Predictors of outcome in patients with degenerative cervical spondylotic myelopathy undergoing surgical treatment: results of a systematic review

Electroacupuncture improves apoptosis of nucleus pulposus cells via the IL-22/JAK2-STAT3 signaling pathway in a rat model of cervical intervertebral disk degeneration

BACKGROUND

Cervical spondylosis (CS) is a prevalent disorder that can have a major negative impact on quality of life. Traditional conservative treatment has limited efficacy, and electroacupuncture (EA) is a novel treatment option. We investigated the application and molecular mechanism of EA treatment in a rat model of cervical intervertebral disk degeneration (CIDD).

METHODS

The CIDD rat model was established, following which rats in the electroacupuncture (EA) group received EA. For overexpression of IL-22 or inhibition of JAK2-STAT3 signaling, the rats were injected intraperitoneally with recombinant IL-22 protein (p-IL-22) or the JAK2-STAT3 (Janus kinase 2-signal transducer and activator of transcription protein 3) inhibitor AG490 after model establishment. Rat nucleus pulposus (NP) cells were isolated and cultured. Cell counting kit-8 and flow cytometry were used to analyze the viability and apoptosis of the NP cells. Expression of IL-22, JAK2 and STAT3 was determined using RT-qPCR. Expression of IL-22/JAK2-STAT3 pathway and apoptosis related proteins was detected by Western blotting (WB).

RESULTS

EA protected the NP tissues of CIDD rats by regulating the IL-22/JAK2-STAT3 pathway. Overexpression of IL-22 significantly promoted the expression of tumor necrosis factor (TNF)-α, IL-6, IL-1β, matrix metalloproteinase (MMP)3 and MMP13 compared with the EA group. WB demonstrated that the expression of IL-22, p-JAK2, p-STAT3, caspase-3 and Bax in NP cells of the EA group was significantly reduced and Bcl-2 elevated compared with the model group. EA regulated cytokines and MMP through activation of IL-22/JAK2-STAT3 signaling in CIDD rat NP cells.

CONCLUSION

We demonstrated that EA affected apoptosis by regulating the IL-22/JAK2-STAT3 pathway in NP cells and reducing inflammatory factors in the CIDD rat model. The results extend our knowledge of the mechanisms of action underlying the effects of EA as a potential treatment approach for CS in clinical practice.

Patients with cervical spondylotic myelopathy and dependency in activities of daily living during hospitalization-descriptive and correlational study

Background and Aim

Cervical spondylotic myelopathy (CSM) causes progressive spinal cord compression and consequent functional decline. Surgical decompression is considered effective in halting disease progression, producing improvements in neurological prognosis. During hospitalization, several conditions may alter these patients' dependency levels. This study aimed to describe patients with CSM and their evolution regarding dependence in activities of daily living (ADL), from hospital admission to discharge.

Methods and Materials

Descriptive and correlational study based on document analysis.

Results

Included 96 files of patients with CSM who were admitted to Neurosurgery Department. The sample was 58.3% men, with a mean age of 64.4 years. Of the participants, 96.9% had surgery, mainly an anterior cervical approach. Hygiene was the ADL involving most dependence, both at admission (39.6%) and at discharge (71.9%). Worsening of dependence levels in ADLs was found at the midterm evaluation (mean 13.34; SD 5.59) and at discharge (mean 11.59; SD 5.28) in relation to the functional condition at admission (mean 9.77; SD 6.06). Gender was not associated with any differences, but age and days of hospitalization were associated with variations in participants' dependency levels (P<.05).

Conclusion

The level of dependence on ADLs increased during the hospitalization of patients with CSM.

Morphological Changes of Deep Extensor Neck Muscles in Relation to the Maximum Level of Cord Compression and Canal Compromise in Patients With Degenerative Cervical Myelopathy

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To examine the relationship between morphological changes of the deep extensor neck muscles in patients with degenerative cervical myelopathy (DCM) and the level of maximum spinal cord compression (MSCC) and canal compromise (MCC). A secondary objective was to examine the relationship between muscle morphological changes with neck pain and functional scores related to neck pain and interference.

METHODS

A total of 171 patients with DCM were included. Total cross-sectional area (CSA), functional CSA (fat free area, FCSA), ratio of FCSA/CSA (fatty infiltration) and asymmetry of the multifidus (MF) and semispinalis cervicis (SCer) together, and cervical muscle as a group (eg, MF, SCer, semispinalis capitis, splenius capitis) were obtained from T2-weighted axial MR images at mid-disc, at the level of maximum cord compression and the level below. The relationship between the muscle parameters of interest, MSCC, MCC and functional scores including the Neck Disability Index (NDI) was assessed using multivariate linear regression models, adjusting for age, body mass index and sex.

RESULTS

Greater MF + Scer fatty infiltration was associated with greater MCC (P = .032) and MSCC (P = .049) at the same level. Greater asymmetry in MF + SCer CSA was also associated with greater MCC (P = .006). Similarly, greater asymmetry in FCSA and FCSA/CSA of the entire extensor muscle was associated with greater MCC (P = .011, P = .013). There was a negative association between asymmetry in FCSA MF + SCer, FCSA/CSA MF + SCer and FCSA/CSA group muscles with NDI score at the level below.

CONCLUSION

Greater MCC is associated with increased fatty infiltration and greater asymmetry of the deep cervical muscles in patients with DCM. A negative association between muscle asymmetry and NDI scores was also observed which has implications for clinical prediction around axial neck pain.

Scoping Review with Topic Modeling on the Diagnostic Criteria for Degenerative Cervical Myelopathy

STUDY DESIGN

This study is a scoping review.

OBJECTIVE

There is a broad variability in the definition of degenerative cervical myelopathy (DCM) and no standardized set of diagnostic criteria to date.

METHODS

We interrogated the Myelopathy.org database, a hand-indexed database of primary clinical studies conducted exclusively on DCM in humans between 2005-2021. The DCM inclusion criteria used in these studies were inputted into 3 topic modeling algorithms: Hierarchical Dirichlet Process (HDP), Latent Dirichlet Allocation (LDA), and BERtopic. The emerging topics were subjected to manual labeling and interpretation.

RESULTS

Of 1676 reports, 120 papers (7.16%) had well-defined inclusion criteria and were subjected to topic modeling. Four topics emerged from the HDP model: disturbance from extremity weakness and motor signs; fine-motor and sensory disturbance of upper extremity; a combination of imaging and clinical findings is required for the diagnosis; and "reinforcing" (or modifying) factors that can aid in the diagnosis in borderline cases. The LDA model showed the following topics: disturbance to the patient is required for the diagnosis; reinforcing factors can aid in the diagnosis in borderline cases; clinical findings from the extremities; and a combination of imaging and clinical findings is required for the diagnosis. BERTopic identified the following topics: imaging abnormality, typical clinical features, range of objective criteria, and presence of clinical findings.

CONCLUSIONS

This review provides quantifiable data that only a minority of past studies in DCM provided meaningful inclusion criteria. The items and patterns found here are very useful for the development of diagnostic criteria for DCM.

Comparison of the patient-derived modified Japanese Orthopaedic Association scale and the European myelopathy score

PURPOSE

To compare the patient-derived modified Japanese Orthopaedic Association (P-mJOA) scale with the European myelopathy score (EMS) for the assessment of patients with degenerative cervical myelopathy (DCM).

METHODS

In this register-based cohort study with prospectively collected data, included patients were surgically treated for DCM and had reported both P-mJOA and EMS scores at baseline, 1-year follow-up, and/or 2-year follow-up to the Swedish Spine Register. P-mJOA and EMS scores were defined as severe (P-mJOA 0-11 and EMS 5-8), moderate (P-mJOA 12-14 and EMS 9-12), or mild (P-mJOA 15-18 and EMS 13-18). P-mJOA and EMS mean scores were compared, and agreement was evaluated with Spearman's rank correlation coefficient (ρ), the intraclass correlation coefficient (ICC), and kappa (κ) statistics.

RESULTS

Included patients (n = 714, mean age 63.2 years, 42.2% female) completed 937 pairs of the P-mJOA and the EMS. The mean P-mJOA and EMS scores were 13.9 ± 3.0 and 14.5 ± 2.7, respectively (mean difference -0.61 [95% CI -0.72 to -0.51; p < 0.001]). Spearman's ρ was 0.84 (p < 0.001), and intra-rater agreement measured with ICC was 0.83 (p < 0.001). Agreement of severity level measured with unweighted and weighted κ was fair (κ = 0.22 [p < 0.001]; κ = 0.34 [p < 0.001], respectively). Severity levels were significantly higher using the P-mJOA (p < 0.001).

CONCLUSION

The P-mJOA and the EMS had similar mean scores, and intra-rater agreement was high, whereas severity levels only demonstrated fair agreement. The EMS has a lower sensitivity for detecting severe myelopathy but shows an increasing agreement with the P-mJOA for milder disease severity. A larger interval to define severe myelopathy with the EMS is recommended.

Patient Characteristics Associated With Worsening of Neck Pain-Related Disability After Surgery for Degenerative Cervical Myelopathy: A Nationwide Study of 1508 Patients

BACKGROUND AND OBJECTIVES

Functional status, pain, and quality of life usually improve after surgery for degenerative cervical myelopathy (DCM), but a subset of patients report worsening. The objective was to define cutoff values for worsening on the Neck Disability Index (NDI) and identify prognostic factors associated with worsening of pain-related disability 12 months after DCM surgery.

METHODS

In this prognostic study based on prospectively collected data from the Norwegian Registry for Spine Surgery, the NDI was the primary outcome. Receiver operating characteristics curve analyses were used to obtain cutoff values, using the global perceived effect scale as an external anchor. Univariable and multivariable analyses were performed using mixed logistic regression to evaluate the relationship between potential prognostic factors and the NDI.

RESULTS

Among the 1508 patients undergoing surgery for myelopathy, 1248 (82.7%) were followed for either 3 or 12 months. Of these, 317 (25.4%) were classified to belong to the worsening group according to the mean NDI percentage change cutoff of 3.3. Multivariable analyses showed that smoking (odds ratio [OR] 3.4: 95% CI 1.2-9.5: P < .001), low educational level (OR 2.5: 95% CI 1.0-6.5: P < .001), and American Society of Anesthesiologists grade >II (OR 2.2: 95% CI 0.7-5.6: P = .004) were associated with worsening. Patients with more severe neck pain (OR 0.8: 95% CI 0.7-1.0: P = .003) and arm pain (OR 0.8: 95% CI 0.7-1.0; P = .007) at baseline were less likely to report worsening.

