Role of Cerebrolysin in cervical spondylotic myelopathy patients: a prospective randomized study

Pharmacological Treatment of Degenerative Cervical Myelopathy: A Critical Review of Current Evidence

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults, representing substantial morbidity and significant financial and resource burdens. Typically, patients with progressive DCM will eventually receive surgical treatment. Nonetheless, despite advancements in pharmacotherapeutics, evidence for pharmacological therapy remains limited. Health professionals from various fields would find interest in pharmacological agents that could benefit patients with mild DCM or enhance surgical outcomes. This review aims to consolidate all clinical and experimental evidence on the pharmacological treatment of DCM. We conducted a comprehensive narrative review that presents all pharmacological agents that have been investigated for DCM treatment in both humans and animal models. Riluzole exhibits effectiveness solely in rat models, but not in treating mild DCM in humans. Cerebrolysin emerges as a potential neuroprotective agent for myelopathy in animals but had contradictory results in clinical trials. Limaprost alfadex demonstrates motor function improvement in animal models and exhibits promising outcomes in a small clinical trial. Glucocorticoids not only fail to provide clinical benefits but may also lead to adverse events. Cilostazol, anti-Fas ligand antibody, and Jingshu Keli display promise in animal studies, while erythropoietin, granulocyte colony-stimulating factor and limaprost alfadex exhibit potential in both animal and human research. Existing evidence mainly rests on weak clinical data and animal experimentation. Current pharmacological efforts target ion channels, stem cell differentiation, inflammatory, vascular, and apoptotic pathways. The inherent nature and pathogenesis of DCM offer substantial prospects for developing neurodegenerative or neuroprotective therapies capable of altering disease progression, potentially delaying surgical intervention, and optimizing outcomes for those undergoing surgical decompression.

Natural history of degenerative cervical myelopathy: a meta-analysis and neurologic deterioration survival curve synthesis

BACKGROUND CONTEXT

Cervical spine surgery is rapidly increasing, and our knowledge of the natural history of degenerative cervical myelopathy (DCM) is limited.

PURPOSE

To synthesize accurate time-based estimates of meaningful neurologic decline in patients with DCM managed conservatively and to provide formulae to help communicate survivorship estimates to patients.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review and meta-analysis was conducted using Cochrane and PRISMA guidelines. A librarian-assisted search strategy using multiple databases with broad search terms and validated filter functions was used. All articles were reviewed in duplicate.

RESULTS

A total of 9570 studies were captured in the initial search, which after deletion of duplicates and manual review of abstracts and full texts revealed 6 studies for analyses. All studies were prospective cohorts or randomized controlled trials. The pooled survival estimates for neurologic stability (95% CrI) for mild DCM patients are: 91% (83%-97%) at one year; 85% (72%-94%) at 2 years; 84% (70%-94%) at 3 years; 75% (54%-90%) at 5 years; 66% (40%-86%) at 15 years; and 65% (39%-86%) at 20 years. The pooled survival estimates for neurologic stability (95% CrI) for moderate/severe DCM patients are: 83% (76%-89%) at 1 year; 72% (62%-81%) at 2 years; 71% (60%-80%) at 3 years; 55% (41%-68%) at 5 years; 44% (27%-59%) at 15 years; and 43% (25%-58%) at 20 years.

CONCLUSIONS

This is the first quantitative synthesis of the totality of published data on DCM natural history. Our review confirms a slow decline in neurologic function. We developed formulae which can be easily used by surgeons to communicate to patients their risk of neurologic deterioration. These formulae can be used to facilitate the shared decision-making process.

Long-Term Survivorship of Cervical Spine Procedures; A Survivorship Meta-Analysis and Meta-Regression

STUDY DESIGN

Systematic Review.

OBJECTIVES

To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery.

METHODS

A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression.

RESULTS

Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55).

CONCLUSIONS

In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Prospective Randomized Control Trial to Compare the Role of Injection Cerebrolysin for 10 Days Duration Against Placebo in Operated Cases of Degenerative Cervical Myelopathy

STUDY DESIGN

Prospective randomized control trial.

