Table 4 Cervical-spondylosis-specific scale (CSSS) criteria

 Describes symptoms: neck pain, radiating pain, stiffness, paresthesia (numbness, tingling, etc.), muscle weakness and dystonia (clumsy hands, gait abnormality, etc.), dysreflexia, restricted motion, ataxia, paralysis, bowel/bladder disturbance, etc. (mentions 1–2 items: 1 point; ≥ 3 items: 2 points)

 Describes epidemiology: prevalent in elders; male patients more than females (0.5 point)

 Describes anatomy and/or function of cervical spine and relevant structures (1 point)

 Describes mechanism and pathophysiology: caused by degenerative change of intervertebral disc and/or adjacent structures, leading to cervical nerve and/or vessels injured; physical compression and/or inflammation (2 point)

 Mentions risk factors: age, trauma, poor postural habit, smoking, high loads, obesity, congenital factors, weak cervical muscles, etc. (mentions 1–2 items: 1 point; ≥ 3 items: 2 points)

 Discusses classification: radiculopathy, myelopathy, etc. (1 point)

Evaluation and diagnosis

 Discusses physical and neurological examination: Spurling sign, shoulder abduction sign, Choi’s/tornado test, manual muscle exam, Eaton sign, Barre-Lieou sign, Hoffmann sign, Babinski sign, L’hermitte sign, finger-escape sign, Wartenberg sign, sensory exam, etc. (mentions 1–2 items: 1 point; ≥ 3 items: 2 points)

 Discusses diagnostic imaging: X-ray, CT, MRI (mentions terms: 1 point; also provides example and explanation: 2 points)?

 Mentions EMG and/or PRO measures: VAS score, NDI score, mJOA score etc. (1 point)

 Mentions differential diagnosis (1 point)

Treatment

 Describes conservative treatments: first-line recommendation for symptomatic patients without myelopathy (1 point)

Mentions non-surgical options: cervical exercise, traction, pharmacotherapy, chiropractic, thermotherapy, electrotherapy, acupuncture, radiofrequency ablation, epidural steroid injection, neck collar immobilization, etc. (mentions 1–2 items: 1 point; ≥ 3 items: 2 points)

 Mentions medication: NSAIDs, neurotrophic drugs, muscle relaxants, steroids (1 point)

 Mentions surgical treatment and indications: patients with severe/progressive pain or neurological deficits, refractory to conservative therapy (1 point)

 Discusses different cervical surgical options with relevant anatomy: anterior or posterior, fusion or non-fusion, open or minimally invasive (2 points)

 Discusses complications: Infection, implant-related complications, neurological deficits, vascular injury, CSF leakage, dysphagia, pseudoarthrosis, psychosocial implication, etc. (1 point)

Posttreatment course

 Discusses natural history and/or prognosis: cervical radiculopathy is often self-limited; majority of patients improve after early and appropriate management; old age, long-term disease course, severe and irreversible symptoms, other underlying diseases, psychological symptoms indicate poor prognosis (1 point)

 Mentions postoperative management: postoperative functional exercise and neurological rehabilitation under professional guidance as soon as possible (1 point)

 Outlines timeline of functional recovery (0.5 point)