Imaging Evaluation of Degenerative Cervical Myelopathy

Laminoplasty Versus Laminectomy and Posterior Fusion for Cervical Myelopathy : A Meta-Analysis of Radiographic and Clinical Outcomes

STUDY DESIGN

Meta-analysis.

OBJECTIVE

This meta-analysis investigates the outcomes of laminoplasty (LP) and laminectomy with fusion (LF) to guide effective patient selection for these 2 procedures.

BACKGROUND

Although LF traditionally offers the ability for excellent posterior decompression, it may alter cervical spine biomechanics and increase the risk of adjacent segment degeneration. LP aims to preserve the natural kinematics of the spine but has not been universally accepted, and may be associated with inadequate decompression, neck pain, and recurrent stenosis.

MATERIALS AND METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched up until March 2024. The outcomes studied were surgery-related outcomes [operative time (OR) time, estimated blood loss (EBL), and length of stay], adverse events (overall complications, C5 palsy, and reoperations), radiographic outcomes (cervical lordosis, cervical sagittal vertical axis, and T1 slope angle), and patient-reported outcome measures (Neck Disability Index, Visual Analog Scale for neck pain, and Japanese Orthopaedic Association).

RESULTS

Twenty-two studies were included in this meta-analysis, of which 19 were retrospective studies, 2 were prospective nonrandomized studies, and 1 was a randomized controlled trial. A total of 2128 patients were included, with 1025 undergoing LP and 1103 undergoing LF. Patients undergoing LP experienced significantly shorter operative time ( P = 0.009), less EBL ( P = 0.02), a lower rate of overall complications ( P < 0.00001) and C5 palsy ( P = 0.003), a lower T1 slope angle ( P = 0.02), and a lower Neck Disability Index ( P = 0.0004). No significant difference was observed in the remaining outcomes.

CONCLUSION

This meta-analysis demonstrates that for cervical myelopathy, LP has the benefits of shorter operative time time, less EBL, and reduced incidence of C5 palsy as well as overall complication rate. Given these findings, LP remains an important surgical option with a favorable complication profile in patients with cervical myelopathy, although careful patient selection is still paramount in choosing the right procedure for individual patients.

LEVEL OF EVIDENCE

4.

An Illustrative Case of Cervical Spondylotic Myelopathy and Medullary Cavernoma: Which Should Be Treated First?

Cervical spondylotic myelopathy (CSM) and spinal cavernoma (SC) represent distinct yet challenging conditions. CSM manifests as progressive neurological dysfunction, whereas SC denotes a benign vascular lesion. The need for documented cases featuring CSM and SC highlights the absence of evidence-based management guidelines for such scenarios. CSM typically presents as a gradual neurological decline, predominantly afflicting middle-aged men. Pathophysiological mechanisms involve axonal stretching and ischemia. Classic symptoms encompass gait instability, bladder dysfunction, limb paresis, hyperreflexia, and somatic pain. Diagnostic complexities persist due to the weak correlation between radiological findings and clinical severity, complicating treatment decisions. In contrast, SC, although often asymptomatic, exhibits a preference for the thoracic and cervical segments and can mimic intramedullary tumors. Diagnosis typically relies on magnetic resonance imaging (MRI) due to the limitations of angiography. This case study of a 66-year-old male with concurrent CSM and SC sheds light on the diagnostic and treatment challenges encountered. Surgical intervention targeting CSM preceded SC resection, resulting in significant clinical improvement. In conclusion, managing patients with concurrent CSM and SC necessitates a tailored approach, considering each condition's distinct characteristics and treatment goals. Further research is warranted to establish standardized management algorithms for this complex clinical scenario.

Imaging protocols for non-traumatic spinal cord injury: current state of the art and future directions

INTRODUCTION

Non-traumatic spinal cord injury (NTSCI) is a term used to describe damage to the spinal cord from sources other than trauma. Neuroimaging techniques such as computerized tomography (CT) and magnetic resonance imaging (MRI) have improved our ability to diagnose and manage NTSCIs. Several practice guidelines utilize MRI in the diagnostic evaluation of traumatic and non-traumatic SCI to direct surgical intervention.

AREAS COVERED

The authors review practices surrounding the imaging of various causes of NTSCI as well as recent advances and future directions for the use of novel imaging modalities in this realm. The authors also present discussions around the use of simple radiographs and advanced MRI modalities in clinical settings, and briefly highlight areas of active research that seek to advance our understanding and improve patient care.

