Epidemiology of Hospitalization and Surgical Therapy in Degenerative Cervical Myelopathy: A Nationwide 20-Year Analysis

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Despite its clinical importance, nationwide data on long-term incidence and surgical management trends in Germany remain scarce. Methods : A retrospective analysis was conducted using the German Federal Statistical Office’s hospital discharge database covering all inpatient cases with the primary diagnosis of DCM (ICD-10-GM code M50.0) from 2005 to 2024. Annual case numbers, age and sex distributions, and surgical procedures were analyzed descriptively. Hospitalization rates per 100,000 inhabitants were calculated using mid-year population data. Results : Between 2005 and 2024, approximately 70,000 hospitalizations for DCM were recorded nationwide. Annual cases increased from 2,477 (2005) to a peak of 4,076 (2015), followed by stabilization at ~3,000 cases/year thereafter. Hospitalization rates rose from 3.0 to 4.9 per 100,000 inhabitants over the same period. DCM predominantly affected men (53%) and individuals aged 50–70 years, with a progressive shift toward older age groups. Mean length of stay decreased steadily from 9–10 days in 2005 to 6–7 days in 2024. Anterior surgical approaches consistently represented most procedures. While posterior and combined approaches accounted for a smaller proportion, their use increased steadily over time. Normalized to annual hospitalizations, the proportion of surgically treated cases rose from ~65% (2005) to ~88% (2023), indicating increasingly selective inpatient admission for operative management. Conclusions : The burden of DCM in Germany rose substantially over the past two decades before stabilizing at a high level. Surgical treatment remains dominated by anterior decompression and fusion, while posterior procedures gain relevance in complex or multilevel disease. Shorter hospital stays and increasing surgical ratios reflect optimized perioperative pathways and more selective inpatient care. These results provide a comprehensive foundation for health-care planning and resource allocation in the management of DCM. cervical myelopathy epidemiology hospital discharge database nationwide analysis cervical surgery OPS ACDF posterior decompression Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Degenerative cervical myelopathy (DCM) is the most common non-traumatic, progressive disorder of the spinal cord in adults [ 1 ]. It results from age-related degenerative changes in the cervical spine (such as disc herniation, osteophyte formation, ligament hypertrophy, and ossification) that cause chronic compression of the cervical spinal cord [ 2 ]. Clinically, DCM manifests with a combination of neck pain, radiculopathy, hand clumsiness, gait instability, and sphincter dysfunction, and it can lead to serious neurological disability if not treated [ 3 ]. While direct epidemiological data for Germany are lacking, estimates from other Western countries indicate that degenerative cervical myelopathy likely affects around 0.1–0.2% of adults, with prevalence increasing sharply in older age groups and many cases remaining undiagnosed [ 4 ]. However, the condition remains underrecognized and underdiagnosed, often being mistaken for other disorders (e.g. peripheral neuropathies) in its early stages. This diagnostic delay means many patients present late, with established myelopathic deficits, which underscores the need for greater awareness and timely intervention [ 3 ]. Surgical decompression is the cornerstone of treatment for DCM. Timely surgery halts the neurologic deterioration and, in most cases, leads to significant functional improvement or recovery [ 5 , 6 ]. Thus, from both a clinical and public health perspective, early diagnosis and surgical referral are critical to prevent irreversible disability. Despite its clinical importance, there have been relatively few longitudinal epidemiological studies examining how the burden of DCM and its surgical management have evolved over time on a national scale. Understanding long-term trends in incidence, patient demographics, and surgical practices can inform healthcare planning and identify gaps in care (for example, potential under-treatment of certain populations). In this study, we present a 20-year nationwide analysis of DCM in Germany, leveraging a comprehensive hospital discharge database. Our objectives were to characterize the epidemiology of DCM from 2005 to 2024 – including incidence of hospitalizations, age and gender distribution of patients – and to evaluate trends in surgical therapy for DCM. Methods Ethical statement The data used in this analysis were aggregated at a national level and fully de-identified. Therefore, no informed consent or ethical approval is required. Study Design and Data Source We conducted a retrospective longitudinal study using the nationwide hospital discharge data from the German Federal Statistical Office (Statistisches Bundesamt). Specifically, we analyzed the DRG (Diagnosis-Related Group) statistics for the years 2005 through 2024. This database captures all patients discharged from hospitals in Germany and includes information on primary diagnoses, procedures, age, sex and length of hospital stay for each admission. Population and Case Identification Degenerative cervical myelopathy (DCM) cases were identified using the ICD-10-GM code M50.0 ( Cervical disc disorder with myelopathy: cervical intervertebral disc degeneration or herniation causing spinal cord compression ). All inpatient cases with a primary diagnosis of DCM were included irrespective of comorbidities or surgical treatment. For each calendar year, the following variables were extracted: Total number of DCM hospitalizations (overall, male, female) Mean length of stay (LOS) Age-specific distribution of DCM cases Surgical Treatment Modalities and Procedure Categorization All surgical interventions performed in hospital cases with a primary diagnosis of Degenerative cervical myelopathy (DCM; ICD-10-GM M50.0) were documented using the German procedure classification system OPS (“Operationen- und Prozedurenschlüssel”). For each year, the dataset provides the complete list of OPS-codes recorded for all cases with the main diagnosis M50.0, but does not allow differentiation which specific OPS code belongs to which individual hospital stay or whether multiple OPS were applied in the same case. Given this limitation, we conducted descriptive analyses on the frequency of OPS-codes across all recorded hospitalizations, stratified by surgical access route and technique. The selected OPS codes were mapped into the following groups and summarized in Table 1. Group Approach & Techniques Example OPS Codes Description A1) Anterior (ventral) decompression Ventral access, decompression 5-030.70 (1 Segment) / 5-030.72 (more than 2 segments) Anterior cervical access, disc removal or decompression A2) Anterior instrumentation/fusion Ventral access with stabilization/ fusion e.g., 5-836.5 (ventral spondylodesis) Anterior access + plate/screw, cage or fusion after decompression B1) Posterior (dorsal) decompression Dorsal access, decompression 5-030.30 / 5-030.32 (dorsal decompression codes) Posterior cervical access, e.g., laminectomy B2) Posterior decompression with instrumentation/fusion Dorsal access with stabilization/ fusion 5-836.3 (dorsal spondylodesis) Posterior cervical access with implants/ fusion C) Revision surgeries Secondary operation after initial procedure Example: 5-839.x (revision of a cervical spine operation) Re-operation, implant exchange or re-decompression D) Combined/hybrid approaches (ventral + dorsal procedures) Ventral + dorsal access or multilevel/multisegmental access 5-836.4 (dorsal and ventral combined) Complex procedure with both anterior and posterior access in the same operation E) Vertebral body replacement Ventral corpectomy with vertebral body prosthesis 5-837.x Replacement of a cervical vertebral body using prosthesis following corpectomy F) Disc arthroplasty Ventral access, disc removal and artificial disc implantation 5-839.1 Cervical disc replacement with prosthesis instead of fusion Table 1. Overview of surgical procedures for degenerative cervical myelopathy (DCM) according to the German OPS system. The table summarises the predefined categories used to group procedures by surgical approach and technique. Representative OPS codes and short descriptions are provided for each category. Abbreviations: OPS – Operationen- und