Potential usefulness of 18F-2-fluoro-deoxy-D-glucose positron emission tomography in cervical compressive myelopathy

Assessment and Management of Patients With Metastatic Spinal Cord Compression: A Multidisciplinary Review

Purpose

Metastatic spinal cord compression (MSCC) can be a catastrophic manifestation of advanced cancer that causes immobilizing pain and significant neurologic impairment. Oncologists can protect their patients by having a high index of suspicion for MSCC when patients present with new or worsening back pain before motor, sensory, bowel, or bladder deficits develop. We provide an updated, evidence-based narrative review of the presentation, diagnosis, and treatment of MSCC.

Methods

This narrative review was conducted by searching MEDLINE and Cochrane Database of Systematic Reviews for relevant literature on the presentation, diagnosis, and treatment of patients with MSCC. The article addresses the key elements of MSCC management germane to the medical oncologist, with special attention given to pain and symptom management, decision making with regard to surgery and radiation therapy, the importance of rehabilitative care, and the value of a multidisciplinary approach.

Results

Magnetic resonance imaging of the entire spine is recommended for the diagnosis of MSCC. Treatment includes glucocorticoid therapy, pain management, radiation therapy with or without surgery, and specialized rehabilitation. When formulating a treatment plan, clinicians should consider the patient’s care goals and psychosocial needs.

Conclusion

Prompt diagnosis and treatment of MSCC can reduce pain and prevent irreversible functional loss. Regular collaboration among multidisciplinary providers may streamline care and enhance achievement of treatment goals.

Clinical value of 2-deoxy-[18F]fluoro-d-glucose positron emission tomography in patients with cervical spondylotic myelopathy

Cervical spondylotic myelopathy (CSM) is one of the most common spinal cord disorders in the elderly. It is usually diagnosed by MRI, but in a significant number of patients the clinical course of CSM does not correlate with the extent of the spinal cord compression. Recent studies have suggested that a distinct metabolic pattern of the cervical cord, as assessed by PET with 2-deoxy-[18F]fluoro-d-glucose (18F-FDG) may predict a patient's clinical outcome after decompressive surgery for cervical spine stenosis. The authors provide an overview of the recent literature regarding the value of PET with 18F-FDG of the cervical cord in patients with CSM, paying attention to prognostic aspects and the potential role of inflammatory processes in the acute phase of the disease.

Changes in (18)f-fluorodeoxyglucose uptake in the spinal cord in a healthy population on serial positron emission tomography/computed tomography

We aimed to determine the changes in ¹⁸F-fluorodeoxyglucose (FDG) uptake in the spinal cord on two serial positron emission tomography/computed tomography (PET/CT) scans in a healthy population. We retrospectively enrolled healthy people who underwent PET/CT twice for cancer screening. We excluded those who had degenerative vertebral disease, neurologic disease, or a history of a vertebral operation. The standardized uptake value (SUVmax) of the spinal cord of each mid-vertebral body was obtained by drawing a region of interest on an axial image of PET/CT. For analysis, the cord-to-background ratio (CTB) was used (CTB=SUVmax of each level/SUVmax of L5 level). Differences in pattern, sex, age, and intervals of the two serial PET/CT scans were analyzed. A total of 60 PET/CT images of 30 people were analyzed. The mean interval between the two PET/CT imaging studies was 2.80±0.94 years. On the follow-up PET/CT, significant change was shown only at the level of the C6 and T10 vertebrae (p<0.005). Mean CTB showed a decreasing pattern from cervical to lumbar vertebrae. There were two peaks at the lower cervical level (C4-6) and at the lower thoracic level (T12). Neither sex nor age significantly affected CTB. The FDG uptake of the spinal cord changed significantly on follow-up PET/CT only at the level of the C6 and T10 vertebrae. This finding is valuable as a baseline reference in the follow-up of metabolic changes in the spinal cord.

Clinical significance of MRI/(18)F-FDG PET fusion imaging of the spinal cord in patients with cervical compressive myelopathy

PURPOSE

(18)F-FDG PET is used to investigate the metabolic activity of neural tissue. MRI is used to visualize morphological changes, but the relationship between intramedullary signal changes and clinical outcome remains controversial. The present study was designed to evaluate the use of 3-D MRI/(18)F-FDG PET fusion imaging for defining intramedullary signal changes on MRI scans and local glucose metabolic rate measured on (18)F-FDG PET scans in relation to clinical outcome and prognosis.