EXPERT OPINION

Although several obstacles must be overcome, it appears highly likely that novel quantitative imaging features and advancements in artificial intelligence (AI) as well as machine learning (ML) will revolutionize degenerative cervical myelopathy (DCM) care by providing earlier diagnosis, accurate localization, monitoring for deterioration and neurological recovery, outcome prediction, and standardized practice. Some intriguing findings in these areas have been published, including the identification of possible serum and cerebrospinal fluid biomarkers, which are currently in the early phases of translation.

Focal compression of the cervical spinal cord alone does not indicate high risk of neurological deterioration in patients with a diagnosis of mild degenerative cervical myelopathy

Degenerative Cervical Myelopathy (DCM) is the functional derangement of the spinal cord resulting from vertebral column spondylotic degeneration. Typical neurological symptoms of DCM include gait imbalance, hand/arm numbness, and upper extremity dexterity loss. Greater spinal cord compression is believed to lead to a higher rate of neurological deterioration, although clinical experience suggests a more complex mechanism involving spinal canal diameter (SCD). In this study, we utilized machine learning clustering to understand the relationship between SCD and different patterns of cord compression (i.e. compression at one disc level, two disc levels, etc.) to identify patient groups at risk of neurological deterioration. 124 MRI scans from 51 non-operative DCM patients were assessed through manual scoring of cord compression and SCD measurements. Dimensionality reduction techniques and k-means clustering established patient groups that were then defined with their unique risk criteria. We found that the compression pattern is unimportant at SCD extremes (≤14.5 mm or > 15.75 mm). Otherwise, severe spinal cord compression at two disc levels increases deterioration likelihood. Notably, if SCD is normal and cord compression is not severe at multiple levels, deterioration likelihood is relatively reduced, even if the spinal cord is experiencing compression. We elucidated five patient groups with their associated risks of deterioration, according to both SCD range and cord compression pattern. Overall, SCD and focal cord compression alone do not reliably predict an increased risk of neurological deterioration. Instead, the specific combination of narrow SCD with multi-level focal cord compression increases the likelihood of neurological deterioration in mild DCM patients.

SCIseg: Automatic Segmentation of T2-weighted Intramedullary Lesions in Spinal Cord Injury

Purpose

To develop a deep learning tool for the automatic segmentation of T2-weighted intramedullary lesions in spinal cord injury (SCI).

Material and Methods

This retrospective study included a cohort of SCI patients from three sites enrolled between July 2002 and February 2023. A deep learning model, SCIseg, was trained in a three-phase process involving active learning for the automatic segmentation of intramedullary SCI lesions and the spinal cord. The data consisted of T2-weighted MRI acquired using different scanner manufacturers with heterogeneous image resolutions (isotropic/anisotropic), orientations (axial/sagittal), lesion etiologies (traumatic/ischemic/hemorrhagic) and lesions spread across the cervical, thoracic and lumbar spine. The segmentations from the proposed model were visually and quantitatively compared with other open-source baselines. Wilcoxon signed-rank test was used to compare quantitative MRI biomarkers (lesion volume, lesion length, and maximal axial damage ratio) computed from manual lesion masks and those obtained automatically with SCIseg predictions.

Results

MRI data from 191 SCI patients (mean age, 48.1 years ± 17.9 [SD]; 142 males) were used for model training and evaluation. SCIseg achieved the best segmentation performance for both the cord and lesions. There was no statistically significant difference between lesion length and maximal axial damage ratio computed from manually annotated lesions and those obtained using SCIseg.

Conclusion

Automatic segmentation of intramedullary lesions commonly seen in SCI replaces the tedious manual annotation process and enables the extraction of relevant lesion morphometrics in large cohorts. The proposed model segments lesions across different etiologies, scanner manufacturers, and heterogeneous image resolutions. SCIseg is open-source and accessible through the Spinal Cord Toolbox.

The Prevalence of Asymptomatic Cervical Spinal Cord Compression in Individuals Presenting With Symptomatic Lumbar Spinal Stenosis: A Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

The aim of this study was to determine the prevalence of asymptomatic cervical spinal cord compression (CSCC) in individuals with lumbar spinal stenosis (LSS).

METHODS

A systematic electronic search was conducted in Medline, EMBASE, Scopus, and Web of Science without language restriction, with no starting date limit to June 8, 2023, to define the prevalence of asymptomatic CSCC in symptomatic LSS patients. Asymptomatic CSCC was defined based on radiographic studies. All types of studies were included in the review. Meta-analysis was performed on the reported prevalence of asymptomatic CSCC in LSS.

