And it's in fact, the most common cause of spinal cord dysfunction in older adults. Um and because this is largely um a disease of somewhat middle age and especially older adults, um it's very likely almost certain that the prevalence is going to grow. Uh So we know that about one third of asymptomatic adults over 60 years will show evidence of spinal cord compression. If you look on imaging, at least to some degree, and about a quarter of those will eventually develop symptomatic myelopathy. So again, over time, um certainly this is a is a fairly common um disease, particularly of, of relatively older patients, as I mentioned. Um this is ultimately arthritis of the neck that compresses the cervical spinal cord and really any form of arthritis um can lead to the development of cervical myelopathy. So certainly we see disc herniations. Um we see times where we can get bony osteophytes or overgrown bone or kind of a combination of a calcified disc with overgrown bone, the facet joints can overgrow. Um you can have um really a sort of a predisposition, what we call congenital spinal stenosis, which means that someone's born with a basically a smaller spinal canal than the average person would have. Um And so generally, those um would not make someone symptomatic, but it will mean that they have a lot less room. So a relatively more minor cause of narrowing, um may make them symptomatic where as the same amount of narrowing, um or disc herniation, whatever the case may be, um may not affect someone else, you know, ossification of ligaments within the spine. Um Certainly people who develop a significant kyphosis, um where their heads kind of pitching forward, um can predispose people to myelopathy because the spinal cord can essentially drape over the bones of the spine. Um or having, you know, a slip or spinal, the um can also cause compression of the spinal cord. And again, the point really is that anything that leads to arthritis, compression of the spinal cord can lead to cervical myelopathy probably more relevant is, you know, how these patients present. Um So patients, you know, probably most commonly present with um unstable or impaired gait balance. Um And along with that, the probably the other most common thing that we see is impaired dexterity. Um So the common things that patients report or problems, you know, trying to feed themselves, opening a can buttoning their shirt, there's their handwritings gotten somewhat worse. Um Also certainly pretty common to see numbness, particularly in the upper extremities but could be upper or lower. Um, usually later in the disease, um is where we see motor weakness. Um, it certainly happen. Um But generally that's, that's a later finding. So most patients, um, who will have, you know, may have pretty impaired dexterity. A pretty bad balance may have numbness. Um, but if you actually just sit there and ask them to squeeze your hands or lift their arms up or push on your feet or, you know, push down their feet, um, their strength may be pretty good and when it does, um, become bad later in the disease, often it's, um we call a spastic paralysis where um the muscles could just deteriorate and be weak, um especially the hand muscles. Um But sometimes they're so hyperreflexic or spastic um from the spinal cord compression that they're just not functionally able to do the things that they need to do. Um And so certainly that's thing that we see also late in the disease, course problems like bladder and bowel dysfunction. And then I have neck pain here with an asterisk because neck pain really is not an inherent sy symptom of cervical myelopathy. Um We generally think of this as a painless disorder. Um that said, you know, most uh it's a disorder of arthritis, the neck. And so even if the compression of the spinal cord itself is not pain, the development of arthritis can certainly be associated with pain for a variety of reasons. Um And so certainly many of these patients, if not, most of these patients present with some degree of pain, either in their neck or arms or both um but certainly not all and, you know, especially many of the ones that end up getting, you know, presenting later in their course, um often don't have any pain. Um And you know, there's a pretty significant impact um in terms of patients quality of life. So here we compared myelopathy um from a or um taken some data from a study, they compared um quality of life, both physical and mental um quality of life in patients with myelopathy versus healthy kind of normal people without major disease. And some of the common um sort of conditions that um you know, we often think of as chronic disease, hard to lung disease cancer. We can see is that um the impairment in quality of life that patients get from myelopathy is really on par with some pretty um profound diseases, you know, such as cancer. Um you know, severe depression, heart attack. Now, obviously, all these things occur on a spectrum and, you know, mild myelopathy is gonna be very different from severe cancer or end stage cancer. Um But the point is that, you know, on average, um this is a pretty disabling disease. Um certainly, um there can be a variety of objective findings that we often but not always see an exam. So um something we call long track signs. So various signs of hyper reflexive or elevated reflexions, whether that be a Hoffman where you tap the finger in the patient's hand, contract, end up going. Tower Babinski, elevated reflexions in the arms or legs or clonus where you basically push their foot back and see kind of sustained, up and down beating and certainly, um, notice impaired gait, particularly