Quantitative Romberg on a Force Plate: Objective Assessment Before and After Surgery for Cervical Spondylotic Myelopathy

STUDY DESIGN

Longitudinal observational cohort.

OBJECTIVES

The purpose of this study was to evaluate the utility of Quantitative Romberg measurements as pre-op and post-op balance outcome measures.

SUMMARY OF BACKGROUND DATA

Cervical spondylotic myelopathy (CSM) is characterized by balance deficiencies produced by impaired proprioception. Evaluation is subjective, and binary physical exam findings lack the precision to assess postoperative outcome improvement.

METHODS

CSM patients were prospectively enrolled to undergo preoperative and postoperative Quantitative Romberg tests on a force plate to record center of pressure (COP) motion for 30 seconds with eyes open followed by eyes closed. Revision cases were excluded. Kinematics of COP movement parameters were compared between preoperative and postoperative state for each patient.

RESULTS

Twenty-seven CSM patients were enrolled and completed both pre/post-testing. The mean age was 60.0 years, with 13 (48%) males and 9 (33%) smokers. Mean number of surgical levels was 2.48. The minimum mean follow-up was six months. There was a statistically significant improvement in eyes closed after surgery compared with preoperative for total COP motion (523.44 vs. 387.00 cm, P <0.001), average sway speed (17.41 vs. 13.00 cm/s, P <0.001), and total lateral COP motion (253.44 vs. 186.70 cm, P <0.001). There was no statistically significant improvement in the modified Japanese Orthopaedic Association (13.29 vs. 14.29, P =0.28).

CONCLUSIONS

CSM balance findings on Quantitative Romberg testing significantly improve postoperatively in patients with CSM. These findings support this testing as representative of proprioceptive balance deficiencies seen in CSM. Quantitative Romberg may be used as an objective measure of clinical outcome and assist in stratification of surgical interventions, surgery timing, and technique.

Monocentric Retrospective Analysis of Clinical Outcomes, Complications, and Adjacent Segment Disease in 507 Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Myelopathy

BACKGROUND

Degenerative cervical myelopathy (DCM) is a leading cause of nontraumatic spinal cord injury. Surgery aims to arrest neurological decline and improve conditions, but controversies surround risks and benefits in elderly patients, outcomes in mild myelopathy, and the risk of adjacent segment disease (ASD).

METHODS

Retrospective data of patients who underwent anterior cervical discectomy and fusion for DCM in our hospital were collected. Patients were stratified by preoperative modified Japanese Orthopaedic Association (mJOA) (mild, moderate, severe) and age (under 70, over 70). Clinical outcomes, complications, and ASD rate were analyzed. We evaluated the relationship between mJOA recovery rate and the risk of complications and various preoperative parameters.

RESULTS

Five hundred seven consecutive patients were included in the study, with a mean follow-up of 43.52 months (12-71). Improvement in all outcome variables was observed in mild, moderate, and severe myelopathy categories, with elderly patients showing a lower improvement. Except for age, no other variable correlated with mJOA recovery rate. We observed 45 complications (11.1% of patients), with 14 in the U70 group and 31 in the O70 group (P value < 0.001). Age, Charlson comorbidity index, and ASA score were found to be predictors of complications. Fourteen patients (2.8% of total), mean age 54.2, developed radiological and clinical ASD. Most had cranial-level ASD with Pfirmann grade ≥ 2 before index surgery.

CONCLUSIONS

Most myelopathic patients improve after anterior cervical discectomy and fusion. Elderly patients show a lower improvement and higher complication rates than their younger counterparts. ASD rates are low, and younger patients with preexisting cranial level alterations are more susceptible.

Flipping the mJOA: Clinical utility of the modified Japanese Orthopaedic Association score as a tool for detecting degenerative cervical myelopathy

Introduction

People with Degenerative Cervical Myelopathy (DCM) often experience diagnostic delay. This could lead to poorer outcomes, including disability.

Research question

Does the modified Japanese Orthopaedic Association scale (mJOA) have clinical utility as an early detection tool for possible DCM?

Materials and methods

This is a prospective study of consecutive adult patients, referred to a National Neurosurgical Centre with a neck problem. Assessing clinicians undertook standard clinical examination and calculated the mJOA score. A consultant radiologist independently reported radiological findings, after which the assessing clinician determined the diagnosis. The sensitivity and specificity of mJOA for DCM at various cut-points was statistically analysed using Receiver Operating Characteristics (ROC) curves.

