⚠️

DRAFT - Pending Review

This plan requires physician review before clinical use.

Cervical Spondylotic Myelopathy (Degenerative Cervical Myelopathy)

VERSION: 1.1 REVISED: January 31, 2026 CREATED: January 30, 2026 STATUS: Draft - Pending Review

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DIAGNOSIS: Cervical Spondylotic Myelopathy (Degenerative Cervical Myelopathy)

ICD-10: M47.12 (Other spondylosis with myelopathy, cervical region), M47.22 (Other spondylosis with radiculopathy, cervical region), M50.00 (Cervical disc disorder with myelopathy, unspecified cervical region)

SYNONYMS: Cervical spondylotic myelopathy, CSM, degenerative cervical myelopathy, DCM, cervical myelopathy, spondylotic myelopathy, cervical spinal stenosis with myelopathy, cervical cord compression, cervical spondylosis with myelopathy

SCOPE: Evaluation and management of chronic/progressive spinal cord dysfunction from degenerative cervical spine changes (disc herniation, osteophyte formation, ligamentum flavum hypertrophy, ossification of the posterior longitudinal ligament). Covers diagnostic workup, severity grading (mJOA), surgical referral criteria, conservative management of mild cases, symptomatic treatment (spasticity, pain, bladder dysfunction), and post-surgical monitoring. Excludes acute traumatic spinal cord injury, acute myelopathy from non-degenerative causes (inflammatory, infectious, vascular — see Acute Myelopathy template), isolated cervical radiculopathy without myelopathy, and cauda equina syndrome (separate template).

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
CBC with differential (CPT 85025)	Baseline pre-operative assessment; infection screen if acute worsening	Normal	STAT	STAT	ROUTINE	STAT
CMP (BMP + LFTs) (CPT 80053)	Renal/hepatic function for medication dosing and pre-operative assessment; electrolytes	Normal	STAT	STAT	ROUTINE	STAT
PT/INR, aPTT (CPT 85610, 85730)	Pre-operative coagulation assessment; evaluate bleeding risk before surgery	Normal	STAT	STAT	ROUTINE	STAT
ESR (CPT 85652)	Elevated in inflammatory/infectious myelopathy; helps distinguish degenerative from inflammatory	Normal (<20 mm/hr)	URGENT	URGENT	ROUTINE	URGENT
CRP (CPT 86140)	Inflammatory marker; elevated suggests infection or inflammatory etiology rather than pure spondylotic compression	Normal (<3 mg/L)	URGENT	URGENT	ROUTINE	URGENT
Blood glucose (CPT 82947)	Diabetes is risk factor for myelopathy progression; pre-operative glycemic assessment	Normal	STAT	STAT	ROUTINE	STAT
HbA1c (CPT 83036)	Assess long-term glycemic control; diabetes worsens myelopathy prognosis and post-surgical outcomes	<7.0%	-	ROUTINE	ROUTINE	-
Urinalysis (CPT 81003)	Baseline bladder function assessment; UTI screen in setting of neurogenic bladder	Normal	URGENT	ROUTINE	ROUTINE	URGENT
Type and screen (CPT 86900)	Pre-operative; potential surgical intervention for moderate-severe myelopathy	On file	URGENT	ROUTINE	-	URGENT

1B. Extended Workup (Second-line)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
Vitamin B12 level (CPT 82607)	Subacute combined degeneration mimics CSM (posterior column + corticospinal tract dysfunction)	Normal (>300 pg/mL)	-	ROUTINE	ROUTINE	-
Methylmalonic acid (CPT 83921)	Elevated in functional B12 deficiency even when B12 level borderline normal	Normal	-	ROUTINE	ROUTINE	-
Copper level (CPT 82525)	Copper deficiency myelopathy mimics CSM; posterior column + corticospinal tract involvement	Normal (70-155 mcg/dL)	-	ROUTINE	ROUTINE	-
Ceruloplasmin (CPT 82390)	Low in copper deficiency; supports diagnosis	Normal (20-35 mg/dL)	-	ROUTINE	ROUTINE	-
Zinc level (CPT 84630)	Zinc excess causes secondary copper deficiency	Normal	-	ROUTINE	ROUTINE	-
TSH (CPT 84443)	Hypothyroidism associated with carpal tunnel and neuropathy that may confound exam; thyroid disease affects surgical outcomes	Normal	-	ROUTINE	ROUTINE	-
RPR/VDRL (CPT 86592)	Syphilitic myelitis (tabes dorsalis) mimics posterior column dysfunction	Non-reactive	-	ROUTINE	ROUTINE	-
HIV 1/2 antigen/antibody (CPT 87389)	HIV-associated vacuolar myelopathy in differential	Negative	-	ROUTINE	ROUTINE	-
ANA (CPT 86235)	Screen for systemic autoimmune disease causing myelopathy (lupus, Sjogren)	Negative	-	ROUTINE	ROUTINE	-
Pre-operative albumin (CPT 82040)	Nutritional status assessment; hypoalbuminemia predicts poor surgical wound healing	>3.5 g/dL	-	ROUTINE	ROUTINE	-

1C. Rare/Specialized (Refractory or Atypical)

Test	Rationale	Target Finding	ED	HOSP	OPD	ICU
AQP4-IgG (aquaporin-4 antibody, serum) — cell-based assay (CPT 86255)	NMOSD with longitudinally extensive transverse myelitis; if MRI findings atypical for pure spondylotic disease	Negative	-	EXT	EXT	-
MOG-IgG antibody (serum) — cell-based assay (CPT 86255)	MOGAD if MRI shows intrinsic cord signal change disproportionate to degree of compression	Negative	-	EXT	EXT	-
HTLV-1/2 antibody (CPT 86687)	HTLV-associated myelopathy/tropical spastic paraparesis if patient from endemic area (Caribbean, Japan, sub-Saharan Africa)	Negative	-	EXT	EXT	-
Paraneoplastic panel (serum) — ANNA-1, CRMP-5, amphiphysin (CPT 86255)	Paraneoplastic myelopathy if known malignancy or unexplained progressive course with red flags	Negative	-	EXT	EXT	-
Serum protein electrophoresis (SPEP) (CPT 86334)	Multiple myeloma causing cord compression; POEMS syndrome	Normal	-	EXT	EXT	-
Anti-SSA (Ro), anti-SSB (La) (CPT 86235)	Sjogren syndrome myelitis if sicca symptoms or autoimmune features present	Negative	-	EXT	EXT	-