if you measure it, you know, in some more objective measurement. But even just asking these patients to walk as they're more symptomatic, you can visibly see that they're just unsteady. Um, they may have impaired sensation, uh, muscle strength or, you know, sometimes certainly visible muscle wasting, especially in the hands. Um is one of the more common places that we see that um the thing is though, um as much as these are very much signs that, you know, we look for um and are relevant and important. Um They're not in incredibly specific or sensitive. So, um this is a study from about 15 years ago that is still probably the best data we have where they compared um patients with cervical myelopathy just to kind of control patients with neck pain. And we can see is that of patients with cervical myelopathy, at least in this relatively small study, about 1/5 had no signs of myelopathy whatsoever even when studied prospectively. But if the control patients who are not myopathic, um over 40% or sorry, over 50% had at least one sign of myelopathy. So it can be a little bit tough. Um Certainly the absence of these signs don't exclude a diagnosis and particularly in a younger person seeing slightly brisk reflexes or an isolated um Hoffman sign um is, you know, very much not specific. So it's really a matter of kind of putting the whole picture together to try to get a better sense of how likely does a patient may have myelopathy. Now, our data on natural history unfortunately, are not great. Um We don't have great studies and most of these data are relatively um dated. Um That said we know that the clinical course is variable. Um But in general, um myelopathy has a a slow and fairly insidious deterioration. So, you know, it's not, you know, although on occasion, patients say I was doing fine until three weeks ago, much more commonly. They say, well, three years ago, I could walk fine. I've probably been using, you know, a cane for at least a year or two. And, you know, in the last several months I've been using a walker. I would say that's a much, much more classic um presentation that we see and the patient tells us I could walk until three weeks ago and it just seemed to get really bad. We do see that, but I would say much less commonly. Um from some older data, we know that about half or more patients with myelopathy will show a measurable um clear neurological deterioration within a couple of years. So, certainly not everyone, some people can be stable for a while. Um and a small minority will have more of a rapid deterioration, um where they may progress pretty rapidly over months or even weeks. Um, in notable ways, I'm sure, you know, many people have heard of sort of rare stories of patients who, you know, get sudden paralysis from relatively minor trauma with pre-existing, um, you know, bad myelopathy or stenosis. Um, and certainly that can happen. And, you know, there's no doubt that patients with cervical myelopathy are at elevated risk of paralysis if they have some trauma that said, I think that, um, you know, certainly in the past and I, I think I still here today, um I think a very overblown risk of this. Um, and I think patients, you know, sometimes probably being scared into having surgery when they really may not have any need for this. And, you know, I mean, by that is that, you know, the average person without myelopathy or without severe spinal cord stenosis walking down the street, I don't know the numbers that I've heard probably is about a one in 40,000 chance um, of being paralyzed, let's say, from a car accident or driving a car or something like that in a given year. Well, maybe the odds are four times higher for someone with myelopathy, that still means it's about one in 10,000 odds. Um Just, you know, in terms of some freak accident, our surgeries are safe and they're effective, but the risk of any complication for any surgery whatsoever that I personally, that I do is always higher than one in 10,000. So, you know, although we certainly need to look at the whole picture. I think that although there is this risk of sudden paralysis that in of itself, I don't think is a reason necessarily, um, you know, to pursue a surgery, um, in terms of, you know, kind of, um, next step, I just want to talk a little bit about some of the areas where I think we have made some progress in recent years in terms of learning more about um you know, we, we ways we can diagnose or evaluate patients with myelopathy. Um basically learning more about our outcomes for treating this disease. Um and some more about um the techniques and which techniques might work better than others. Um And so to start with talk a little bit about imaging, um you know, I'm sure, you know, many people know that typically an MRI, the cervical spine is the, the way that we would generally um diagnose a patient with having my optic in conjunction with their clinical findings. Um or we would at least diagnose their spinal cord compression. Um rarely, maybe ac T myelogram of patient can't get an MRI. Um but that, you know, that's a fairly coarse tool and we know that the severity of compression really has a very weak correlation um with a patient's symptoms, their prognosis. Um or really, you know, many other aspects of their disease. Um People have tried looking at um tract gray from things called diffusion tensor and diffusion tensor imaging. Um But it doesn't necessarily, you know, have a much stronger correlation with outcome. And so, um you know, groups have tried a number of different areas to try to improve um what can be done here. And one of the areas um where there's been some, you know, promising