Understanding gaps in the diagnosis of degenerative cervical myelopathy in Aotearoa New Zealand’s primary healthcare – a nationwide cross-sectional survey
Rohil V. Chauhan
1 2 * , Joanne Kennedy 3 , Steven White 2
1
2
3
Abstract
Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Adequate condition awareness and the ability to recognise key clinical signs are crucial for timely referral and diagnostic imaging. However, the level of awareness and diagnostic confidence among New Zealand primary care clinicians remains unclear.
This study aimed to evaluate self-reported condition awareness, diagnostic confidence, and understanding of DCM signs, symptoms, and management pathways among New Zealand primary care clinicians.
A cross-sectional survey with two sections was developed, piloted, and distributed through professional associations. Participants included general practitioners, nurse practitioners, physiotherapists, osteopaths, and chiropractors. Section A (demographics, DCM education, and ratings of awareness and confidence) was completed by all respondents. Section B (knowledge-based items) was completed by respondents who reported being at least ‘slightly’ confident.
The survey yielded 336 responses, of which there were 320 complete responses for Section A and 227 complete responses for Section B. Over half (57.2%) of respondents reported no prior DCM education, and 43.1 and 32.5% reported ‘average’ or ‘limited’ awareness respectively. Low diagnostic confidence was reported by 25.9 (slightly confident) and 22.2% (not at all confident). Symptoms such as upper limb paraesthesia/numbness and neck pain/stiffness were selected by 98 and 95% of respondents as being associated with DCM. The most recognised clinical sign, tandem gait disturbance, was noted by only 65%. Magnetic resonance imaging was identified as the key diagnostic investigation by 73.6%, and 64.8% selected referral to an orthopaedic surgeon, spine surgeon, or neurosurgeon.
These findings reveal critical gaps in DCM awareness, diagnostic confidence, and knowledge among New Zealand primary care clinicians. It is possible that these gaps contribute to missed and delayed diagnosis for people living with DCM, who subsequently face irreversible neurological compromise resulting from delayed intervention. This study suggests that there is a need for improved education of primary healthcare professionals in regard to this condition and the development of standardised diagnostic criteria.
Keywords: assessment, awareness, clinical diagnosis, clinical education, degenerative cervical myelopathy, New Zealand, orthopaedics, primary healthcare.
References
1 Badhiwala JH, Ahuja CS, Akbar MA, et al. Degenerative cervical myelopathy - update and future directions. Nat Rev Neurol 2020; 16(2): 108-24.
| Crossref | Google Scholar | PubMed |
2 Smith SS, Stewart ME, Davies BM, et al. The prevalence of asymptomatic and symptomatic spinal cord compression on magnetic resonance imaging: a systematic review and meta-analysis. Global Spine J 2021; 11(4): 597-607.
| Crossref | Google Scholar | PubMed |
3 Davies BM, Mowforth OD, Smith EK, et al. Degenerative cervical myelopathy. BMJ 2018; 360: 186.
| Crossref | Google Scholar | PubMed |
4 Nouri A, Tetreault L, Singh A, et al. Degenerative cervical myelopathy: epidemiology, genetics, and pathogenesis. Spine 2015; 40(12): 675-93.
| Crossref | Google Scholar | PubMed |
5 Davies BM, Mowforth O, Wood H, et al. Improving awareness could transform outcomes in degenerative cervical myelopathy [AO Spine RECODE-DCM Research Priority Number 1]. Global Spine J 2022; 12(1_suppl): 28.
| Crossref | Google Scholar | PubMed |
6 Pope DH, Mowforth OD, Davies BM, et al. Diagnostic delays lead to greater disability in degenerative cervical myelopathy and represent a health inequality. Spine 2020; 45(6): 368-77.
| Crossref | Google Scholar | PubMed |
7 Behrbalk E, Salame K, Regev GJ, et al. Delayed diagnosis of cervical spondylotic myelopathy by primary care physicians. Neurosurg Focus 2013; 35(1): E1.
| Crossref | Google Scholar | PubMed |
8 Fehlings MG, Wilson JR, Kopjar B, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am 2013; 95(18): 1651-8.
| Crossref | Google Scholar | PubMed |
9 Fehlings MG, Tetreault LA, Riew KD, et al. A clinical practice guideline for the management of patients with degenerative cervical myelopathy: recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression. Global Spine J 2017; 7(3 Suppl): 70S-83S.
| Crossref | Google Scholar | PubMed |
10 Rufus-Toye RM, Rafati Fard A, Mowforth OD, et al. Degenerative cervical myelopathy awareness in primary care: UK national cross-sectional survey of general practitioners. JMIR Form Res 2024; 8: e58802.