Results

Of 201 patients (98 male, mean age 52.6 ± 13y) assessed over 13 months, 21 were diagnosed with DCM (prevalence 10.4%). Fifteen (71.4%) had a mJOA score classifying disease severity as mild, 4/21 (19%) had moderate disease and two (9.5%) had severe disease. A mJOA score ≤17 (cutpoint ≥1) showed sensitivity of 95% and specificity of 71% for the clinical diagnosis of DCM. mJOA score ≤16 (cutpoint ≥2) had sensitivity of 62% and specificity of 90%. The ROC area under the curve was 0.885 (95% confidence interval: 0.82 to 0.95). 87% of patients were correctly classified.

Discussion and conclusion

mJOA score ≤16 is 90% specific for a subsequent diagnosis of DCM in people with neck problems and has potential to be used as an early detection tool. Further research is needed to replicate these findings and establish feasibility and acceptability in primary care.

The value of Clinical signs in the diagnosis of Degenerative Cervical Myelopathy - A Systematic review and Meta-analysis

STUDY DESIGN

Delayed diagnosis of degenerative cervical myelopathy (DCM) is likely due to a combination of its subtle symptoms, incomplete neurological assessments by clinicians and a lack of public and professional awareness. Diagnostic criteria for DCM will likely facilitate earlier referral for definitive management.

OBJECTIVES

This systematic review aims to determine (i) the diagnostic accuracy of various clinical signs and (ii) the association between clinical signs and disease severity in DCM?

METHODS

A search was performed to identify studies on adult patients that evaluated the diagnostic accuracy of a clinical sign used for diagnosing DCM. Studies were also included if they assessed the association between the presence of a clinical sign and disease severity. The QUADAS-2 tool was used to evaluate the risk of bias of individual studies.

RESULTS

This review identified eleven studies that used a control group to evaluate the diagnostic accuracy of various signs. An additional 61 articles reported on the frequency of clinical signs in a cohort of DCM patients. The most sensitive clinical tests for diagnosing DCM were the Tromner and hyperreflexia, whereas the most specific tests were the Babinski, Tromner, clonus and inverted supinator sign. Five studies evaluated the association between the presence of various clinical signs and disease severity. There was no definite association between Hoffmann sign, Babinski sign or hyperreflexia and disease severity.

CONCLUSION

The presence of clinical signs suggesting spinal cord compression should encourage health care professionals to pursue further investigation, such as neuroimaging to either confirm or refute a diagnosis of DCM.

Residual Paresthesia After Surgery for Degenerative Cervical Myelopathy: Incidence and Impact on Clinical Outcomes and Satisfaction

STUDY DESIGN

Multicenter, prospective cohort study.

OBJECTIVE

The current study aimed to identify the incidence of residual paresthesias after surgery for degenerative cervical myelopathy (DCM), and to demonstrate the impact of these symptoms on clinical outcomes and patient satisfaction.

SUMMARY OF BACKGROUND DATA

Surgery for DCM aims to improve and/or prevent further deterioration of physical function and quality-of-life (QOL) in the setting of DCM. However, patients are often not satisfied with their treatment for myelopathy when they have severe residual paresthesias, even when physical function and QOL are improved after surgery.

MATERIALS AND METHODS

The authors included 187 patients who underwent laminoplasty for DCM. All patients were divided into two groups based on their visual analog scale score for paresthesia of the upper extremities at one year postoperatively (>40 vs. ≤40 mm). Preoperative factors, changes in clinical scores and radiographic factors, and satisfaction scales at one year postoperatively were compared between groups. The authors used mixed-effect linear and logistic regression modeling to adjust for confounders.

RESULTS

Overall, 86 of 187 patients had severe residual paresthesia at one year postoperatively. Preoperative patient-oriented pain scale scores were significantly associated with postoperative residual paresthesia ( P =0.032). A mixed-effect model demonstrated that patients with severe postoperative residual paresthesia showed significantly smaller improvements in QOL ( P =0.046) and myelopathy ( P =0.037) than patients with no/mild residual paresthesia. Logistic regression analysis identified that residual paresthesia was significantly associated with lower treatment satisfaction, independent of improvements in myelopathy and QOL (adjusted odds ratio: 2.5, P =0.010).

CONCLUSION

In total, 45% of patients with DCM demonstrated severe residual paresthesia at one year postoperatively. These patients showed significantly worse treatment satisfaction, even after accounting for improvements in myelopathy and QOL. As such, in patients who experience higher preoperative pain, multidisciplinary approaches for residual paresthesia, including medications for neuropathic pain, might lead to greater clinical satisfaction.