new developments um is in a technique called diffusion basis spectrum imaging. Um And basically, it's a variation of um uh diffusion tensor imaging, but it looks at the neuronal integrity in multiple different sort of planes to get more detailed information um about neuronal integrity. Um and some of the associated structures and it's not meant to be a detailed imaging talk. So I'm not go into, you know, a ton of detail about it, but just to say that rather than just having an MRI where you can say, ok, the spinal cord is compressed, you can get more quantitative information about things like the integrity of the axon or inflammation or swelling um or myelination. Um And this was a technique that was really initially developed um by a couple of folks here um at Washington University to study multiple sclerosis, which obviously is also disease um of white matter pathology often um impacts the spinal cord. Um And um and you know, they've really kind of developed this technique to try to better understand um how multiple sclerosis was impacting patients or sorry, um how the spinal cord and spinal cord integrity is being impacting patients with multiple sclerosis. Um But then, um more recently, I say over the last 58 years, um folks here um particularly led by um you know, one of my partners Zach Ray um in collaboration with Victor Song, who um is the uh phd kind of engineer physicist who worked to develop this really been applying this to patients with cervical myelopathy. Um And so, um you know, we found that this seems to have a much um potentially be much more valuable certainly than a routine MRI but even much more valuable than something like diffusion tensor imaging, which, you know, is sort of the relative state of the art um for the last 1015 years. Um And so when we look at, you know, whether DT I, which is again kind of our standard advanced imaging does that correlate with things like myelopathy severity? And we can see that it really doesn't. Um whereas our, you know, DB SI kind of this new modern iteration seems to have a pretty notable association with myelopathy severity gauge clinically. So it seems like we are really picking up um characteristics that seem more relevant um to clinical disease. We've also looked at our ability um to predict clinical outcomes after surgery. So we've looked at um both myelopathy severity itself, which is this MGO A or modified Japanese or Pic Association scale. Um A variety of other sort of um scales related to um pain and function, neck pain and function quality of life. And basically, we found that in general um DB SI, this, you know, new technique that we've been using can predict um those outcomes much better than any clinical symptoms alone. And particularly if we combine clinical and imaging data from DB SI, then the accuracy with which we can predict these types of outcomes is substantially higher than any of our routine clinical assessments. Excuse me. So, um I think certainly there is a suggestion that, you know, this is a really promising technique that eventually could really change the way we evaluate these patients. Now for a variety of reasons, isn't, you know, really kind of mainstream the clinical practice setting yet. But certainly something that, you know, we're working towards, um I would say as a field, we've also learned a lot more about the outcomes of treating um this disease. And I think um although many people have worked on this, I think a lot of the best data we have um come from uh a group of um Canadian centers that have been prospectively studying this um for a number of years in a collaborative fashion. Um And so I think really a lot of the credit goes to them. And so, um you know, one of the questions that they've helped address um is really how well we actually achieve the primary goal of surgery, which is stabilizing disease. Um, so I know whenever I'm, you know, speaking a patient who had surgery for myelopathy, I tell them that I certainly hope their, you know, neurological impairment gets better. Um, and there's certainly some chance that it very well might get better. But our primary goal is to stabilize a decline to stop this from getting worse. Um, because we know that for many people, certainly, if it's actively declining, it will continue to do so over time. And so what we found um through some of these multi center prospective groups, um is that we are very effective but not perfect in doing that. Um And so in a fairly large cohort, we can see that almost 95% of patients have at least stable myelopathy severity, 12 months after surgery. So overall kind of very high success rate and at least stabilizing disease. But, you know, at the same time, there's a small percentage where even if you get the spinal cord decompressed um may still continue to progress. Um And so we know that that, you know, that group does exist. Um again, from some of these same studies, we learned a lot more about how effective we are not just in stabilizing disease, um but also um in actually leading to some sort of measurable improvement um in areas that are relevant to patients. Um So for example, um when we look at improvement in this MJO A or which is really a myelopathy score, it's an 18 point scale. Um we can see that there's a, a two point improvement on average. So, so although not overwhelming, there is some measurable improvement for the average patient in the severity of their myelopathy. Um in addition to the much larger group that we, you know, we at least stabilize symptoms. We can see that, you know, many of these patients obviously pre present with other symptoms that are impairing their quality