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI cervical spine without and with gadolinium contrast (CPT 72156)	STAT if acute neurologic deterioration; URGENT for new/progressive myelopathic symptoms; ROUTINE for outpatient evaluation	Cord compression (disc, osteophyte, ligamentum flavum hypertrophy, OPLL); T2 hyperintensity within cord (myelomalacia or edema); T1 hypointensity (irreversible cord damage — poor prognostic sign); canal stenosis measurement	GFR <30 (relative — give contrast if needed); gadolinium allergy (premedicate); pacemaker/implant (MRI-conditional protocol)	STAT	STAT	ROUTINE	STAT
X-ray cervical spine AP, lateral, and flexion-extension views (CPT 72052)	Within 24-48h; or at initial outpatient evaluation	Spondylotic changes (disc space narrowing, osteophytes, facet hypertrophy); dynamic instability on flexion-extension (>3.5 mm translation or >11 degrees angular change); OPLL; alignment (kyphosis vs lordosis — affects surgical approach)	None significant	URGENT	ROUTINE	ROUTINE	URGENT
CT cervical spine without contrast (CPT 72125)	If MRI contraindicated; or for surgical planning to evaluate bony anatomy	Osteophyte size and morphology; OPLL extent and classification; facet arthropathy; foraminal stenosis; canal diameter measurement; bony anatomy for surgical approach planning	Pregnancy (relative)	STAT	ROUTINE	ROUTINE	STAT

2B. Extended

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
MRI thoracic spine without and with contrast (CPT 72157)	If clinical findings suggest lower thoracic cord involvement or tandem stenosis suspected	Concomitant thoracic cord compression (tandem stenosis present in 5-25%); thoracic disc herniation; additional cord signal change	GFR <30 (relative — give contrast if needed); gadolinium allergy (premedicate); pacemaker/implant (MRI-conditional protocol)	-	ROUTINE	ROUTINE	-
MRI brain without and with contrast (CPT 70553)	If considering MS or other intrinsic cord pathology in differential; atypical MRI cord findings	Periventricular/juxtacortical lesions (MS); absence of brain lesions supports spondylotic etiology	GFR <30 (relative — give contrast if needed); gadolinium allergy (premedicate); pacemaker/implant (MRI-conditional protocol)	-	ROUTINE	ROUTINE	-
CT myelogram (CPT 72126, 62284)	If MRI contraindicated (non-MRI-conditional implant); or to clarify degree of compression when MRI equivocal	Dynamic cord compression; CSF column cutoff; degree of stenosis in comparison to MRI	Contrast allergy; coagulopathy; infection at puncture site	-	ROUTINE	ROUTINE	-
NCS/EMG (CPT 95907-95913, 95886)	Within 1-2 weeks; outpatient evaluation preferred	Distinguish myelopathy from peripheral neuropathy, radiculopathy, ALS, or combined pathology; lower motor neuron signs at compression level	None significant	-	ROUTINE	ROUTINE	-
Somatosensory evoked potentials (SSEPs) (CPT 95925, 95926)	Elective; pre-operative baseline or for objective functional assessment	Delayed or absent cortical potentials indicating dorsal column dysfunction; severity correlates with prognosis; intraoperative monitoring baseline	None	-	ROUTINE	ROUTINE	-
DEXA scan (CPT 77080)	Pre-operative in patients >50 or with osteoporosis risk factors	T-score assessment; instrumented fusion outcomes worse with osteoporosis	None	-	ROUTINE	ROUTINE	-
CT angiography of neck (CPT 70498)	Pre-operative planning for anterior approaches; if vertebral artery anomaly suspected	Vertebral artery course and dominance; vascular anatomy for surgical planning	Contrast allergy; renal impairment	-	EXT	EXT	-

2C. Rare/Specialized

Study	Timing	Target Finding	Contraindications	ED	HOSP	OPD	ICU
Motor evoked potentials (MEPs) (CPT 95929)	Elective; pre-operative baseline	Corticospinal tract function assessment; prognostic value	Epilepsy (relative); implanted devices	-	EXT	EXT	-
Upright/dynamic MRI (CPT 72156)	If positional symptoms and standard MRI shows borderline compression	Dynamic cord compression in flexion/extension not seen on supine MRI	GFR <30 (relative); gadolinium allergy (premedicate); pacemaker/implant (MRI-conditional protocol)	-	-	EXT	-
Whole-body PET-CT (CPT 78816)	If malignancy suspected as cause of cord compression rather than degenerative disease	Occult primary malignancy; metastatic disease	Pregnancy; uncontrolled diabetes	-	EXT	EXT	-

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Dexamethasone	IV	Acute neurologic deterioration from cervical cord compression with progressive deficit; reduces vasogenic edema	10 mg :: IV :: load, then 4 mg q6h :: 10 mg IV loading dose, then 4 mg IV q6h; transition to oral taper over 5-7 days once stable	Active untreated infection; uncontrolled diabetes (relative — monitor closely)	Blood glucose q6h; GI prophylaxis with PPI; blood pressure; mental status changes	STAT	STAT	-	STAT
Methylprednisolone	IV	Alternative to dexamethasone for acute cord compression with progressive neurologic decline	1000 mg :: IV :: daily x 3 days :: 1000 mg IV daily for 3 days; infuse over 1 hour; reserve for severe acute deterioration	Active untreated infection; uncontrolled diabetes (relative)	Blood glucose q6h; blood pressure; GI prophylaxis with PPI; insomnia; psychosis risk	STAT	STAT	-	STAT
Cervical collar (rigid — Miami J or Aspen type)	-	Cervical spine immobilization for acute myelopathic presentation to prevent further cord injury from instability	Apply rigid cervical collar; maintain until spine cleared by imaging and surgical evaluation	Severe skin breakdown at collar contact points	Skin checks under collar q shift; collar fit assessment	STAT	STAT	-	STAT
DVT prophylaxis: Enoxaparin	SC	Immobilized myelopathy patients at high risk for venous thromboembolism	40 mg :: SC :: daily :: 40 mg SC daily; start within 24-48h of admission if no active bleeding and no imminent surgery	Active bleeding; coagulopathy; planned surgery within 12h	Platelets q3 days; signs of bleeding; renal function (dose adjust CrCl <30)	-	ROUTINE	-	ROUTINE
DVT prophylaxis: Heparin (unfractionated)	SC	Alternative DVT prophylaxis if CrCl <30 mL/min or high bleeding risk	5000 units :: SC :: q8h :: 5000 units SC q8h; preferred over enoxaparin in renal impairment	Active bleeding; HIT history	Platelets q3 days; signs of bleeding	-	ROUTINE	-	ROUTINE
Pneumatic compression devices	-	Mechanical DVT prophylaxis for all immobilized patients; use in combination with pharmacologic prophylaxis or alone if anticoagulation contraindicated	Apply bilateral sequential compression devices immediately on admission	Acute DVT in affected limb; severe peripheral arterial disease	Skin checks; device compliance	STAT	STAT	-	STAT
Bladder management: Foley catheter or intermittent catheterization	-	Urinary retention from neurogenic bladder (common in cervical myelopathy); post-void residual >200 mL	Foley catheter if acute retention; transition to intermittent catheterization (q4-6h) as soon as feasible; measure post-void residuals	N/A	Intake/output; post-void residual; UTI surveillance	STAT	STAT	-	STAT
Famotidine	IV/PO	GI prophylaxis during corticosteroid therapy to prevent stress ulcer	20 mg :: IV/PO :: daily :: 20 mg IV or PO daily while on corticosteroids	Severe renal impairment (dose adjust)	GI symptoms	STAT	ROUTINE	-	STAT
Pantoprazole	IV/PO	Alternative GI prophylaxis during corticosteroid therapy	40 mg :: IV/PO :: daily :: 40 mg IV or PO daily while on corticosteroids	Hypersensitivity; avoid long-term use if possible	GI symptoms; magnesium with prolonged use	STAT	ROUTINE	-	STAT