LEVEL OF EVIDENCE

3.

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.

The Impact of Preoperative Symptom Duration on Patient Outcomes After Posterior Cervical Decompression and Fusion

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To determine if decreased preoperative symptom duration is associated with greater clinical improvement in function and myelopathic symptoms after posterior cervical decompression and fusion (PCDF).

METHODS

All patients over age 18 who underwent primary PCDF for cervical myelopathy or myeloradiculopathy at a single institution between 2014 and 2020 were retrospectively identified. Patient demographics, surgical characteristics, duration of symptoms, and preoperative and postoperative patient reported outcomes measures (PROMs) including modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), Visual Analogue Scale (VAS) Neck, VAS Arm, and SF-12 were collected. Univariate and multivariate analyses were performed to compare change in PROMs and minimum clinically important difference achievement (%MCID) between symptom duration groups (< 6 months, 6 months-2 years, > 2 years).

RESULTS

Preoperative symptom duration groups differed significantly by sex and smoking status. Patients with < 6 months of preoperative symptoms improved significantly in all PROMs. Patients with 6 months-2 years of preoperative symptoms did not improve significantly in mJOA, Physical Component Scores (PCS), or NDI. Patients with > 2 years of symptoms failed to demonstrate significant improvement in mJOA, NDI, or Mental Component Scores (MCS). Univariate analysis demonstrated significantly decreased improvement in mJOA with longer symptom durations. Increased preoperative symptom duration trended toward decreased %MCID for mJOA and MCS. Regression analysis demonstrated that preoperative symptom duration of > 2 years relative to < 6 months predicted decreased improvement in mJOA and NDI and decreased MCID achievement for mJOA and MCS.

CONCLUSION

Increased duration of preoperative symptoms (> 2 years) before undergoing PCDF was associated with decreased postoperative improvement in myelopathic symptoms.

Increased blood flow of spinal cord lesion after decompression improves neurological recovery of degenerative cervical myelopathy: an intraoperative ultrasonography-based prospective cohort study

INTRODUCTION

Surgical decompression is a highly effective therapy for degenerative cervical myelopathy (DCM), but the mechanisms of neurological recovery following decompression remain unclear. This study aimed to evaluate the spinal cord blood flow status after sufficient decompression by intraoperative contrast-enhanced ultrasonography (CEUS) and to analyze the correlation between neurological recovery and postdecompressive spinal cord blood perfusion in DCM.

MATERIALS AND METHODS

Patients with multilevel DCM were treated by ultrasound-guided modified French-door laminoplasty using a self-developed rongeur. Neurological function was evaluated using the modified Japanese Orthopaedic Association (mJOA) score preoperatively and at 12 months postoperatively. Spinal cord compression and cervical canal enlargement before and after surgery were assessed by magnetic resonance imaging and computerized tomography. The decompression status was evaluated in real time by intraoperative ultrasonography, while the spinal cord blood flow after sufficient decompression was assessed by CEUS. Patients were categorized as favourable (≥50%) or unfavourable (<50%) recovery according to the recovery rate of the mJOA score at 12 months postoperatively.

RESULTS

Twenty-nine patients were included in the study. The mJOA scores were significantly improved in all patients from 11.2±2.1 preoperatively to 15.0±1.1 at 12 months postoperatively, with an average recovery rate of 64.9±16.2%. Computerized tomography and intraoperative ultrasonography confirmed adequate enlargement of the cervical canal and sufficient decompression of the spinal cord, respectively. CEUS revealed that patients with favourable neurological recovery had a greater increased blood flow signal in the compressive spinal cord segment after decompression.

CONCLUSIONS

In DCM, intraoperative CEUS can clearly reflect spinal cord blood flow. Patients with increased blood perfusion of the spinal cord lesion immediately after surgical decompression tended to achieve greater neurological recovery.

Clinical Improvements in Myelopathy Result in Improved Patient-Reported Outcomes Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine if myelopathy severity predicted the magnitude of improvement in health-related quality of life metrics following anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Surgery for myelopathy is primarily performed to halt disease progression. However, it is still controversial if these patients can expect significant health-related quality-of life improvements following ACDF. We explore the relationship between modified Japanese Orthopaedic Association (mJOA) improvements and its effect on other health-related quality-of life metrics.