Prozedurenschlüssel (German Procedure Classification); DCM – degenerative cervical myelopathy. Because cases cannot be individually assigned, the analysis describes aggregate volumes of each procedure group per year, rather than linking specific OPS codes to individual patient outcomes. Outcomes The primary outcomes assessed were: Annual incidence of DCM hospitalizations: expressed as the total number of DCM cases per year nationwide. We also calculated hospitalization rates per 100,000 population for each year using mid-year population estimates for Germany for context. Population data were obtained from the Federal Statistical Office of Germany. Hospitalization rates were calculated as: Patient demographics: including the age distribution and sex ratio of DCM patients over time. The source data provided counts in discrete age brackets (in 5-year bins), which we used to identify the predominant age groups affected each year. We report the proportion of cases in older age categories and the male-to-female ratio of patients, and how these changed over the 20-year period. In addition, we examined the average LOS. Surgical intervention trends: For each calendar year from 2005 to 2024, we aggregated the number of surgeries in each category as defined above (Table 1). We used the combination frequency of each OPS code with the DCM diagnoses as reported in the DRG statistics (noting that instances with fewer than 3 cases are suppressed in the source data). We plotted time trends of the major procedure categories. Statistical Analysis All statistical analyses were performed using R software (version 4.3.2). Descriptive statistics were used to summarize annual case counts, age and sex distributions, and surgical procedure frequencies. Annual hospitalization rates were calculated by dividing the number of DCM hospitalizations by the mid-year population of Germany for each calendar year and expressed per 100 000 inhabitants. Year-to-year percentage changes were computed to describe temporal trends. Trends in hospitalization rates, age distribution, and surgical procedures were visualized using line plots and heatmaps generated with the ggplot2 package. Temporal trends were assessed descriptively, with visual smoothing using the geom_smooth() function (method = “loess”) to highlight long-term tendencies. To evaluate potential shifts in demographic composition, relative proportions of age and sex groups were compared across the study period. The incidence of surgical procedures was analyzed both in absolute terms and normalized to the annual number of DCM cases to estimate the relative surgical rate per diagnosis year. Because the dataset consisted of fully aggregated, anonymized administrative data without patient-level identifiers, no inferential statistical testing (e.g., regression or hypothesis testing) was conducted. Statistical significance was therefore not defined, and all results are presented descriptively to illustrate nationwide patterns and longitudinal developments. Results Annual Incidence of DCM hospitalizations Between 2005 and 2024, approximately 70 000 hospitalizations for degenerative cervical myelopathy (ICD-10-GM M50.0) were recorded in Germany. The number of annual hospitalizations increased from 2 477 cases in 2005 to a peak of 4 076 cases in 2015, followed by a slight decline to 3 037 cases in 2024 (Figure 1a). When adjusted for population size, the hospitalization rate per 100 000 inhabitants rose from 3.0 per 100 000 in 2005 to 4.96 per 100 000 in 2015, before stabilizing around 3.7 per 100 000 in 2024 (Figure 1b). Overall, the data indicate a long-term upward trend in DCM-related hospitalizations over the past two decades, with relative stabilization in the most recent years. Patient demographics When stratified by sex, male patients consistently accounted for a higher number of hospitalizations compared to females (Figure 2). In 2024, 53.3 % of cases occurred in men (n = 1 618) and 46.7 % in women (n = 1 419). Both sexes showed parallel temporal patterns with the highest case numbers observed between 2015 and 2017 and a slight decrease thereafter. Age-specific analysis revealed that DCM predominantly affects middle-aged and older adults, with a clear concentration of cases in the 50–70 year range (Figure 3). A gradual rightward shift toward older age groups was observed over time, indicating an ageing patient population. Younger individuals (<40 years) consistently accounted for less than 10 % of annual hospitalizations, whereas the proportion of patients aged ≥70 years increased progressively during the observation period. Length-of-hospital-stay The mean LOS decreased continuously across all age groups between 2005 and 2024 ( Figure 4 ). While older patients (>70 years) consistently had the longest LOS, averaging around 9–10 days in 2005 and 7 days in 2024, younger patients (≤30 years) were discharged earlier, typically after 5–6 days. Surgical intervention trends The temporal distribution of cervical spine procedures in Germany between 2005 and 2024 demonstrated a clear predominance of anterior (ventral) approaches. As shown in Figure 5, anterior decompressions (Group A1) represented the largest proportion throughout the study period, with a continuous increase until around 2017, followed by a moderate decline in recent years. Anterior instrumentation and fusion procedures (Group A2) showed a similar trend but on a lower absolute level. Posterior decompression (Group B1) and posterior fusion (Group B2) procedures remained considerably less frequent but demonstrated a slight overall increase over time. Revision surgeries (Group C) remained relatively stable without a clear trend. Combined or hybrid procedures (Group D), vertebral body replacements (Group E), and disc arthroplasties (Group F) occurred much less frequently and contributed only marginally to the total number of cases. Overall, anterior approaches (A1–A2) consistently accounted for most interventions, indicating that ventral decompression and fusion remain the most common surgical strategies for degenerative cervical myelopathy in Germany. When normalized to the annual number of hospitalizations, the proportion of surgically treated DCM cases increased steadily between 2005 and 2024 (Figure 6). The total surgery-to-hospitalization ratio rose from approximately 0.65 in 2005 to 0.88 in 2023, indicating a growing tendency toward inpatient admissions with operative indication. Throughout the observation period, anterior decompression procedures consistently accounted for most surgeries, representing roughly 70–78 % of all DCM hospitalizations. In contrast, posterior decompression procedures contributed only 6–11 %, but demonstrated a gradual increase over time, particularly after 2015. While the total number of hospitalizations peaked in 2015, the corresponding total and anterior surgical ratios continued to rise thereafter, suggesting that inpatient treatment became increasingly selective, with a focus on operative rather than purely diagnostic admissions. The stable predominance of anterior approaches and the modest but continuous rise in posterior decompressions reflect the sustained clinical preference for ventral access in focal disease and the expanding use of dorsal techniques in multilevel or OPLL-related cases. Discussion This nationwide analysis provides a comprehensive overview of the epidemiology and surgical management of degenerative cervical myelopathy (DCM) in Germany over the past two decades. Epidemiological trends Between 2005 and 2024, annual DCM hospitalizations nearly doubled, peaking around 2015 before declining modestly in subsequent years. This rise likely reflects both improved diagnostic awareness and the increasing availability of MRI imaging, which facilitated earlier detection of myelopathy [7, 8]. The subsequent plateau and mild decline appear to result from evolving treatment pathways and changing healthcare structures rather than a true decrease in disease incidence [9, 10]. Although the overall number of DCM-related hospitalizations declined after 2015, the reduction in surgical procedures was considerably less pronounced. Major anterior decompressions showed only a moderate decrease, while posterior approaches remained largely stable. Consequently, the proportion of surgically treated cases per hospitalization increased markedly, as demonstrated by the rising total and anterior surgery-to-hospitalization ratios. This discrepancy indicates that the decline in hospitalizations