3B. Symptomatic Treatments

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Gabapentin	PO	Neuropathic pain (radicular pain, burning dysesthesias, central neuropathic pain from cord compression)	300 mg :: PO :: TID :: Start 300 mg qHS; titrate by 300 mg q3-5d; target 900-1800 mg/day divided TID; max 3600 mg/day; adjust for renal function (CrCl <60)	Severe renal impairment (dose reduce); suicidal ideation	Sedation; dizziness; peripheral edema; renal function	-	ROUTINE	ROUTINE	-
Pregabalin	PO	Neuropathic pain; alternative to gabapentin with more predictable pharmacokinetics	75 mg :: PO :: BID :: Start 75 mg BID; increase to 150 mg BID after 1 week; max 600 mg/day; adjust for renal function	Severe renal impairment (dose reduce); suicidal ideation; angioedema history	Sedation; dizziness; peripheral edema; weight gain; renal function	-	ROUTINE	ROUTINE	-
Duloxetine	PO	Neuropathic pain with comorbid depression or anxiety; mixed pain syndrome	30 mg :: PO :: daily :: Start 30 mg PO daily x 1 week, then increase to 60 mg daily; max 120 mg/day	Hepatic impairment; concurrent MAOIs; uncontrolled narrow-angle glaucoma; CrCl <30	Blood pressure; hepatic function; serotonin syndrome signs; discontinuation syndrome (taper slowly)	-	ROUTINE	ROUTINE	-
Amitriptyline	PO	Neuropathic pain with insomnia; central pain syndrome from cervical myelopathy	10 mg :: PO :: qHS :: Start 10 mg PO qHS; titrate by 10-25 mg q1-2 weeks; max 150 mg qHS	Cardiac conduction abnormality; recent MI; urinary retention; angle-closure glaucoma; concurrent MAOIs; elderly (falls risk)	ECG if dose >100 mg/day or age >40; anticholinergic side effects; orthostatic hypotension; sedation	-	ROUTINE	ROUTINE	-
Baclofen	PO	Spasticity from upper motor neuron dysfunction (stiff gait, muscle spasms, clonus)	5 mg :: PO :: TID :: Start 5 mg PO TID; increase by 5 mg/dose q3 days; target 30-80 mg/day divided TID; max 80 mg/day; do NOT stop abruptly (withdrawal seizures)	Seizure history (lowers threshold); renal impairment (accumulates)	Sedation; weakness (may unmask weakness); falls; abrupt withdrawal causes seizures and hallucinations	-	ROUTINE	ROUTINE	-
Tizanidine	PO	Spasticity; alternative to baclofen; useful when baclofen causes excess sedation	2 mg :: PO :: TID :: Start 2 mg PO qHS; increase by 2 mg q3-4 days; max 36 mg/day divided TID; take consistently with or without food	Hepatic impairment; concurrent CYP1A2 inhibitors (ciprofloxacin, fluvoxamine)	LFTs at baseline, 1 month, 3 months, then q6 months; blood pressure (hypotension); sedation	-	ROUTINE	ROUTINE	-
Dantrolene	PO	Spasticity refractory to baclofen and tizanidine; acts peripherally on muscle	25 mg :: PO :: daily :: Start 25 mg PO daily; increase by 25 mg q4-7 days; max 400 mg/day divided TID-QID	Active hepatic disease; severely impaired cardiac or pulmonary function	LFTs at baseline, then monthly for first 6 months; muscle weakness (reduces overall strength); hepatotoxicity	-	ROUTINE	ROUTINE	-
Acetaminophen	PO	Axial neck pain and musculoskeletal pain; first-line analgesic	650-1000 mg :: PO :: q6h PRN :: 650-1000 mg PO q6h PRN pain; max 3000 mg/day (2000 mg/day if hepatic impairment or age >65)	Severe hepatic disease; active liver failure	LFTs if chronic use; total daily dose tracking across all formulations	STAT	ROUTINE	ROUTINE	STAT
Naproxen	PO	Axial neck pain and musculoskeletal pain; anti-inflammatory for spondylotic pain	250-500 mg :: PO :: BID :: 250-500 mg PO BID with food; max 1000 mg/day; limit to 2 weeks when possible	Active GI bleeding; CKD stage 4-5; aspirin-sensitive asthma; third trimester pregnancy; concurrent anticoagulation	Renal function; GI symptoms; blood pressure; concurrent anticoagulant use	URGENT	ROUTINE	ROUTINE	-
Ibuprofen	PO	Axial neck pain; alternative NSAID for musculoskeletal pain	400-600 mg :: PO :: q6-8h PRN :: 400-600 mg PO q6-8h PRN with food; max 2400 mg/day; limit to 2 weeks when possible	Active GI bleeding; CKD stage 4-5; aspirin-sensitive asthma; third trimester pregnancy; concurrent anticoagulation	Renal function; GI symptoms; blood pressure; concurrent anticoagulant use	URGENT	ROUTINE	ROUTINE	-
Cyclobenzaprine	PO	Cervical muscle spasm and neck pain; short-term adjunctive use for acute exacerbation	5 mg :: PO :: TID :: 5-10 mg PO TID; limit to 2-3 weeks; avoid in elderly	Concurrent MAOIs; hyperthyroidism; cardiac arrhythmia; heart failure; elderly (anticholinergic burden)	Sedation; dry mouth; urinary retention; falls risk in elderly	-	ROUTINE	ROUTINE	-
Methocarbamol	PO	Muscle spasm; alternative to cyclobenzaprine with less sedation	1500 mg :: PO :: QID :: 1500 mg PO QID x 2-3 days, then 750 mg PO q6h PRN; max 4500 mg/day maintenance	Myasthenia gravis; renal impairment (accumulates)	Sedation; dizziness; discolored urine (brown-black, benign)	-	ROUTINE	ROUTINE	-
Oxybutynin	PO	Neurogenic bladder with urgency and urge incontinence from upper motor neuron dysfunction	5 mg :: PO :: BID-TID :: 5 mg PO BID-TID; extended-release: 5-10 mg PO daily; max 20 mg/day	Urinary retention (use only for overactive bladder, NOT retention); uncontrolled narrow-angle glaucoma; GI obstruction	Post-void residual; anticholinergic side effects (dry mouth, constipation, cognitive impairment in elderly)	-	ROUTINE	ROUTINE	-
Mirabegron	PO	Neurogenic bladder with urgency; alternative to anticholinergics with fewer cognitive side effects	25 mg :: PO :: daily :: Start 25 mg PO daily; increase to 50 mg daily after 8 weeks if needed	Uncontrolled hypertension; severe hepatic impairment; end-stage renal disease	Blood pressure; urinary retention; hepatic function	-	ROUTINE	ROUTINE	-
Tamsulosin	PO	Urinary hesitancy and retention from neurogenic bladder; facilitates bladder emptying	0.4 mg :: PO :: daily :: 0.4 mg PO daily 30 minutes after same meal; max 0.8 mg daily	Concurrent PDE5 inhibitors (orthostatic risk); planned cataract surgery (intraoperative floppy iris)	Orthostatic hypotension; dizziness; retrograde ejaculation	-	ROUTINE	ROUTINE	-
Docusate sodium	PO	Constipation prevention in neurogenic bowel; maintain regular bowel program	100 mg :: PO :: BID :: 100 mg PO BID; take with adequate fluids	Intestinal obstruction	Bowel frequency; abdominal distension	-	ROUTINE	ROUTINE	-
Senna	PO	Constipation treatment in neurogenic bowel; stimulant laxative for bowel program	8.6-17.2 mg :: PO :: qHS :: 8.6-17.2 mg PO qHS; adjust based on bowel response	Intestinal obstruction; acute abdominal pain	Bowel frequency; electrolytes with chronic use	-	ROUTINE	ROUTINE	-
Polyethylene glycol 3350 (MiraLAX)	PO	Chronic constipation from neurogenic bowel; osmotic laxative	17 g :: PO :: daily :: 17 g dissolved in 8 oz water PO daily; adjust frequency based on response	Bowel obstruction; bowel perforation	Bowel frequency; electrolytes; hydration status	-	ROUTINE	ROUTINE	-
Trazodone	PO	Insomnia with comorbid pain or depression; avoids benzodiazepine use in myelopathy patients at fall risk	25-50 mg :: PO :: qHS :: Start 25-50 mg PO qHS; max 100 mg qHS for sleep; avoid in combination with serotonergic agents	Concurrent MAOIs; QT prolongation; priapism history	Sedation; orthostatic hypotension; priapism (rare); serotonin syndrome if combined with SSRIs	-	ROUTINE	ROUTINE	-
Melatonin	PO	Insomnia; circadian rhythm disruption during hospitalization; safer alternative in elderly	3-5 mg :: PO :: qHS :: 3-5 mg PO 30 minutes before bedtime	Autoimmune disease (theoretical — immunostimulant)	Daytime drowsiness; vivid dreams	-	ROUTINE	ROUTINE	-
Sertraline	PO	Depression and anxiety associated with chronic myelopathy and functional disability	25-50 mg :: PO :: daily :: Start 25-50 mg PO daily; titrate by 25-50 mg q2-4 weeks; max 200 mg/day	Concurrent MAOIs; concurrent pimozide; QT prolongation risk	Suicidality monitoring (first 2-4 weeks); serotonin syndrome signs; sexual dysfunction; GI effects	-	ROUTINE	ROUTINE	-