MATERIALS AND METHODS

Patients undergoing ACDF for myelopathy were grouped based on preoperative mJOA scores into mild (15-17), moderate (12-14), and severe (<12) groups. Patients were subsequently categorized based on if they attained the minimum clinically detectable improvement (MCID) threshold for mJOA. Multivariate linear regression was performed to determine the magnitude of improvement in ∆patient-reported outcome measures.

RESULTS

A total of 374 patients were identified for inclusion. Of those, 169 (45.2%) had mild myelopathy, 125 (33.4%) had moderate, and 80 (21.4%) had severe myelopathy. Only the moderate and severe groups had significant improvements in mJOA following surgery (mild: P =0.073, moderate: P <0.001, severe: P <0.001). There were no significant differences in the magnitude of improvement for any patient-reported outcome measure based on myelopathy severity, except for mJOA (mild: 0.27, moderate: 1.88, severe: 3.91; P <0.001). Patients meeting the MCID for mJOA had better ∆Short-Form 12 Mental Component Score (3.29 vs. -0.21, P =0.007), ∆Short-Form 12 Physical Component Score (6.82 vs. 1.96, P <0.001), ∆Visual Analog Scale Neck (-3.11 vs. -2.17, P =0.001), ∆Visual Analog Scale Arm (-2.92 vs. -1.48, P <0.001), ∆Neck Disability Index (-18.35 vs. -7.86, P <0.001), and ∆mJOA (3.38 vs. -0.56, P <0.001) compared with patients who did not.

CONCLUSIONS

Worse baseline myelopathy severity predicts worse postoperative outcomes. However, baseline myelopathy severity is not predictive of the magnitude of postoperative improvement with the exception of mJOA. Patients who attain MCID improvement in mJOA had greater postoperative improvement for other health-related quality of life metrics.

The Role of Magnetic Transcranial Stimulation in the Diagnosis and Post-Surgical Follow-Up of Cervical Spondylotic Myelopathy

Degenerative cervical myelopathy (DCM) consists of spinal cord damage due to its compression through the cervical spine. The leading cause is degenerative. The diagnosis is clinical, and the therapeutic approach is usually surgical. Confirmation of the diagnostic suspicion is done by magnetic resonance imaging (MRI); however, this test lacks functional information of the spinal cord, the abnormality of which may precede involvement in neuroimaging. Neurophysiological examination using somatosensory evoked potentials (SSEPs) and transcranial magnetic stimulation (TMS) allows for an evaluation of spinal cord function, and provides information in the diagnostic process. Its role in the post-surgical follow-up of patients undergoing decompressive surgery is being studied. We present a retrospective study of 24 patients with DCM and surgical decompression who underwent neurophysiological tests (TMS and SSEP) before, 6, and 12 months after surgery. The result of the TMS and the SSEP in the post-operative follow-up did not correlate with the clinical outcome, either subjective or measured by clinical scales at six months. We only found post-surgical improvement of central conduction times (CMCTs) in patients with severe pre-surgical motor impairment on TMS. In patients with normal pre-surgical CMCT, we found a transient worsening with return to baseline at the one-year follow-up. Most patients presented pre-surgical increased P40 latency at diagnosis. CMCT and SSEP were more related to clinical outcomes one year after the surgical procedure and were very useful in diagnosing.

Patient-reported Data as Predictors of Surgical Outcome in Patients With Degenerative Cervical Myelopathy: Analysis of a National Multicenter Dataset

STUDY DESIGN

Retrospective study design on prospectively collected registry data.

OBJECTIVE

To investigate whether improvement after surgery for degenerative cervical myelopathy is associated with preoperative disease severity and to identify predictors of outcome.

SUMMARY OF BACKGROUND DATA

Degenerative cervical myelopathy is the most common cause of spinal cord compromise in adults and surgery is often the treatment of choice. Identifying predictors may help to improve patient selection.

MATERIALS AND METHODS

This nationwide study from the Swedish spine registry included 901 patients treated surgically for degenerative cervical myelopathy. To investigate improvement in different disease severity groups, the individuals were divided into quartiles based on their preoperative European Myelopathy Scale (EMS) and EuroQol-5 Dimension (EQ-5D) index. Statistical analyses were made with analysis of variance, χ 2 , McNemar, and t tests. Multivariable linear or logistic regression was used to identify predictors for one-year improvement in EMS and EQ-5D index, and satisfaction at one year. In the regressions, the patient-reported outcome measures were dichotomized at their median, except improvement in EMS.

