The decision-making process regarding the surgical approach in patients with multilevel degenerative cervical myelopathy (mDCM) is very difficult. It depends on the clinical as well as neuroradiological hard-facts, however, the experience and training of the surgeon should be considered as well. In the past, several papers addressed the challenges for the surgeon to choose the most appropriate surgical approach. A consensus has yet to be reached which might imply that there is not just “one best surgical approach.” Further, cultural differences in the decision-making process between surgeons in Asia, Europe, and America are obvious. This fact is not bad by itself, however, it shows that guidelines to facilitate the surgical decision-making process are urgently needed.

A 7-letter code (7LC) was developed based on clinical and radiological parameters. The intent of the 7LC is primarily to support surgeons in a structured analysis of the relevant clinical and imaging parameters influencing the choice of the surgical approach. This new tool allows to reduce gut feelings guided intuitive decisions and encourages the surgeon to make a structured and self-reflected decision, rather than simply pointing out the “best approach.”

The paper by Papavero et al. [1] evaluates the feasibility of the 7LC tool with regard to the choice of an anterior, posterior or mixed approach. Further, the intra- as well the interrater reliability in a multinational group of junior and senior surgeons was analysed. In a first step, the surgeons were asked to choose their favourite approach in straight forward cases in order to get familiar with the 7LC tool. In a second step, they were exposed to more demanding clinical and radiological cases which offer different surgical solutions.

It is recommended to check out and download (https://7LC.org) the 7LC application on your smartphone to fully understand the value of this paper. The step-by-step decisionmaking process reflects the various parameters and is helpful to find a structured solution with regard to the surgical approach. The tool allows junior doctors to understand which parameters are important in the decision-making process. This kind of guidelines are essential during surgical training.

On the other hand, senior surgeons are encouraged to self-reflect their way of making a decision. This might allow to reduce the risk of complications which may come with overconfidence of experienced surgeons. The 7LC tool helps to take a step back and make a structured decision.

In summary, Papavero et al. [1] present a study showing the need for guidelines and tools to evaluate the most appropriate surgical approach in mDCM. In combination with the 7LC smartphone application, the urgent need for guidelines and structured support for an adequate decision-making process in this often demanding patient population.

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