3C. Second-line/Refractory

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Intrathecal baclofen pump	IT	Severe spasticity refractory to maximum oral medications; intolerable side effects from oral antispasticity agents	50-100 mcg :: IT :: continuous :: Trial with intrathecal bolus 50-100 mcg; if >50% spasticity reduction, proceed to pump implantation; maintenance 100-900 mcg/day	Infection at insertion site; CSF leak history; inability to follow up for pump refills	Pump refill schedule (q1-3 months); withdrawal syndrome if pump malfunction (fever, seizures, rhabdomyolysis — EMERGENCY); catheter complications	-	EXT	EXT	-
Botulinum toxin A (onabotulinumtoxinA)	IM	Focal spasticity in specific muscle groups (biceps, forearm flexors, finger flexors) refractory to oral agents; improves range of motion and function	Dose varies by muscle :: IM :: q12 weeks :: EMG or ultrasound-guided injection; biceps 100-200 units, brachioradialis 50-100 units, finger flexors 25-50 units per muscle; total dose per session varies; repeat q12 weeks	Infection at injection site; known hypersensitivity; neuromuscular junction disorders (myasthenia gravis — relative)	Excessive weakness; dysphagia if injecting cervical muscles; antibody formation with repeated use	-	EXT	ROUTINE	-
Tramadol	PO	Moderate neuropathic and musculoskeletal pain refractory to non-opioid agents	50 mg :: PO :: q6h PRN :: Start 50 mg PO q6h PRN; max 400 mg/day (200 mg/day if age >75); avoid extended-release initially	Seizure disorder (lowers threshold); concurrent MAOIs; concurrent serotonergic agents; severe hepatic or renal impairment	Seizure risk; serotonin syndrome; sedation; respiratory depression; constipation	-	ROUTINE	ROUTINE	-
Capsaicin 8% patch (Qutenza)	TOP	Localized neuropathic pain in areas with preserved sensation; radicular distribution pain	1-4 patches :: TOP :: q3 months :: Apply to painful area for 60 minutes; may repeat q3 months; pre-treat with topical lidocaine	Open wounds; broken skin; mucous membranes	Transient burning at application; blood pressure during application	-	-	ROUTINE	-
Lidocaine 5% patch	TOP	Localized neck or radicular pain; adjunctive for neuropathic pain	1-3 patches :: TOP :: daily :: Apply up to 3 patches to painful area for 12 hours on, 12 hours off	Severe hepatic disease; known lidocaine hypersensitivity	Local skin reaction; cardiac arrhythmia (minimal systemic absorption)	-	ROUTINE	ROUTINE	-
Diazepam	PO	Severe acute spasticity and muscle spasm with anxiety component; short-term use only	2 mg :: PO :: BID :: Start 2 mg PO BID; max 10 mg TID; short-term use only (2-4 weeks); taper to discontinue	Acute narrow-angle glaucoma; severe respiratory depression; myasthenia gravis; severe hepatic impairment	Sedation; respiratory depression; falls (especially in myelopathy patients); dependence; cognitive impairment	-	ROUTINE	EXT	-
Carbamazepine	PO	Lancinating radicular pain; paroxysmal neuropathic pain; trigeminal component	100 mg :: PO :: BID :: Start 100 mg PO BID; increase by 200 mg/day q1 week; max 1200 mg/day; use extended-release formulation	AV block; bone marrow suppression; concurrent MAOIs; HLA-B*1502 positive (Asian descent — SJS risk)	CBC with differential at baseline, 2 weeks, 4 weeks, then q3 months; LFTs; sodium (SIADH); drug level (target 4-12 mcg/mL); HLA-B*1502 testing before starting in at-risk populations	-	ROUTINE	ROUTINE	-

