Table 3 Codebook for diagnostic clinical signs and symptoms in DCM.

1

Clinical Diagnosis

The process of diagnosing degenerative cervical myelopathy based on patient history, physical examination, and imaging studies.

‐ “Despite significant advances in the understanding of the disorder, cervical myelopathy remains a clinical diagnosis. Commonly used criteria in establishing the diagnosis include a history of myelopathic complaints, physical examination demonstrating myelopathic signs, and advanced imaging studies showing correlative compression of the cervical cord.”

‐ “While the presence of these clinical signs is helpful, examination findings may be absent entirely and a diagnosis of DCM can still be made using a combination of patient-reported symptoms and imaging findings.”

Emphasizes the importance of clinical diagnosis despite advancements in imaging.

2

Imaging Confirmation

Any deformation of the cervical spinal cord due to a compressive lesion observed on CT myelogram or MRI.

‐ “Cervical cord compression was defined as any deformation of the spinal cord due to a compressive lesion on CT myelogram or MRI.”

Imaging evidence is critical for confirming cervical cord compression.

3

Absence of Upper Motor Neuron Signs

Diagnosis of DCM can still be made even if upper motor neuron signs are absent.

‐ “The absence of upper motor neuron signs does not rule out a diagnosis of DCM.”

A diagnosis of DCM should not be excluded solely based on the absence of upper motor neuron signs.

4

Sensitivity of Clinical Tests for DCM

The effectiveness of clinical tests in correctly identifying patients with DCM.

‐ “The most sensitive clinical tests for diagnosing DCM are the Tromner sign and hyperreflexia.”

‐ “Most sensitive clinical examination: Tromner and hyperreflexia.”

Tromner sign and hyperreflexia are the most effective tests for initial screening of DCM.

5

Specificity of Clinical Tests for DCM

The effectiveness of clinical tests in correctly identifying patients without DCM.

‐ “The most specific tests are the Babinski, Tromner sign, clonus and inverted supinator sign.”

‐ “Only the inverted supinator sign and the Babinski sign demonstrated significant diagnostic accuracy.”

‐ “Clonus most specific.”

‐ “Most specific clinical examination: Babinski, Tromner, clonus and inverted supinator sign.”

Babinski, Tromner, clonus, and inverted supinator sign are crucial for confirming DCM diagnosis.

6

Diagnostic Accuracy of Clinical Signs in DCM Diagnosis

The reliability of specific clinical signs in diagnosing DCM.

‐ “Only the inverted supinator sign and the Babinski sign demonstrated significant diagnostic accuracy.”

‐ “The most accurate finding to confirm the presence of myelopathy on MRI was the Babinski sign in isolation. Combinations of findings did not improve the diagnostic accuracy of the tests at a rate greater than the standalone test of the Babinski sign.”

‐ “Hoffman may not be present.”

‐ “The Hoffmann sign may modestly increase the predicted probability of cervical spinal cord compression and offer a modest contribution to the overall diagnosis, it is not foolproof for the diagnosis of cervical spinal cord compression.”

Individual signs vary in reliability; combined findings often do not significantly enhance diagnostic accuracy.

7

Clinical Signs and Disease Severity

The relationship between various clinical signs and the severity of DCM.

‐ “There was no definite association between Hoffmann sign, Babinski sign or hyperreflexia and disease severity.

Indicates no clear link between certain clinical signs and disease severity.

8

Clinical Examination Preferences

Preferences for specific clinical signs during examination.

‐ “I always look for the inverted supinator reflex.”

‐ “Hoffmann and clonus”.

Spine surgeons may have preferences for specific signs, such as the inverted supinator reflex, due to their diagnostic value.

9

Sensitive Symptoms for DCM

Symptoms with high sensitivity for diagnosing DCM.

‐ “Hand numbness is frequently reported in DCM patients.”

‐ “Hand paresthesias are a commonly reported symptom in DCM.”

‐ “Loss of dexterity is a sensitive indicator for DCM, particularly in hand function.”

‐ “Neck pain is moderately to highly sensitive for diagnosing DCM, but not specific.”

‐ “Gait abnormalities are often present due to upper motor neuron and proprioceptive dysfunction.”

High sensitivity symptoms should raise suspicion of DCM.

10

Specific Symptoms for DCM

Symptoms with high specificity for diagnosing DCM.

‐ “Autonomic dysfunction is a rare but highly specific symptom for DCM.”

‐ “Bladder dysfunction is uncommon but more frequent than bowel or sexual impairment.”

Specific symptoms, though less sensitive, are still crucial to recognise.