Spine 2026;51(16):1123–1129
The optimal timing of surgery for degenerative cervical myelopathy remains important because neurological decline may be slow and apparently tolerable. This large prospective multicenter cohort relates symptom duration to neurological recovery and patient-reported physical health. Surgery produced clinically meaningful neurological improvement even after prolonged symptoms. However, patients operated within two years were more likely to achieve meaningful improvement in physical quality of life. The study supports timely referral without implying that patients with longstanding disease no longer benefit.
Objective
To determine how symptom duration before surgery influences neurological, functional and patient-reported recovery after operative treatment for degenerative cervical myelopathy.
Methods
The prospective cohort included 874 patients treated at 10 institutions and followed for 2 years. Symptom duration was categorized as less than 6 months, 6 months to 2 years, 2–5 years or at least 5 years. Outcomes included the Japanese Orthopaedic Association score, SF-36, pain and neuropathic-pain scales, and JOACMEQ domains. Minimum clinically important differences were 2.5 points for JOA and 4 points for the SF-36 physical component.
Main results
Every symptom-duration group exceeded the minimum clinically important improvement in JOA score, including patients symptomatic for at least 5 years. In contrast, only patients with symptoms for less than 2 years exceeded the clinically important threshold for improvement in the SF-36 physical component.
After adjustment for relevant covariates, shorter symptom duration was associated with better recovery of extremity and bladder function and better quality-of-life outcomes on the JOACMEQ.
Interpretation
Delayed surgery does not eliminate the possibility of neurological improvement, but it may reduce the probability that recovery translates into a patient-perceived gain in physical health. The two-year point is a prognostic association rather than a rigid biological deadline.
Limitations
Patients were not randomized to early or delayed surgery, so symptom duration may correlate with access to care, disease phenotype or unmeasured severity. Recall of symptom onset can be imprecise. The cohort and instruments were predominantly Japanese, and the results do not identify ideal timing for an individual patient with mild or stable disease.
Clinical takeaway
Refer and evaluate degenerative cervical myelopathy promptly. Surgery can still be worthwhile after years of symptoms, but counseling should explain that intervention within two years is associated with a better chance of meaningful physical and quality-of-life recovery.
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