RESULTS

All patient-reported outcome measures improved from baseline to the one-year follow-up ( P <0.001). Statistically significant outcome improvements were seen in all disease severity groups. Preoperative low EMS (β=-1.37, P <0.001), long walking distance (<500 vs. >500 m; β=0.44, P =0.030), and low NDI (β=-0.43, P =0.048) were independent predictors of improvement in EMS. R2 was 0.11 for the multivariable model. Preoperative low EQ-5D index (odds ratio=0.11; 95% confidence interval: 0.07-0.16) and low NDI (0.56; 0.36-0.88) were independent predictors of improvement in EQ-5D index. Preoperative high EMS (1.86; 1.20-2.90) and shorter arm pain duration [<12 vs. >12 months (0.54; 0.33-0.88)] were independent predictors of satisfaction.

CONCLUSIONS

Postoperative improvement was seen over the whole range of disease severity. Disease severity, symptom duration, and walking distance were predictors of outcome in patients treated surgically for degenerative cervical myelopathy.

LEVEL OF EVIDENCE

III.

Impact of preoperative symptom duration in patients undergoing lateral lumbar interbody fusion

BACKGROUND

Few studies have examined the influence of preoperative symptom duration on clinical outcomes in patients undergoing lateral lumbar interbody fusion (LLIF) for degenerative conditions.

METHODS

Patients undergoing LLIF presenting with radiculopathy and/or neurogenic claudication were separated into two groups: preoperative symptom duration < 1-year (shorter duration) versus duration ≥ 1-year (longer duration). Patients undergoing surgery for trauma/malignancy/infection were excluded. Patient-reported outcome measures (PROMs) of Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), 12-Item Short Form Physical/Mental Component Score (SF-12 PCS/MCS), Patient Health Questionnaire-9 (PHQ-9), visual analog scale (VAS) back/leg, and Oswestry Disability Index (ODI) were collected at preoperative and postoperative time points.

RESULTS

Eighty-two total patients, with 34 shorter-duration patients, were identified after propensity score matching for demographics. Longer-duration patients had higher estimated blood loss. All patients reported significant improvement in physical function, mental function, pain, and disability in at least one postoperative time point, except for SF-12 MCS in the shorter duration cohort. The longer duration cohort had higher MCID achievement in 12-week VAS back.

CONCLUSION

Patients undergoing LLIF demonstrated significant postoperative improvement in physical function, mental function, pain, and disability outcomes independent of preoperative symptom duration. Both cohorts, when compared by preoperative symptom duration, demonstrated similar postoperative PROM scores. Patients with longer preoperative symptom duration had higher 12-week leg pain MCID achievement. These findings suggest that delayed time to surgery may not lead to inferior clinical outcomes in patients undergoing LLIF for degenerative conditions.

Screening for degenerative cervical myelopathy with the 10-second grip-and-release test using a smartphone and machine learning: A pilot study

Objective

Early detection and intervention are essential for the mitigation of degenerative cervical myelopathy (DCM). However, although several screening methods exist, they are difficult to understand for community-dwelling people, and the equipment required to set up the test environment is expensive. This study investigated the viability of a DCM-screening method based on the 10-second grip-and-release test using a machine learning algorithm and a smartphone equipped with a camera to facilitate a simple screening system.

Methods

Twenty-two participants comprising a group of DCM patients and 17 comprising a control group participated in this study. A spine surgeon diagnosed the presence of DCM. Patients performing the 10-second grip-and-release test were filmed, and the videos were analyzed. The probability of the presence of DCM was estimated using a support vector machine algorithm, and sensitivity, specificity, and area under the curve (AUC) were calculated. Two assessments of the correlation between estimated scores were conducted. The first used a random forest regression model and the Japanese Orthopaedic Association scores for cervical myelopathy (C-JOA). The second assessment used a different model, random forest regression, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

The final classification model had a sensitivity of 90.9%, specificity of 88.2%, and AUC of 0.93. The correlations between each estimated score and the C-JOA and DASH scores were 0.79 and 0.67, respectively.

Conclusions

The proposed model could be a helpful screening tool for DCM as it showed excellent performance and high usability for community-dwelling people and non-spine surgeons.

Long-term functional outcome of surgical treatment for degenerative cervical myelopathy

OBJECTIVE

Degenerative cervical myelopathy (DCM) is a major global cause of spinal cord dysfunction. Surgical treatment is considered a safe and effective way to improve functional outcome, although information about long-term functional outcome remains scarce despite increasing longevity. The objective of this study was to describe functional outcome 10 years after surgery for DCM.