primarily affected non-operative or diagnostic admissions, whereas operative management of clinically relevant DCM remained stable. The trend therefore reflects a shift toward more selective inpatient admission and stricter surgical indication thresholds, paralleled by improvements in outpatient diagnostic and conservative care [11, 12]. The decline in hospitalization rates in Germany since 2015 is largely driven by non-demographic and system-related factors. Structural changes in healthcare delivery, including the shift of diagnostic and conservative management to the outpatient sector [12], regional population changes (e.g., population decline in certain federal states) [9], and the introduction of new reimbursement models and DRG reforms, have all contributed to this pattern. Furthermore, the COVID-19 pandemic temporarily reduced elective and orthopedic admissions after 2020, further impacting inpatient care for degenerative spine conditions such as DCM [13]. The observed male predominance (approximately 53% of cases) aligns with previous reports and is attributed to sex-related differences in cervical spine morphology, occupation-related mechanical loading, and a higher prevalence of spondylotic degeneration in men [14, 15]. The gradual rightward shift toward older age groups underscores the effect of population ageing and the cumulative nature of degenerative spinal cord compression over time [16]. Length of hospital stay The mean LOS decreased steadily across all age groups, from approximately 9–10 days in 2005 to about 6–7 days in 2024. This reduction reflects broader healthcare trends in Germany, including enhanced perioperative care, implementation of fast-track rehabilitation concepts, and most importantly financial incentives within the DRG system promoting shorter inpatient durations [12]. Despite shorter hospitalizations, older patients consistently exhibited longer stays, which likely reflect higher comorbidity burdens and postoperative care needs. Surgical management Across the 20-year observation period, anterior decompression and fusion procedures clearly dominated the surgical treatment spectrum of DCM, consistently accounting for most interventions. In contrast, posterior decompression and fusion procedures, though performed less frequently, demonstrated a gradual increase over time. This trend likely reflects the rising number of multilevel stenoses, ossification of the posterior longitudinal ligament (OPLL), and cases with preserved or lordotic alignment in which dorsal decompression is biomechanically advantageous [16]. The stable ratio between anterior and posterior procedures over the years indicates that both strategies maintain well-defined indications within German clinical practice. The relative stability of revision and combined procedures (<5%) suggests overall consistency in primary surgical outcomes and a low need for secondary interventions at the population level. Disc arthroplasty and vertebral body replacement remained rare, reflecting their selective indications, cost considerations, and limited reimbursement incentives within the German healthcare system. Clinical and public health implications From a clinical perspective, the findings underline the importance of early recognition and timely referral for surgical evaluation. Given the strong association between delayed treatment and poorer neurological recovery, awareness among primary care physicians, neurologists, and spine surgeons remains crucial [17]. The ageing demographic structure suggests that DCM will continue to represent a major cause of neurological disability in the elderly population, underscoring the need for efficient diagnostic algorithms, standardized referral pathways, and timely surgical decision-making [18]. Establishing interdisciplinary spine boards or integrated care networks between neurology, spine surgery, and rehabilitation medicine could help to streamline management and improve long-term functional outcomes. From a policy standpoint, these nationwide data provide valuable information for healthcare planning and workforce allocation. The consistent demand for cervical spine surgery emphasizes the need for sustained surgical expertise, adequate hospital infrastructure, and postoperative rehabilitation capacity. In light of population ageing and increasing multimorbidity, perioperative optimization and coordinated postoperative care will become even more important to maintain good outcomes and cost-effectiveness [18]. Continuous monitoring of epidemiological and procedural trends will be essential to anticipate future needs, allocate resources efficiently, and ensure equitable access to surgical care for patients with DCM across all regions in Germany. Conclusion This nationwide 20-year analysis shows that degenerative cervical myelopathy remains a relevant and steadily treated condition within the German healthcare system. Hospitalization rates increased markedly until the mid-2010s, driven by demographic ageing and the growing availability of advanced diagnostic imaging, before stabilizing in recent years. Despite the slight decline in overall hospital admissions, the proportion of surgically treated cases continued to rise, indicating more selective inpatient referrals and a shift toward early operative management. These findings highlight that DCM continues to pose a considerable clinical and socioeconomic burden and will likely remain an important healthcare challenge due to demographic trends. Increasing awareness, streamlined referral pathways, and timely surgical evaluation are essential to prevent irreversible neurological decline. The observed nationwide treatment patterns provide a foundation for future resource planning, development of standardized care pathways, and continuous quality improvement in the management of DCM. Limitations This study is based on nationwide administrative DRG and OPS coding data, which imposes several relevant limitations. First, the accuracy of case identification relies entirely on correct hospital coding; miscoding or variability in coding practices between institutions cannot be ruled out. Second, the dataset provides aggregated counts rather than patient-level information, which prevents differentiation between primary and repeated admissions, linking procedures to individual patients, or identifying true revision surgeries. Third, important clinical variables—such as symptom duration, neurological severity scores, radiological findings, or postoperative functional outcomes—are not available in the administrative dataset. Consequently, no conclusions can be drawn regarding indications, surgical decision-making, patient-reported outcomes, or long-term neurological recovery. Fourth, changes in health-care structures, reimbursement regulations, and the increasing shift of diagnostic evaluation to the outpatient sector may have influenced hospitalization rates independently of the true epidemiological burden of DCM. Lastly, suppression of OPS codes with <3 cases introduces minor data loss, particularly in rare and complex procedures. Declarations Conflict of Interest The authors declare no conflict of interest. Funding This research received no external funding. Author Contribution YN- information retrieval, data analysis, conceptualization and design of study, conceptualization of the figures, interpretation of the results, writing of the manuscript.MR - initiation of the project, interpretation of the results, critical revision of the manuscript for important intellectual content.PH - critical revision of the manuscript for important intellectual content.FS- conceptualization and design of study, writing of the manuscript, critical revision of the manuscript for important intellectual content.PD - critical revision of the manuscript for important intellectual content.YA - critical revision of the manuscript for important intellectual content.MN - supervision of the data acquisition, interpretation of the results, writing of the manuscript, critical revision of the manuscript for important intellectual content Data Availability All data analyzed during this study are included in the Supplementary Information files. 