of life related to um potentially pain or um other, you know, kind of disabilities. And so this neck disability index on average drops dramatically from 40 to 20 we can see that quality of life scores get much better. Um and that pain scores, although not everyone is pain on average do tend to improve pretty notably. But something else that I think we've learned um that, you know, we've been able to quantify better but is really kind of building on something that I think we sort of knew was true to some degree for a while is that outcomes are very different for patients with mild versus maybe more moderate or severe disease. So for our patients with mild disease, you can see that in terms of myelopathy severity, on average, there's not much change. Um there's some other studies that suggest that maybe, you know, patients do a bit better on average and you know, there's probably a variety of factors that explains that heterogeneity. But in general, we're not having a dramatic impact on myelopathy severity um in patients with mild disease because their symptoms, you know, are from a myelopathy standpoint tend to be more mild and you know, this can be a little bit harder to see dramatic improvements. Now, many of those patients also have other complaints and we do see that they still have a pretty substantial improvement in their neck disability in their quality of life and in their pain scores. When we compare that to patients with more severe disease, we can see as they have a more notable improvement in their myelopathy, a larger drop in their neck disability, um to some degree, maybe a better improvement in their quality of life scores. But the thing is these patients never do as well as the mild patients. So they, you know, my optic scores improve, but they're still substantially worse than the um more mild patients even after surgery, their neck is building improves, but it never gets to the point that the mild patients do same with the quality of life. And so, you know, this creates this tension that I know. I and I think, you know, many of us think about often when we're speaking with patients. We on the one hand, I think for a very mild disease, it may be very reasonable to, you know, observe things and not do surgery Um, on the other hand, for patients that have a clear progression, we want to try to catch them before they get to the severe stage. Because even though I think surgery can definitely be helpful for those patients, they're never going to do as well as patients that we catch earlier in their disease course. Um, and will likely never achieve the same degree of outcome on average. So, something else, you know, I think that's been important that we've learned through these same groups of studies, um is the time course for improvement. Um, so patients often, you know, want to know well, ok, if I undergo surgery for this, when am I gonna see some improvements the next day, the next year? Um And I think what we've learned is that really most of the improvement that we see from, um, from a standpoint of myelopathy, um, you know, true kind of neurological, most of that occurs in the first three months. Now, certainly there's a lot of variabilities you can see with these error bars. Um, but most of this improvement occurs in the first three months, um which I think is helpful for patients to know. Um and then also can be helpful because when patients really have not had any meaningful improvement in the first three months, um, it's a reason that I think, you know, certainly I will, um, you know, talk with them about potentially repeating imaging, make sure there's not any new or um recurrent stenosis that, you know, is impairing the recovery. Um So I think this is kind of, this is also important information. Um And then lastly, I think one of the areas where we've seen some really meaningful progress in the last several years is in terms of some of our surgical techniques. Um So, you know, very different from, I think, you know, maybe um the internal medicine world, we don't have a lot of randomized trials in neurosurgery or spine surgery for really anything we do. And so when we do, we get very excited about it. And so, um there was actually a, a very well done randomized trial published a couple of years ago, um basically looking primarily at the effects of dead matter doing surgery for cervical myelopathy where there's sort of clinical echo poise if you go from the front of the neck or the back of the neck, that was really the question that they were trying to um look at. Um And essentially, you know, I'm sure probably many of you have seen we can do these surgeries where we do typically a discectomy infusion. Um often, you know, or potentially at several levels, we can do a Laminectomy infusion um where we basically remove some of the bone in the back, the lamina and put rods and screws or um we can do a laminoplasty where rather than um removing the lamina, we basically hinge it open like you're opening a door kind of halfway open and then put these plates on, send you to hold things open. Um And so it's really comparing primarily ventral surgery with these ac anterior discectomy infusions versus post here in terms of whatever, you know, the surgeon wanted to do. And basically, we found it doesn't really matter, both techniques work well. Um These lines, basically the lines that go up, show patients that got better, the lines that show down, that go down show patients that got worse. Um And generally, you can see that in general that um or that for the vast majority of patients, um people did very well and showed improvement. Um And that there is not really a