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Degenerative cervical myelopathy (DCM) is a progressive cervical spinal cord injury brought about by mechanical stress from degenerative changes in the cervical spine. It is typically diagnosed on clinical symptoms and examination findings together with MRI findings. In this study, we explore the significance of these degenerative pathology to onset of DCM by performing the first meta-analysis on the prevalence of degenerative features reported on MRI amongst healthy and asymptomatic populations and compare this to the prevalence of degenerative features reported on MRI amongst a symptomatic population calculated in a previous review. We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines, cognizant of their adaptation for epidemiological studies. A search strategy was used to identify original research carrying out MRI screening of cervical spines of asymptomatic patients in MEDLINE and Embase from 1985 to present day. The search yielded a total of 1098 studies of which 17 were included in this meta-analysis covering a total of 5059 patients. Ossification of posterior longitudinal ligament (pooled asymptomatic prevalence of 0.4%, 95% Confidence Interval [0.1%, 0.8%]), enlargement of ligamentum flavum (pooled asymptomatic prevalence of 11.8%, 95% Confidence Interval [5.3%, 18.4%]) and degenerative multilevel disc pathology (pooled asymptomatic prevalence of 64.5%, 95% Confidence Interval [48.3%, 80.8%], I

BACKGROUND In shared decision-making (SDM), clinicians and patients collaborate to reach evidence-based choices that reflect the unique circumstances, values, and preferences of each individual. This approach to clinical care is uniquely beneficial when embedded in the context of chronic illness where ongoing decisions and management are required and patients frequently face complex or difficult treatment decisions. SDM is, therefore, likely highly relevant to degenerative cervical myelopathy (DCM), a type of non-traumatic spinal cord injury caused by degenerative and/or congenital pathology. The chronicity, clinical heterogeneity, management complexity, and disease course of DCM engender an imperative for a patient-centric decision-making approach that diligently accounts for the unique needs, experiences, and priorities of each individual afflicted with this condition. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise along the course of care currently hinder the fruitful participation of healthcare providers and patients in SDM. This study protocol presents the rationale for deploying SDM in DCM and delineates the groundwork required to achieve this. OBJECTIVE The study’s primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their onward informed decision-making. This is known as a Core Information Set (CIS). The secondary outcome is the creation of a detailed process map (PM) that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterising the critical decision points along a patient's journey will allow an effective exploration of SDM tools for routine clinical practice towards enhancing patient-centered care and improving clinical outcomes. METHODS Co-production of CISs and PMs is achieved through a collaborative and iterative process involving input and consensus from multiple stakeholders. This will be facilitated by Myelopathy.org, a global DCM Charity, and its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy (RECODE-DCM) community. To develop the CIS, a three-round, web-based Delphi process will be employed, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The PM will be developed iteratively using semi-structured interviews with patients and professionals and validated by all key stakeholders to ensure its accuracy and completeness. RESULTS A multimethod approach to lay the foundations for SDM in DCM. The Delphi and PM studies are scheduled to commence in March and April 2023, respectively. CONCLUSIONS This study will inform the investigation, development, and evaluation of SDM tools in DCM clinical practice. By engaging international stakeholders in this preliminary work, we provide an exhaustive launchpad for formulating SDM tools suitable for the DCM community at large.

Study Design Modified DELPHI Consensus Process Objective To agree a single unifying term and definition. Globally, cervical myelopathy caused by degenerative changes to the spine is known by over 11 different names. This inconsistency contributes to many clinical and research challenges, including a lack of awareness. Method AO Spine RECODE-DCM (Research objectives and Common Data Elements Degenerative Cervical Myelopathy). To determine the index term, a longlist of candidate terms and their rationale, was created using a literature review and interviews. This was shared with the community, to select their preferred terms (248 members (58%) including 149 (60%) surgeons, 45 (18%) other healthcare professionals and 54 (22%) People with DCM or their supporters) and finalized using a consensus meeting. To determine a definition, a medical definition framework was created using inductive thematic analysis of selected International Classification of Disease definitions. Separately, stakeholders submitted their suggested definition which also underwent inductive thematic analysis (317 members (76%), 190 (59%) surgeons, 62 (20%) other healthcare professionals and 72 (23%) persons living with DCM or their supporters). Using this definition framework, a working definition was created based on submitted content, and finalized using consensus meetings. Results Degenerative Cervical Myelopathy was selected as the unifying term, defined in short, as a progressive spinal cord injury caused by narrowing of the cervical spinal canal Conclusion A consistent term and definition can support education and research initiatives. This was selected using a structured and iterative methodology, which may serve as an exemplar for others in the future.

Supplemental Material for We Choose to Call it ‘Degenerative Cervical Myelopathy’: Findings of AO Spine Research objectives and Common Data Elements Degenerative Cervical Myelopathy, an International and Multi-Stakeholder Partnership to Agree a Standard Unifying Term and Definition for a Disease by Benjamin M. Davies, Danyal Z Khan, Kara Barzangi, Ahmad Ali, Oliver D. Mowforth, Aria Nouri, James S. Harrop, Bizhan Aarabi, Vafa Rahimi-Movaghar, Shekar N Kurpad, James D. Guest, Lindsay Tetreault, Brian K. Kwon, Timothy F Boerger, Ricardo Rodrigues-Pinto, Julio C. Furlan, Robert Chen, Carl Moritz Zipser, Armin Curt, James Milligan, Sukhivinder Kalsi-Rayn, Ellen Sarewitz, Iwan Sadler, Shirley Widdop, Michael G. Fehlings, and Mark R.N. Kotter in Global Spine Journal