| Crossref | Google Scholar | PubMed |
11 Waqar M, Wilcock J, Garner J, et al. Quantitative analysis of medical students’ and physicians’ knowledge of degenerative cervical myelopathy. BMJ Open 2020; 10(1): e028455.
| Crossref | Google Scholar | PubMed |
12 Cook CE, Wilhelm M, Cook AE, et al. Clinical tests for screening and diagnosis of cervical spine myelopathy: a systematic review. J Manip Physiol Ther 2011; 34(8): 539-46.
| Crossref | Google Scholar | PubMed |
13 Cook C, Brown C, Isaacs R, et al. Clustered clinical findings for diagnosis of cervical spine myelopathy. J Man Manip Ther 2010; 18(4): 175-80.
| Crossref | Google Scholar | PubMed |
14 Grodzinski B, Stubbs DJ, Davies BM. Most degenerative cervical myelopathy remains undiagnosed, particularly amongst the elderly: modelling the prevalence of degenerative cervical myelopathy in the United Kingdom. J Neurol 2023; 270(1): 311-9.
| Crossref | Google Scholar | PubMed |
15 Hilton B, Gardner EL, Jiang Z, et al. Establishing diagnostic criteria for degenerative cervical myelopathy [AO Spine RECODE-DCM Research Priority Number 3]. Global Spine J 2022; 12(1_suppl): 55.
| Crossref | Google Scholar | PubMed |
16 Jiang Z, Davies B, Zipser C, et al. The value of clinical signs in the diagnosis of degenerative cervical myelopathy - A systematic review and meta-analysis. Global Spine J 2024; 14(4): 1369-94.
| Crossref | Google Scholar | PubMed |
17 Hilton B, Tempest-Mitchell J, Davies B, et al. Assessment of degenerative cervical myelopathy differs between specialists and may influence time to diagnosis and clinical outcomes. PLoS One 2018; 13(12): e0207709.
| Crossref | Google Scholar | PubMed |
18 Rhee JM, Heflin JA, Hamasaki T, et al. Prevalence of physical signs in cervical myelopathy: a prospective, controlled study. Spine 2009; 34(9): 890-5.
| Crossref | Google Scholar | PubMed |
19 Martin AR, Tetreault L, Nouri A, et al. Imaging and electrophysiology for degenerative cervical myelopathy [AO Spine RECODE-DCM Research Priority Number 9]. Global Spine J 2022; 12(1_suppl): 130.
| Crossref | Google Scholar | PubMed |
20 Tetreault LA, Zhu MP, Howard RM, et al. The discrepancy between functional outcome and self-reported health status after surgery for degenerative cervical myelopathy. Spine J 2019; 19(11): 1809-15.
| Crossref | Google Scholar | PubMed |
21 Goacher E, Yardanov S, Phillips R, et al. Cost-effectiveness of surgery for degenerative cervical myelopathy in the United Kingdom. Br J Neurosurg 2024; 1-5.
| Crossref | Google Scholar | PubMed |
22 Oh T, Lafage R, Lafage V, et al. Comparing quality of life in cervical spondylotic myelopathy with other chronic debilitating diseases using the short form survey 36-health survey. World Neurosurg 2017; 106: 699-706.
| Crossref | Google Scholar | PubMed |
23 Goddard-Hodge D, Boukebous B, Baker JF. Anteroposterior cervical spine canal diameter: exploring ethnic variation between European and Polynesian populations. ANZ J Surg 2024; 94: 1963-70.
| Crossref | Google Scholar | PubMed |
24 Overley SC, Kim JS, Gogel BA, et al. Tandem spinal stenosis: a systematic review. JBJS Rev 2017; 5(9): e2.
| Crossref | Google Scholar | PubMed |
25 Jiang Z, Davies B, Zipser C, et al. The frequency of symptoms in patients with a diagnosis of degenerative cervical myelopathy: results of a scoping review. Global Spine J 2023; 14(4): 1395-421.
| Crossref | Google Scholar | PubMed |
26 Zhang H, Buell T, Baldwin III E, et al. High prevalence of cervical myelopathy among hip fracture patients. Oper Tech Orthop 2023; 33(4): 101066.
| Crossref | Google Scholar |
27 Tetreault L, Kopjar B, Nouri A, et al. The modified Japanese Orthopaedic Association scale: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy. Eur Spine J 2017; 26(1): 78-84.
| Crossref | Google Scholar | PubMed |
28 Treanor C, Gallagher C, Lenehan W, et al. Flipping the mJOA: clinical utility of the modified Japanese Orthopaedic Association score as a tool for detecting degenerative cervical myelopathy. Brain Spine 2024; 4: 102853.
| Crossref | Google Scholar | PubMed |
