Patient and Surgeon Willingness to Participate in a Randomized Trial of Surgery Versus Observation for Mild Cervical Spondylotic Myelopathy: A Cross-Sectional Survey Study
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Background
Cervical spondylotic myelopathy (CSM) is the most common cause of nontraumatic spinal cord dysfunction in adults. For mild disease, guidelines recommend shared decision-making between surgery and structured rehabilitation based on clinical equipoise, yet no comparative effectiveness study has reported outcomes in this population. Whether a randomized trial is feasible is unknown.
Methods
We conducted two cross-sectional surveys between December 2025 and July 2026: one of patients with surgeon-confirmed CSM recruited from academic outpatient spine clinics, and one of practicing neurosurgical and orthopedic spine surgeons. Respondents rated willingness to participate in (1) a randomized trial of early surgery versus observation and (2) a prospective observational study in which treatment was patient selected. Responses of likely or very likely were classified as willing. Groups were compared using Fisher exact tests, designs within respondents using exact McNemar tests, and predictors using univariable logistic regression.
Results
Fifty-four patients and 52 surgeons completed the surveys. Patients were markedly less willing than surgeons to accept randomization (15 of 54, 27.8% versus 44 of 52, 84.6%; p < 0.001). Both groups accepted the observational design (39 of 54, 72.2% versus 51 of 52, 98.1%; p < 0.001), and 26 of 39 patients unwilling to be randomized were willing to enroll in an observational study (p < 0.001). Willingness to be randomized did not differ across mJOA severity (mild 30.4%, moderate 25.0%, severe 27.3%; p = 0.93). Among patients declining randomization, 85.2% cited a wish to retain control over treatment, whereas fear of surgery was cited by one respondent. Forty-five surgeons (86.5%) considered both surgery and observation reasonable, and preference was divided (46.2% favoring early surgery, 48.1% favoring initial observation).
Conclusions
Surgeons report equipoise and high willingness to randomize, but most patients would decline random allocation, citing a wish to retain treatment choice rather than fear or distrust. A prospective observational study appears the more feasible route to comparative evidence in mild CSM. Feasibility assessments restricted to clinicians may substantially overestimate attainable accrual.