RESULTS

The database search yielded 10,272 articles. After a full-text review, five studies were included in the final review, comprising a total of 1043 cases. Two studies had a low risk for bias, two moderate, and one estimated to be high risk. The range of prevalence of asymptomatic CSCC in LSS in the five included studies was between 24% and 61%. Meta-analysis on the reported prevalence of asymptomatic CSCC patients with symptomatic LSS demonstrated that the random pooled prevalence was 35% (95% CI: 23 to 48).

CONCLUSIONS

Asymptomatic CSCC appears to occur in a high number of patients, with this study noting its presence in one-third of patients with LSS. Based on these findings, we strongly recommend that spine surgeons exercise particular caution during the positioning of patients who are undergoing surgery for lumbar stenosis. Furthermore, it is imperative to monitor individuals with symptomatic LSS closely for any potential signs of emerging myelopathy.

Degenerative Cervical Myelopathy: A Concept Review and Clinical Approach

STUDY DESIGN

Narrative review.

OBJECTIVE

To provide an overview of the evaluation and diagnosis of degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM describes several etiologies of degenerative, nontraumatic spinal cord impairment. Early diagnosis and intervention can decrease neurological decline.

METHODS

An extensive literature review was conducted.

RESULTS

The incidence and prevalence of DCM are increasing worldwide. Asymptomatic spinal cord compression can progress to cervical myelopathy. Static and dynamic factors contribute to spinal cord compression. Patients frequently present with decreased manual dexterity, gait instability, and neck pain. On physical exam, patients frequently present with upper motor neuron signs, a Lhermitte sign, a failed Romberg test, global proprioceptive dysfunction, and decreased pain sensation. Anatomic variation may complicate physical exam interpretation. The modified Japanese Orthopaedic Association Scale and Nurick Classification, based on functional impairment, provide diagnostic utility. Magnetic Resonance Imaging imaging is useful in narrowing the differential diagnosis, evaluating the severity of neurological impairment, and predicting disease progression.

CONCLUSIONS

Understanding the pathophysiology of DCM and the diagnostic utility of the signs and symptoms of DCM is critical. The decision for anterior cervical discectomy and fusion (ACDF), laminoplasty, or combined ACDF and posterior cervical fusion is individualized for each patient.

Degenerative cervical myelopathy: Where have we been? Where are we now? Where are we going?

Degenerative cervical myelopathy (DCM), a recently coined term, encompasses a group of age-related and genetically associated pathologies that affect the cervical spine, including cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL). Given the significant contribution of DCM to global disease and disability, there are worldwide efforts to promote research and innovation in this area. An AO Spine effort termed 'RECODE-DCM' was initiated to create an international multistakeholder consensus group, involving patients, caregivers, physicians and researchers, to focus on launching actionable discourse on DCM. In order to improve the management, treatment and results for DCM, the RECODE-DCM consensus group recently identified ten priority areas for translational research. The current article summarizes recent advancements in the field of DCM. We first discuss the comprehensive definition recently refined by the RECODE-DCM group, including steps taken to arrive at this definition and the supporting rationale. We then provide an overview of the recent advancements in our understanding of the pathophysiology of DCM and modalities to clinically assess and diagnose DCM. A focus will be set on advanced imaging techniques that may offer the opportunity to improve characterization and diagnosis of DCM. A summary of treatment modalities, including surgical and nonoperative options, is then provided along with future neuroprotective and neuroregenerative strategies. This review concludes with final remarks pertaining to the genetics involved in DCM and the opportunity to leverage this knowledge toward a personalized medicine approach.

Cerebrospinal fluid biomarkers of white matter injury and astrogliosis are associated with the severity and surgical outcome of degenerative cervical spondylotic myelopathy

BACKGROUND CONTEXT

Degenerative cervical spondylotic myelopathy (DCM) is the commonest form of spinal cord injury in adults. However, a limited number of clinical reports have assessed the role of biomarkers in DCM.

PURPOSE

We evaluated cerebrospinal fluid (CSF) biomarkers in patients scheduled for DCM surgery and hypothesized that CSF biomarkers levels (1) would reflect the severity of preoperative neurological status; and (2) correlate with radiological appearance; and (3) correlate with clinical outcome.

STUDY DESIGN/SETTING

Prospective clinical and laboratory study.

