STUDY DESIGN: Literature Review (Narrative). OBJECTIVE: To propose a new framework, to support the investigation and understanding of the pathobiology of DCM, AO Spine RECODE-DCM research priority number 5. METHODS: Degenerative cervical myelopathy is a common and disabling spinal cord disorder. In this perspective, we review key knowledge gaps between the clinical phenotype and our biological models. We then propose a reappraisal of the key driving forces behind DCM and an individual's susceptibility, including the proposal of a new framework. RESULTS: Present pathobiological and mechanistic knowledge does not adequately explain the disease phenotype; why only a subset of patients with visualized cord compression show clinical myelopathy, and the amount of cord compression only weakly correlates with disability. We propose that DCM is better represented as a function of several interacting mechanical forces, such as shear, tension and compression, alongside an individual's vulnerability to spinal cord injury, influenced by factors such as age, genetics, their cardiovascular, gastrointestinal and nervous system status, and time. CONCLUSION: Understanding the disease pathobiology is a fundamental research priority. We believe a framework of mechanical stress, vulnerability, and time may better represent the disease as a whole. Whilst this remains theoretical, we hope that at the very least it will inspire new avenues of research that better encapsulate the full spectrum of disease.

Department of Neurological Surgery 6559Thomas Jefferson University Philadelphia PA USA

Department of Neurology University Hospital Brno and Faculty of Medicine 37748Masaryk University Brno Czech Republic

Department of Neurosurgery 2152University of Cambridge Cambridge UK

Department of Neurosurgery 5506Medical College of Wisconsin Wauwatosa WI USA

Department of Neurosurgery 60078St Vincent's Hospital Melbourne Fitzroy VIC Australia

Department of Neurosurgery 8789University of California Davis Sacramento CA USA

Department of Neurosurgery and the Miami Project to Cure Paralysis The Miller School of Medicine 12235University of Miami Miami FL USA

Department of Neurosurgery Sina Trauma and Surgery Research Center 48439Tehran University of Medical Sciences Tehran Iran

Department of Orthopaedics and Traumatology Li Ka Shing Faculty of Medicine 25809The University of Hong Kong Hong Kong China

Department of Pathology Brain Research Institute 12978Niigata University Niigata Japan

Division of Anaesthesia Department of Medicine 2152University of Cambridge Cambridge UK

Division of Neurosurgery Department of Surgery 7938University of Toronto Toronto ON Canada

Division of Neurosurgery Geneva University Hospitals 27230University of Geneva Genève Switzerland

Instituto de Ciências Biomédicas Abel Salazar Porto Portugal

New York University Langone Health Graduate Medical Education 5894Department of Neurology New York NY USA

Spinal Unit Department of Orthopaedics 112085Centro Hospitalar Universitário do Porto Hospital de Santo António Porto Portugal

University Spine Center 31031Balgrist University Hospital Zurich Switzerland

Vancouver Spine Surgery Institute Department of Orthopedics The University of British Columbia Vancouver BC Canada

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Evidence-based commentary on the diagnosis, management, and further research of degenerative cervical spinal cord compression in the absence of clinical symptoms of myelopathy