substantial improvement between, you know, whether the surgeons went from the front to the neck or the back of the neck. And you know, I think this is really helpful. These authors also did a subgroup analysis and they were comparing the three different techniques. Now, again, keep in mind, this was not the primary goal of the study. The primary goal is just ask the question doesn't matter if you go from the front or the back. But again, this was a preplanned subgroup analysis. And what they found is that in the subgroup analysis, it seemed like the laminoplasty patients in this blind line seem to do the best. They showed the most improvement and generally showed um the most rapid improvement and overall achieve the best outcomes. Um Now there's a lot of um I'd say limitations in how far we can interpret that because the fact patients weren't randomized, whether they got a laminoplasty or not, and how were they selected in a variety of factors there. But I think that aside, um I think many of us interpret this as saying that there's at least a subgroup of patients that clearly seem to do better with laminoplasty. I think this is really um expanded, you know, what was probably already some growing enthusiasm for laminoplasty, um which already I think has some, you know, good advantages because it does preserve much more motion compared to fusions. Um So I know, you know, I perform many laminoplasty for myelopathy. And I think, you know, a number of my partners do too because although not every patient is a good candidate for it. Um I do think that many are so, you know, those were kind of, I'd say some of the things where we've learned a lot in recent years. At the same time, I think there are many areas unfortunately where we still have a lot of room to grow. Um in terms of, you know, our ability to raise awareness of this disease and um support early diagnosis, establishing diagnostic criteria for diagnosis, how we actually assess and monitor this disease. Um how we can support patients rehabilitation strategies before and after surgery. Um the socio-economic impact and disparities um as it relates to this disease. And um ultimately also our understanding of natural history. So, you know, one of the key problems that was recently identified in a review by one of the international leading spine organizations is that there's relatively very low awareness of this disease compared to many other diseases of similar, maybe even lesser prevalence or um or lesser morbidity. And so with that, we know um that on average, it takes, you know, about 2 to 6 years between the time that patients develop symptoms to the time that they even get a evaluated, um you know, with an advanced imaging study. And then um at that point, there are still often several additional points where there could be delays and they are ultimately achieving care in terms of being referred to a spine surgeon, being evaluated, actually getting into the spine surgeon, um and an undergoing surgery. Um And so there's a um a variety of ways where we, I think can improve this process to try to prevent um having as many patients with that severe disease that we know we never do as well with. Um But again, there's a variety of factors that influence this. Um as I talked about the um development of myelopathy tends to be insidious. So it's a slow kind of creeping up onset and patients often don't realize that something is clearly getting wrong until, you know, they can barely walk with a walker at times we don't really have any established screening pathways for actually trying to diagnose this condition. Her diagnostic criteria are vague um and really just kind of lacking um in terms of really established criteria, even our terminology is um not terribly consistent. So um I'm using what I think is, you know, kind of been established as the um let's say, preferred term, which is degenerative cervical myelopathy. But, you know, for years, people have also called this cervical spondylitic myelopathy. Does that really matter? Maybe not, but it also does lead to some confusion in terms of um messaging. Um you know, for probably a variety of reasons, there's been very limited research funding for this disease and, you know, along the same lines, very um limited public education. And so, you know, one of the things that I, you know, along with um you know, some other collaborators here, Washington at Washington University have been trying to work on is see, well, could we use technology to see if there are better ways where we could actually have perhaps targeted screening for this disease? Find patients that are at risk um in more past ways in particular, can we use the data that exist in the electronic health record? Um structured things like diagnosis codes um for maybe things like unsteady gait, maybe risk factors for disease that patients, you know, that kind of weren't recognized like maybe diabetes or tobacco use. Um other studies or things that may suggest that the patient already has myelopathy, like maybe they have a prescription for a walker and combine this with, you know, advanced artificial intelligence modeling to actually improve our ability to pick up patients who are probably at high risk. And then we're trying to integrate that information from structured elements in the E hr like diagnosis codes like lab values um with the data that we can get from notes. So as we all know, um probably most of the information E hr is contained within unstructured notes. Um and that can, you know, incredibly valuable in terms of our ability to identify patients that might be at risk. So we're trying, we're working with computer