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Ancillary Outcome Measures for Assessment of Individuals With Cervical Spondylotic Myelopathy

Kalsi-Ryan, Sukhvinder BScPT, MSc, PhD*,†; Singh, Anoushka RN, PhD*; Massicotte, Eric M. MD, MSc, FRCSC*,†; Arnold, Paul M. MD§; Brodke, Darrel S. MD; Norvell, Daniel C. PhD; Hermsmeyer, Jeffrey T. BSc; Fehlings, Michael G. MD, PhD, FRCSC, FACS*

doi: 10.1097/BRS.0b013e3182a7f499
Diagnosis, Work-Up, and Treatment Planning

Study Design. Narrative review.

Objective. To identify suitable outcome measures that can be used to quantify neurological and functional impairment in the management of cervical spondylotic myelopathy (CSM).

Summary of Background Data. CSM is the leading cause of acquired spinal cord disability, causing varying degrees of neurological impairment which impact on independence and quality of life. Because this impairment can have a heterogeneous presentation, a single outcome measure cannot define the broad range of deficits seen in this population. Therefore, it is necessary to define outcome measures that characterize the deficits with greater validity and sensitivity.

Methods. This review was conducted in 3 stages. Stage I: To evaluate the current use of outcome measures in CSM, PubMed was searched using the name of the outcome measure and the common abbreviation combined with “CSM” or “myelopathy.” Stage II: Having identified a lack of appropriate outcome measures, we constructed criteria by which measures appropriate for assessing the various aspects of CSM could be identified. Stage III: A second literature search was then conducted looking at specified outcomes that met these criteria. All literature was reviewed to determine specificity and psychometric properties of outcomes for CSM.

Results. Nurick grade, modified Japanese Orthopaedic Association Scale, visual analogue scale (VAS) for pain, Short Form (36) Health Survey (SF-36), and Neck Disability Index were the most commonly cited measures. The Short-Form 36 Health Survey and Myelopathy Disability Index have been validated in the CSM population with multiple studies, whereas the modified Japanese Orthopaedic Association Scale score, Nurick grade, and European Myelopathy Scale each had only one study assessing psychometric characteristics. No validity, reliability, or responsiveness studies were found for the VAS or Neck Disability Index in the CSM population.

Conclusion. We recommend that the modified Japanese Orthopaedic Association Scale, Nurick grade, Myelopathy Disability Index, Neck Disability Index, and 30-Meter Walk Test are most appropriate for the assessment of CSM. However, 6 additional outcome measures (QuickDASH, Berg Balance Scale, Graded Redefined Assessment of Strength Sensibility and Prehension, Grip Dynamometer, and GAITRite Anlaysis) were identified, which provide complementary assessments for CSM.

Summary Statements. There does not exist a single or composite of outcome instruments that measures myelopathy impairment, function/disability, and participation that have also demonstrated reliability, validity, and responsiveness in a CSM population. More work in the development and psychometric evaluation of new or existing measures is necessary to identify the ideal composite of measures to be used in the clinical and research settings.

  • The mJOA, Nurick grade, NDI, MDI, and 30MWT should be adopted in any clinical practice that treats CSM both for screening and clinical follow-up.
  • We propose that clinicians and researchers consider using the ancillary measures identified, such as the QuickDASH, Berg Balance Scale, GRASSP version 1.0, Grip Strength, and GAITRite Analysis.
  • It is highly recommended that baseline and follow-up measurements should be performed in patients with CSM.

Supplemental Digital Content is Available in the Text.This review defines a number of sensitive, meaningful outcome measures that can be used to assess the outcomes of individuals with cervical spondylotic myelopathy (CSM) being managed with operative or nonoperative methods. Although no single outcome measure fully defines the range of deficits seen in CSM, we recommend the use of the modified Japanese Orthopaedic Association Scale, Neck Disability Index, Nurick Scale, and 30-Meter Walk Test.

*University Health Network, Krembil Neuroscience Centre, Toronto Western Hospital, Toronto, Ontario, Canada

University of Toronto, Toronto, Ontario, Canada

Spectrum Research, Inc, Tacoma, WA

§University of Kansas, Lawrence, KS

University of Utah, Salt Lake City, UT.

Address correspondence and reprint requests to Michael G. Fehlings, MD, PhD, FRCSC, FACS, Toronto Western Hospital, Ste 4W449, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8; E-mail:

Acknowledgment date: March 8, 2013. First revision date: June 10, 2013. Second revision date: July 19, 2013. Acceptance date: July 22, 2013.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Supported by AOSpine North America, Inc. Analytic support for this work was provided by Spectrum Research, Inc., with funding from the AOSpine North America.

Relevant financial activities outside the submitted work: support for travel, fees for participation in review activities, payment for writing, or reviewing the manuscript, board membership, consultancy, royalties, grants/grants pending, stock/stock options, and travel/accommodations/meeting expenses.

© 2013 by Lippincott Williams & Wilkins