METHODS

A prospective observational cohort study was undertaken in a university-affiliated neurosurgery department. All patients who underwent surgery for DCM between 2008 and 2010 as part of the multicenter Cervical Spondylotic Myelopathy International trial were included. Participants were approached for additional virtual assessment 10 years after surgery. Functional outcome was assessed according to the modified Japanese Orthopaedic Association (mJOA; scores 0-18) score at baseline and 1, 2, and 10 years after surgery. The minimal clinically important difference was defined as 1-, 2-, or 3-point improvement for mild, moderate, and severe myelopathy, respectively. Outcome was considered durable when stabilization or improvement after 2 years was maintained at 10 years. Self-evaluated effect of surgery was assessed using a 4-point Likert-like scale. Demographic, clinical, and surgical data were compared between groups that worsened and improved or remained stable using descriptive statistics. Functional outcome was compared between various time points during follow-up with linear mixed models.

RESULTS

Of the 42 originally included patients, 37 participated at follow-up (11.9% loss to follow-up, 100% response rate). The mean patient age was 56.1 years, and 42.9% of patients were female. Surgical approaches were anterior (76.2%), posterior (21.4%), or posterior with fusion (2.4%). The mean follow-up was 10.8 years (range 10-12 years). The mean mJOA score increased significantly from 13.1 (SD 2.3) at baseline to 14.2 (SD 3.3) at 10 years (p = 0.01). A minimal clinically important difference was achieved in 54.1%, and stabilization of functional status was maintained in 75.0% in the long term. Patients who worsened were older (median 63 vs 52 years, p < 0.01) and had more comorbidities (70.0% vs 25.9%, p < 0.01). A beneficial effect of surgery was self-reported by 78.3% of patients.

CONCLUSIONS

Surgical treatment for DCM results in satisfactory improvement of functional outcome that is maintained at 10-year follow-up.

Improving Awareness Could Transform Outcomes in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 1]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness.

METHODS

Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM.

RESULTS

DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness.

CONCLUSION

Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.

Impact of Prolonged Duration of Symptoms on Mental Health in Anterior Cervical Disectomy and Fusion Patients

INTRODUCTION

Prolonged duration of symptoms is associated with worse pain and disability in patients undergoing anterior cervical discectomy and fusion (ACDF). Our study aims to determine the effect of symptom duration on severity of depression among ACDF patients.

METHODS

We retrospectively reviewed a prospective surgical database from 2006 to 2019 for primary, single, or multilevel ACDF. Patients missing the duration of symptom information or patient-reported outcome measures (PROMs) were excluded. PROMs included Patient Health Questionnaire-9, 12-Item Short Form Mental Component Score, and 12-Item Veterans RAND Mental Component Score and were collected at preoperative, 6-week, 12-week, 6-month, 1-year, and 2-year timepoints. The minimum clinically important difference (MCID) was calculated using the established values. Patients were categorized based on preoperative duration of symptoms as follows: <6 months, ≥6 months and <1 year, 1 to 2 years, and >2 years. Univariate analysis was done to determine differences in demographics and perioperative characteristics. Intergroup differences in PROMs and MCID achievement were evaluated using linear regression and logistic regression, respectively.

RESULTS

Two hundred thirty-one ACDF patients included had a mean age of 49.6 years and most were male (61.0%) and nonobese (<30 kg/m2; 55.0%). The groups differed by their American Society of Anesthesiologists classification (P = 0.029), workers' compensation status (P = 0.022), and diagnosis of herniated nucleus pulposus (P = 0.010). Postoperative mental health outcomes did not significantly differ between duration groups except for Veterans Rand-12 Mental Component Score at 12 weeks (P = 0.044). MCID achievement rates did not significantly differ.

CONCLUSION

Patients undergoing ACDF largely did not demonstrate differences in mental health scores or achievement of MCID based on the duration of symptoms.

Surgery for degenerative cervical myelopathy in the elderly: a nationwide registry-based observational study with patient-reported outcomes

BACKGROUND

The aim of this study was to investigate whether clinical outcomes in patients aged ≥ 70 undergoing decompressive surgery for degenerative cervical myelopathy (DCM) differ from those of younger patients (50-70 years) at 1 year.

METHODS

Data were obtained from the Norwegian Registry for Spine Surgery (NORspine). Among 651 patients included, 177 (27.2%) were ≥ 70 years old. The primary outcome was change in the Neck Disability Index (NDI). Secondary outcomes were changes in the European Myelopathy Score (EMS), quality of life (EuroQoL EQ-5D), numeric rating scales (NRS) for headache, neck pain, and arm pain, and complications.