3D. Surgical Interventions (Disease-Modifying)

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Anterior cervical discectomy and fusion (ACDF)	Surgical	1-2 level anterior compression; disc herniation with myelopathy; focal kyphosis correction	Surgical procedure; 1-2 level disc removal + interbody graft + anterior plate fixation	Pre-operative MRI and CT; coagulation studies; medical clearance; anesthesia evaluation; DEXA if osteoporosis risk; smoking cessation counseling	Medically unfit for surgery; multi-level disease >3 levels (relative — consider posterior approach); severe osteoporosis (cage subsidence risk)	Neurologic exam post-op q2h x 24h; airway monitoring (retropharyngeal hematoma risk — EMERGENCY if stridor/dyspnea); dysphagia assessment; wound check; upright X-ray before discharge	URGENT	URGENT	ROUTINE	URGENT
Anterior cervical corpectomy and fusion (ACCF)	Surgical	Multi-level anterior compression (2-3 levels); OPLL; vertebral body pathology; large central disc herniations	Surgical procedure; vertebral body removal + strut graft + anterior plate	Pre-operative MRI and CT; coagulation studies; medical clearance; anesthesia evaluation; DEXA if osteoporosis risk	Medically unfit for surgery; >3 level corpectomy (high failure rate); severe osteoporosis	Neurologic exam post-op q2h x 24h; airway monitoring (retropharyngeal hematoma risk — EMERGENCY if stridor/dyspnea); dysphagia assessment; wound check; upright X-ray before discharge; higher risk of graft subsidence; longer immobilization; halo vest may be needed for multi-level	-	URGENT	ROUTINE	URGENT
Laminoplasty (open-door or French-door)	Surgical	Multi-level posterior compression (3+ levels); preserved cervical lordosis; OPLL; congenital stenosis	Surgical procedure; posterior approach; unilateral or bilateral hinge creation to expand canal	Pre-operative MRI and CT; coagulation studies; medical clearance; anesthesia evaluation	Cervical kyphosis (will not decompress anteriorly compressed cord); instability; prior posterior surgery at same levels	Neurologic exam post-op q2h x 24h; C5 palsy monitoring (deltoid/biceps weakness — occurs in 5-10%; usually recovers); wound drainage; neck range of motion at follow-up	-	URGENT	ROUTINE	URGENT
Posterior cervical laminectomy with lateral mass fusion	Surgical	Multi-level posterior compression with instability; failed laminoplasty; need for deformity correction	Surgical procedure; laminectomy + lateral mass screw fixation + rod placement + fusion	Pre-operative MRI and CT; coagulation studies; medical clearance; anesthesia evaluation; CT angiography if vertebral artery anomaly suspected	Medically unfit for surgery; vertebral artery anomaly at planned screw levels (relative)	Neurologic exam post-op q2h x 24h; C5 palsy monitoring (deltoid/biceps weakness); wound drainage; hardware position on X-ray; wound drainage monitoring; motion restriction during fusion	-	URGENT	ROUTINE	URGENT