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Age Ageing 50:705–715. https://doi.org/10.1093/ageing/afaa236 Tetreault L, Wilson JR, Kotter MRN, et al (2019) Is Preoperative Duration of Symptoms a Significant Predictor of Functional Outcomes in Patients Undergoing Surgery for the Treatment of Degenerative Cervical Myelopathy? Neurosurgery 85:642–647. https://doi.org/10.1093/neuros/nyy474 Grodzinski B, Stubbs DJ, Davies BM (2023) Most degenerative cervical myelopathy remains undiagnosed, particularly amongst the elderly: modelling the prevalence of degenerative cervical myelopathy in the United Kingdom. J Neurol 270:311–319. https://doi.org/10.1007/s00415-022-11349-8 Additional Declarations No competing interests reported. Supplementary Files HDM471113M50020242005.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:21:29","extension":"xml","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":66776,"visible":true,"origin":"","legend":"","description":"","filename":"b706f95481594188a63711db0c518c5a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/540d06fb8dfa644e37aaa047.xml"},{"id":97270334,"identity":"33b01509-2641-4ccc-8f53-5342bdf39a80","added_by":"auto","created_at":"2025-12-02 14:54:21","extension":"html","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":74867,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/185428277cb45b2d6d64c989.html"},{"id":97270319,"identity":"5ac9b726-c5f6-4204-a866-407627c1d20d","added_by":"auto","created_at":"2025-12-02 14:54:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":146202,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eNationwide hospitalizations for degenerative cervical myelopathy (DCM) in Germany, 2005–2024.\u003cbr\u003e\n(\u003c/em\u003e\u003cem\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e) Annual number of hospital discharges with the ICD-10-GM code M50.0 (Cervical disc disorder with myelopathy), representing cervical intervertebral disc degeneration or herniation causing spinal cord compression. After a gradual increase from 2005 to 2016, the total number of cases peaked around 2015–2017 and showed a slight decline thereafter.\u003cbr\u003e\n(\u003c/em\u003e\u003cem\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e) Hospitalization rates per 100 000 inhabitants, calculated by dividing the annual number of cases by the mid-year population of Germany. The rate increased steadily until 2016, followed by a plateau and minor year-to-year fluctuations.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/8f34c78ac11526fe14768a9d.png"},{"id":97367672,"identity":"f31c8cd0-531a-4218-a3d9-c90425a2d9e8","added_by":"auto","created_at":"2025-12-03 16:20:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":112460,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTrends in nationwide hospitalizations for degenerative cervical myelopathy (ICD-10-GM M50.0) in Germany, 2005–2024. Hospitalizations stratified by sex, showing consistently higher numbers in men throughout the study period, with parallel temporal trends for both sexes.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/aa13d1d1e103ec2e9242c81a.png"},{"id":97368864,"identity":"fd99a96d-be9d-455c-ab5c-76105f34bc98","added_by":"auto","created_at":"2025-12-03 16:23:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":122611,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDistribution of hospitalizations for degenerative cervical myelopathy (M50.0) in Germany by age group and year (2005–2024).\u003cbr\u003e\nHeatmap illustrating the annual number of hospital discharges across different age groups.\u003cbr\u003e\nThe highest concentrations of cases were observed in the 50–70 year age range, with an increasing burden in older patients over time.\u003cbr\u003e\nYounger age groups (\u0026lt;40 years) consistently accounted for only a small proportion of total hospitalizations\u003c/em\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/d3913e668b4f84e2f9766103.png"},{"id":97270314,"identity":"33460581-f229-454c-992d-814e915cd33f","added_by":"auto","created_at":"2025-12-02 14:54:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":221436,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMean length of hospital stay (LOS) for degenerative cervical myelopathy by age group in Germany, 2005–2024.\u003cbr\u003e\nAverage LOS decreased steadily across all age groups over the observation period.\u003cbr\u003e\nOlder patients (\u0026gt;70 years) consistently had the longest stays, while younger patients (≤30 years) were discharged more quickly.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/afb175da2718db1e5c3a6ad6.png"},{"id":97270326,"identity":"51631355-63c6-49a0-8689-81eb64f12ab6","added_by":"auto","created_at":"2025-12-02 14:54:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":197316,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTemporal trends of cervical spine surgery procedures in Germany from 2005 to 2024, stratified by surgical approach. The figure displays absolute annual numbers for each procedure group: A1 = anterior decompression, A2 = anterior instrumentation/fusion, B1 = posterior decompression, B2 = posterior fusion, C = revision surgeries, D = combined/hybrid procedures, E = vertebral body replacement, and F = disc arthroplasty. Data are presented as absolute counts per year.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/878f53675fdb7a1a342aa62f.png"},{"id":97367177,"identity":"a1ed6eb0-f5ed-49ed-8a86-511264be2a90","added_by":"auto","created_at":"2025-12-03 16:17:18","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":151816,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eRatio of surgical interventions to hospitalizations for degenerative cervical myelopathy in Germany, 2005–2024.\u003cbr\u003e\nThe total surgical ratio (green) increased steadily, while anterior decompressions (orange) consistently dominated the operative spectrum. Posterior decompressions (blue) accounted for a smaller but gradually increasing share. The rise in total and anterior ratios after 2015 reflects a trend toward more selective inpatient admissions focusing on operative management.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/56e3215075383a6a7428e025.png"},{"id":100857660,"identity":"e4e8cda1-ccae-4d70-a735-2356d6187802","added_by":"auto","created_at":"2026-01-22 07:17:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1510530,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/b7049843-240a-4e46-87ce-8be11e5c031d.pdf"},{"id":97367282,"identity":"a99bfb98-996b-43ff-b462-b32f14e8a240","added_by":"auto","created_at":"2025-12-03 16:17:56","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":208682,"visible":true,"origin":"","legend":"","description":"","filename":"HDM471113M50020242005.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-8206205/v1/d6af4f94fd562d3848969544.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiology of Hospitalization and Surgical Therapy in Degenerative Cervical Myelopathy: A Nationwide 20-Year Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDegenerative cervical myelopathy (DCM) is the most common non-traumatic, progressive disorder of the spinal cord in adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It results from age-related degenerative changes in the cervical spine (such as disc herniation, osteophyte formation, ligament hypertrophy, and ossification) that cause chronic compression of the cervical spinal cord [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Clinically, DCM manifests with a combination of neck pain, radiculopathy, hand clumsiness, gait instability, and sphincter dysfunction, and it can lead to serious neurological disability if not treated [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile direct epidemiological data for Germany are lacking, estimates from other Western countries indicate that degenerative cervical myelopathy likely affects around 0.1\u0026ndash;0.2% of adults, with prevalence increasing sharply in older age groups and many cases remaining undiagnosed [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, the condition remains underrecognized and underdiagnosed, often being mistaken for other disorders (e.g. peripheral neuropathies) in its early stages. This diagnostic delay means many patients present late, with established myelopathic deficits, which underscores the need for greater awareness and timely intervention [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Surgical decompression is the cornerstone of treatment for DCM. Timely surgery halts the neurologic deterioration and, in most cases, leads to significant functional improvement or recovery [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThus, from both a clinical and public health perspective, early diagnosis and surgical referral are critical to prevent irreversible disability. Despite its clinical importance, there have been relatively few longitudinal epidemiological studies examining how the burden of DCM and its surgical management have evolved over time on a national scale. Understanding long-term trends in incidence, patient demographics, and surgical practices can inform healthcare planning and identify gaps in care (for example, potential under-treatment of certain populations).