CONCLUSION

We defined a cutoff value of 3.3 for worsening after DCM surgery using the mean NDI percentage change. The independent prognostic factors associated with worsening of pain-related disability were smoking, low educational level, and American Society of Anesthesiologists grade >II. Patients with more severe neck and arm pain at baseline were less likely to report worsening at 12 months.

An innovative approach to assess spinal canal expansion following French-door cervical laminoplasty by intraoperative ultrasonography

OBJECTIVE

To investigate the feasibility and effectiveness of applying intraoperative ultrasound (IOUS) to evaluate spinal canal expansion in patients undergoing French-door cervical laminoplasty (FDCL).

MATERIALS AND METHODS

Twenty-five patients who underwent FDCL for multilevel degenerative cervical myelopathy were prospectively recruited. Formulae describing the relationship between laminoplasty opening angle (LOA) and laminoplasty opening size, the increase in sagittal canal diameter and the spinal canal area were deduced with trigonometric functions. The LOA was measured with IOUS imaging during surgery, and other spinal canal parameters were assessed. Actual spinal canal enlargement was verified on postoperative CT images. Linear correlation analysis and Bland‒Altman analysis were used to evaluate correlation and agreement between the intraoperative and postoperative measurements.

RESULTS

The LOA at C5 measured with IOUS was 27.54 ± 3.12°, and it was 27.23 ± 3.02° on postoperative CT imaging. Linear correlation analysis revealed a significant correlation between IOUS and postoperative CT measurements (r = 0.88; p < 0.01). Bland-Altman plots showed good agreement between these two methods, with a mean difference of 0.30°. For other spinal canal expansion parameter measurements, correlation analysis showed a moderate to a high degree of correlation (p < 0.01), and Bland-Altman analysis indicated good agreement.

CONCLUSION

In conclusion, during the French-door cervical laminoplasty procedure, application of IOUS can accurately evaluate spinal canal expansion. This innovative method may be helpful in improving surgical accuracy by enabling the operator to measure and determine canal enlargement during surgery, leading to ideal clinical outcomes and fewer postoperative complications.

CLINICAL RELEVANCE STATEMENT

The use of intraoperative ultrasonography to assess spinal canal expansion following French-door cervical laminoplasty may improve outcomes for patients undergoing this procedure by providing more accurate measurements of spinal canal expansion.

KEY POINTS

• Spinal canal expansion after French-door cervical laminoplasty substantially influences operative prognosis; insufficient or excessive lamina opening may result in unexpected outcomes. • Prediction of spinal canal expansion during surgery was previously impracticable, but based on this study, intraoperative ultrasonography offers an innovative approach and strongly agrees with postoperative CT measurement. • Since this is the first research to offer real-time canal expansion guidance for cervical laminoplasty, it may improve the accuracy of the operation and produce ideal clinical outcomes with fewer postoperative complications.

Causal associations between modifiable risk factors and intervertebral disc degeneration

BACKGROUND

Intervertebral disc degeneration (IVDD) is a common degenerative condition, which is thought to be a major cause of lower back pain (LBP). However, the etiology and pathophysiology of IVDD are not yet completely clear.

PURPOSE

To examine potential causal effects of modifiable risk factors on IVDD.

STUDY DESIGN

Bidirectional Mendelian randomization (MR) study.

PATIENT SAMPLE

Genome-wide association studies (GWAS) with sample sizes between 54,358 and 766,345 participants.

OUTCOME MEASURES

Outcomes included (1) modifiable risk factors associated with IVDD use in the forward MR; and (2) modifiable risk factors that were determined to have a causal association with IVDD in the reverse MR, including smoking, alcohol intake, standing height, education level, household income, sleeplessness, hypertension, hip osteoarthritis, HDL, triglycerides, apolipoprotein A-I, type 2 diabetes, fasting glucose, HbA1c, BMI and obesity trait.

METHODS

We obtained genetic variants associated with 33 exposure factors from genome-wide association studies. Summary statistics for IVDD were obtained from the FinnGen consortium. The risk factors of IVDD were analyzed by inverse variance weighting method, MR-Egger method, weighted median method, MR-PRESSO method and multivariate MR Method. Reverse Mendelian randomization analysis was performed on risk factors found to be caustically associated with IVDD in the forward Mendelian randomization analysis. The heterogeneity of instrumental variables was quantified using Cochran's Q statistic.

RESULTS

Genetic predisposition to smoking (OR=1.221, 95% CI: 1.068-1.396), alcohol intake (OR=1.208, 95% CI: 1.056-1.328) and standing height (OR=1.149, 95% CI: 1.072-1.231) were associated with increased risk of IVDD. In addition, education level (OR=0.573, 95%CI: 0.502-0.654)and household income (OR=0.614, 95%CI: 0.445-0.847) had a protective effect on IVDD. Sleeplessness (OR=1.799, 95%CI: 1.162-2.783), hypertension (OR=2.113, 95%CI: 1.132-3.944) and type 2 diabetes (OR=1.069, 95%CI: 1.024-1.115) are three important risk factors causally associated with the IVDD. In addition, we demonstrated that increased levels of triglycerides (OR=1.080, 95%CI:1.013-1.151), fasting glucose (OR=1.189, 95%CI:1.007-1.405), and HbA1c (OR=1.308, 95%CI:1.017-1.683) could significantly increase the odds of IVDD. Hip osteoarthritis, HDL, apolipoprotein A-I, BMI and obesity trait factors showed bidirectional causal associations with IVDD, therefore we considered the causal associations between these risk factors and IVDD to be uncertain.

CONCLUSIONS

This MR study provides evidence of complex causal associations between modifiable risk factors and IVDD. It is noteworthy that metabolic disturbances appear to have a more significant effect on IVDD than biomechanical alterations, as individuals with type 2 diabetes, elevated triglycerides, fasting glucose, and elevated HbA1c are at higher risk for IVDD, and the causal association of obesity-related characteristics with IVDD incidence is unclear. These findings provide new insights into potential therapeutic and prevention strategies. Further research is needed to clarify the mechanisms of these risk factors on IVDD.

Developing predictive models for surgical outcomes in patients with degenerative cervical myelopathy: a comparison of statistical and machine learning approaches

BACKGROUND CONTEXT

Machine learning (ML) is widely used to predict the prognosis of numerous diseases.

PURPOSE

This retrospective analysis aimed to develop a prognostic prediction model using ML algorithms and identify predictors associated with poor surgical outcomes in patients with degenerative cervical myelopathy (DCM).

STUDY DESIGN

A retrospective study.

PATIENT SAMPLE

A total of 406 symptomatic DCM patients who underwent surgical decompression were enrolled and analyzed from three independent medical centers.

OUTCOME MEASURES

We calculated the area under the curve (AUC), classification accuracy, sensitivity, and specificity of each model.

METHODS

The Japanese Orthopedic Association (JOA) score was obtained before and 1 year following decompression surgery, and patients were grouped into good and poor outcome groups based on a cut-off value of 60% based on a previous study. Two datasets were fused for training, 1 dataset was held out as an external validation set. Optimal feature-subset and hyperparameters for each model were adjusted based on a 2,000-resample bootstrap-based internal validation via exhaustive search and grid search. The performance of each model was then tested on the external validation set.

RESULTS

The Support Vector Machine (SVM) model showed the highest predictive accuracy compared to other methods, with an AUC of 0.82 and an accuracy of 75.7%. Age, sex, disease duration, and preoperative JOA score were identified as the most commonly selected features by both the ML and statistical models. Grid search optimization for hyperparameters successfully enhanced the predictive performance of each ML model, and the SVM model still had the best performance with an AUC of 0.93 and an accuracy of 86.4%.

CONCLUSIONS

Overall, the study demonstrated that ML classifiers such as SVM can effectively predict surgical outcomes for patients with DCM while identifying associated predictors in a multivariate manner.

Clinical outcome of surgical management of mild cervical compressive myelopathy based on minimum clinically important difference

BACKGROUND CONTEXT

Cervical compressive myelopathy (CCM), caused by cervical spondylosis (cervical spondylotic myelopathy [CSM]) or ossification of the posterior longitudinal ligament (OPLL), is a common neurological disorder in the elderly. For moderate/severe CCM, surgical management has been the first-line therapeutic option. Recently, surgical management is also recommended for mild CCM, and a few studies have reported the surgical outcome for this clinical population. Nonetheless, the present knowledge is insufficient to determine the specific surgical outcome of mild CCM.

PURPOSE

To examine the surgical outcomes of mild CCM while considering the minimum clinically important difference (MCID).

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Patients who underwent subaxial cervical surgery for CCM caused by CSM and OPLL between 2013 and 2022 were enrolled.

OUTCOME MEASURES

The Japanese Orthopedic Association score (JOA score) was employed as the clinical outcomes. Based on previous reports, the JOA score threshold to determine mild myelopathic symptoms was set at ≥14.5 points, and the MCID of the JOA score for mild CCM was set at 1 point.

METHODS

The patients with a JOA score of ≥14.5 points at baseline were stratified into the mild CCM and were examined while considering the MCID. The mild CCM cohort was dichotomized into the improvement group, including the patients with an achieved MCID (JOA score ≥1 point) or with a JOA score of 17 points (full mark) at 1 year postoperatively, and the nonimprovement group, including the others. Demographics, symptomatology, radiographic findings, and surgical procedure were compared between the two groups and studied using the receiver operating characteristic (ROC) curve.

RESULTS

Of 335 patients with CCM, 43 were stratified into the mild CCM cohort (mean age, 58.5 years; 62.8% male). Among them, 25 (58.1 %) patients were assigned to the improvement group and 18 (41.9 %) were assigned to the nonimprovement group. The improvement group was significantly younger than the nonimprovement group; however, other variables did not significantly differ. ROC curve analysis showed that the optimal cutoff point of the patient's age to discriminate between the improvement and nonimprovement groups was 58 years with an area under the curve of 0.702 (p=.015).

CONCLUSIONS

In the present study, the majority of patients with mild CCM experienced improvement reaching the MCID of JOA score at 1 year postoperatively. The present study suggests that for younger patients with mild CCM, especially those aged below 58 years, subjective neurological recovery is more likely to be obtained. Meanwhile, the surgery takes on a more prophylactic significance to halt disease progression for older patients. The results of this study can help in the decision-making process for this clinical population.