RESULTS

Significant improvements in all patient-reported outcomes (PROMs) were detected for both age cohorts at 1 year. For the two age cohorts combined, there was a statistically significant improvement in the NDI score (mean 9.2, 95% CI 7.7 to 10.6, P < 0.001). There were no differences between age cohorts in mean change of NDI (- 8.9 vs. - 10.1, P = 0.48), EQ-5D (0.13 vs. 0.17, P = 0.37), or NRS pain scores, but elderly patients experienced a larger improvement in EMS (0.7 vs. 1.3, P = 0.02). A total of 74 patients (15.6%) in the younger cohort and 43 patients (24.3%) in the older cohort experienced complications or adverse effects within 3 months of surgery, mainly urinary and respiratory tract infections.

CONCLUSION

Surgery for DCM was associated with significant improvement across a wide range of PROMs for both younger and elderly patients. Surgery for DCM should not be denied based on age alone.

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.

Degenerative Cervical Myelopathy: Towards a Personalized Approach

Degenerative cervical myelopathy (DCM) is a recently coined term encompassing a variety of age-related and genetically associated pathologies, including cervical spondylotic myelopathy, degenerative disc disease, and ligamentous aberrations such as ossification of the posterior longitudinal ligament. All of these pathologies produce chronic compression of the spinal cord causing a clinical syndrome characterized by decreased hand dexterity, gait imbalance, and potential genitourinary or sensorimotor disturbances. Substantial variability in the underlying etiology of DCM and its natural history has generated heterogeneity in practice patterns. Ongoing debates in DCM management most commonly center around clinical decision-making, timing of intervention, and the ideal surgical approach. Pivotal basic science studies during the past two decades have deepened our understanding of the pathophysiologic mechanisms surrounding DCM. Growing knowledge of the key pathophysiologic processes will help us tailor personalized approaches in an increasingly heterogeneous patient population. This article focuses on summarizing the most exciting approaches in personalizing DCM patient treatments including biomarkers, factors affecting clinical decision-making, and choice of the optimal surgical approach. Throughout we provide a concise review on the conditions encompassing DCM and discuss the underlying pathophysiology of chronic spinal cord compression. We also provide an overview on clinical-radiologic diagnostic modalities as well as operative and nonoperative treatment strategies, thereby addressing knowledge gaps and controversies in the field of DCM.

Intensity of Intraoperative Spinal Cord Hyperechogenicity as a Novel Potential Predictive Indicator of Neurological Recovery for Degenerative Cervical Myelopathy

OBJECTIVE

To analyze the correlations between intraoperative ultrasound and MRI metrics of the spinal cord in degenerative cervical myelopathy and identify novel potential predictive ultrasonic indicators of neurological recovery for degenerative cervical myelopathy.

MATERIALS AND METHODS

Twenty-two patients who underwent French-door laminoplasty for multilevel degenerative cervical myelopathy were followed up for 12 months. The Japanese Orthopedic Association (JOA) scores were assessed preoperatively and 12 months postoperatively. Maximum spinal cord compression and compression rates were measured and calculated using both intraoperative ultrasound imaging and preoperative T2-weight (T2W) MRI. Signal change rates of the spinal cord on preoperative T2W MRI and gray value ratios of dorsal and ventral spinal cord hyperechogenicity on intraoperative ultrasound imaging were measured and calculated. Correlations between intraoperative ultrasound metrics, MRI metrics, and the recovery rate JOA scores were analyzed using Spearman correlation analysis.

RESULTS

The postoperative JOA scores improved significantly, with a mean recovery rate of 65.0 ± 20.3% (p < 0.001). No significant correlations were found between the operative ultrasound metrics and MRI metrics. The gray value ratios of the spinal cord hyperechogenicity was negatively correlated with the recovery rate of JOA scores (ρ = -0.638, p = 0.001), while the ventral and dorsal gray value ratios of spinal cord hyperechogenicity were negatively correlated with the recovery rate of JOA-motor scores (ρ = -0.582, p = 0.004) and JOA-sensory scores (ρ = -0.452, p = 0.035), respectively. The dorsal gray value ratio was significantly higher than the ventral gray value ratio (p < 0.001), while the recovery rate of JOA-motor scores was better than that of JOA-sensory scores at 12 months post-surgery (p = 0.028).