\u003c/p\u003e\u003cp\u003eIn this study, we present a 20-year nationwide analysis of DCM in Germany, leveraging a comprehensive hospital discharge database. Our objectives were to characterize the epidemiology of DCM from 2005 to 2024 \u0026ndash; including incidence of hospitalizations, age and gender distribution of patients \u0026ndash; and to evaluate trends in surgical therapy for DCM.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eEthical statement\u003c/h2\u003e\n\u003cp\u003eThe data used in this analysis were aggregated at a national level and fully de-identified. Therefore, no informed consent or ethical approval is required.\u003c/p\u003e\n\u003ch2\u003eStudy Design and Data Source\u003c/h2\u003e\n\u003cp\u003eWe conducted a retrospective longitudinal study using the nationwide hospital discharge data from the German Federal Statistical Office (Statistisches Bundesamt). Specifically, we analyzed the DRG (Diagnosis-Related Group) statistics for the years 2005 through 2024. This database captures all patients discharged from hospitals in Germany and includes information on primary diagnoses, procedures, age, sex and length of hospital stay for each admission.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePopulation and Case Identification\u003c/h2\u003e\n\u003cp\u003eDegenerative cervical myelopathy (DCM) cases were identified using the\u0026nbsp;ICD-10-GM code M50.0\u0026nbsp;(\u003cem\u003eCervical disc disorder with myelopathy: cervical intervertebral disc degeneration or herniation causing spinal cord compression\u003c/em\u003e).\u003c/p\u003e\n\u003cp\u003eAll inpatient cases with a primary diagnosis of DCM were included irrespective of comorbidities or surgical treatment. For each calendar year, the following variables were extracted:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTotal number of DCM hospitalizations (overall, male, female)\u003c/li\u003e\n \u003cli\u003eMean length of stay (LOS)\u003c/li\u003e\n \u003cli\u003eAge-specific distribution of DCM cases\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eSurgical Treatment Modalities and Procedure Categorization\u003c/h2\u003e\n\u003cp\u003eAll surgical interventions performed in hospital cases with a primary diagnosis of Degenerative cervical myelopathy (DCM; ICD-10-GM M50.0) were documented using the German procedure classification system OPS (\u0026ldquo;Operationen- und Prozedurenschl\u0026uuml;ssel\u0026rdquo;).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor each year, the dataset provides the\u0026nbsp;complete list of OPS-codes\u0026nbsp;recorded for all cases with the main diagnosis M50.0, but\u0026nbsp;does not allow differentiation\u0026nbsp;which specific OPS code belongs to which individual hospital stay or whether multiple OPS were applied in the same case.\u003cbr\u003e\u0026nbsp;Given this limitation, we conducted descriptive analyses on the frequency of OPS-codes across all recorded hospitalizations, stratified by surgical access route and technique. The selected OPS codes were mapped into the following groups and summarized in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eApproach \u0026amp; Techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eExample OPS Codes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eA1) Anterior (ventral) decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eVentral access, decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e5-030.70 (1 Segment) / 5-030.72 (more than 2 segments)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eAnterior cervical access, disc removal or decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eA2) Anterior instrumentation/fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eVentral access with stabilization/ fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003ee.g., 5-836.5 (ventral spondylodesis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eAnterior access + plate/screw, cage or fusion after decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eB1) Posterior (dorsal) decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eDorsal access, decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e5-030.30 / 5-030.32 (dorsal decompression codes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003ePosterior cervical access, e.g., laminectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eB2) Posterior decompression with instrumentation/fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eDorsal access with stabilization/ fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e5-836.3 (dorsal spondylodesis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003ePosterior cervical access with implants/ fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eC) Revision surgeries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eSecondary operation after initial procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eExample: 5-839.x (revision of a cervical spine operation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eRe-operation, implant exchange or re-decompression\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eD) Combined/hybrid approaches (ventral + dorsal procedures)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eVentral + dorsal access or multilevel/multisegmental access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e5-836.4 (dorsal and ventral combined)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eComplex procedure with both anterior and posterior access in the same operation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eE) Vertebral body replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eVentral corpectomy with vertebral body prosthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e5-837.x\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eReplacement of a cervical vertebral body using prosthesis following corpectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eF) Disc arthroplasty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eVentral access, disc removal and artificial disc implantation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e5-839.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eCervical disc replacement with prosthesis instead of fusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1.\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eOverview of surgical procedures for degenerative cervical myelopathy (DCM) according to the German OPS system.\u003cbr\u003e\u0026nbsp;The table summarises the predefined categories used to group procedures by surgical approach and technique.\u003cbr\u003e\u0026nbsp;Representative OPS codes and short descriptions are provided for each category.\u003cbr\u003e\u0026nbsp;Abbreviations: OPS \u0026ndash; Operationen- und Prozedurenschl\u0026uuml;ssel (German Procedure Classification); DCM \u0026ndash; degenerative cervical myelopathy.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBecause cases cannot be individually assigned, the analysis describes\u0026nbsp;aggregate volumes of each procedure group per year, rather than linking specific OPS codes to individual patient outcomes.\u003c/p\u003e\n\u003ch2\u003eOutcomes\u003c/h2\u003e\n\u003cp\u003eThe primary outcomes assessed were:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAnnual incidence of DCM hospitalizations: expressed as the total number of DCM cases per year nationwide. We also calculated hospitalization rates per 100,000 population for each year using mid-year population estimates for Germany for context. Population data were obtained from the Federal Statistical Office of Germany. Hospitalization rates were calculated as:\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1764680254.png\" width=\"747\" height=\"124\"\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePatient demographics: including the age distribution and sex ratio of DCM patients over time. The source data provided counts in discrete age brackets (in 5-year bins), which we used to identify the predominant age groups affected each year. We report the proportion of cases in older age categories and the male-to-female ratio of patients, and how these changed over the 20-year period.