Indication as a predictor for outcomes in anterior cervical discectomy and fusion: The impact of myelopathy on disposition

BACKGROUND

While the indication for Anterior Cervical Discectomy and Fusion (ACDF) may influence the expected postoperative course, there is limited data comparing how length of stay (LOS) and disposition for patients with myelopathy differ from those with radiculopathy. This study aimed to compare LOS and discharge disposition, in patients undergoing ACDF for cervical radiculopathy versus those for myelopathy.

METHODS

A retrospective review of all adult ACDF cases between 2013 and 2019 was conducted analyzing sex, age, race, comorbidities, level of surgery, myelopathy measures when applicable, complications, dysphagia, hospital LOS, and discharge disposition.

RESULTS

A total of 157 patients were included in the study with 73 patients undergoing an ACDF for radiculopathy and 84 for myelopathy. Univariate analysis determined older age (p < 0.01), male sex (p = 0.03), presence of CKD (p < 0.01) or COPD (p = 0.01), surgery at C3/4 level (p = 0.01), and indication (p < 0.01) as predictors for a discharge to either acute rehabilitation or a skilled nursing facility rather than to home. Multivariate logistic regression demonstrated age and indication as the only independent predictors of disposition, with home disposition being more likely with decreased age (OR 0.92, 95 % CI 0.86-0.98) and radiculopathy as the diagnosis (OR 6.72, 95 % CI 1.22- 37.02).

CONCLUSIONS

Myelopathic patients, as compared to those with radiculopathy at presentation, had significantly longer LOS, increased dysphagia, and were more often discharged to a facility. Understanding these two distinct populations as separate entities will streamline the pre and post-surgical care as the current DRG codes and ICD 10 PCS do not differentiate the expected post-operative course in patients undergoing ACDF for myelopathy versus radiculopathy.

Anterior cervical discectomy fusion versus posterior decompression and fusion in octogenarians with cervical myelopathy: Clinical outcomes and complications with a 3-year follow-up

Introduction

Cervical stenosis and concurrent Cervical Spondylotic Myelopathy (CSM) are prevalent in the elderly. Treatment options include Anterior Cervical Discectomy Fusion (ACDF) and Posterior Decompression and Fusion (PDF).

Research question

This study aims to compare clinical outcomes and complications between ACDF and PDF in patients aged 80 and above.

Material and methods

Data from electronic medical records between 2005 and 2021 at a single institution were analyzed. Logistic and linear regression analyses were performed to explore risk factors and the relationship between comorbidities and neurological conditions.

Results

21 patients with ACDF and 26 with PDF were studied over 16 years. PDF patients had more operated levels, higher blood loss, and longer hospital stays, but mortality rates and mJOA improvements were similar in both groups. The presence of comorbidities was a unique risk factor for postoperative complications.

Discussion and conclusion

ACDF and PDF led to neurological improvements in elderly CSM patients. However, the decision of surgical procedure should carefully consider the potential for postoperative complications, particularly in patients with comorbidities.

Blood-spinal cord barrier disruption in degenerative cervical myelopathy

Degenerative cervical myelopathy (DCM) is the most prevalent cause of spinal cord dysfunction in the aging population. Significant neurological deficits may result from a delayed diagnosis as well as inadequate neurological recovery following surgical decompression. Here, we review the pathophysiology of DCM with an emphasis on how blood-spinal cord barrier (BSCB) disruption is a critical yet neglected pathological feature affecting prognosis. In patients suffering from DCM, compromise of the BSCB is evidenced by elevated cerebrospinal fluid (CSF) to serum protein ratios and abnormal contrast-enhancement upon magnetic resonance imaging (MRI). In animal model correlates, there is histological evidence of increased extravasation of tissue dyes and serum contents, and pathological changes to the neurovascular unit. BSCB dysfunction is the likely culprit for ischemia-reperfusion injury following surgical decompression, which can result in devastating neurological sequelae. As there are currently no therapeutic approaches specifically targeting BSCB reconstitution, we conclude the review by discussing potential interventions harnessed for this purpose.

Diffusion basis spectrum imaging predicts long-term clinical outcomes following surgery in cervical spondylotic myelopathy

BACKGROUND CONTEXT

A major shortcoming in improving care for cervical spondylotic myelopathy (CSM) patients is the lack of robust quantitative imaging tools to guide surgical decision-making. Diffusion basis spectrum imaging (DBSI), an advanced diffusion-weighted MRI technique, provides objective assessments of white matter tract integrity that may help prognosticate outcomes in patients undergoing surgery for CSM.

PURPOSE

To examine the ability of DBSI to predict clinically important CSM outcome measures at 2-years follow-up.

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

Patients undergoing decompressive cervical surgery for CSM.

OUTCOME MEASURES

Neurofunctional status was assessed by the mJOA, MDI, and DASH. Quality-of-life was measured by the SF-36 PCS and SF-36 MCS. The NDI evaluated self-reported neck pain, and patient satisfaction was assessed by the NASS satisfaction index.

METHODS

Fifty CSM patients who underwent cervical decompressive surgery were enrolled. Preoperative DBSI metrics assessed white matter tract integrity through fractional anisotropy, fiber fraction, axial diffusivity, and radial diffusivity. To evaluate extra-axonal diffusion, DBSI measures restricted and nonrestricted fractions. Patient-reported outcome measures were evaluated preoperatively and up to 2-years follow-up. Support vector machine classification algorithms were used to predict surgical outcomes at 2-years follow-up. Specifically, three feature sets were built for each of the seven clinical outcome measures (eg, mJOA), including clinical only, DBSI only, and combined feature sets.

RESULTS

Twenty-seven mild (mJOA 15-17), 12 moderate (12-14) and 11 severe (0-11) CSM patients were enrolled. Twenty-four (60%) patients underwent anterior decompressive surgery compared with 16 (40%) posterior approaches. The mean (SD) follow-up was 23.2 (5.6, range 6.1-32.8) months. Feature sets built on combined data (ie, clinical+DBSI metrics) performed significantly better for all outcome measures compared with those only including clinical or DBSI data. When predicting improvement in the mJOA, the clinically driven feature set had an accuracy of 61.9 [61.6, 62.5], compared with 78.6 [78.4, 79.2] in the DBSI feature set, and 90.5 [90.2, 90.8] in the combined feature set.

CONCLUSIONS

When combined with key clinical covariates, preoperative DBSI metrics predicted improvement after surgical decompression for CSM with high accuracy for multiple outcome measures. These results suggest that DBSI may serve as a noninvasive imaging biomarker for CSM valuable in guiding patient selection and informing preoperative counseling.

LEVEL OF EVIDENCE

II.

A clinical model to predict postoperative improvement in sub-domains of the modified Japanese Orthopedic Association score for degenerative cervical myelopathy

PURPOSE

The modified Japanese Orthopedic Association (mJOA) score consists of six sub-domains and is used to quantify the severity of cervical myelopathy. The current study aimed to assess for predictors of postoperative mJOA sub-domains scores following elective surgical management for patients with cervical myelopathy and develop the first clinical prediction model for 12-month mJOA sub-domain scores.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Byron F.] Last name [Stephens], Author 2 Given name: [Lydia J.] Last name [McKeithan], Author 3 Given name: [W. Hunter] Last name [Waddell], Author 4 Given name: [Anthony M.] Last name [Steinle], Author 5 Given name: [Wilson E.] Last name [Vaughan], Author 6 Given name: [Jacquelyn S.] Last name [Pennings], Author 7 Given name: [Jacquelyn S.] Last name [Pennings], Author 8 Given name: [Scott L.] Last name [Zuckerman], Author 9 Given name: [Kristin R.] Last name [Archer], Author 10 Given name: [Amir M.] Last name [Abtahi] Also, kindly confirm the details in the metadata are correct.Last Author listed should be Kristin R. Archer METHODS: A multivariable proportional odds ordinal regression model was developed for patients with cervical myelopathy. The model included patient demographic, clinical, and surgery covariates along with baseline sub-domain scores. The model was internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

RESULTS

The model identified mJOA baseline sub-domains to be the strongest predictors of 12-month scores, with numbness in legs and ability to walk predicting five of the six mJOA items. Additional covariates predicting three or more items included age, preoperative anxiety/depression, gender, race, employment status, duration of symptoms, smoking status, and radiographic presence of listhesis. Surgical approach, presence of motor deficits, number of surgical levels involved, history of diabetes mellitus, workers' compensation claim, and patient insurance had no impact on 12-month mJOA scores.

CONCLUSION

Our study developed and validated a clinical prediction model for improvement in mJOA scores at 12 months following surgery. The results highlight the importance of assessing preoperative numbness, walking ability, modifiable variables of anxiety/depression, and smoking status. This model has the potential to assist surgeons, patients, and families when considering surgery for cervical myelopathy.

LEVEL OF EVIDENCE

Level III.

Depression and anxiety in cervical degenerative disc disease: Who are susceptible?

Background

Pre-operative depression and anxiety are associated with poorer patient-reported outcomes following cervical spine surgery. Identification of and interventions for these disorders are key to preventing related negative effects. However, most spine surgeons do not routinely evaluate mental health disorders. Few studies have investigated which patients with cervical degenerative disc diseases (CDDD) are susceptible to depression and anxiety.

Objective

To determine the factors associated with depression and anxiety in patients with CDDD.

Methods

Three hundred twelve patients with CDDD were recruited in this cross-sectional case-control study. Patients underwent a structured interview to acquire demographic and clinical characteristic information, which included the Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), and Visual Analog Scale (VAS) for neck/arm pain. Depression and anxiety were evaluated using the Zung Self-Rating Depression and Anxiety Scales. Univariate and multivariate logistic regression analyses were used to identify factors associated with depression and anxiety.

Results

Of all patients, 102 (32.7%) had depression and 92 (29.5%) had anxiety. Two hundred six (66.0%) patients with neither depression nor anxiety were defined as the control group. Univariate analysis indicated that gender, educational level, occupation type, Charlson comorbidity index, symptom duration, symptomatology, surgery history, NDI, mJOA, VAS-neck, and VAS-arm scores were associated with depression and anxiety (except for symptom duration for anxiety). Multivariate logistic regression analysis indicated that females [odds ratio (OR) 1.81, 95% confidence interval (CI) 1.01-3.23], physical work (OR 2.06, 95% CI 1.16-3.65), poor mJOA score (ORmoderate 2.67, 95% CI 1.40-5.07; ORsevere 7.63, 95% CI 3.85-15.11), and high VAS-neck score (OR 1.24, 95% CI 1.11-1.39) were independent risk factors for depression. Physical work (OR 1.84, 95% CI 1.01-3.35), poor mJOA score (ORmoderate 2.66, 95% CI 1.33-5.33; ORsevere 9.26, 95% CI 4.52-18.99), and high VAS-neck score (OR 1.34, 95% CI 1.19-1.51) were independent risk factors for anxiety.

