Neck pain may exist within the entire spectrum of DCM. Patients may initially present to a clinician with simple neck pain or stiffness, and as the condition progresses, patients may experience gait ataxia, autonomic dysfunction, limb weakness, and severe neurological impairment. The physical examination of these patients may reveal signs indicative of upper motor neuron disease, suggestive of spinal cord pathology. A common way of functionally grading DCM patients is with the modified Japanese Orthopaedics Association (mJOA) score. The mJOA score is a specialised clinical tool used to evaluate the severity of neurological deficits in patients with cervical myelopathy. The mJOA assesses motor function in the extremities, sensory function in the upper extremities and trunk, and bladder function. The total score ranges from 0 to 18 with lower scores indicating a more severe neurological impairment. Interpretation of the mJOA score in conjunction with clinical assessment and radiological findings is useful for the diagnosis of cervical myelopathy. Neck pain is not scored in mJOA. Clinicians can alternately use the Neck Disability Index (NDI), a self-reported questionnaire designed to measure neck specific disability by assessing the impact of neck pain on a patient’s daily life.

Neck pain is not always a major symptom but is often an associated symptom of DCM. Neck pain is reported to be as high as 80% in patients with DCM compared with the total population prevalence of neck pain at approximately 15% [12]. It is not known how neck pain is initiated, whether the cause is degeneration, inflammation, or movement. Within the spectrum of DCM, a critical gap remains in our understanding of the dynamic progression of clinical symptoms. Specifically, there is a lack of clarity regarding the fluctuating nature of symptomatology, including the phenomenon of waxing and waning symptoms, the presence of an unstable plateau phase, periods of clinical improvement, and eventual clinical deterioration. The prevalence and progression patterns along with risk factors are critical for the management of asymptomatic cervical cord compression (Supplementary 1). Symptom severity in DCM spans a broad spectrum, complicating the clinical identification of the onset of myelopathy.

The severity of DCM can vary depending on the extent of the damage to the spinal cord and the location of compression. Some individuals may experience only mild symptoms that do not significantly impact their daily lives, while others may experience significant disability and may require surgery. Not all of the clinical manifestations present as pain. Whilst the etiological factors for non-specific neck pain are poorly understood, neck pain correlates with spinal degeneration such as cervical spondylosis [13], however, in the context of DCM, neck pain is a confounder.