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cul\u003e\n \u003cli\u003eIn addition, we examined the average LOS.\u003c/li\u003e\n \u003cli\u003eSurgical intervention trends: For each calendar year from 2005 to 2024, we aggregated the number of surgeries in each category as defined above (Table 1). We used the combination frequency of each OPS code with the DCM diagnoses as reported in the DRG statistics (noting that instances with fewer than 3 cases are suppressed in the source data). We plotted time trends of the major procedure categories.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eAll statistical analyses were performed using \u003cstrong\u003eR software (version 4.3.2).\u003c/strong\u003e Descriptive statistics were used to summarize annual case counts, age and sex distributions, and surgical procedure frequencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnnual hospitalization rates were calculated by dividing the number of DCM hospitalizations by the mid-year population of Germany for each calendar year and expressed per 100 000 inhabitants. Year-to-year percentage changes were computed to describe temporal trends.\u003c/p\u003e\n\u003cp\u003eTrends in hospitalization rates, age distribution, and surgical procedures were visualized using \u003cstrong\u003eline plots\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eheatmaps\u0026nbsp;\u003c/strong\u003egenerated with the \u003cem\u003eggplot2\u003c/em\u003e package. Temporal trends were assessed descriptively, with visual smoothing using the \u003cem\u003egeom_smooth()\u003c/em\u003e function (method = \u0026ldquo;loess\u0026rdquo;) to highlight long-term tendencies.\u003c/p\u003e\n\u003cp\u003eTo evaluate potential shifts in demographic composition, relative proportions of age and sex groups were compared across the study period. The incidence of surgical procedures was analyzed both in absolute terms and normalized to the annual number of DCM cases to estimate the relative surgical rate per diagnosis year.\u003c/p\u003e\n\u003cp\u003eBecause the dataset consisted of fully aggregated, anonymized administrative data without patient-level identifiers, \u003cstrong\u003eno inferential statistical testing\u003c/strong\u003e (e.g., regression or hypothesis testing) was conducted. Statistical significance was therefore not defined, and all results are presented descriptively to illustrate nationwide patterns and longitudinal developments.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eAnnual Incidence of DCM hospitalizations\u003c/h2\u003e\n\u003cp\u003eBetween\u0026nbsp;2005 and 2024, approximately 70 000 hospitalizations for degenerative cervical myelopathy (ICD-10-GM M50.0) were recorded in Germany.\u003cbr\u003eThe number of annual hospitalizations increased from 2 477 cases in 2005 to a peak of 4 076 cases in 2015, followed by a slight decline to 3 037 cases in 2024 (Figure 1a).\u003c/p\u003e\n\u003cp\u003eWhen adjusted for population size, the\u0026nbsp;hospitalization rate per 100 000 inhabitants rose from 3.0 per 100 000 in 2005 to 4.96 per 100 000 in 2015, before stabilizing around 3.7 per 100 000 in 2024 (Figure 1b).\u003cbr\u003eOverall, the data indicate a long-term upward trend in DCM-related hospitalizations over the past two decades, with relative stabilization in the most recent years.\u003c/p\u003e\n\u003ch2\u003ePatient demographics\u003c/h2\u003e\n\u003cp\u003eWhen stratified by sex,\u0026nbsp;male patients consistently accounted for a higher number of hospitalizations\u0026nbsp;compared to females (Figure 2).\u003cbr\u003e\u0026nbsp;In 2024, 53.3 % of cases occurred in men (n = 1 618) and 46.7 % in women (n = 1 419).\u003cbr\u003e\u0026nbsp;Both sexes showed parallel temporal patterns with the highest case numbers observed between 2015 and 2017 and a slight decrease thereafter.\u003c/p\u003e\n\u003cp\u003eAge-specific analysis revealed that DCM predominantly affects middle-aged and older adults, with a clear concentration of cases in the 50\u0026ndash;70 year range (Figure 3).\u003cbr\u003e\u0026nbsp;A gradual rightward shift toward older age groups was observed over time, indicating an ageing patient population.\u003cbr\u003e\u0026nbsp;Younger individuals (\u0026lt;40 years) consistently accounted for less than 10 % of annual hospitalizations, whereas the proportion of patients aged \u0026ge;70 years increased progressively during the observation period.\u003c/p\u003e\n\u003ch2\u003eLength-of-hospital-stay\u003c/h2\u003e\n\u003cp\u003eThe\u0026nbsp;mean LOS\u0026nbsp;decreased continuously across all age groups between\u0026nbsp;2005 and 2024\u0026nbsp;(\u003cem\u003eFigure 4\u003c/em\u003e). While older patients (\u0026gt;70 years) consistently had the\u0026nbsp;longest LOS, averaging around\u0026nbsp;9\u0026ndash;10 days in 2005\u0026nbsp;and\u0026nbsp;7 days in 2024, younger patients (\u0026le;30 years) were discharged earlier, typically after\u0026nbsp;5\u0026ndash;6 days.\u003c/p\u003e\n\u003ch2\u003eSurgical intervention trends\u003c/h2\u003e\n\u003cp\u003eThe temporal distribution of cervical spine procedures in Germany between 2005 and 2024 demonstrated a clear predominance of anterior (ventral) approaches. As shown in Figure 5, anterior decompressions (Group A1) represented the largest proportion throughout the study period, with a continuous increase until around 2017, followed by a moderate decline in recent years. Anterior instrumentation and fusion procedures (Group A2) showed a similar trend but on a lower absolute level.\u003c/p\u003e\n\u003cp\u003ePosterior decompression (Group B1) and posterior fusion (Group B2) procedures remained considerably less frequent but demonstrated a slight overall increase over time. Revision surgeries (Group C) remained relatively stable without a clear trend. Combined or hybrid procedures (Group D), vertebral body replacements (Group E), and disc arthroplasties (Group F) occurred much less frequently and contributed only marginally to the total number of cases.\u003c/p\u003e\n\u003cp\u003eOverall, anterior approaches (A1\u0026ndash;A2) consistently accounted for most interventions, indicating that ventral decompression and fusion remain the most common surgical strategies for degenerative cervical myelopathy in Germany.\u003c/p\u003e\n\u003cp\u003eWhen normalized to the annual number of hospitalizations, the proportion of surgically treated DCM cases increased steadily between 2005 and 2024 (Figure 6). The total surgery-to-hospitalization ratio rose from approximately 0.65 in 2005 to 0.88 in 2023, indicating a growing tendency toward inpatient admissions with operative indication.\u003c/p\u003e\n\u003cp\u003eThroughout the observation period, anterior decompression procedures consistently accounted for most surgeries, representing roughly 70\u0026ndash;78 % of all DCM hospitalizations. In contrast, posterior decompression procedures contributed only 6\u0026ndash;11 %, but demonstrated a gradual increase over time, particularly after 2015.\u003c/p\u003e\n\u003cp\u003eWhile the total number of hospitalizations peaked in 2015, the corresponding total and anterior surgical ratios continued to rise thereafter, suggesting that inpatient treatment became increasingly selective, with a focus on operative rather than purely diagnostic admissions. The stable predominance of anterior approaches and the modest but continuous rise in posterior decompressions reflect the sustained clinical preference for ventral access in focal disease and the expanding use of dorsal techniques in multilevel or OPLL-related cases.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis nationwide analysis provides a comprehensive overview of the epidemiology and surgical management of degenerative cervical myelopathy (DCM) in Germany over the past two decades.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEpidemiological trends\u003c/h2\u003e\n\u003cp\u003eBetween 2005 and 2024, annual DCM hospitalizations nearly doubled, peaking around 2015 before declining modestly in subsequent years. This rise likely reflects both improved diagnostic awareness and the increasing availability of MRI imaging, which facilitated earlier detection of myelopathy [7, 8]. The subsequent plateau and mild decline appear to result from evolving treatment pathways and changing healthcare structures rather than a true decrease in disease incidence [9, 10].