Conclusion

Approximately one-third of patients with CDDD had depression or anxiety. Patients who engaged in heavy work and had severe symptoms (poor mJOA and high VAS-neck scores) are susceptible to depression and anxiety. Additionally, female patients are susceptible to depression. Our findings may help identify CDDD patients with depression and anxiety in clinical practice.

Cervical spondylotic myelopathy with severe axial neck pain: is anterior or posterior approach better?

OBJECTIVE

The aim of this study was to determine whether multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical laminectomy and fusion (PCLF) is superior for patients with cervical spondylotic myelopathy (CSM) and high preoperative neck pain.

METHODS

This was a retrospective study of prospectively collected data using the Quality Outcomes Database (QOD) CSM module. Patients who received a subaxial fusion of 3 or 4 segments and had a visual analog scale (VAS) neck pain score of 7 or greater at baseline were included. The 3-, 12-, and 24-month outcomes were compared for patients undergoing ACDF with those undergoing PCLF.

RESULTS

Overall, 1141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score > 6). After applying inclusion and exclusion criteria, we compared 65 patients (54.6%) undergoing 3- and 4-level ACDF and 54 patients (45.4%) undergoing 3- and 4-level PCLF. Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs 45.9 ± 16.8, p = 0.03) but similar neck pain (p > 0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively). At the 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p < 0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p > 0.05). However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (β = 1.5 [95% CI 0.5-2.6], adjusted p = 0.01), higher EQ-5D score (β = 0.1 [95% CI 0.01-0.2], adjusted p = 0.04), and higher likelihood for return to baseline activities (OR 1.2 [95% CI 1.1-1.4], adjusted p = 0.002).

CONCLUSIONS

Severe neck pain is prevalent among patients undergoing surgery for CSM, affecting more than 40% of patients. Both ACDF and PCLF achieved comparable postoperative neck pain improvement 3, 12, and 24 months following 3- or 4-segment surgery for patients with CSM and severe neck pain. However, multilevel ACDF was associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.

Utility of Diffusion Basis Spectrum Imaging in Quantifying Baseline Disease Severity and Prognosis of Cervical Spondylotic Myelopathy

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim was to assess the association between diffusion tensor imaging (DTI) and diffusion basis spectrum imaging (DBSI) measures and cervical spondylotic myelopathy (CSM) clinical assessments at baseline and two-year follow-up.

SUMMARY OF BACKGROUND DATA

Despite advancements in diffusion-weighted imaging, few studies have examined associations between diffusion magnetic resonance imaging (MRI) markers and CSM-specific clinical domains at baseline and long-term follow-up.

MATERIALS AND METHODS

A single-center prospective cohort study enrolled 50 CSM patients who underwent surgical decompression and 20 controls from 2018 to 2020. At initial evaluation, all patients underwent diffusion-weighted MRI acquisition, followed by DTI and DBSI analyses. Diffusion-weighted MRI metrics assessed white matter integrity by fractional anisotropy, axial diffusivity, radial diffusivity, and fiber fraction. To improve estimations of intra-axonal anisotropic diffusion, DBSI measures intra-/extra-axonal fraction and intra-axonal axial diffusivity. DBSI also evaluates extra-axonal isotropic diffusion by restricted and nonrestricted fraction. Clinical assessments were performed at baseline and two-year follow-up and included the modified Japanese Orthopedic Association (mJOA); 36-Item Short Form Survey physical component summary (SF-36 PCS); SF-36 mental component summary; neck disability index; myelopathy disability index; and disability of the arm, shoulder, and hand. Pearson correlation coefficients were computed to compare associations between DTI/DBSI and clinical measures. A False Discovery Rate correction was applied for multiple comparisons testing.

RESULTS

At baseline presentation, of 36 correlations analyzed between DTI metrics and CSM clinical measures, only DTI fractional anisotropy showed a positive correlation with SF-36 PCS ( r =0.36, P =0.02). In comparison, there were 30/81 (37%) significant correlations among DBSI and clinical measures. Increased DBSI axial diffusivity, intra-axonal axial diffusivity, intra-axonal fraction, restricted fraction, and extra-axonal anisotropic fraction were associated with worse clinical presentation (decreased mJOA; SF-36 PCS/mental component summary; and increased neck disability index; myelopathy disability index; disability of the arm, shoulder, and hand). At latest follow-up, increased preoperative DBSI intra-axonal axial diffusivity and extra-axonal anisotropic fraction were significantly correlated with improved mJOA.

CONCLUSIONS

This findings demonstrate that DBSI measures may reflect baseline disease burden and long-term prognosis of CSM as compared with DTI. With further validation, DBSI may serve as a noninvasive biomarker following decompressive surgery.

LEVEL OF EVIDENCE

3.

The Natural History of Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is the most frequent cause of spinal cord dysfunction and injury in the adult population and leads to significant loss of quality of life and economic impact from its associated medical care expenditures and loss of work. Surgical intervention is recommended for patients manifesting progressing neurological signs and symptoms of myelopathy, but the optimal management in individuals who have mild and clinically stable disease manifestations is controversial. Understanding the natural history of DCM is, thus, important in assessing patients and identifying those most appropriately indicated for surgical management. Despite the attempts to rigorously perform studies of the natural history of these patients, most published investigations suffer from methodological weaknesses or are underpowered to provide definitive answers. Investigations of particular patient subsets, however, provide some clinical guidance as to which patients stand most to benefit from surgery, and these may include those with lower baseline mJOA scores, evidence of segmental hypermobility, cord signal changes on MRI, abnormal somatosensory or motor-evoked potentials, or the presence of certain inflammatory markers. Clinicians should assess patients with mild myelopathy and those harboring asymptomatic cervical spinal cord compression individually when making treatment decisions and an understanding of the various factors that may influence natural history may aid in identifying those best indicated for surgery. Further investigations will likely identify how variables that affect natural history can be used in devising more precise treatment algorithms.

Predictors of home discharge after scheduled surgery for degenerative cervical myelopathy

OBJECTIVE

Degenerative cervical myelopathy (DCM) is an important public health issue. Surgery is the mainstay of treatment for moderate and severe DCM. Delayed discharge of patients after DCM surgery is associated with increased healthcare costs. There is a paucity of data regarding predictive factors for discharge destination after scheduled surgery for patients with DCM. The purpose of this study was to identify factors predictive of home versus nonhome discharge after DCM surgery.

METHODS

Patients undergoing scheduled DCM surgery who had been enrolled in a prospective DCM substudy of the Canadian Spine Outcomes and Research Network registry between January 2015 and October 2020 were included in this retrospective analysis. Patient data were evaluated to identify potential factors predictive of home discharge after surgery. Logistic regression was used to identify independent factors predictive of home discharge. A multivariable model was then used as a final model.

RESULTS

Overall, 639 patients were included in the initial analysis, 543 (85%) of whom were discharged home. The mean age of the entire cohort was 60 years (SD 11.8 years), with a BMI of 28.9 (SD 5.7). Overall, 61.7% of the patients were female. The mean length of stay was 2.72 days (SD 1.7 days). The final internally validated bootstrapped multivariable model revealed that younger age, higher 9-Item Patient Health Questionnaire score, lower Neck Disability Index scores, fewer operated levels, mJOA scores indicating mild disease, anterior cervical discectomy and fusion procedure, and no perioperative adverse effects were predictive of home discharge.

CONCLUSIONS

Younger age, less neck-related disability, fewer operated levels, more significant depression, less severe myelopathy, anterior cervical discectomy and fusion procedure, and no perioperative adverse effects are predictive of home discharge after surgery for DCM. These factors can help to guide clinical decision-making and optimize postoperative care pathways.

Management and Scheduling of Spine Surgery in a Level 1 Trauma Center in the Setting of the COVID-19 Pandemic: Feasibility and Considerations for Reimplementation of Elective Spine Surgery

Introduction

Determination of what constitutes necessary surgery in the setting of acute hospital resource strain during the COVID-19 pandemic is an unprecedented challenge for healthcare systems. Over the past two years during the COVID-19 pandemic, there have been many changes in reviews of medically necessary spine surgery. There continues to be no clear guidelines on recommendations and further discussion is necessary to continue to provide appropriate and high-level care during future pandemics.

Significance

This review critically appraises and evaluates current barriers to medically necessary spine surgery during the COVID-19 pandemic and evaluates future decision making to maintain spine surgery during future pandemics or limitations in medical care.

Results

Multiple studies included in this review have shown that while various orthopaedic surgeries may be considered elective, medically necessary spine surgery will need to continue during settings of limited medical care. This review discussed multiple methods and recommendations to limit transmission of virus from patients to providers and providers to patients.

Conclusion

Continued medically necessary spine surgery in the setting of the COVID-19 pandemic and future pandemics should continue while limiting risk of transmission to continue providing high-level medical care and allowing hospitals to maintain financial responsibility.

A scoping review of information provided within degenerative cervical myelopathy education resources: Towards enhancing shared decision making

Background

Degenerative cervical myelopathy (DCM) is a chronic neurological condition estimated to affect 1 in 50 adults. Due to its diverse impact, trajectory and management options, patient-centred care and shared decision making are essential. In this scoping review, we aim to explore whether information needs in DCM are currently being met in available DCM educational resources. This forms part of a larger Myelopathy.org project to promote shared decision making in DCM.

Methods

A search was completed encompassing MEDLINE, Embase and grey literature. Resources relevant to DCM were compiled for analysis. Resources were grouped into 5 information types: scientific literature, videos, organisations, health education websites and patient information leaflets. Resources were then further arranged into a hierarchical framework of domains and subdomains, formed through inductive analysis. Frequency statistics were employed to capture relative popularity as a surrogate marker of potential significance.

Results

Of 2674 resources, 150 information resources addressing DCM were identified: 115 scientific literature resources, 28 videos, 5 resources from health organisations and 2 resources from health education websites. Surgical management was the domain with the largest number of resources (66.7%, 100/150). The domain with the second largest number of resources was clinical presentation and natural history (28.7%, 43/150). Most resources (83.3%, 125/150) were designed for professionals. A minority (11.3% 17/150) were written for a lay audience or for a combined audience (3.3%, 5/150).