PATIENT SAMPLE

Twenty-three DCM patients, aged 66.4±12.8 years and seven controls aged 45.4±5.3 years were included.

OUTCOME MEASURES

The American Spinal Injury Association Impairment Scale, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire and EuroQol 5-dimensions were assessed preoperatively and at 3 months post-surgery.

METHODS

We measured preoperative biomarkers (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], phosphorylated neurofilament-H [pNF-H] and Ubiquitin C-terminal hydrolase L1) in CSF samples collected from patients with progressive clinical DCM who underwent surgical treatment. Biomarker concentrations in DCM patients were compared with those of cervical radiculopathy controls.

RESULTS

The median symptom duration was 10 (interquartile range 6) months. The levels of GFAP, NFL, pNF-H, Ubiquitin C-terminal hydrolase L1 were significantly higher in the DCM group compared to controls (p=.044, p=.002, p=.016, and p=.006, respectively). Higher pNF-H levels were found in patients with low signal on T1 Magnetic Resonance Imaging sequence compared to those without (p=.022, area under the receiver operating characteristic curve [AUC] 0.780, 95% Confidence Interval: 0.59-0.98). Clinical improvement following surgery correlated mainly with NFL and GFAP levels (p<.05).

CONCLUSIONS

Our results suggest that CSF biomarkers of white matter injury and astrogliosis may be a useful tool to assess myelopathy severity and predict outcome after surgery, while providing valuable information on the underlying pathophysiology.

Degenerative Cervical Myelopathy: A Practical Approach to Diagnosis

STUDY DESIGN

Narrative Review.

OBJECTIVES

The objective of this review is to provide a stepwise approach to the assessment of patients with potential symptoms of degenerative cervical myelopathy (DCM).

METHODS

N/A.

RESULTS

DCM is an overarching term used to describe progressive compression of the cervical spinal cord by age-related changes to the spinal axis. These alterations to normal anatomy narrow the spinal canal, reduce the space available for the spinal cord, and may ultimately compress the ascending and descending neural tracts. Patients with DCM present with a wide range of symptoms that can significantly impact quality of life, including bilateral hand numbness and paresthesia, gait impairment, motor weakness of the upper and lower extremities, and bladder and bowel dysfunction. Unfortunately, DCM is often misdiagnosed, resulting in delayed assessment and management by the appropriate specialist. The proper evaluation of a patient with suspected DCM includes obtaining a detailed patient history, conducting a comprehensive neurological examination, and ordering appropriate tests to rule in or out other diagnoses.

CONCLUSION

This review summarizes a stepwise approach to the diagnosis of patients with DCM.

Development of a Novel Diagnostic Support Tool for Degenerative Cervical Myelopathy Combining 10-s Grip and Release Test and Grip Strength: A Pilot Study

Early diagnosis of degenerative cervical myelopathy (DCM) is desirable, as delayed treatment can cause irreversible spinal cord injury and subsequent activity of daily living (ADL) impairment. We attempted to develop a straightforward and accurate diagnostic tool for DCM by combining the grip and release test (GRT) and grip strength. As a pilot study, we measured the GRT and grip strength of patients with DCM (n = 247) and a control group (n = 721). Receiver operating characteristic analysis was performed using the lower left and right. The Youden index was used to set cutoff values by sex and age group. The diagnostic performance of each test varied by sex and age, and a diagnostic support tool was created to determine any abnormal results in a test. The calculated M/F cutoff values for GRT were as follows: 40–59 years, 21/18; 60–69 years, 17/17; 70–79 years, 15/15; and 80–89 years, 11/12. The calculated M/F cutoff values for grip strength 32/20, 29/13, 21/15, and 19/10. When either GRT or grip strength was judged as positive, the overall sensitivity was 88.2%, specificity was 78.1%, positive likelihood ratio was 4.03, and the negative likelihood ratio was 0.15. This novel diagnostic support tool was superior to using GRT and grip strength alone in the early DCM diagnosis. Future research to obtain age- and sex-specific data is necessary to validate and further improve the tool.

Establishing Diagnostic Criteria for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 3]

STUDY DESIGN

Narrative review.

OBJECTIVES

To discuss the importance of establishing diagnostic criteria in Degenerative Cervical Myelopathy (DCM), including factors that must be taken into account and challenges that must be overcome in this process.

METHODS

Literature review summarising current evidence of establishing diagnostic criteria for DCM.