CONCLUSION

For degenerative cervical myelopathy, the correlations between intraoperative ultrasound and preoperative T2W MRI metrics were not significant. Gray value ratios of the spinal cord hyperechogenicity and dorsal and ventral spinal cord hyperechogenicity were significantly correlated with neurological recovery at 12 months postoperatively.

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.

Impact of preoperative weakness and duration of symptoms on health-related quality-of-life outcomes following anterior cervical discectomy and fusion

BACKGROUND CONTEXT

The majority of patients with preoperative upper extremity weakness show improvements in motor function after anterior cervical discectomy and fusion (ACDF). Although numerous studies have examined both the extent and time course to which motor function can be expected to improve, few have shown that these improvements in motor function translate to improved health related quality of life (HRQOL) outcomes.

PURPOSE

The purpose of this study was to examine the effect of preoperative weakness and duration of symptoms on HRQOL outcomes in patients who underwent ACDF.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Adult patients who underwent an ACDF procedure at an academic hospital from January 2015 to December 2016 by a fellowship-trained spine surgeon.

OUTCOME MEASURES

The primary outcomes of interest were HRQOL outcomes: Short Form-12 Physical/Mental Component Scores (SF-12 PCS/MCS), Neck Disability Index (NDI), and Visual Analog Scale Arm/Neck scores (VAS Arm/Neck).

METHODS

Patient demographics, surgical case characteristics, and motor strength exams were collected in patients who underwent ACDF over a 2-year period. Preoperative weakness was defined by a strength grade ≤3 (on a scale from 0 to 5) in at least one upper extremity muscle group. Multivariate linear regression analysis was performed to determine the effect of the preoperative weakness on HRQOL outcomes.

RESULTS

Of the 276 patients identified, 45 (16.3%) showed evidence of preoperative weakness, 44 (97.8%) of which showed subsequent postoperative motor improvements after ACDF. All patients reported significant improvements in all HRQOL outcome measures. Patients with preoperative weakness reported significantly worse preoperative VAS Arm (6.9 vs. 5.2; p=.01) and VAS Neck (6.1 vs. 4.8; p=.02) pain scores. Compared with patients without preoperative weakness, those with preoperative weakness reported significantly more improvement in NDI (β: -10.9; p=.001). Patients with symptoms greater than or equal to 12 months and preoperative weakness showed significantly less improvement in NDI (β: 14.8; p=.03).

CONCLUSIONS

Patients with preoperative weakness generally exhibited worse pain and HRQOL measures preoperatively, and showed greater potential for improvement after ACDF. Patients with a shorter duration of preoperative weakness had greater potential for improvement in HRQOL measures after ACDF compared with those with longer duration of symptoms. ACDF is an effective procedure to improve strength and HRQOL measures across all patient groups under appropriate indications.

Predictors of Return to Normal Neurological Function After Surgery for Moderate and Severe Degenerative Cervical Myelopathy: An Analysis of A Global AOSpine Cohort of Patients

BACKGROUND

Multiple studies have established the safety and efficacy of surgical intervention for degenerative cervical myelopathy (DCM). Although the main goal of surgery is symptom stabilization, a subset of patients achieves remarkable improvements.

OBJECTIVE

To identify predictors of return to normal neurological function after surgery for moderate or severe DCM.

METHODS

This is an analysis of 2 prospective multicenter studies (the AOSpine CSM-North America and CSM-International studies) conducted between 2005 and 2011. For patients with complete preoperative magnetic resonance imaging (MRI) and 2-yr follow-up, characteristics were compared between those who achieved a modified Japanese Orthopaedic Association (mJOA) score of 18 at 2 yr (no signs of myelopathy) vs controls. Only patients with baseline mJOA ≤ 14 (moderate and severe myelopathy) were included to minimize ceiling effects.

RESULTS

A total of 51 patients (20.3%) out of 251 with moderate or severe baseline myelopathy achieved an mJOA score of 18 at 2 yr. On stepwise multiple logistic regression analysis, T1-weighted (T1W1)-hypointensity (odds ratio [OR] 0.10; 95% confidence interval [CI], 0.01-0.79; P = .03) and longer walking time on the 30-m walking test (OR 0.95; 95% CI, 0.92-0.99; P = .03) were independent predictors of outcome, with an area under the curve of 0.71 for the model.

CONCLUSION

In this study, T1W-hypointensity on MRI and longer walking time were found to predict a less likelihood of achieving return to normal neurological function after surgery for moderate or severe DCM. These findings may provide useful information for patient counseling and perioperative expectations.