Conclusion

Educational resources for DCM are largely directed at professionals and focus on surgical management. This is at odds with the needs of stakeholders in a lifelong condition that is often managed without surgery, highlighting an unmet educational need.

Improving Assessment of Disease Severity and Strategies for Monitoring Progression in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 4]

STUDY DESIGN

Narrative Review.

OBJECTIVE

To (i) discuss why assessment and monitoring of disease progression is critical in Degenerative cervical myelopathy (DCM); (ii) outline the important features of an ideal assessment tool and (iii) discuss current and novel strategies for detecting subtle deterioration in DCM.

METHODS

Literature review.

RESULTS

Degenerative cervical myelopathy is an overarching term used to describe progressive injury to the cervical spinal cord by age-related changes of the spinal axis. Based on a study by Smith et al (2020), the prevalence of DCM is approximately 2.3% and is expected to rise as the global population ages. Given the global impact of this disease, it is essential to address important knowledge gaps and prioritize areas for future investigation. As part of the AO Spine RECODE-DCM (Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy) project, a priority setting partnership was initiated to increase research efficiency by identifying the top ten research priorities for DCM. One of the top ten priorities for future DCM research was: What assessment tools can be used to evaluate functional impairment, disability and quality of life in people with DCM? What instruments, tools or methods can be used or developed to monitor people with DCM for disease progression or improvement either before or after surgical treatment?

CONCLUSIONS

With the increasing prevalence of DCM, effective surveillance of this population will require both the implementation of a monitoring framework as well as the development of new assessment tools.

Degenerative cervical myelopathy: Neuroradiological, neurophysiological and clinical correlations in 27 consecutive cases

•

New insight into prognostic factors for recovery of clinical function following posterior decompression for degenerative cervical myelopathy.

•

An increase of IOM amplitude of at least 50% coupled with preoperative T2-only and diffuse T2 signal changes on MRI is a positive prognostic factors for clinical improvement 6 months after surgery.

•

Clinical improvement at 6 months follow-up can be expected in patients with T1 hypo intensity if a diffuse border of the lesion on T2 images is present.

The impact of preoperative neurological symptom severity on postoperative outcomes in cervical spondylotic myelopathy

Study Design:

The study design is a retrospective cohort study.

Objective:

To compare patient-reported outcomes between patients with mild versus moderate-to-severe myelopathy following surgery for cervical spondylotic myelopathy (CSM).

Summary of Background Data:

Recent studies have demonstrated that decompression for CSM leads to improved quality of life when measured by patient-reported outcomes. However, it is unknown if preoperative myelopathy classification is predictive of superior postoperative improvements.

Materials and Methods:

A retrospective review of patients treated surgically for CSM at a single institution from 2014 to 2015 was performed. Preoperative myelopathy severity was classified according to the modified Japanese Orthopaedic Association (mJOA) scale as either mild (≥15) or moderate-to-severe (<15). Other outcomes included neck disability index (NDI), 12-item short-form survey (SF-12), and visual analog scale (VAS) for arm and neck pain. Differences in outcomes were tested by linear mixed-effects models followed by pairwise comparisons using least square means. Multiple linear regression determined whether any baseline outcomes or demographics predicted postoperative mJOA.

Results:

There were 67 patients with mild and 50 patients with moderate-to-severe myelopathy. Preoperatively, patients with moderate-to-severe myelopathy reported significantly worse outcomes compared to the mild group for NDI, Physical Component Score (PCS-12), and VAS arm (P = 0.031). While both groups experienced improvements in NDI, PCS-12, VAS Arm and Neck after surgery, only the moderate-to-severe patients achieved improved mJOA (+3.1 points, P < 0.001). However, mJOA was significantly worse in the moderate-to-severe when compared to the mild group postoperatively (-1.2 points, P = 0.017). Both younger age (P = 0.017, β-coefficient = −0.05) and higher preoperative mJOA (P < 0.001, β-coefficient = 0.37) predicted higher postoperative mJOA.

Conclusions:

Although patients with moderate-to-severe myelopathy improved for all outcomes, they did not achieve normal absolute neurological function, indicating potential irreversible spinal cord changes. Early surgical intervention should be considered in patients with mild myelopathy if they seek to prevent progressive neurological decline over time.

First neurological symptoms in degenerative cervical myelopathy: does it predict the outcome?

PURPOSE

Degenerative cervical myelopathy (DCM) is the most common non-traumatic cause of spinal cord dysfunction. Prediction of the neurological outcome after surgery is important. The aim of this study was to analyze the relationship between first symptoms of DCM and the neurological outcome after surgery.

METHODS

A retrospective analysis over a period of 10 years was performed. First symptoms such as cervicobrachial neuralgia, sensory and motor deficits and gait disturbances were evaluated regarding the postoperative neurological outcome. The modified Japanese Orthopedic Association Score (mJOA Score) was used to evaluate neurological outcome.

RESULTS

In total, 411 patients (263 males, 64%) with a median age of 62.6 ± 12.1 years were included. Cervicobrachial neuralgia was described in 40.2%, gait disturbance in 31.6%, sensory deficits in 19% and motor deficits in 9.2% as first symptom. Patients with cervicobrachial neuralgia were significantly younger (median age of 58 years, p = 0.0005) than patients with gait disturbances (median age of 68 years, p = 0.0005). Patients with gait disturbances and motor deficits as first symptom showed significantly lower mJOA Scores than other patients (p = 0.0005). Additionally, motor deficits and gait disturbance were negative predictors for postoperative outcome according to the mJOA Score.

CONCLUSION

Motor deficits and gait disturbances as the first symptom of DCM are negative predictors for postoperative neurological outcome. Nevertheless, patients with motor deficits and gait disturbance significantly profit from the surgical treatment despite poor preoperative mJOA Score.

Prognostic factors for neurological outcome after anterior decompression and fusion for proximal-type cervical spondylotic amyotrophy - A retrospective analysis of 77 cases

BACKGROUND

Decompression through an anterior approach is theoretically effective for the surgical treatment of cervical spondylotic amyotrophy (CSA), because the pathology usually locates at the anterior side. However, most previous studies investigated posterior surgery or a mix of anterior surgery and posterior surgery in their investigation. Only a few small case series have investigated the surgical outcomes of anterior decompression and fusion (ADF). Therefore, we conducted a multicenter retrospective study that included patients who underwent ADF for proximal-type CSA.

METHODS

We analyzed the outcomes of 77 consecutive spinal surgeries performed on proximal-type CSA patients who underwent ADF. Preoperative and postoperative manual muscle tests (MMT) and the patients' backgrounds, radiological findings, and complications were reviewed. We divided the cases into two groups, good-outcome group (MMT improvement ≧ 2 or improved to MMT 5) and poor-outcome group (others) and evaluated the prognostic factors for outcomes.

RESULTS

Of the 77 patients, 48 (62%) showed good neurological outcome. Multiple compressive lesions at anterior horn (AH) and/or ventral nerve roots (VNRs) were detected in 66 patients (85.7%) on the magnetic resonance images. The patients with a single compressive lesion at VNR or AH tended to show good neurological recovery when compare to those with multiple lesions. Age and duration of symptoms were related to the poor outcome in univariate analysis. Duration of symptoms was an independent factor associated with postoperative neurological outcome. The cut-off value for poor outcome was 7.0 months for the symptom duration (sensitivity: 79%, specificity: 54%, area under the curve: 0.69).

CONCLUSIONS

Patients with proximal-CSA were more likely to have multiple compressive lesions at an AH and/or a VNR. The prognostic factor for poor neurological outcome was duration of symptoms of ≥7 months.

Expression of AIF and Caspase-3 in New Zealand rabbit with Cervical Spondylosis Myelopathy model

Introduction

Cervical spondylosis myelopathy (CSM) is a clinical syndrome of motoric or sensoric, caused by degenerative process chronically causing narrowing of cervical canal and compressing the spinal cord. The narrowing of canalis spinalis causing chronic compression and disrupting vascular patency in spinal cord. This is worsened on repetitive trauma on flexion, extension and rotation. CSM has an incidence of 4.04 in 100.000 cases per year and the total patients undergoing treatment operative or nonoperatively in year increasing for 7 times. Apoptosis plays a critical role in important biological processes such as morphogenesis, tissue homeostasis, and immunity; furthermore, its aberrant activation or impairment may contribute to a number of diseases. The understanding of CSM pathophysiology from apoptotic pathway is an essential topic to discussed and the treatment of this case in future.

Method

This study uses experimental study with Post test Only Control Group, using New Zealand rabbits. The rabbits given the compression on cervical as high as C5 to induce CSM. The tissue was taken from spinal cord on compression area and histopathology examination was done to calculate apoptotic factor expression such as AIF and caspase-3.

Result

Chronic compression on spinal cord causing myelopathy clinically on animal study, resulted in weakness of all extremities. Based on this study, the expression of AIF and caspase-3 is increasing in compression group in day 14 to day 21.

Conclusion

Chronic compression in spinal cord causing increase in AIF and caspase-3 in day 14 and day 21, and this may be caused by increasing of apoptotic expression on animal study.

Degenerative Cervical Myelopathy: Clinical Presentation, Assessment, and Natural History

Degenerative cervical myelopathy (DCM) is a leading cause of spinal cord injury and a major contributor to morbidity resulting from narrowing of the spinal canal due to osteoarthritic changes. This narrowing produces chronic spinal cord compression and neurologic disability with a variety of symptoms ranging from mild numbness in the upper extremities to quadriparesis and incontinence. Clinicians from all specialties should be familiar with the early signs and symptoms of this prevalent condition to prevent gradual neurologic compromise through surgical consultation, where appropriate. The purpose of this review is to familiarize medical practitioners with the pathophysiology, common presentations, diagnosis, and management (conservative and surgical) for DCM to develop informed discussions with patients and recognize those in need of early surgical referral to prevent severe neurologic deterioration.