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Neurology consult for diagnosis confirmation, myelopathy severity grading (mJOA score), and differentiation from non-spondylotic myelopathy	STAT	STAT	ROUTINE	STAT
Spine surgery (neurosurgery or orthopedic spine) for surgical candidacy evaluation in moderate-severe myelopathy (mJOA <15) or progressive deficit	STAT	STAT	ROUTINE	STAT
Physical therapy for gait training, balance assessment, fall prevention, strengthening of upper and lower extremities, and cervical stabilization exercises	-	URGENT	ROUTINE	URGENT
Occupational therapy for fine motor assessment, hand dexterity rehabilitation (myelopathy hand), ADL adaptation, assistive device fitting, and home safety evaluation	-	URGENT	ROUTINE	URGENT
Pain management referral for refractory neuropathic pain not responding to first-line and second-line agents, or for consideration of interventional procedures (cervical epidural steroid injection, nerve blocks)	-	ROUTINE	ROUTINE	-
Rehabilitation medicine (physiatry) for comprehensive functional assessment, rehabilitation program coordination, and disposition planning	-	ROUTINE	ROUTINE	-
Urology for neurogenic bladder evaluation, urodynamic testing, and management of urinary retention or incontinence	-	ROUTINE	ROUTINE	-
Speech-language pathology for swallow evaluation if dysphagia symptoms present (cervical cord compression may affect bulbar function; also assess post-operatively after anterior cervical surgery)	-	ROUTINE	ROUTINE	-
Respiratory therapy for pulmonary function assessment if high cervical cord compression (C3-C5) affecting diaphragmatic function	-	URGENT	-	STAT
Social work for discharge planning, durable medical equipment coordination, disability assessment, and caregiver support	-	ROUTINE	ROUTINE	-
Psychology or psychiatry for adjustment disorder, depression, and anxiety related to chronic disability and functional limitation	-	ROUTINE	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Return to ED immediately if sudden worsening of weakness, new inability to walk, loss of bowel or bladder control, or difficulty breathing (may indicate acute cord compression requiring emergency surgery)	STAT	STAT	ROUTINE
Avoid high-risk activities including contact sports, diving, trampolines, roller coasters, and extreme neck flexion/extension (risk of acute cord injury with narrowed spinal canal)	URGENT	ROUTINE	ROUTINE
Use caution on stairs and uneven surfaces; use handrails at all times due to impaired balance and gait instability from myelopathy	-	ROUTINE	ROUTINE
Do not drive until cleared by neurology or spine surgeon due to impaired hand dexterity, delayed reaction time, and balance impairment	-	ROUTINE	ROUTINE
Perform prescribed physical therapy and occupational therapy exercises between sessions to maintain and improve function	-	ROUTINE	ROUTINE
Report any new numbness in hands, increasing hand clumsiness (dropping objects, difficulty with buttons), or worsening gait to your neurologist promptly as these may indicate disease progression requiring surgical intervention	-	ROUTINE	ROUTINE
If wearing cervical collar, follow prescribed schedule; perform skin checks under collar daily to prevent pressure sores	-	ROUTINE	ROUTINE
After cervical spine surgery: follow all post-operative activity restrictions; report fever, wound drainage, increasing pain, new weakness, or difficulty swallowing immediately	-	ROUTINE	ROUTINE
Keep follow-up appointments with spine surgeon and neurologist; repeat MRI will be needed to monitor response to treatment	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Smoking cessation to improve surgical outcomes and reduce pseudarthrosis risk (smoking impairs bone fusion by up to 2-3 fold)	-	ROUTINE	ROUTINE
Fall prevention: remove loose rugs, install grab bars in bathroom, use non-slip mats, adequate lighting, and wear supportive footwear with non-slip soles	-	ROUTINE	ROUTINE
Ergonomic workstation setup: monitor at eye level, avoid prolonged neck flexion (looking down at phone/laptop), use document holders, take breaks every 30 minutes	-	-	ROUTINE
Weight management to reduce axial loading on cervical spine and optimize surgical outcomes (BMI >35 associated with worse outcomes)	-	ROUTINE	ROUTINE
Low-impact exercise program (swimming, stationary cycling, walking) to maintain cardiovascular fitness and muscle strength without high-impact cervical loading	-	ROUTINE	ROUTINE
Cervical spine protection: avoid extreme neck flexion/extension; use appropriate cervical pillow for sleep; avoid overhead work for prolonged periods	-	ROUTINE	ROUTINE
Bone health optimization: calcium 1000-1200 mg/day + vitamin D 1000-2000 IU/day for patients with osteoporosis risk to improve fusion outcomes	-	ROUTINE	ROUTINE
Bowel program maintenance with adequate fiber (25-30 g/day), fluid intake (2L/day), and regular toileting schedule to prevent neurogenic bowel complications	-	ROUTINE	ROUTINE
Depression and anxiety screening at each follow-up visit using PHQ-9 and GAD-7; chronic myelopathy carries high rates of mood disorders	-	ROUTINE	ROUTINE
Alcohol moderation to reduce fall risk and avoid interaction with medications (gabapentin, pregabalin, muscle relaxants)	-	ROUTINE	ROUTINE

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5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Multiple sclerosis (MS)	Young adult; relapsing-remitting course; short segment cord lesion (<3 vertebral segments); brain lesions (periventricular, juxtacortical); optic neuritis; Lhermitte sign present in both MS and CSM	MRI brain (periventricular/juxtacortical lesions); CSF oligoclonal bands; cord lesion pattern (eccentric, short segment in MS vs central cord compression in CSM)
Vitamin B12 deficiency (subacute combined degeneration)	Symmetric posterior column dysfunction (proprioception, vibration loss) + corticospinal tract signs; macrocytic anemia; cognitive changes; peripheral neuropathy	Serum B12; methylmalonic acid; homocysteine; CBC (macrocytosis); normal MRI spine structurally (cord T2 signal in posterior columns)
Amyotrophic lateral sclerosis (ALS)	Combined upper and lower motor neuron signs WITHOUT sensory findings; fasciculations; bulbar symptoms (dysarthria, dysphagia); progressive course without pain	EMG/NCS (diffuse denervation in 3+ regions); no sensory loss; no cord compression on MRI; no bladder dysfunction initially
Syringomyelia	"Cape-like" suspended sensory loss (pain/temperature); hand weakness; may coexist with Chiari malformation; progressive	MRI cervical spine (syrinx cavity within cord); MRI brain/cervicomedullary junction (Chiari); CSF flow study
Normal pressure hydrocephalus (NPH)	Gait apraxia (magnetic gait); urinary incontinence; cognitive decline (triad); shuffling rather than spastic gait	MRI brain (ventriculomegaly out of proportion to atrophy); lumbar puncture with large-volume tap test (gait improvement)
Copper deficiency myelopathy	Mimics B12 deficiency; posterior column + corticospinal tract; history of gastric surgery, zinc supplements, or chronic zinc exposure	Serum copper and ceruloplasmin (low); zinc level (may be elevated); MRI (posterior column T2 signal)
HTLV-1 associated myelopathy (HAM/TSP)	Progressive spastic paraparesis; endemic areas (Caribbean, Japan, sub-Saharan Africa); bladder dysfunction prominent; slow progression over years	HTLV-1 antibody (serum and CSF); MRI may show cord atrophy without structural compression
Spinal dural arteriovenous fistula (dAVF)	Older male; progressive myelopathy; flow voids on MRI; dorsal cord edema disproportionate to enhancement; stepwise or progressive course	MRI (flow voids, dorsal cord edema); spinal angiography (gold standard); presentation overlaps with CSM in older patients
Hereditary spastic paraplegia	Family history; slowly progressive bilateral lower extremity spasticity; onset often younger; minimal sensory findings; normal MRI structurally	Genetic testing (SPG genes); family history; MRI spine (cord atrophy without compression); EMG/NCS
Vascular myelopathy (spinal cord infarction)	Hyperacute onset (minutes to hours); anterior spinal artery syndrome (motor + pain/temperature loss, preserved proprioception); vascular risk factors	MRI DWI (restricted diffusion); CTA aorta; vascular risk factors; onset is acute (vs CSM which is chronic/progressive)
Ossification of posterior longitudinal ligament (OPLL)	Overlaps with CSM; more common in East Asian populations; may be incidental on imaging; progressive myelopathy from ossified ligament	CT cervical spine (ossified ligament — better seen than MRI); MRI for cord compression and signal change; distinguished by mechanism but managed similarly to CSM
Functional neurological disorder (FND)	Non-anatomic sensory loss; Hoover sign; give-way weakness; inconsistent exam findings; normal MRI	Normal MRI spine; normal electrodiagnostic studies; positive signs on exam (Hoover, drift without pronation)

