Outcome factors in surgically treated patients for cervical spondylotic myelopathy

Spinal cord perfusion is associated with microstructural damage in cervical spondylotic myelopathy patients who underwent cervical laminoplasty

OBJECTIVES

To investigate the association between spinal cord perfusion and microstructural damage in CSM patients who underwent cervical laminoplasty using MR dynamic susceptibility contrast (DSC), diffusion tensor imaging (DTI), and neurite orientation dispersion and density imaging (NODDI) techniques.

METHODS

A follow-up cohort study was conducted with 53 consecutively recruited CSM patients who had undergone cervical laminoplasty 12-14 months after the surgery from April 2016 to December 2016. Twenty-one aged-matched healthy volunteers were recruited as controls. For each patient, decompressed spinal cord levels were imaged on a 3.0-T MRI scanner by diffusion and DSC sequences to quantify the degrees of microstructural damage and perfusion conditions, respectively. The diffusion data were analyzed by DTI and NODDI models to produce diffusion metrics. Classic indicator dilution model was used to quantify the DSC metrics. Mann-Whitney U test was performed for comparison of diffusion metrics between patients and healthy controls. Pearson correlation was used to explore the associations between the metrics of spinal cord perfusion and microstructural damage.

RESULTS

DTI metrics, neurite density, and isotropic volume fraction had significant differences between postoperative patients and healthy controls. Pearson correlation test showed that SCBV was significantly positively correlated with RD, MD, and ODI, and negatively correlated with FA and NDI. SCBF was found to be significantly positively correlated with RD and MD, and negatively correlated with FA.

CONCLUSIONS

Increased spinal cord perfusion quantified by DSC is associated with microstructural damage assessed by diffusion MRI in CSM patients who underwent cervical laminoplasty.

CLINICAL RELEVANCE STATEMENT

This study found that the spinal cord perfusion is associated with microstructural damage in postoperative cervical spondylotic myelopathy patients, indicating that high perfusion may play a role in the pathophysiological process of cervical spondylotic myelopathy and deserves more attention.

KEY POINTS

• Spinal cord microstructural damage can be persistent despite the compression had been relieved 12-14 months after the cervical laminoplasty in cervical spondylotic myelopathy (CSM) patients. • Spinal cord perfusion is associated with microstructural damage in CSM patients after the cervical laminoplasty. • Inflammation in the decompressed spinal cord may be a cause of increased perfusion and is associated with microstructural damage during the recovery period of CSM.

A Systematic Review on Neurological Outcomes for Cervical Degenerative Myelopathy After Anterior Decompression Surgery: Motion Preservation vs Fusion

BACKGROUND

Although it is well established that surgically treated patients with cervical degenerative myelopathy (CDM) improve irrespective of the anterior decompression technique used, no consensus exists on what technique is superior in terms of neurological recovery. A general concern exists that anterior cervical discectomy with arthroplasty (ACDA) leads to less favorable outcomes in CDM due to microtrauma caused by preserved mobility. It is remarkable that current literature mainly uses pain scores to assess clinical outcomes after anterior decompression surgery, especially considering that pain may not be the most relevant outcome for CDM. This systematic review evaluated the literature concerning neurological outcomes in patients with CDM treated with anterior decompression surgery and assessed by validated myelopathy scores.

METHODS

Systematic searches were carried out in PubMed, EMBASE, Web of Science, CINAHL, and the Cochrane Library. Prospective studies were included when patients with isolated CDM were treated with anterior decompression surgery, and a validated myelopathy outcome score was used.

RESULTS

A total of 11 studies were included from the 16,032 identified studies. All studies used the modified Japanese Orthopedic Association (JOA) outcome score and showed improvement for all anterior techniques. The mean improvement in anterior cervical discectomy and fusion (ACDF) was 4.80 and 3.64 for the modified JOA and JOA outcome scores, respectively. The JOA for ACDA showed a mean improvement of 5.51. The overall quality of the included articles was low to moderate according to the Cochrane tool.

CONCLUSION

Neurological recovery of CDM is similar after all anterior decompression techniques, including ACDA when compared with ACDF.

CLINICAL RELEVANCE

The current literature gives no reason to dissuade the use of ACDA in cervical myelopathy.

LEVEL OF EVIDENCE: 3

Cacna2d2 inhibits axonal regeneration following surgical decompression in a rat model of cervical spondylotic myelopathy

Background

Cervical spondylotic myelopathy (CSM) is a clinically symptomatic condition due to spinal cord compression, leading to spinal cord dysfunction. Surgical decompression is the main treatment of CSM, but the mechanisms of axonal regeneration after surgical decompression are still fragmentary.

Methods

In a rat model of CSM, the cacna2d2 (α2δ2) expression levels in anterior horn of spinal cord were observed following compression and decompression by western blot and immunofluorescence. The expression levels of 5 hydroxytryptamine (5HT) and GAP43 were also analyzed by immunofluorescence. Furthermore, gabapentin intervention was performed for 4 weeks after decompression to analyze the changes of behaviors and anterior horn of spinal cords.

Results

Following decompression, the expression levels of α2δ2 in the anterior horn of spinal cord were decreased, but the expression levels of 5HT andGAP43 were increased. Compared with the vehicle treated rats, gabapentin treatment for 4 weeks ameliorated the behaviors of rats and improved the damaged anterior horn of spinal cord. Besides, inhibition of α2δ2 through gabapentin intervention enhanced the axonal regeneration in the anterior horn of damaged spinal cord.