scientists here at was U um to try to see if we can use the same types of large language models that basically underpin things like chad GP T and related um advances. And if we can use that to um or apply that to the notes in the E HR combine that with things like diagnosis codes or lab values um to ultimately really do a better job of identifying patients that are at risk um and hopefully catch them early in the disease process. Um But to do so in a way that's not just um you know, that's basically helping clinicians hopefully by really focusing on patients that are at high risk because we know that we can't just be getting MRI S in every person. Um It's just not practical for all sorts of reasons, probably would be harmful in all honesty. Um So we're trying to really see if we can use data and use the hr to focus in um on patients that may be at higher risk. We also know that there are a variety of socio-economic disparities in how um patients receive treatment for this disease. Uh So from previous studies, um that have been done, we know that African American patients have on average about four times the odds of a treatment delay compared to white patients. Um And we know just from both literature, um including work that we've done here at was U um looking at our own patients, um that patients that have greater social deprivation, um or live in areas that with um lesser access to health care, uh tend to present with more severe disease before surgery and then ultimately achieve worse outcomes after surgery. Um, which is basically what you can see here in these two groups. And this really turns into a vicious cycle where patients with more disadvantage, um, tend to present with more advanced disease. And, you know, again, as we talked about patients with worse disease, tend to achieve worse outcomes, save more disability can't function as well in society. They have greater health care utilization and then that contributes to them staying um, disadvantage. Um So it really becomes a vicious cycle for these people. Um, and certainly one of the areas where we're hoping to improve is to try to um particularly improve the equity with which we can diagnose patients in greatest need. Um We've developed some partnerships with um some of the safety and organizations here in Saint Louis, as we think through these strategies to try to see how we can do better, as I mentioned, um it's kind of crazy but we don't really have great well-established agreed upon diagnostic criteria for CER for DC M. We kind of all to some degree know what we're talking about, we can agree on it most of the time, but there's not actually established criteria and this really impairs our ability to get a timely diagnosis. Establish what we think the standards of care should be makes that our referral pathways very inefficient and certainly impairs efforts to actually research or study this disease. Another one of the I think the the main challenges that, you know, we face is that we still don't have great tools for actually evaluating this disease, for assessing it. And then ultimately for monitoring it, um either for patients not undergoing surgery at all um or for patients that are undergoing surgery to see what their outcomes are. Um So in general, the vast majority of our tools um that we use to evaluate these patients are essentially questionnaires. So the myelopathy scale dimension, the MJ A that's really a clinician administered scale, but it's just the clinician looking at the patient and be, um, and grading them in some several idea or several different domains. But it's not a true objective measure. It's not a true objective measure their gate. It's not a true objective measure of their hand function, which is ultimately what we're trying to get at. And then we've got a variety of patient reported scales and certainly the patient's symptoms are very important for, you know, understanding their quality of life, understanding pain. But at the same time, there are a variety of objective deficits or problems that we're trying to monitor for. Um whether they're progressing in patients that were kind of holding off on surgery or we under um in patients that have undergone surgery in terms of understanding, um whether they're getting better or not, and we don't really capture those things very well at all um in routine clinical practice and all the more. So we do a particularly poor job of being able to monitor those things at home when patients leave the hospital. Um in because we know that obviously most of these things are happening in the home environment in terms of our patients getting worse, are they getting better? Um And certainly we, we really lack the tools um to do an effective job of measuring that in the home environment. But, you know, there is an opportunity to do better and many diseases are doing better. I think probably many of, you know, better than I do. Um that we have continuous glucose monitoring for diabetes, you know, for heart disease. Obviously, we've had loop monitors and home monitors, arrhythmias for many years. Now, there's an increasing number of technologies that can be um used to monitor um cardiac arrhythmias and related pathologies. Um There's increasing advances for Parkinson's disease and how we can monitor disease, severity and track progression um of disease in the home environment. But we don't use these technologies. Um We haven't really applied them for um cervical myelopathy. I mean, certainly this is one of the areas that, you know, I feel pretty passionately about and so have been working um really in the early stages um with folks here um at watch U to try to