OBJECTIVE

To analyze outcomes following the injection of cerebrolysin in surgically treated patients with degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

Previous research has concluded that superior functional outcomes are achieved with the use of cerebrolysin in surgically treated patients of DCM for 21 days. Our study has been conducted to analyze the use of this drug for a shorter duration (10 days) and compare its clinical efficacy.

METHODS

Ninety operated cases of mild to severe DCM were randomized into two groups. Sixty patients received the injection Cerebrolysin for 10 days postoperatively. The remaining 30 patients received a placebo. Functional outcomes were measured using modified Japanese Orthopaedic Association (mJOA) scores and visual analogue scale (VAS). The American Spinal Injury Association (ASIA) scale was used to document neurological recovery. Hand function was assessed by measuring the grip strength and the upper limb function score the upper extremity motor mJOA plus upper extremity sensory mJOA score. Assessments were performed and preoperatively and postoperatively and at one-month, three-month, six-month, and one-year following surgery.

RESULTS

Preoperative mJOA and VAS scores were comparable in both groups ( P >0.05). Both groups experienced an improvement in mJOA and VAS scores at all time-points during follow-up as compared with preoperative scores. However, the cerebrolysin group demonstrated significantly greater mJOA scores (16.37±1) when compared with the placebo (15.2±1.8) at one-year follow-up ( P <0.0001). Neurological improvement with cerebrolysin therapy was also superior ( P =0.04). No significant adverse reactions were documented.

CONCLUSION

Injection cerebrolysin, when administered for 10 days postoperatively, can result in significantly greater neurological improvement and hand function in patients with DCM who also receive surgery.

A New Framework for Investigating the Biological Basis of Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 5]: Mechanical Stress, Vulnerability and Time

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To propose a new framework, to support the investigation and understanding of the pathobiology of DCM, AO Spine RECODE-DCM research priority number 5.

METHODS

Degenerative cervical myelopathy is a common and disabling spinal cord disorder. In this perspective, we review key knowledge gaps between the clinical phenotype and our biological models. We then propose a reappraisal of the key driving forces behind DCM and an individual's susceptibility, including the proposal of a new framework.

RESULTS

Present pathobiological and mechanistic knowledge does not adequately explain the disease phenotype; why only a subset of patients with visualized cord compression show clinical myelopathy, and the amount of cord compression only weakly correlates with disability. We propose that DCM is better represented as a function of several interacting mechanical forces, such as shear, tension and compression, alongside an individual's vulnerability to spinal cord injury, influenced by factors such as age, genetics, their cardiovascular, gastrointestinal and nervous system status, and time.

CONCLUSION

Understanding the disease pathobiology is a fundamental research priority. We believe a framework of mechanical stress, vulnerability, and time may better represent the disease as a whole. Whilst this remains theoretical, we hope that at the very least it will inspire new avenues of research that better encapsulate the full spectrum of disease.

Prospective Randomized Control Pilot Study to Compare the Role of Injection Cerebrolysin in Operated cases of Degenerative Cervical Myelopathy

STUDY DESIGN

Prospective randomized control trial.

OBJECTIVE

The aim of this study was to analyze role of cerebrolysin in patients of degenerative cervical myelopathy (DCM) managed by surgical modalities.

SUMMARY OF BACKGROUND DATA

Cerebrolysin has been extensively researched with variable success in neurodegenerative pathologies. There has been only one study in published literature till date that has studied role of cerebrolysin in DCM in conservatively managed patients but none in the patients treated surgically. We present our pilot study which analyzes the role of cerebrolysin in patients of DCM managed by surgical modalities.

METHODS

This prospective randomized control trial was conducted at a tertiary care institute in Mumbai. Sixty operated cases of DCM were randomly divided into 2 groups. The first group was given Injection Cerebrolysin 5 mL diluted in 100 mL Normal Saline over 30 minutes once a day for 21 days postoperatively. The second group was given placebo. Modified Japanese Orthopedic Association scores (mJOA) and visual analog scale (VAS) were used to document functional outcomes at 3 weeks, 3 months, 6 months, and 1 year. Recovery of hand function was separately accessed by improvement in hand power and sensations.