RESULTS

Degenerative Cervical Myelopathy (DCM) is characterised by a degenerative process of the cervical spine resulting in chronic spinal cord dysfunction and subsequent neurological disability. Diagnostic delays lead to progressive neurological decline with associated reduction in quality of life for patients. Surgical decompression may halt neurologic worsening and, in many cases, improves function. Therefore, making a prompt diagnosis of DCM in order to facilitate early surgical intervention is a clinical priority in DCM.

CONCLUSION

There are often extensive delays in the diagnosis of DCM. Presently, no single set of diagnostic criteria exists for DCM, making it challenging for clinicians to make the diagnosis. Earlier diagnosis and subsequent specialist referral could lead to improved patient outcomes using existing treatment modalities.

Intraoperative monitoring of CSF pressure in patients with degenerative cervical myelopathy (COMP-CORD Study): a prospective cohort study

Degenerative cervical myelopathy (DCM) is hallmarked by spinal canal narrowing and related cord compression and myelopathy. CSF pressure dynamics are likely disturbed due to spinal canal stenosis. The study aims to investigate the diagnostic value of continuous intraoperative CSF pressure monitoring during surgical decompression. Prospective single center study (NCT02170155) with enrolment of DCM patients that underwent surgical decompression between December 2019 and May 2021. Data from N=17 patients were analyzed, symptom severity graded with the modified Japanese Orthopedic Score (mJOA). CSF pulsations were continuously monitored with a lumbar intrathecal catheter during surgical decompression. Mean patient age was 62±9 years (range 38-73; 8F), symptoms were mild-moderate in most patients (mean mJOA 14±2, range 10-18). Measurements were well tolerated without safety concerns. In 15/16 (94%) CSF pulsations increased at the time of surgical decompression. In one case, responsiveness could not be evaluated for technical reasons. Unexpected CSF pulsation decrease was related to adverse events (i.e., CSF leakage). Median CSF pulsation amplitudes increased from pre-decompression (0.52 mmHg [IQR 0.71]) to post-decompression (0.72 mmHg [IQR 0.96]) (P=0.001). Mean baseline CSF pressure increased with lower magnitude than pulsations, from 9.5±3.5 to 10.3±3.8 mmHg (P=0.003). Systematic relations of CSF pulsations were confined to surgical decompression, independent of arterial blood pressure (P=0.927) or heart rate (P=0.102). Intraoperative CSF pulsation monitoring was sensitive, timely, and specifically related to surgical decompression while in addition adverse events could be discerned. Further investigation of the clinical value of intraoperative guidance for decompression in complex DCM surgery is promising.

Effects of Various Therapeutic Agents on Vasospasm and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage-Results of a Network Meta-Analysis

BACKGROUND

Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH.

METHODS

A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH.

RESULTS

Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63-56.71), decreasing mortality (OR, 0.08; 95% CrI, 0-0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057-0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97-6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12-1.15). Fasudil (OR, 0.16; 95% CrI, 0.03-0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057-1.0) in preventing delayed ischemic neurologic deficits.

CONCLUSIONS

Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings.

T1 Mapping for Microstructural Assessment of the Cervical Spinal Cord in the Evaluation of Patients with Degenerative Cervical Myelopathy

BACKGROUND AND PURPOSE

Although current radiologic evaluation of degenerative cervical myelopathy by conventional MR imaging accurately demonstrates spondylosis or degenerative disc disease causing spinal cord dysfunction, conventional MR imaging still fails to provide satisfactory anatomic and clinical correlations. In this context, we assessed the potential value of quantitative cervical spinal cord T1 mapping regarding the evaluation of patients with degenerative cervical myelopathy.

MATERIALS AND METHODS

Twenty patients diagnosed with mild and moderate-to-severe degenerative cervical myelopathy and 10 healthy subjects were enrolled in a multiparametric MR imaging protocol. Cervical spinal cord T1 mapping was performed with the MP2RAGE sequence procedure. Retrieved data were processed and analyzed regarding the global spinal cord and white and anterior gray matter on the basis of the clinical severity and the spinal canal stenosis grading.

RESULTS

Noncompressed levels in healthy controls demonstrated significantly lower T1 values than noncompressed, mild, moderate, and severe stenotic levels in patients. Concerning the entire spinal cord T1 mapping, patients with moderate-to-severe degenerative cervical myelopathy had higher T1 values compared with healthy controls. Regarding the specific levels, patients with moderate-to-severe degenerative cervical myelopathy demonstrated a T1 value increase at C1, C7, and the level of maximal compression compared with healthy controls. Patients with mild degenerative cervical myelopathy had lower T1 values than those with moderate-to-severe degenerative cervical myelopathy at the level of maximal compression. Analyses of white and anterior gray matter confirmed similar results. Strong negative correlations between individual modified Japanese Orthopaedic Association scores and T1 values were also observed.