\u003c/p\u003e\n\u003cp\u003eAlthough the overall number of DCM-related hospitalizations declined after 2015, the reduction in surgical procedures was considerably less pronounced. Major anterior decompressions showed only a moderate decrease, while posterior approaches remained largely stable. Consequently, the proportion of surgically treated cases per hospitalization increased markedly, as demonstrated by the rising total and anterior surgery-to-hospitalization ratios. This discrepancy indicates that the decline in hospitalizations primarily affected non-operative or diagnostic admissions, whereas operative management of clinically relevant DCM remained stable. The trend therefore reflects a shift toward more selective inpatient admission and stricter surgical indication thresholds, paralleled by improvements in outpatient diagnostic and conservative care [11, 12].\u003c/p\u003e\n\u003cp\u003eThe decline in hospitalization rates in Germany since 2015 is largely driven by non-demographic and system-related factors. Structural changes in healthcare delivery, including the shift of diagnostic and conservative management to the outpatient sector [12], regional population changes (e.g., population decline in certain federal states) [9], and the introduction of new reimbursement models and DRG reforms, have all contributed to this pattern.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, the COVID-19 pandemic temporarily reduced elective and orthopedic admissions after 2020, further impacting inpatient care for degenerative spine conditions such as DCM [13].\u003c/p\u003e\n\u003cp\u003eThe observed male predominance (approximately 53% of cases) aligns with previous reports and is attributed to sex-related differences in cervical spine morphology, occupation-related mechanical loading, and a higher prevalence of spondylotic degeneration in men [14, 15]. The gradual rightward shift toward older age groups underscores the effect of population ageing and the cumulative nature of degenerative spinal cord compression over time [16].\u003c/p\u003e\n\u003ch2\u003eLength of hospital stay\u003c/h2\u003e\n\u003cp\u003eThe mean LOS decreased steadily across all age groups, from approximately 9\u0026ndash;10 days in 2005 to about 6\u0026ndash;7 days in 2024. This reduction reflects broader healthcare trends in Germany, including enhanced perioperative care, implementation of fast-track rehabilitation concepts, and most importantly financial incentives within the DRG system promoting shorter inpatient durations [12]. Despite shorter hospitalizations, older patients consistently exhibited longer stays, which likely reflect higher comorbidity burdens and postoperative care needs.\u003c/p\u003e\n\u003ch2\u003eSurgical management\u003c/h2\u003e\n\u003cp\u003eAcross the 20-year observation period, anterior decompression and fusion procedures clearly dominated the surgical treatment spectrum of DCM, consistently accounting for most interventions. In contrast, posterior decompression and fusion procedures, though performed less frequently, demonstrated a gradual increase over time. This trend likely reflects the rising number of multilevel stenoses, ossification of the posterior longitudinal ligament (OPLL), and cases with preserved or lordotic alignment in which dorsal decompression is biomechanically advantageous [16]. The stable ratio between anterior and posterior procedures over the years indicates that both strategies maintain well-defined indications within German clinical practice.\u003c/p\u003e\n\u003cp\u003eThe relative stability of revision and combined procedures (\u0026lt;5%) suggests overall consistency in primary surgical outcomes and a low need for secondary interventions at the population level. Disc arthroplasty and vertebral body replacement remained rare, reflecting their selective indications, cost considerations, and limited reimbursement incentives within the German healthcare system.\u003c/p\u003e\n\u003ch2\u003eClinical and public health implications\u003c/h2\u003e\n\u003cp\u003eFrom a clinical perspective, the findings underline the importance of early recognition and timely referral for surgical evaluation. Given the strong association between delayed treatment and poorer neurological recovery, awareness among primary care physicians, neurologists, and spine surgeons remains crucial [17]. The ageing demographic structure suggests that DCM will continue to represent a major cause of neurological disability in the elderly population, underscoring the need for efficient diagnostic algorithms, standardized referral pathways, and timely surgical decision-making [18]. Establishing interdisciplinary spine boards or integrated care networks between neurology, spine surgery, and rehabilitation medicine could help to streamline management and improve long-term functional outcomes.\u003c/p\u003e\n\u003cp\u003eFrom a policy standpoint, these nationwide data provide valuable information for healthcare planning and workforce allocation. The consistent demand for cervical spine surgery emphasizes the need for sustained surgical expertise, adequate hospital infrastructure, and postoperative rehabilitation capacity. In light of population ageing and increasing multimorbidity, perioperative optimization and coordinated postoperative care will become even more important to maintain good outcomes and cost-effectiveness [18]. Continuous monitoring of epidemiological and procedural trends will be essential to anticipate future needs, allocate resources efficiently, and ensure equitable access to surgical care for patients with DCM across all regions in Germany.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis nationwide 20-year analysis shows that degenerative cervical myelopathy remains a relevant and steadily treated condition within the German healthcare system. Hospitalization rates increased markedly until the mid-2010s, driven by demographic ageing and the growing availability of advanced diagnostic imaging, before stabilizing in recent years. Despite the slight decline in overall hospital admissions, the proportion of surgically treated cases continued to rise, indicating more selective inpatient referrals and a shift toward early operative management.\u003c/p\u003e\n\u003cp\u003eThese findings highlight that DCM continues to pose a considerable clinical and socioeconomic burden and will likely remain an important healthcare challenge due to demographic trends. Increasing awareness, streamlined referral pathways, and timely surgical evaluation are essential to prevent irreversible neurological decline. The observed nationwide treatment patterns provide a foundation for future resource planning, development of standardized care pathways, and continuous quality improvement in the management of DCM.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThis study is based on nationwide administrative DRG and OPS coding data, which imposes several relevant limitations. First, the accuracy of case identification relies entirely on correct hospital coding; miscoding or variability in coding practices between institutions cannot be ruled out. Second, the dataset provides aggregated counts rather than patient-level information, which prevents differentiation between primary and repeated admissions, linking procedures to individual patients, or identifying true revision surgeries. Third, important clinical variables\u0026mdash;such as symptom duration, neurological severity scores, radiological findings, or postoperative functional outcomes\u0026mdash;are not available in the administrative dataset. Consequently, no conclusions can be drawn regarding indications, surgical decision-making, patient-reported outcomes, or long-term neurological recovery. Fourth, changes in health-care structures, reimbursement regulations, and the increasing shift of diagnostic evaluation to the outpatient sector may have influenced hospitalization rates independently of the true epidemiological burden of DCM. Lastly, suppression of OPS codes with \u0026lt;3 cases introduces minor data loss, particularly in rare and complex procedures.