The influence of ApoE4 on the clinical outcomes and pathophysiology of degenerative cervical myelopathy

Degenerative cervical myelopathy (DCM) is the most common cause of nontraumatic spinal cord injury in adults worldwide. Surgical decompression is generally effective in improving neurological outcomes and halting progression of myelopathic deterioration. However, a subset of patients experience suboptimal neurological outcomes. Given the emerging evidence that apolipoprotein E4 (ApoE4) allelic status influences neurodegenerative conditions, we examined whether the presence of the ApoE4 allele may account for the clinical heterogeneity of treatment outcomes in patients with DCM. Our results demonstrate that human ApoE4⁺ DCM patients have a significantly lower extent of improvement after decompression surgery. Functional analysis of our DCM mouse model in targeted-replacement mice expressing human ApoE4 revealed delayed gait recovery, forelimb grip strength, and hind limb mechanical sensitivity after decompression surgery, compared with their ApoE3 counterparts. This was accompanied by an exacerbated proinflammatory response resulting in higher concentrations of TNF-α, IL-6, CCL3, and CXCL9. At the site of injury, there was a significant decrease in gray matter area, an increase in the activation of microglia/macrophages, and increased astrogliosis after decompression surgery in the ApoE4 mice. Our study is the first to our knowledge to investigate the pathophysiological underpinnings of ApoE4 in DCM, which suggests a possible personalized medicine approach for the treatment of DCM in ApoE4 carriers.

Role of preoperative cervical alignment on postoperative dysphagia after occipitocervical fusion

Background:

Dysphagia is one of the most serious complications of occipitocervical fusion (OCF). The previous studies have shown that postoperative cervical alignment, documented with occipito (O)-C2 angles, C2-C6 angles, and pharyngeal inlet angles (PIA), impacted the incidence of postoperative dysphagia in patients undergoing OCF. Here, we investigated the relationship of preoperative versus postoperative cervical alignment on the incidence of postoperative dysphagia after OCF.

Methods:

We retrospectively reviewed the clinical data/medical charts for 22 patients following OCF (2006– 2019). The O-C2 angles, C2-C6 angles, PIA, and narrowest pharyngeal airway spaces (nPAS) were assessed using plain lateral radiographs of the cervical spine before and after the surgery. The severity of dysphagia was assessed with the functional oral intake scale (FOIS) levels as documented in medical charts; based on this, patients were classified into the nondysphagia (FOIS: 7) versus dysphagia (FOIS: 1–6) groups.

Results:

Seven patients (35%) experienced dysphagia after OCF surgery. Preoperative PIA and nPAS were smaller in the dysphagia group. Spearman rank correlation showed a positive correlation between preoperative PIA and FOIS and between preoperative nPAS and FOIS.

Conclusion:

This study suggests that preoperative cervical alignment may best predict the incidence of postoperative dysphagia after OCF.

A Bibliometric Analysis and Visualization of Current Research Trends in the Treatment of Cervical Spondylotic Myelopathy

STUDY DESIGN

Bibliometric analysis.

OBJECTIVE

Cervical spondylotic myelopathy (CSM) has become the most common cause of spinal cord dysfunction. Many topics of CSM still remain controversial. This study aimed to illustrate the overall knowledge structure and development trends of CSM.

METHODS

Research data sets were acquired from the Web of Science database and the time span was defined as "2000 to 2019." VOS viewer and Citespace software was used to analyze the data and generate visualization knowledge maps. Annual trends of publications, distribution, H-index status, co-authorship status, and research hotspots were analyzed.

RESULTS

A total of 2367 publications met the requirement. The largest number of articles was from the United States, followed by Japan, China, Canada, and India. The highest H-index was found for articles from the United States. The highest number of articles was published in Spine. The cooperation between the countries, institutes, and authors were relatively weak. Cervical sagittal alignment, predictive factor, diffusion tensor imaging, and the natural history of CSM may become a frontier in this research field.

CONCLUSION

The number of publications showed an upward trend with a stable rise. Most of the publications are limited to a few countries and institutions with relatively weak interaction. The United States, Canada, Japan, China, and India have made significant contributions to the field of CSM. The United States is the country with the highest productivity, not only in quality but also in quantity. Cervical sagittal alignment, predictive factor, diffusion tensor imaging, and the natural history of CSM are the research hotspots in the recent years.

The effect of ageing on presentation, management and outcomes in degenerative cervical myelopathy: a systematic review

OBJECTIVE

Degenerative cervical myelopathy (DCM) is a disabling neurological condition. The underlying degenerative changes are known to be more common with age, but the impact of age on clinical aspects of DCM has never been synthesised. The objective of this study is to determine whether age is a significant predictor in three domains-clinical presentation, surgical management and post-operative outcomes of DCM.

METHODS

a systematic review of the Medline and Embase databases (inception to 12 December 2019), registered with PROSPERO (CRD42019162077) and reported in accordance with preferred reporting items of systematic reviews and meta-analysis (PRISMA) guidelines, was conducted. The inclusion criteria were full text articles in English, evaluating the impact of age on clinical aspects of DCM.

RESULTS

the initial search yielded 2,420 citations, of which 206 articles were eventually included. Age was found to be a significant predictor in a variety of measures. Within the presentation domain, older patients have a worse pre-operative functional status. Within the management domain, older patients are more likely to undergo posterior surgery, with more levels decompressed. Within the outcomes domain, older patients have a worse post-operative functional status, but a similar amount of improvement in functional status. Because of heterogenous data reporting, meta-analysis was not possible.

CONCLUSION

the current evidence demonstrates that age significantly influences the presentation, management and outcomes of DCM. Although older patients have worse health at all individual timepoints, they experience the same absolute benefit from surgery as younger patients. This finding is of particular relevance when considering the eligibility of older patients for surgery.

Cortical volume reductions as a sign of secondary cerebral and cerebellar impairment in patients with degenerative cervical myelopathy

•

Degenerative cervical myelopathy is the most common cause of chronic impairment of the spinal cord.

•

MRI-based anatomical assessment of cerebral and cerebellar areas revealed significant tissue volume reduction in DCM patients compared to healthy controls.

•

Disease severity correlated with cerebral and cerebellar atrophy in the primary motor cortex, primary somatosensory cortex and cerebellar areas.

•

Chronic injury to the spinal cord seems to have impact on remote anatomical structures in the brain.

This study investigated supra- and infratentorial structural gray and white matter (GM, WM) alterations in patients with degenerative cervical myelopathy (DCM) as an indicator of secondary harm due to chronic cervical cord compression and micro trauma. With MRI-based anatomical assessment and subsequent voxel-based morphometry analyses, pre- and postoperative volume alterations in the primary motor cortex (MI), the primary somatosensory cortex (SI), the supplementary motor area (SMA), and the cerebellum were analyzed in 43 DCM patients and 20 controls. We assessed disease-related symptom severity by the modified Japanese Orthopaedic Association scale (mJOA). The study also explored symptom severity-based brain volume alterations as well as their association with clinical status. Patients had lower mJOA scores (p = .000) and lower GM volume than controls in SI (p = .016) and cerebellar regions (p = .001). Symptom severity-based subgroup analyses revealed volume reductions in almost all investigated GM ROIs (MI: p = .001; CB: p = .040; SMA: p = .007) in patients with severe clinical symptoms as well as atrophy already present in patients with moderate symptom severity. Clinical symptoms in DCM were associated with cortical and cerebellar volume reduction. GM volume alterations may serve as an indicator of both disease severity and ongoing disease progression in DCM, and should be considered in further patient care and treatment monitoring.

Surgery for Degenerative Cervical Myelopathy: What Really Counts?

STUDY DESIGN

Retrospective study (data analysis).

OBJECTIVE

The purpose of this study was to assess the role of different factors on postoperative outcome of patients with degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

Ongoing degenerative changes of DCM lead to progressive neurological deficits. The optimal timing of surgical treatment is still unclear, especially in patients with mild DCM.

METHODS

Patients with DCM treated in our clinic between 2007 and 2016 were retrospectively analyzed. Pre- and postoperative neurological function was assessed by the modified Japanese Orthopaedic Association Score (mJOA Score) at different stages. The minimum clinically important difference (MCID) was used to evaluate the improvement after surgery. The comorbidities were recorded using the Charlson Comorbidity Index (CCI). Possible associations between age, sex, CCI, preoperative symptoms duration, high signal intensity (SI) on T2-weighted magnetic resonance imaging (MRI) with mJOA Score and MCID were analyzed using univariate analysis and multivariate regression models. Additionally, subgroup analysis was performed according to the severity of DCM (mild: mJOA Score ≥15 points; moderate: mJOA Score of 12-14 points; and severe: mJOA Score <12 points).

RESULTS

The mean age of the final cohort (n = 411) was 62.6 years (range: 31-96 years), 36.0% were females. High SI on T2-weighted MRI was detected in 60.3% of the cases. In the multivariate analysis, patients' age (P = 0.005), higher CCI (P = 0.001), and presence of high SI on T2-weighted MRI (P = 0.0005) were associated independently with lower pre- and postoperative mJOA Score and postoperative MCID. Subgroup analysis revealed age and high SI on T2-weighted MRI as predictors of pre- and postoperative mJOA. However, symptom duration did not influence neurological outcome according to the severity of DCM.

CONCLUSION

Surgery for DCM leads to significant functional improvement. However, better outcome was observed in younger individuals with lower CCI and absence of radiographic myelopathy signs. Therefore, DCM surgery, particularly before occurrence of high SI on MRI, seems to be essential for postoperative functional improvement regardless the above-mentioned confounders.Level of Evidence: 3.

Cerebrospinal fluid biomarkers of glial and axonal injury in cervical spondylotic myelopathy

OBJECTIVE

Degenerative cervical spondylotic myelopathy (CSM) is a major cause of spinal cord dysfunction with an unpredictable prognosis. Βiomarkers reflecting pathophysiological processes in CSM have been insufficiently investigated. It was hypothesized that preoperative cerebrospinal fluid (CSF) biomarker levels are altered in patients with CSM and correlate with neurological status and outcome.

METHODS

CSF biomarkers from patients with CSM and controls were analyzed with immunoassays. Spinal cord changes were evaluated with MRI. The American Spinal Cord Injury Association Impairment Scale, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), and the EQ-5D questionnaire were applied prior to and 3 months after surgery. A p value < 0.05 was considered statistically significant.

RESULTS

Twenty consecutive CSM patients with a mean age of 67.7 ± 13 years and 63 controls with a mean age of 65.2 ± 14.5 years (p > 0.05) were included in the study. In the CSM subjects, CSF neurofilament light subunit (NF-L) and glial fibrillary acidic protein (GFAP) concentrations were higher (p < 0.05), whereas fatty acid-binding protein 3 (FABP3), soluble amyloid precursor proteins (sAPPα and sAPPβ), and amyloid β (Aβ) peptide (Aβ38, Aβ40, and Aβ42) concentrations were lower than in controls (p < 0.05). Aβ peptide levels correlated positively with symptom duration. Preoperative JOACMEQ lower extremity function and CSF NF-L levels correlated positively, and the JOACMEQ bladder function correlated negatively with sAPPα and sAPPβ (p < 0.05). CSF NF-L and FABP3 levels were higher in patients with improved outcome (EQ-5D visual analog scale difference > 20).