CONCLUSIONS

In this preliminary study, 3D-MP2RAGE T1 mapping demonstrated increased T1 values in the pathology tissue samples, with diffuse medullary alterations in all patients with degenerative cervical myelopathy, especially relevant at C1 (nonstenotic level) and at the maximal compression level. Encouraging correlations observed with the modified Japanese Orthopaedic Association score make this novel approach a potential quantitative biomarker related to clinical severity in degenerative cervical myelopathy. Nevertheless, patients with mild degenerative cervical myelopathy demonstrated nonsignificant results compared with healthy controls and should now be studied in multicenter studies with larger patient populations.

A deep learning model for detection of cervical spinal cord compression in MRI scans

Magnetic Resonance Imaging (MRI) evidence of spinal cord compression plays a central role in the diagnosis of degenerative cervical myelopathy (DCM). There is growing recognition that deep learning models may assist in addressing the increasing volume of medical imaging data and provide initial interpretation of images gathered in a primary-care setting. We aimed to develop and validate a deep learning model for detection of cervical spinal cord compression in MRI scans. Patients undergoing surgery for DCM as a part of the AO Spine CSM-NA or CSM-I prospective cohort studies were included in our study. Patients were divided into a training/validation or holdout dataset. Images were labelled by two specialist physicians. We trained a deep convolutional neural network using images from the training/validation dataset and assessed model performance on the holdout dataset. The training/validation cohort included 201 patients with 6588 images and the holdout dataset included 88 patients with 2991 images. On the holdout dataset the deep learning model achieved an overall AUC of 0.94, sensitivity of 0.88, specificity of 0.89, and f1-score of 0.82. This model could improve the efficiency and objectivity of the interpretation of cervical spine MRI scans.

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.

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.

Degenerative cervical myelopathy: Recent updates and future directions

Advances in patient selection, surgical techniques, and postoperative care have facilitated spine surgeons to manage complex spine cases with shorter operative times, reduced hospital stay and improved outcomes. We focus this article on a few areas which have shown maximum developments in management of degenerative cervical myelopathy and also throw a glimpse into the future ahead. Imaging modalities, surgical decision making, robotics and neuro-navigation, minimally invasive spinal surgery, motion preservation, use of biologics are few of them. Through this review article, we hope to provide the readers with an insight into the present state of art in cervical myelopathy and what the future has in store for us.

Traumatic and nontraumatic spinal cord injury: pathological insights from neuroimaging

Pathophysiological changes in the spinal cord white and grey matter resulting from injury can be observed with MRI techniques. These techniques provide sensitive markers of macrostructural and microstructural tissue integrity, which correlate with histological findings. Spinal cord MRI findings in traumatic spinal cord injury (tSCI) and nontraumatic spinal cord injury - the most common form of which is degenerative cervical myelopathy (DCM) - have provided important insights into the pathophysiological processes taking place not just at the focal injury site but also rostral and caudal to the spinal injury. Although tSCI and DCM have different aetiologies, they show similar degrees of spinal cord pathology remote from the injury site, suggesting the involvement of similar secondary degenerative mechanisms. Advanced quantitative MRI protocols that are sensitive to spinal cord pathology have the potential to improve diagnosis and, more importantly, predict outcomes in patients with tSCI or nontraumatic spinal cord injury. This Review describes the insights into tSCI and DCM that have been revealed by neuroimaging and outlines current activities and future directions for the field.

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick’s grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski’s sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

Controversies in the Management of Cervical Spine Conditions in Elite Athletes

Cervical spine injuries in elite athletes can have detrimental consequences, which makes return to play for professional athletes after cervical spine injury controversial. Although most athletes can return to sport under some circumstances, such as single-level anterior cervical diskectomy and fusion for cervical disk herniation, return to play after cervical disk arthroplasty and multilevel fusion for cervical disk herniation remains controversial. Allowing athletes to return to play after a finding of cervical stenosis and in the incidence of pseudarthrosis remains unclear. This review provides a systematic framework to guide return-to-play decision-making in common cervical conditions in elite athletes. [Orthopedics. 2019; 42(4):e370-e375.].