6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Neurologic exam (motor strength, sensory level, reflexes, gait assessment, hand dexterity — grip and release test)	ED: at presentation; HOSP: q4-8h x 48h, then q shift; OPD: each visit; ICU: q2-4h	Stable or improving; no ascending sensory level; grip-release >20 in 10 seconds	If worsening motor exam or ascending sensory level: STAT MRI; urgent surgical consult	STAT	STAT	ROUTINE	STAT
mJOA score (modified Japanese Orthopaedic Association)	At initial evaluation; at each outpatient visit; pre- and post-operatively	Mild ≥15; Moderate 12-14; Severe <12; goal is stability or improvement	mJOA <12 or declining score: urgent surgical referral; mJOA decline >1 point warrants re-evaluation	STAT	ROUTINE	ROUTINE	STAT
Respiratory function (FVC, NIF) — if C3-C5 compression	q4-6h if cervical cord compression above C5; q2h if declining	FVC >20 mL/kg; NIF more negative than -30 cmH2O	FVC <20 mL/kg or NIF weaker than -30 cmH2O: ICU transfer; prepare for intubation	STAT	STAT	-	STAT
Bladder function (post-void residual)	At initial evaluation; daily inpatient; each outpatient visit initially	PVR <200 mL	PVR >200 mL: start intermittent catheterization; >500 mL: Foley catheter; urology referral	URGENT	ROUTINE	ROUTINE	URGENT
Pain assessment (NRS 0-10; neuropathic pain screening — DN4 or LANSS)	At initial evaluation; daily inpatient; each outpatient visit	NRS <4 with treatment; identification of neuropathic component	NRS >6 despite treatment: escalate analgesics; consider pain management referral; distinguish nociceptive vs neuropathic	URGENT	ROUTINE	ROUTINE	URGENT
Gait assessment (Nurick grade; 10-meter walk test; Timed Up and Go)	At initial evaluation; each outpatient visit; post-operatively at 6 weeks, 3 months, 6 months, 12 months	Stable or improving; Nurick grade ≤3	Progressive gait deterioration: urgent surgical reassessment; PT intensification	-	ROUTINE	ROUTINE	-
Post-operative airway (after anterior cervical surgery)	q1h x 6h post-op, then q2h x 18h	No stridor; no progressive dyspnea; no neck swelling	Stridor or progressive neck swelling: EMERGENCY — retropharyngeal hematoma; STAT surgical evacuation; secure airway	-	STAT	-	STAT
Post-operative neurologic exam	q2h x 24h post-op, then q4h	Stable or improved from pre-operative baseline; no new deficits	New post-operative weakness (especially C5 palsy with deltoid/biceps weakness): STAT MRI to rule out epidural hematoma; dexamethasone; most C5 palsies recover over weeks-months	-	STAT	-	STAT
Imaging follow-up (X-ray cervical spine)	Post-operative: before discharge, 6 weeks, 3 months, 6 months, 12 months, then annually	Hardware in position; progressive fusion; maintained alignment; no adjacent segment disease	Hardware failure, cage subsidence, pseudarthrosis: surgical revision consideration; adjacent segment disease: monitor closely, repeat MRI if symptomatic	-	ROUTINE	ROUTINE	-
MRI cervical spine follow-up	3-6 months post-operative; then if new symptoms; annually for conservatively managed patients	Cord decompression; resolving T2 signal change; no new compression; no adjacent segment stenosis	Persistent or new cord compression: surgical reassessment; worsening signal change: poor prognostic sign	-	ROUTINE	ROUTINE	-
Blood glucose (on corticosteroids)	q6h while on IV steroids; daily on oral taper	<180 mg/dL	Sliding scale insulin; endocrine consult if persistent hyperglycemia	STAT	ROUTINE	-	STAT
Skin assessment (pressure areas)	q shift inpatient; daily if wearing cervical collar	Intact skin; no erythema under collar or at pressure points	Pressure relief; collar padding; wound care; specialty mattress if immobile	-	ROUTINE	ROUTINE	ROUTINE

7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Mild myelopathy (mJOA ≥15); stable exam; ambulatory without significant fall risk; independent bladder function (PVR <200 mL); adequate pain control on oral medications; MRI completed; surgical referral arranged if indicated; home environment safe; reliable follow-up within 1-2 weeks
Admit to floor	Moderate-severe myelopathy (mJOA <15); progressive neurologic deficit requiring observation; inability to ambulate safely; neurogenic bladder requiring catheterization; IV steroids indicated; pending surgical evaluation; inadequate pain control; need for inpatient PT/OT assessment
Admit to ICU	High cervical cord compression (C3-C5) with respiratory compromise (FVC <20 mL/kg); post-operative monitoring after complex cervical spine surgery; hemodynamic instability; acute deterioration with rapidly progressive quadriparesis
Post-operative ICU	Complex multi-level surgery; significant blood loss; airway concerns after anterior approach; hemodynamic instability; pre-existing pulmonary compromise
Transfer to higher level	Need for spine surgery not available at current facility; need for MRI not available emergently; need for neurology/neurosurgery subspecialty input
Inpatient rehabilitation	Significant motor deficits preventing independent ADLs; gait impairment requiring assistive device training; neurogenic bladder/bowel requiring structured program; able to participate in 3 hours/day of therapy
Skilled nursing facility	Unable to tolerate 3 hours/day of intensive rehabilitation; requires skilled nursing care; ongoing wound care; cannot return home safely

