Degenerative Cervical Myelopathy and Clinical Predictors of Neurological Deterioration: A Structured Narrative Review

Background: Degenerative cervical myelopathy (DCM) has a heterogeneous course, ranging from prolonged stability to progressive loss of hand function, gait, and independence. Risk estimates are complicated by differences between incident myelopathy, deterioration of established disease, and postoperative recovery. Objective: To critically evaluate clinical predictors of neurological deterioration and their interaction with imaging, electrophysiology, and longitudinal assessment. Methods: A targeted PubMed-based narrative review examined guidelines, nonoperative natural-history cohorts, prospective studies of nonmyelopathic cord compression, and prognostic investigations available through October 24, 2026. Endpoints and populations were analyzed separately; no new meta-analysis or prediction model was developed. Results: Worsening gait, hand dexterity, objective weakness, and sphincter function are important indicators of clinical progression, but few baseline features reliably predict an individual trajectory. Symptomatic radiculopathy and electrophysiological abnormalities predict incident myelopathy in selected nonmyelopathic compression cohorts. Their effect sizes should not be transferred directly to established DCM. Historical reviews report deterioration in 20%–62% of nonoperatively treated symptomatic patients over several years, whereas a recent mild-DCM cohort reported 13.3% deterioration at one year among evaluable patients. These estimates differ in severity, follow-up, and outcome definition. Cord signal change, instability, and quantitative MRI can refine concern, but no imaging-only threshold reliably determines deterioration or surgical timing. Conclusions: Serial clinical change is more actionable than an isolated baseline risk marker. Moderate or severe DCM and neurological deterioration warrant surgical assessment; selected mild stable disease may be observed with structured follow-up and explicit escalation criteria.