Presenting Symptoms Define Time to Diagnosis in Degenerative Cervical Myelopathy: Process Mapping From a Musculoskeletal Triage Unit in the UK.

Abstract

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Tackling delayed diagnosis in degenerative cervical myelopathy (DCM) is a global research priority. On average, it takes 2-5 years, leading to worse outcomes from surgery and greater disability. Many countries in the UK use interface triage units run by specialist physiotherapists that sit between primary and secondary care termed musculoskeletal services. Their role in the efficient diagnosis of DCM is unknown. The aim of this study was to map the journey of the patient in the musculoskeletal service and to establish the presenting signs and symptoms. METHODS: A retrospective review of 2.5 years of clinical notes was performed in a musculoskeletal service. Process mapping was utilised to visualise the patient's journey and identify delays to diagnosis and presenting signs and symptoms. RESULTS: Twenty-seven cases were reviewed. Patients spent an average of three months in the service. There was a wide variety of presenting symptoms. DCM was more often suspected if patients had both upper limb symptoms and gait disturbance or pathological reflexes. Delays occurred when patients had no gait disturbance or a normal or incomplete neurological assessment. Longest delays occurred when patients received electrophysiology tests for differential diagnosis of peripheral neuropathies. Delays were also seen with incorrect triaging of MRI results. CONCLUSIONS: Where DCM is the principal differential diagnosis, diagnosis was faster. Incomplete examination, misinterpretation of MRI findings or delays in other investigations contributed to delays. Improved awareness and protocols of care within musculoskeletal services represent an opportunity to accelerate diagnosis in DCM.