CONCLUSIONS

CSF biomarkers of glial and axonal damage, inflammation, and synaptic changes are altered in symptomatic CSM patients, indicating that axonal injury, astroglial activation, and Aβ dysmetabolism may be present in these individuals. These findings reflect CSM pathophysiology and may aid in prognostication. However, future studies including larger patient cohorts, postoperative biomarker data and imaging, and longer follow-up times are required to validate the present findings.

Baseline severity of myelopathy predicts neurological outcomes after posterior decompression surgery for cervical spondylotic myelopathy: a retrospective study

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVES

To identify the usefulness of the baseline severity of myelopathy for predicting surgical outcomes for cervical spondylotic myelopathy (CSM).

SETTING

Seventeen institutions in Japan.

METHODS

This study included 675 persons with CSM who underwent posterior decompression. According to baseline severity, the individuals were divided into the mild (Japanese Orthopaedic Association [JOA] score ≥ 14.5), moderate (JOA score = 10.5-14), and severe (JOA score ≤ 10) groups. Surgical outcomes and clinical variables were compared between the groups. Logistic regression analysis was used to develop a prediction model for unsatisfactory symptom state (postoperative JOA score ≤ 14, residual moderate or severe myelopathy).

RESULTS

The mean (±standard deviation) age was 67 ± 12 years. The participants in the severe group were older than those in the mild group. Postoperative JOA scores were higher in the mild group than in the severe group. According to multivariate logistic regression analysis, the prediction model included preoperative JOA scores (odds ratio [OR] 0.60; 95% confidence interval [CI] 0.55-0.67) and age (OR 1.06, 95% CI 1.04-1.08). On the basis of the model, a representative combination of the thresholds to maximize the value of "sensitivity - (1 - specificity)" demonstrated a preoperative JOA score of 11.5 as a predictor of postoperative unsatisfactory symptom state in people around the mean age of the study cohort (67 years).

CONCLUSIONS

The combination of the baseline severity of myelopathy and age can predict postoperative symptom states after posterior decompression surgery for CSM.

Predictors of Outcomes After Single-level Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy: A Multivariate Analysis

STUDY DESIGN

This was a retrospective study that was carried out using prospectively collected registry data.

OBJECTIVE

The objective of this study was to identify preoperative predictors of outcomes after anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy.

SUMMARY OF BACKGROUND DATA

Proper patient selection is paramount to achieving good surgical results. Identifying predictors of outcomes may aid surgical decision-making and facilitate counseling of patients to manage expectations.

METHODS

Prospectively collected registry data of 104 patients who underwent single-level ACDF for cervical spondylotic myelopathy were reviewed. Outcomes assessed at 2 years were the presence of residual neck pain/arm pain (AP), and attainment of a minimal clinically important difference (MCID) for Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) score, and Physical Component Score (PCS) of SF-36, as well as patient satisfaction, fulfilment of expectations, willingness to undergo same surgery again, return to work (RTW), and return to function (RTF). Receiver operating characteristic curves and multivariate stepwise logistical regression were performed to identify independent predictors of each outcome using 22 covariates including demographics, comorbidities, and preoperative disease state.

RESULTS

Lower preoperative NDI was predictive of the absence of residual neck pain/AP at 2 years. Higher preoperative JOA score was predictive of MCID attainment for PCS, satisfaction, expectation fulfilment, willingness to undergo the same surgery for same condition, and RTF. Poorer preoperative scores of NDI, JOA, and PCS were predictors of attaining MCID of the respective scores. Older patients were less likely to attain MCID for JOA. Higher preoperative AP was a risk factor for unsuccessful RTW.

CONCLUSIONS

In general, the preoperative JOA score was the best predictor of outcomes after ACDF. A preoperative JOA cutoff value of 9.25-10.25 predicted satisfaction, expectation fulfilment, willingness to undergo same surgery, and RTF with at least 70% sensitivity and 50% specificity. These findings may aid surgeons in identifying patients at risk of a poor outcome and guide preoperative counseling to establish realistic expectations of the surgical outcome.

LEVEL OF EVIDENCE

Level III-Non-randomized controlled cohort/follow-up study.

Surgical Outcomes of Postural Instability in Patients With Cervical Myelopathy

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

The objective of this study was to investigate the surgical outcomes of postural instability and its predictors in patients with cervical myelopathy (CM).

SUMMARY OF BACKGROUND DATA

Although several studies have shown impaired postural stability in CM patients, there remains a paucity of literature examining its surgical outcome.

MATERIALS AND METHODS

Postural stability was assessed using a stabilometer preoperatively, at the early phase (3-6 months postoperatively), and 1-year postoperatively, employing 2 stabilometric parameters: sway area [SwA (cm): the amount of sway of gravity center assessed by the outer peripheral area of the stabilogram] and sway density [SwD (/cm): the indicator of proprioceptive reflexes calculated by the locus length of the stabilogram per SwA]. Twenty-seven healthy age-matched, sex-matched, and body mass index-matched subjects were recruited as controls. To investigate the predictors of postoperative postural instability, univariate, and multivariate analyses were performed, including demographic data, preoperative neurological symptom severity, radiographic findings, and preoperative stabilometric parameters as independent variables.

RESULTS

Altogether, 54 CM patients were included in the present study. SwA was 7.89±0.84, 4.78±0.68, and 4.85±0.49, and SwD was 14.63±0.85, 20.41±1.23, and 19.36±1.40 preoperatively, at the early phase, and 1-year postoperatively, respectively, and significant improvement was found in both parameters postoperatively. However, at all timepoints, these parameters were significantly worse in CM patients than in the healthy subjects (SwA: 2.68±0.24, SwD: 24.91±1.83). Multivariate analyses showed that worse preoperative stabilometric parameters were significantly related to worse postoperative stabilometric parameters.

CONCLUSIONS

Surgery significantly improved postural stability in CM patients; however, it did not reach the level observed in healthy controls, even postoperatively. A predictor of greater residual postoperative postural instability was a greater level of preoperative postural instability. In CM patients, to achieve better surgical outcome of postural stability, surgical intervention is recommended before the symptoms related to bodily imbalance deteriorate.

LEVEL OF EVIDENCE

Level III.

Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy

BACKGROUND

Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored.

OBJECTIVE

To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM.

METHODS

This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest.

RESULTS

A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in their myelopathic symptoms, compared to patients with mild mJOA score in.

CONCLUSION

Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.

Magnetization Transfer Ratio and Morphometrics of the Spinal Cord Associates with Surgical Recovery in Patients with Degenerative Cervical Myelopathy

OBJECTIVES

We assessed the prognostic value of the preoperative magnetization transfer ratio (MTR) and morphometrics of the spinal cord in patients with degenerative cervical myelopathy (DCM) in a longitudinal cohort study.

METHODS

Thirteen subjects with DCM underwent 3T magnetization transfer imaging. The MTR was calculated for the spinal cord regions and specific white matter tracts. Morphometric measures were extracted. Clinical (modified Japanese Orthopaedics Association [mJOA] and Nurick scale scores) and health-related quality of life scores were assessed before and after cervical decompression surgery. The association between the magnetic resonance imaging (MRI) metrics and postoperative recovery was assessed (Spearman's correlation). Receiver operating characteristics were used to assess the accuracy of MRI metrics in identifying ≥50% recovery in function.

RESULTS

Preoperative anterior cord MTRs were associated with recovery in mJOA scores (ρ = 0.608; P = 0.036; area under the curve [AUC], 0.66). Preoperative lateral cord MTR correlated with the neck disability index (ρ = 0.699; P = 0.011) and pain interference scale (ρ = 0.732; P = 0.007). Preoperative rubrospinal tract MTR was associated with mJOA score recovery (ρ = 0.573; P = 0.041; AUC, 0.86). Preoperative corticospinal tract and reticulospinal MTRs were related to recovery in pain interference scores (ρ = 0.591; P = 0.033; and ρ = 0.583; P = 0.035, respectively). Eccentricity of the cord was associated with Nurick scores (ρ = 0.606; P = 0.028) and mJOA scores (ρ = 0.651; P = 0.025; AUC, 0.92).

CONCLUSIONS

Preoperative MTR and eccentricity measurements of the spinal cord have prognostic value in assessing the response to surgery and recovery in patients with DCM. Advanced MRI and atlas-based postprocessing techniques can inform interventions and advance the healthcare received by patients with DCM.

A partial least squares analysis of functional status, disability, and quality of life after surgical decompression for degenerative cervical myelopathy

Previous studies aimed at identifying predictors of clinical outcomes following surgical decompression for degenerative cervical myelopathy (DCM) are limited by multicollinearity among predictors, whereby the high degree of correlation between covariates precludes detection of potentially significant findings. We apply partial least squares (PLS), a data-driven approach, to model multi-dimensional variance and dissociate patient phenotypes associated with functional, disability, and quality of life (QOL) outcomes in DCM. This was a post-hoc analysis of DCM patients enrolled in the prospective, multi-center AOSpine CSM-NA/CSM-I studies. Baseline clinical covariates evaluated as predictors included demographic (e.g., age, sex), clinical presentation (e.g., signs and symptoms), and treatment (e.g., surgical approach) characteristics. Outcomes evaluated included change in functional status (∆mJOA), disability (∆NDI), and QOL (∆SF-36) at 2 years. PLS was used to derive latent variables (LVs) relating specific clinical covariates with specific outcomes. Statistical significance was estimated using bootstrapping. Four hundred and seventy-eight patients met eligibility criteria. PLS identified 3 significant LVs. LV1 indicated an association between presentation with hand muscle atrophy, treatment by an approach other than laminectomy alone, and greater improvement in physical health-related QOL outcomes (e.g., SF-36 Physical Component Summary). LV2 suggested the presence of comorbidities (respiratory, rheumatologic, psychological) was associated with lesser improvements in functional status post-operatively (i.e., mJOA score). Finally, LV3 reflected an association between more severe myelopathy presenting with gait impairment and poorer mental health-related QOL outcomes (e.g., SF-36 Mental Component Summary). Using PLS, this analysis uncovered several novel insights pertaining to patients undergoing surgical decompression for DCM that warrant further investigation: (1) comorbid status and frailty heavily impact functional outcome; (2) presentation with hand muscle atrophy is associated with better physical QOL outcomes; and (3) more severe myelopathy with gait impairment is associated with poorer mental QOL outcomes.