Conclusions

Inhibition of α2δ2 could enhance axonal recovery in anterior horn of damaged spinal cord induced by CSM after surgical decompression, providing a potential method for promoting axon regeneration following surgery.

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.

Effect of timeliness incentive nursing on postoperative rehabilitation in patients with cervical spondylotic myelopathy

OBJECTIVE

To explore the effect of timeliness incentive nursing on postoperative rehabilitation of patients with cervical spondylotic myelopathy (CSM).

METHODS

a total of 104 CSM patients treated in our hospital were recruited, who were evenly divided into two groups according to a random number table method. The control group was given routine nursing, and the research group was given timeliness incentive nursing based on routine nursing. The out-of-bed activity time after surgery, the length of hospital stay, the visual analog scale (VAS) scores before and after intervention, the Japanese Orthopedic Association (JOA) scores, the cervical spine range of motion (ROM), changes of quality of life (QOL), complications, and nursing satisfaction were compared between the two groups.

RESULTS

After intervention, the out-of-bed activity time and length of hospital stay in the research group were significantly shorter than those of the control group (P<0.001). Compared with before intervention, VAS scores were significantly decreased, while JOA scores and ROM were both considerably increased after intervention in both groups (P<0.001). Of note, the improvement in the research group was more significant compared with the control group. The incidence of complications of the research group was remarkably lower than that of the control group (P<0.05). Compared with before intervention, physiological functions, physiological and emotional responsibilities, social function, mental health, energy, and overall health scores were all significantly increased after intervention in both groups, whereas the physical pain was significantly decreased (P<0.001), and these measures of the research group were higher than those of the control group. The nursing satisfaction in the research group was notably higher than that of the control group (P<0.05).

CONCLUSION

Timeliness incentive nursing can effectively improve postoperative rehabilitation of patients with CSM, reduce the pain, decrease the incidence of complications, improve the QOL, and increase nursing satisfaction.

Cervical Decompression for Myelopathy in a Resource-Poor Region: Initial Experience

BACKGROUND

The aim of this study was to document the initial experience and challenges of cervical decompression in a resource-poor region.

METHODS

Forty-three patients with cervical myelopathy who had surgery were included in the study. Details including evaluations pre- and postoperative (at 6 weeks and 6 months) using the Nurick score were recorded prospectively. Details of surgery were also documented.

RESULTS

The mean age at surgery was 58.0 years. There were 37 men and 6 women. Surgeries performed were anterior cervical decompression and fusion (51.2%), cervical laminectomy (32.6%), corpectomy and occipitocervical fixation (2.3% each), and decompression with lateral mass fixation (11.6%). Four patients presented within 3 months of onset of symptoms (early), whereas 39 after 3 months (late). The Nurick grade significantly improved in 41 patients (97.6%) following surgery (P < 0.001). The average Nurick preoperative score was 3.2, and postoperative it was 2.12 and 1.14 at 6 weeks and 6 months, respectively. In the early presentation group, scores improved from an average preoperative of 2.5-0.5 at 6 months, whereas in the late presentation group, score improved from an average of 3.3 preoperative to 1.2 at 6 months postoperative.

CONCLUSIONS

Despite the challenges of poverty, late presentation, and lack of basic standard instruments and equipment, patients with cervical myelopathy in the resource-poor setting had outcomes similar to other well-established centers after surgical decompression. We infer that challenges in setting up a spine unit in a resource-poor region can be circumvented safely.

Perturbation-Based Balance Training in Postoperative Individuals With Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is a common aging condition caused by spinal cord compression. Individuals with DCM often presented with residual balance and functional impairments postoperatively. Perturbation-based balance training (PBT) has been shown to have positive effects on populations with neurological disorders but has yet to be investigated in DCM. The objective of this study was therefore to evaluate the effects of PBT on balance and functional performance in postoperative individuals with DCM. Fifteen postoperative individuals with DCM (DCM group) and 14 healthy adults (healthy control group) were recruited. The DCM group received a 4-weeks PBT using a perturbation treadmill. The outcome measures included mean velocity of center of pressure (COP) during quiet standing; center of mass (COM) variance and reaction time to balance perturbation during standing with forward and backward perturbation; gait speed during level ground walking; Timed Up and Go Test (TUG) and disability questionnaire scores including Visual Analog Scale, Neck Disability Index, and Lower Extremity Function of Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire. The assessments were conducted pre- and post-training postoperatively for the DCM group but only once for the healthy control group. Significant improvements were observed in the mean velocity of COP, COM variance, reaction time, gait speed, and TUG in the DCM group. Disability questionnaire scores were not significantly different after training in DCM group. For between-group comparisons, significant differences that were observed pre-training were not observed post-training. The 4-weeks PBT is a potential rehabilitation strategy for addressing balance and functional impairment in postoperative individuals with DCM. In addition, the post-training performance in the DCM group exhibited trends comparable to those of age-matched healthy controls. Furthermore, the training regimens offer a practical reference for future studies on populations with balance disorders. Future studies complemented with neurophysiological assessments could reveal more information of the underlying mechanisms of PBT.