8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
Surgical decompression superior to conservative management for moderate-severe CSM	Class I, Level B	Fehlings et al. CSM-North America (2013); Fehlings et al. Spine (2017)
Earlier surgical intervention associated with better neurologic outcomes in moderate-severe CSM	Class IIa, Level B	Tetreault et al. Neurosurgery (2015); duration of symptoms is strongest predictor of outcome
mJOA score validated for severity grading and surgical decision-making in CSM	Class I, Level B	Tetreault et al. Global Spine J (2015); mild ≥15, moderate 12-14, severe <12
MRI T2 signal change (myelomalacia) correlates with worse surgical outcomes	Class II, Level B	Nouri et al. Spine (2015); Tetreault et al. Spine (2013)
T1 hypointensity on MRI indicates irreversible cord damage and poorer prognosis	Class II, Level B	Nouri et al. Spine J (2017)
ACDF effective for 1-2 level anterior compression in CSM	Class I, Level B	Ghogawala et al. Lancet Neurol (2019)
Laminoplasty effective for multi-level posterior compression with preserved lordosis	Class IIa, Level B	Hirabayashi et al. Spine (1983); original technique; multiple validation studies
C5 palsy occurs in 5-10% after posterior decompression; usually recovers	Class II, Level B	Nassr et al. J Bone Joint Surg Am (2012)
Conservative management reasonable for mild CSM (mJOA ≥15) with close monitoring	Class IIb, Level C	Kadanka et al. Spine (2011); mild cases may not progress; surgery for progression
Smoking cessation improves fusion rates and surgical outcomes	Class I, Level B	Berman et al. Spine (2017); pseudarthrosis rates 2-3x higher in smokers
Gabapentin and pregabalin effective for neuropathic pain in myelopathy	Class I, Level A	Finnerup et al. Lancet Neurol (2015); NeuPSIG guidelines for neuropathic pain
Baclofen first-line for spasticity in spinal cord conditions	Class I, Level B	Expert consensus; extensive clinical experience; Taricco et al. Cochrane (2000)
DVT prophylaxis in acute myelopathy with immobilization	Class I, Level A	High thrombotic risk in immobilized patients with spinal cord dysfunction; Geerts et al. Chest (2008)
Retropharyngeal hematoma is life-threatening complication after anterior cervical surgery requiring emergent surgical evacuation	Class I, Level C	Palumbo et al. Eur Spine J (2012); incidence 1-6%; airway compromise can be fatal
AAN/CNS/AANS guidelines recommend against conservative management for rapidly progressive CSM	Class I, Level B	Mummaneni et al. J Neurosurg Spine (2009)
Flexion-extension X-rays for dynamic instability assessment in CSM	Class II, Level C	Expert consensus; translation >3.5 mm or angulation >11° indicates instability requiring fusion
Tandem stenosis (cervical + lumbar) present in 5-25% of CSM patients	Class II, Level C	Dagi et al. J Neurosurg Spine (2011); always evaluate for tandem stenosis
OPLL more common in East Asian populations; CT superior to MRI for detection	Class II, Level B	Epstein et al. Spine (2002); prevalence 1.9-4.3% in Japanese populations
Intermittent catheterization preferred over indwelling catheter for neurogenic bladder	Class I, Level B	Spinal cord injury guidelines; lower UTI rates with intermittent catheterization

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CHANGE LOG

v1.1 (January 31, 2026) - Standardized all medication dosing to structured dose :: route :: frequency :: full_instructions format across Sections 3A, 3B, and 3C (enables clickable order sentences in clinical tool) - Fixed Dexamethasone dosing field (removed embedded route/frequency from standard_dose field) - Fixed Methylprednisolone dosing field (moved frequency to correct field) - Fixed Famotidine and Pantoprazole dosing fields (separated dose from frequency) - Fixed Enoxaparin and Heparin dosing fields (separated dose from frequency) - Cleaned all Section 3B medications: removed dose-tier lists from standard_dose field, populated empty frequency fields (Gabapentin, Pregabalin, Duloxetine, Amitriptyline, Baclofen, Tizanidine, Dantrolene, Acetaminophen, Naproxen, Ibuprofen, Cyclobenzaprine, Methocarbamol, Oxybutynin, Mirabegron, Tamsulosin, Docusate, Senna, PEG 3350, Trazodone, Melatonin, Sertraline) - Cleaned all Section 3C medications: Intrathecal baclofen pump, Tramadol, Lidocaine patch, Diazepam, Carbamazepine - Fixed Mirabegron HOSP setting from "-" to "ROUTINE" (can be prescribed/continued inpatient) - Eliminated cross-references in Section 2B imaging (MRI thoracic, MRI brain: replaced "Same as cervical MRI" with actual contraindication content) - Eliminated cross-reference in Section 2C imaging (Upright/dynamic MRI: replaced "Same as MRI" with actual contraindications) - Eliminated cross-references in Section 3D surgical monitoring (ACCF: replaced "Same as ACDF" with standalone monitoring content; Posterior laminectomy + fusion: replaced "Same as laminoplasty" with standalone monitoring content) - Version bumped from v1.0 to v1.1

v1.0 (January 30, 2026) - Initial template creation - Comprehensive coverage of degenerative cervical myelopathy across ED, HOSP, OPD, ICU settings - Includes conservative management, symptomatic treatment, and surgical options (ACDF, corpectomy, laminoplasty, laminectomy + fusion) - mJOA severity grading incorporated into monitoring and disposition - Post-operative monitoring parameters including C5 palsy and retropharyngeal hematoma - Full neuropathic pain, spasticity, and neurogenic bladder management

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APPENDIX A: mJOA Score (Modified Japanese Orthopaedic Association Score)

Domain	Score	Description
Motor dysfunction — Upper extremity	0	Inability to move hands
	1	Inability to eat with a spoon but able to move hands
	2	Inability to button shirt but able to eat with a spoon
	3	Able to button shirt with great difficulty
	4	Able to button shirt with mild difficulty
	5	No dysfunction
Motor dysfunction — Lower extremity	0	Complete loss of motor and sensory function
	1	Sensory preservation without ability to move legs
	2	Able to move legs but unable to walk
	3	Able to walk on flat floor with walking aid
	4	Able to walk up or down stairs with handrail
	5	Moderate to significant lack of stability but able to walk unaided
	6	Mild lack of stability but walks with smooth reciprocal pattern
	7	No dysfunction
Sensation — Upper extremity	0	Complete loss of hand sensation
	1	Severe sensory loss or pain
	2	Mild sensory loss
	3	No dysfunction
Sensation — Lower extremity	0	Complete loss of sensation
	1	Severe sensory loss or pain
	2	Mild sensory loss
	3	No dysfunction

Total Score: 0-18

Severity	mJOA Score	Management
Mild	≥15	Conservative management with close monitoring; surgery if progression
Moderate	12-14	Surgical decompression recommended
Severe	<12	Surgical decompression strongly recommended; earlier surgery = better outcomes

APPENDIX B: Surgical Approach Selection Guide

Clinical Scenario	Preferred Approach	Rationale
1-2 level anterior compression, maintained lordosis	ACDF	Direct decompression; high fusion rate; good outcomes
2-3 level anterior compression, vertebral body pathology	ACCF (corpectomy)	Wider decompression; addresses OPLL/body involvement
≥3 level compression, maintained lordosis, no kyphosis	Laminoplasty	Preserves motion; avoids anterior approach risks; effective posterior decompression
Multi-level compression with instability or kyphosis	Posterior laminectomy + fusion	Addresses instability; deformity correction; instrumented fixation
Combined anterior + posterior compression	Combined (staged or same-day)	360° decompression for severe cases
OPLL (continuous or mixed type)	Posterior approach preferred (laminoplasty or laminectomy + fusion)	Avoids risk of OPLL fragment displacement from anterior approach; exception: segmental OPLL may be approached anteriorly

Key Factors in Approach Decision: - Cervical alignment (lordosis vs kyphosis) - Number of levels involved - Location of compression (anterior vs posterior vs circumferential) - OPLL presence and type - Patient age and comorbidities - Bone quality (osteoporosis status) - Surgeon experience and preference