RESULTS

Preoperative mJOA and VAS scores were comparable between 2 groups. Both groups showed significant improvement in both mJOA and VAS scores at 3weeks, 3 months, 6 months and 1-year follow-up (P < 0.01). In comparing the two groups, there was no difference in improvement of mJOA and VAS scores. However, cerebrolysin group showed significant improvement in hand function at 1 year compared to the placebo. Postoperative neurological recovery was better in the cerebrolysin group with 66.7% patients showing complete neurological recovery compared to 56.7% for placebo, but this was statistically insignificant. Two patients developed headache and one patient complained of dizziness in the cerebrolysin group, but these resolved without any intervention.

CONCLUSION

Use of cerebrolysin in postoperative cases of DCM is safe and results in improved hand function.Level of Evidence: 1.

The Role of Nutrition in Degenerative Cervical Myelopathy: A Systematic Review

Introduction

Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord impairment worldwide, encompassing chronic compression of the spinal cord, neurological disability and diminished quality of life. Evidence on the contribution of environmental factors is sparse; in particular, the role of nutrition in DCM is unknown. The objective of this review was to assess the effect of nutrition on DCM susceptibility, severity and surgical outcome.

Methods

A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English papers, focussing on cervical myelopathy and nutrition, published before January 2020 were considered eligible. Quality assessments were performed using the GRADE assessment tool. Patient demographics, nutritional factor and DCM outcomes measures were recorded. Relationships between nutritional factors, interventions and disease prognosis were assessed.

Results

In total, 5835 papers were identified of which 44 were included in the final analysis. DCM patients with pathological weight pre-operatively were more likely to see poorer improvements post-surgically. These patients experienced poorer physical and mental health improvements from surgery compared to normal weight patients and were more likely to suffer from post-operative complications such as infection, DVT, PE and hospital readmissions. Two trials reporting benefits of nutritional supplements were identified, with 1 suggesting Cerebrolysin to be significant in functional improvement. An unbalanced diet, history of alcohol abuse and malnourishment were associated with poorer post-operative outcome.

Conclusion

Although the overall strength of recommendation is low, current evidence suggests nutrition may have a significant role in optimising surgical outcome in DCM patients. Although it may have a role in onset and severity of DCM, this is a preliminary suggestion. Further work needs to be done on how nutrition is defined and measured, however, the beneficial results from studies with nutritional interventions suggest nutrition could be a treatment target in DCM.

Protective effect of pig brain polypeptides against corticosterone-induced oxidative stress, inflammatory response, and apoptosis in PC12 cells

OBJECTIVE

Pig brain polypeptides (PBP), active polypeptides hydrolysate extracted from fresh porcine brain tissue, has been shown to have neuroprotective effects in both in vitro and in vivo studies. The present study aimed to explore the molecular mechanisms underlying the neuroprotective effects of PBP in corticosterone (CORT)-induced rat adrenal pheochromocytoma PC12 cells.

METHODS

Cell viability and lactate dehydrogenase (LDH) release were measured in PC12 cells induced with 200 μM CORT in the presence or absence of various concentrations of PBP for 48 h. Intracellular reactive oxygen species (ROS) generation, the activities of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) and glutathione (GSH) content were examined to analyze the effect of PBP on CORT-induced oxidative stress. The levels of pro-inflammatory factors, the percentage of apoptotic cells, and apoptosis-related protein expression in PC12 cells were determined.

RESULTS

PBP is mainly composed of protein subunits with molecular weights ranging from 1000 to 10,000 Da. PBP treatment increased cell viability and decreased the release of LDH in CORT-stimulated PC12 cells. Moreover, PBP reduced the level of CORT-induced oxidative stress by decreasing ROS levels and increasing SOD, GSH-Px activities and GSH content. PBP had an inhibitory effect on the CORT-induced inflammatory response through inhibition of the NF-κB signaling pathway. PBP also inhibited CORT-induced apoptosis by downregulating the mitochondrial apoptotic signaling pathway.

CONCLUSION

These results suggest that PBP exerts a neuroprotective effect against CORT-induced cell injury by inhibiting oxidative stress, inflammation, and apoptosis. PBP could act as a neuroprotective agent against nerve injury induced by CORT.