Is laminectomy and fusion the better choice than laminoplasty for multilevel cervical myelopathy with signal changes on magnetic resonance imaging? A comparison of two posterior surgeries

Background

This study aimed to compare the clinical outcomes and complications between laminectomy and fusion (LF) and laminoplasty (LP) for multi-level cervical spondylotic myelopathy (MCSM) with increased signal intensity (ISI) on T2-weighted images (T2WI).

Methods

In this retrospective cohort study, we analyzed 52 patients with MCSM with ISI on T2WI who underwent laminoplasty (LP group). The Japanese Orthopedic Association (JOA) score, the Visual Analogue Scale (VAS) score, the physical and mental component scores (PCS and MCS) of Short-Form 36 (SF-36), and the extension and flexion ranges of motion (ROMs) were recorded. As controls, propensity score matching identified 52 patients who underwent laminectomy and fusion (LF group) from January 2014 to June 2016 using 7 independent variables (preoperation): age, sex, JOA score, SF-36 PCS, SF-36 MCS, preoperative symptom duration and high signal intensity ratio (HSIR).

Results

The operative duration in the LF group was significantly higher than that in the LP group. At the last follow-up, the JOA score, VAS score, and SF-36 (PCS and MCS) scores were all significantly improved in both groups. The extension and flexion ROMs were decreased in both groups but significantly better in the LP group than in the LF group. Both groups demonstrated similar clinical improvements at the final follow-up. The complication rate was higher in the LF group.

Conclusion

The present study demonstrates that LP for MCSM with ISI on T2WI achieves similar clinical improvement as LF. However, longer operative durations, higher complication rates and lower extension and flexion ROMs were found in the LF group.

Upright Balance Control in Individuals with Cervical Myelopathy Following Cervical Decompression Surgery: A Prospective Cohort Study

Patients with cervical myelopathy may manifest impairments in functional activities and balance control caused by compression of the spinal cord. The objective of the current study was to determine long-term changes in the upright balance control of patients with cervical myelopathy who had undergone cervical decompression surgery. This is a prospective cohort study from the preoperative phase to 3 months, 6 months, and 1 year postsurgery. Fifty-three patients with cervical myelopathy were recruited for the cervical myelopathy group and 22 age-matched healthy controls were recruited for the control group. Functional assessments including Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire-Lower Extremity Function (JOACMEQ-LEF) and 10-second step test; as well as balance assessments including postural sway (center-of-pressure: COP) were performed for both groups. The JOACMEQ-LEF (p = 0.036) scores of the myelopathy group improved postoperatively, and a significant decrease in COP variables of postural sway was observed. The upright posture was less stable in the myelopathy group than in the control group (p < 0.05) both before and after surgery. The effect size and standard response mean of the COP variables ranged from −0.49 to 0.03 at 3 months, 6 months, and 1 year postsurgery. The upright balance control had improved significantly 6 months after decompression surgery. However, the balance control of the patients who had undergone decompression surgery remained less stable than that of the age-matched healthy controls. Balance training should be initiated before 6 months postsurgery to accelerate balance control recovery in patients with cervical myelopathy.

The Influence of Cervical Spondylolisthesis on Clinical Presentation and Surgical Outcome in Patients With DCM: Analysis of a Multicenter Global Cohort of 458 Patients

STUDY DESIGN

Ambispective study with propensity matching.

OBJECTIVE

To assess the impact of cervical spondylolisthesis (CS) on clinical presentation and surgical outcome in patients with degenerative cervical myelopathy (DCM).

METHODS

A total of 458 magnetic resonance images (MRIs) from the AOSpine CSM-NA and CSM-I studies were reviewed and CS was identified. Patients with DCM were divided into 2 cohorts, those with CS and those without, and propensity matching was performed. Patient demographics, neurological and functional status at baseline and 2-year follow-up were compared.

RESULTS

Compared with nonspondylolisthesis (n = 404), CS patients (n = 54) were 8.8 years older (P < .0001), presented with worse baseline neurological and functional status (mJOA [modified Japanese Orthopaedic Association Assessment Scale], P = .008; Nurick, P = .008; SF-36-PCS [Short Form-36 Physical Component Score], P = .01), more commonly presented with ligamentum flavum enlargement (81.5% vs 53.5%, P < .0001), and were less commonly from Asia (P = .0002). Surgical approach varied between cohorts (P = .0002), with posterior approaches favored in CS (61.1% vs 37.4%). CS patients had more operated levels (4.3 ± 1.4 vs 3.6 ± 1.2, P = .0002) and tended to undergo longer operations (196.6 ± 89.2 vs 177.2 ± 75.6 minutes, P = .087). Neurological functional recovery was lower with CS (mJOA [1.5 ± 3.6 vs 2.8 ± 2.7, P = .003]; Nurick [-0.8 ± 1.4 vs -1.5 ± 1.5, P = .002]), and CS was an independent predictor of worse mJOA recovery ratio at 2 years (B = -0.190, P < .0001). After propensity matching, improvement of neurological function was still lower in CS patients (mJOA [1.5 ± 3.6 vs 3.2 ± 2.8, P < .01]; Nurick [-0.8 ± 1.4 vs -1.4 ± 1.6, P = .02]).

CONCLUSIONS

CS patients are older, present with worse neurological/functional impairment, and receive surgery on more levels and more commonly from the posterior. CS may indicate a more advanced state of DCM pathology and is more likely to result in a suboptimal surgical outcome.

Degenerative cervical myelopathy - update and future directions

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.

Grip force control during object manipulation in cervical myelopathy

STUDY DESIGN

Cross-sectional research.

OBJECTIVES

To objectively evaluate grip force (GF) control while holding a freely movable object in individuals with cervical myelopathy (CM).

SETTING

Harunaso Hospital, Takasaki, Japan.

METHODS

We studied 52 hands from 26 individuals with CM. Participants performed a grip-and-lift task by pulp pinch using the thumb and index finger before surgery. We monitored individual finger GF (N) during the first 3 s while lifting and holding an object. Correlations between the GF and other clinical tests were evaluated. A multiple stepwise regression analysis was used to examine the contribution of the GF to the severity of clinical symptoms.

RESULTS

Thumb GF was negatively correlated with the 10-s test (rs = -0.32), and index finger GF was positively correlated with its cutaneous pressure threshold (rs = 0.34). Multiple regression for the severity of upper extremity symptoms revealed that the model including the GF had a larger adjusted R² and a lower AIC value than that of conventionally used clinical tests.

CONCLUSIONS

These results suggested that the assessment of individual finger GF control could provide an indicator of the clinical severity of upper extremity in individuals with CM.

Degenerative Cervical Myelopathy in Higher-Aged Patients: How Do They Benefit from Surgery?

Background: Degenerative cervical myelopathy (DCM) is the most common reason for spinal cord disease in elderly patients. This study analyzes the preoperative status and postoperative outcome of higher-aged patients in comparison to young and elderly patients in order to determine the benefit to those patients from DCM surgery. Methods: A retrospective analysis of the clinical data, radiological findings, and operative reports of 411 patients treated surgically between 2007 and 2016 suffering from DCM was performed. The preoperative and postoperative neurological functions were evaluated using the modified Japanese Orthopedic Association Score (mJOA Score), the postoperative mJOA Score improvement, the neurological recovery rate (NRR) of the mJOA Score, and the minimum clinically important difference (MCID). The Charlson Comorbidity Index (CCI) was used to evaluate the impact of comorbidities on the preoperative and postoperative mJOA Score. The comparisons were performed between the following age groups: G1: ≤50 years, G2: 51–70 years, and G3: >70 years. Results: The preoperative and postoperative mJOA Score was significantly lower in G3 than in G2 and G1 (p < 0.0001). However, the mean mJOA Score’s improvement did not differ significantly (p = 0.81) between those groups six months after surgery (G1: 1.99 ± 1.04, G2: 2.01 ± 1.04, G: 2.00 ± 0.91). Furthermore, the MCID showed a significant improvement in every age-group. The CCI was evaluated for each age-group, showing a statistically significant group effect (p < 0.0001). Analysis of variance revealed a significant group effect on the delay (weeks) between symptom onset and surgery (p = 0.003). The duration of the stay at the hospital did differ significantly between the age groups (p < 0.0001). Conclusion: Preoperative and postoperative mJOA Scores, but not the extent of postoperative improvement, are affected by the patients’ age. Therefore, patients should be considered for DCM surgery regardless of their age.

Treatment of Mild Cervical Myelopathy: Factors Associated With Decision for Surgical Intervention

STUDY DESIGN

Prospective Cohort OBJECTIVE.: The aim of this study was to evaluate which demographic, clinical, or radiographic factors are associated with selection for surgical intervention in patients with mild cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

Surgery has not been shown superior to best conservative management in mild CSM comparative studies; trials of conservative management represent an acceptable alternative to surgical decompression. It is unknown what patients benefit from surgery.

METHODS

This is a prospective study of patients with mild CSM, defined as modified Japanese Orthopaedic Association Score (mJOA) ≥15. Patients were recruited from seven sites contributing to the Canadian Spine Outcomes Research Network. Demographic, clinical, radiographic and health related quality of life data were collected on all patients at baseline. Multivariate logistic regression modeling was used to identify factors associated with surgical intervention.

RESULTS

There were 122 patients enrolled, 105 (86.0%) were treated surgically, and 17 (14.0%) were treated nonoperatively. Overall mean age was 54.8 years (SD 12.6) with 80 (65.5%) males. Bivariate analysis revealed no statistically significant differences between surgical and nonoperative groups with respect to age, sex, BMI, smoking status, number of comorbidities and duration of symptoms; mJOA scores were significantly higher in the nonoperative group (16.8 [SD 0.99] vs. 15.9 [SD 0.89], P < 0.001). There was a statistically significant difference in Neck Disability Index, SF12 Physical Component, SF12 Mental Component Score, EQ5D, and PHQ-9 scores between groups; those treated surgically had worse baseline questionnaire scores (P < 0.05). There was no difference in radiographic parameters between groups. Multivariable analysis revealed that lower quality of life scores on EQ5D were associated with selection for surgical management (P < 0.018).

CONCLUSION

Patients treated surgically for mild cervical myelopathy did not differ from those treated nonoperatively with respect to baseline demographic or radiographic parameters. Patients with worse EQ5D scores had higher odds of surgical intervention.

LEVEL OF EVIDENCE

3.