see if we can do better. Um Can we develop tools where we can um assess more objectively, patients gait to quantify their disease parity, track whether they're getting worse in objective ways or getting better after surgery. Can we use things like smartphones um and tasks that we can do on the smartphone to also measure hand function objectively again, to know, is it getting worse? Can we pick that up early in the process? Um or can we measure if they're getting better um or you know, guide their therapy? And so this has been, you know, applied to other diseases, we know this is doable. Um But we need to figure out how we can do a better job of applying this to cervical myelopathy. And I think that ultimately, um if we're able to do this and do this effectively, um there'll be a variety of ways where I think this will help our patients. Um We can certainly um I think do a much better job of understanding the natural history of disease. Um And I think we can also do a much better job of supporting rehabilitation strategies. Um So for example, um you know, for, for stroke, um there are applications where patients um are able to actually use smartphones um to support the rehabilitation to track the rehabilitation. Um And these things have been found, you know, to help patients as they recover from stroke. Um I think there's good reason to think that there are a lot of opportunities to apply these types of approaches to cervical myelopathy. Um But we need to do that, we need to figure out what are the specific tasks we should be doing, how we integrate this into rehabilitation programs. Um So I think there's a lot of work to be done there. Um But again, you can see that these types of tasks um that sort of rationale behind it, I think is already there. And we just, I think we need to apply these advances to do a better job of taking care of our patients along the same lines for um pulmonary fibrosis. Um There are trials where patients are using home um Digital incentive spirometry measures and integrating that with digital patient reported outcomes. Um and other information in the chart to actually track their disease over time. Um You know, as I mentioned, most of our data about natural history is quite dated for many years. Um comes with relatively small sample sizes and really lacks um objective measures of neurological function. So I think there's a huge opportunity for us to try to do a better job of integrating these assessments, particularly if they can be done in a usable fashion at home, to do a better job of understanding um that, you know, in a more perhaps accurate nuanced way, the natural history of this disease. So, um with that, I'll start wrapping up. Um and just to say, cervical myelopathy, you know, as I said, it's, it's common, it's underdiagnosed and it's almost certainly going to become more pro a more common as the population ages. Um I do think we've learned a lot in recent years. Um that's helped us know better um how patients are likely to do after surgery, how effective outcomes are, how those outcomes differ for patients with milder disease versus patients with more advanced disease. And what sort of benefit we can potentially offer both patients. And, you know, I think we're starting to learn more about how we can optimize um the techniques that we apply. Um in terms of things like using laminoplasty. And, you know, one of the things that we're, I think starting to really explore is combining these, you know, hybrid techniques and whether that can improve outcomes. Um but really try to more in with high quality studies, understand how um you know, we can determine if one of these techniques that you know, we use does better than others. Um But we have a lot of opportunities to improve. We know that we can do much better in terms of diagnosing this earlier in the disease course. I mean, that can have a really profound um impact on patients um long term outcomes because um our surgeries are only so effective in kind of reversing symptoms. Once they've gotten quite severe along the same lines, we know we can do much better in assessing and monitoring this disease to try to identify when patients are sort of going the wrong direction um before they've become, you know, very symptomatic or, you know, become much more severe monitoring their outcomes from surgery, using these technologies to actually support structure rehabilitation efforts that we can track and um optimize and again, understanding the natural history of disease, what is the likelihood that patients are gonna worsen in a year or two years? And we have estimates, but the truth is those are relatively, you know, poorly done studies from 1020 years ago with small sample sizes. Um So, you know, I think there's a huge opportunity for us to really understand that better and with all these advances, um to try to apply them in a way that really addresses, you know, i improving treatment equity to try to understand that we know that outcomes are not the same across racial and so socio-economic groups. Um And so to try to identify or recognize those disparities and figure out how we can do a better job um of rectifying them. Uh So I appreciate the opportunity to be here. Um Thank you for, you know, inviting me. Um I hope that there is some helpful information here and I'm certainly happy to um take any questions um about this talk or, or anything else I can, you know, help, um provide information about so much Doctor Greenberg. Created by Presenters Jacob Greenberg, MD, MSCI Assistant Professor of Neurosurgery and Orthopedic SurgeryCo-Director, Patient Safety and Quality Improvement View full profile
