Diagnostic Delays Lead to Greater Disability in Degenerative Cervical Myelopathy and Represent a Health Inequality

Daniel H. Pope, BA; Oliver D. Mowforth, BA; Benjamin M. Davies, M.R.C.S, BSc; Mark R.N. Kotter, MD, M.Phil, PhD

Disclosures

Spine. 2020;45(6):368-377. 

In This Article

Abstract and Introduction

Abstract

Study Design: Online survey.

Objective: This study seeks to quantify delays faced, determine demographics of patients most likely to face delay, and determine whether delays affect surgical management and outcomes.

Summary of Background Data: Patients report significant delays in diagnosis of degenerative cervical myelopathy (DCM).

Methods: Seven hundred seventy-eighty patients with self-reported DCM recruited via online survey hosted on myelopathy.org. A cumulative odds ordinal logistic regression was run to determine the effects of demographic (sex, country of residence, ethnicity, household income, and educational status) on the delay in diagnosis of DCM. Chi-square tests of homogeneity were run to determine the effects of delayed diagnosis on functional outcomes (patient-derived modified Japanese Orthopaedic Association disability score, support dependence, and employment status) and surgical management (anterior/posterior approach, single-/multilevel surgery). A Kruskal-Wallis H test was used to determine whether delayed diagnosis affected the number of operations undergone.

Results: The average delay in diagnosis faced was "1–2 years." Greater delays in diagnosis were faced by Black or African American patients (P = 0.010). Delayed diagnosis was predictive of greater disability as assessed by patient-derived modified Japanese Orthopaedic Association score (P = 0.001), support dependence (P = 0.040), and employment status (P < 0.0005). Delayed diagnosis did not affect the likelihood of surgery, the number of operations undergone or perioperative characteristics.

Conclusion: Patients continue to face significant delays in diagnosis of DCM. Ethnicity significantly influences length of delay experienced. Longer delays do not appear to affect surgical management but are associated with greater disability.

Level of Evidence: 3

Introduction

Degenerative cervical myelopathy (DCM) is the commonest cause of spinal cord impairment in the adult population and its incidence is expected to rise as the population continues to age.[1] The term DCM is an umbrella term for cervical spinal cord compression due to degenerative pathology such as cervical spondylosis, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, and degenerative disc disease. Such degenerative changes of the cervical spine are a common finding above the age of 40 years, and in the majority of cases incidental.[2] In a subset of individuals, compression of the spinal cord will lead to a progressive, "slow-motion" spinal cord injury termed DCM.[3] The resultant disability ranges from mild sensory dysfunction to severe sensorimotor deficit and pain.[1,4,5] There is significant overlap of symptomatology with other neurological conditions which may cause difficulties in diagnosis.[6]

DCM has often devastating effects on quality of life. A recent study has shown that SF-36 scores amongst patients with DCM are lower than many other chronic diseases, including cancer and diabetes.[7] Furthermore, the profound effects of the disease are not limited to patients but extend also to their carers.[4,8]

DCM is a progressive disease. The only effective treatment option available is surgical decompression. Surgery is able to halt disease progression and can lead to modest improvements.[9,10] The main predictor of the outcome of surgery is the preoperative disease severity. In addition, the duration of symptoms also influence postoperative outcome,[11,12] with better surgical results obtained in those who receive decompression within 4 to 6 months of symptom onset.[13–15] Patients with moderate or severe myelopathy who do not undergo surgical intervention typically face worse outcomes.[16] Prompt diagnosis and treatment is therefore essential to achieving the best possible outcomes, and therefore "time is spine."

DCM patients may, however, be at risk of delayed diagnosis. At present only two studies have sought to investigate time to diagnosis in DCM. A retrospective examination of 42 patients' case records from a single tertiary hospital in Israel revealed the mean interval between onset of symptoms and diagnosis to be 2.2 years, with one patient waiting almost 9 years. Furthermore, patients made an average of 5.2 visits to their doctor during this interval with myelopathy-related complaints.[17] These findings are echoed in our retrospective cohort study of 43 patients in a UK tertiary center, which showed that the average time to from symptom onset to spinal review was more than 15 months.[15] Because of the progressive nature of DCM, delays are likely to contribute to significant and lifelong disability amongst patients.[18] This is significant, as currently the only modifiable factor to improve outcomes from surgery and thereby improve the quality of life in our patients is to minimize delays of diagnosis, and if necessary treatment.

The objective of this study was to investigate whether the diagnostic delay reported in the small previous studies is systematic and whether it can be replicated in a large cross-sectional cohort. Moreover, we sought to examine the impact of delays on outcome and determine whether any specific subgroups are at greater risk of delays of diagnosis and treatment.

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