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYN- information retrieval, data analysis, conceptualization and design of study, conceptualization of the figures, interpretation of the results, writing of the manuscript.MR - initiation of the project, interpretation of the results, critical revision of the manuscript for important intellectual content.PH - critical revision of the manuscript for important intellectual content.FS- conceptualization and design of study, writing of the manuscript, critical revision of the manuscript for important intellectual content.PD - critical revision of the manuscript for important intellectual content.YA - critical revision of the manuscript for important intellectual content.MN - supervision of the data acquisition, interpretation of the results, writing of the manuscript, critical revision of the manuscript for important intellectual content\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data analyzed during this study are included in the Supplementary Information files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBernhardt M, Hynes RA, Blume HW, White AA (1993) Cervical spondylotic myelopathy. The Journal of Bone \u0026amp; Joint Surgery 75:119\u0026ndash;128. https://doi.org/10.2106/00004623-199301000-00016\u003c/li\u003e\n\u003cli\u003eDavies BM, Mowforth OD, Smith EK, Kotter MR (2018) Degenerative cervical myelopathy. BMJ k186. https://doi.org/10.1136/bmj.k186\u003c/li\u003e\n\u003cli\u003eMunro CF, Yurac R, Moritz ZC, et al (2023) Targeting earlier diagnosis: What symptoms come first in Degenerative Cervical Myelopathy? PLoS ONE 18:e0281856. https://doi.org/10.1371/journal.pone.0281856\u003c/li\u003e\n\u003cli\u003eBoogaarts HD, Bartels RHMA (2015) Prevalence of cervical spondylotic myelopathy. Eur Spine J 24 Suppl 2:139\u0026ndash;141. https://doi.org/10.1007/s00586-013-2781-x\u003c/li\u003e\n\u003cli\u003eNoufal Y, Richter M, Hartung P, et al (2025) In Cervical Myelopathy: Clinical Effect of the Posterior Myelon Shifting After Dorsal Decompression and Instrumentation. Journal of Clinical Medicine 14:4319. https://doi.org/10.3390/jcm14124319\u003c/li\u003e\n\u003cli\u003eNoufal Y, Richter M, Hartung P, et al (2025) Anterior-only decompression insufficient in concentric stenosis in degenerative cervical myelopathy. J Orthop 68:270\u0026ndash;275. https://doi.org/10.1016/j.jor.2025.07.019\u003c/li\u003e\n\u003cli\u003eBadhiwala JH, Ahuja CS, Akbar MA, et al (2020) Degenerative cervical myelopathy - update and future directions. Nat Rev Neurol 16:108\u0026ndash;124. https://doi.org/10.1038/s41582-019-0303-0\u003c/li\u003e\n\u003cli\u003eNouri A, Cheng JS, Davies B, et al (2020) Degenerative Cervical Myelopathy: A Brief Review of Past Perspectives, Present Developments, and Future Directions. J Clin Med 9:535. https://doi.org/10.3390/jcm9020535\u003c/li\u003e\n\u003cli\u003eNowossadeck E, Pr\u0026uuml;tz F (2018) [Regional differences in the development of hospitalizations : An effect of different demographic trends?]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 61:358\u0026ndash;366. https://doi.org/10.1007/s00103-018-2695-1\u003c/li\u003e\n\u003cli\u003eSchoffer O, Schriefer D, Werblow A, et al (2023) Modelling the effect of demographic change and healthcare infrastructure on the patient structure in German hospitals - a longitudinal national study based on official hospital statistics. BMC Health Serv Res 23:1081. https://doi.org/10.1186/s12913-023-10056-y\u003c/li\u003e\n\u003cli\u003eMesserle R, Hoogestraat F, Wild E-M (2024) Which factors influence the decision of hospitals to provide procedures on an outpatient basis? -Mixed-methods evidence from Germany. Health Policy 150:105193. https://doi.org/10.1016/j.healthpol.2024.105193\u003c/li\u003e\n\u003cli\u003ePioch C, Busse R, Mansky T, Nimptsch U (2025) The Potential for Providing Treatment on an Outpatient Rather Than Inpatient Basis: A Nationwide Analysis of Hospital Discharge Data in Germany for the Year 2022. Dtsch Arztebl Int 122:151\u0026ndash;155. https://doi.org/10.3238/arztebl.m2025.0012\u003c/li\u003e\n\u003cli\u003eKapsner LA, Kampf MO, Seuchter SA, et al (2020) Reduced Rate of Inpatient Hospital Admissions in 18 German University Hospitals During the COVID-19 Lockdown. Front Public Health 8:594117. https://doi.org/10.3389/fpubh.2020.594117\u003c/li\u003e\n\u003cli\u003eHukuda S, Kojima Y (2002) Sex discrepancy in the canal/body ratio of the cervical spine implicating the prevalence of cervical myelopathy in men. Spine (Phila Pa 1976) 27:250\u0026ndash;253. https://doi.org/10.1097/00007632-200202010-00009\u003c/li\u003e\n\u003cli\u003eNorthover JR, Wild JB, Braybrooke J, Blanco J (2012) The epidemiology of cervical spondylotic myelopathy. Skeletal Radiol 41:1543\u0026ndash;1546. https://doi.org/10.1007/s00256-012-1388-3\u003c/li\u003e\n\u003cli\u003eGrodzinski B, Durham R, Mowforth O, et al (2021) The effect of ageing on presentation, management and outcomes in degenerative cervical myelopathy: a systematic review. Age Ageing 50:705\u0026ndash;715. https://doi.org/10.1093/ageing/afaa236\u003c/li\u003e\n\u003cli\u003eTetreault L, Wilson JR, Kotter MRN, et al (2019) Is Preoperative Duration of Symptoms a Significant Predictor of Functional Outcomes in Patients Undergoing Surgery for the Treatment of Degenerative Cervical Myelopathy? Neurosurgery 85:642\u0026ndash;647. https://doi.org/10.1093/neuros/nyy474\u003c/li\u003e\n\u003cli\u003eGrodzinski B, Stubbs DJ, Davies BM (2023) Most degenerative cervical myelopathy remains undiagnosed, particularly amongst the elderly: modelling the prevalence of degenerative cervical myelopathy in the United Kingdom. J Neurol 270:311\u0026ndash;319. https://doi.org/10.1007/s00415-022-11349-8\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cervical myelopathy, epidemiology, hospital discharge database, nationwide analysis, cervical surgery, OPS, ACDF, posterior decompression","lastPublishedDoi":"10.21203/rs.3.rs-8206205/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8206205/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Despite its clinical importance, nationwide data on long-term incidence and surgical management trends in Germany remain scarce.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A retrospective analysis was conducted using the German Federal Statistical Office’s hospital discharge database covering all inpatient cases with the primary diagnosis of DCM (ICD-10-GM code M50.0) from 2005 to 2024. Annual case numbers, age and sex distributions, and surgical procedures were analyzed descriptively. Hospitalization rates per 100,000 inhabitants were calculated using mid-year population data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Between 2005 and 2024, approximately 70,000 hospitalizations for DCM were recorded nationwide. Annual cases increased from 2,477 (2005) to a peak of 4,076 (2015), followed by stabilization at ~3,000 cases/year thereafter. Hospitalization rates rose from 3.0 to 4.9 per 100,000 inhabitants over the same period. DCM predominantly affected men (53%) and individuals aged 50–70 years, with a progressive shift toward older age groups. Mean length of stay decreased steadily from 9–10 days in 2005 to 6–7 days in 2024.\u003c/p\u003e\n\u003cp\u003eAnterior surgical approaches consistently represented most procedures. While posterior and combined approaches accounted for a smaller proportion, their use increased steadily over time. Normalized to annual hospitalizations, the proportion of surgically treated cases rose from ~65% (2005) to ~88% (2023), indicating increasingly selective inpatient admission for operative management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The burden of DCM in Germany rose substantially over the past two decades before stabilizing at a high level. Surgical treatment remains dominated by anterior decompression and fusion, while posterior procedures gain relevance in complex or multilevel disease. Shorter hospital stays and increasing surgical ratios reflect optimized perioperative pathways and more selective inpatient care. These results provide a comprehensive foundation for health-care planning and resource allocation in the management of DCM.\u003c/p\u003e","manuscriptTitle":"Epidemiology of Hospitalization and Surgical Therapy in Degenerative Cervical Myelopathy: A Nationwide 20-Year Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-02 14:54:16","doi":"10.21203/rs.3.rs-8206205/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ee579623-0c59-48e3-a3d6-d1258fac61e4","owner":[],"postedDate":"December 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-23T10:55:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-02 14:54:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8206205","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8206205","identity":"rs-8206205","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}