METHODS

We studied 24 patients undergoing decompressive surgery for cervical compressive myelopathy. All patients underwent 3-D MRI and (18)F-FDG PET before surgery. Quantitative analysis of intramedullary signal changes on MRI scans included calculation of the signal intensity ratio (SIR) as the ratio between the increased lesional signal intensity and the signal intensity at the level of the C7/T1 disc. Using an Advantage workstation, the same slices of cervical 3-D MRI and (18)F-FDG PET images were fused. On the fused images, the maximal count of the lesion was adopted as the standardized uptake value (SUV(max)). In a similar manner to SIR, the SUV ratio (SUVR) was also calculated. Neurological assessment was conducted using the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy.

RESULTS

The SIR on T1-weighted (T1-W) images, but not SIR on T2-W images, was significantly correlated with preoperative JOA score and postoperative neurological improvement. Lesion SUV(max) was significantly correlated with SIR on T1-W images, but not with SIR on T2-W images, and also with postoperative neurological outcome. The SUVR correlated better than SIR on T1-W images and lesion SUV(max) with neurological improvement. Longer symptom duration was correlated negatively with SIR on T1-W images, positively with SIR on T2-W images, and negatively with SUV(max).

CONCLUSION

Our results suggest that low-intensity signal on T1-W images, but not on T2-W images, is correlated with a poor postoperative neurological outcome. SUV(max) of lesions showing increased signal intensity and SUVR measured on fusion MRI/PET scans are more sensitive parameters for predicting clinical outcome than signal intensity on the MRI scan.

Effects of magnetic resonance imaging signal change in myelopathic patients: a meta-analysis

STUDY DESIGN

Meta-analysis.

OBJECTIVE

Meta-analysis of the data to determine the effect of magnetic resonance imaging (MRI) signal change on preoperative and postoperative Japanese Orthopedic Association (JOA) scores and on recovery rate after surgery.

SUMMARY OF BACKGROUND DATA

MRI signal changes are commonly found in myelopathy. There is often an increased T2 signal with or without a decreased T1 signal. The clinical significance of these signal changes remains debated.

METHODS

A comprehensive review of the literature was performed to identify all published studies with data on the presence of MRI signal change and JOA scores in myelopathic patients. T tests were performed to determine if there were significant differences between preoperative and postoperative JOA scores in patients with or without MRI signal change. The recovery rate was calculated for all patients undergoing surgery. T tests were performed to determine whether significant differences occurred in recovery rate in patients with or without MRI signal change.

RESULTS

A total of 16 studies were used for the meta-analysis. The total population included 886 patients: 659 with MRI signal change, and 227 without MRI signal change. Preoperative and postoperative JOA scores and the recovery rates were significantly better in patients without MRI signal changes (P < 0.05). The mean preoperative JOA scores were 10.63 and 11.37 for patients with and without MRI signal changes, respectively. The mean postoperative JOA scores were 13.37 and 14.19 for patients with and without MRI signal changes, respectively. The mean recovery rates were 43.87% and 49.31% for patients with and without MRI signal changes, respectively.

CONCLUSION

A meta-analysis of the literature revealed statistically better preoperative and postoperative JOA scores and recovery rates following surgery in myelopathic patients without MRI signal change. Although the data were statistically significant, the clinical significance of the differences might be less due to the relatively small differences in actual values.

Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression

Object

The effects of sagittal kyphotic deformities or mechanical stress on the development of cervical spondylotic myelopathy, or the reduction and fusion of kyphotic sagittal alignment have not been consistently documented. The aim in this study was to determine the effects of kyphotic sagittal alignment of the cervical spine in terms of neurological morbidity and outcome after 2 types of surgical intervention.

Methods

The authors retrospectively reviewed the records of 476 patients who underwent cervical spine surgeries for spondylotic myelopathy between 1993 and 2006 at their university medical center. Among these were identified 43 patients—30 men and 13 women, with a mean age of 58.8 years—who had cervical kyphosis exceeding 10° on preoperative sagittal lateral radiographs obtained in the neutral position, and their cases were analyzed in this study. Anterior decompression with interbody fusion was conducted in 28 patients, and en bloc open-door C3–7 laminoplasty in 15 patients. Both pre- and postoperative neurological, radiographic, and MR imaging findings were assessed in both surgical groups.

Results

The mean preoperative kyphotic angle in all 43 patients was 15.9 ± 5.9° in the neutral position. Segmental instability was noted in 26 patients (61%) and reversed dynamic spinal canal stenosis at the level above the local kyphosis in 22 (51%). Preoperative T2-weighted MR images showed high-intensity signal within the cord at and around the level of maximal compression or segmental instability in 28 patients (65%). The mean kyphotic angle in both the neutral and flexion positions was significantly smaller at 4–6 weeks after surgery in the anterior spondylectomy group than in the laminoplasty group (p < 0.001). Furthermore, the angle in the neutral position was significantly smaller on follow-up in the anterior spondylectomy group than in the laminoplasty group (p = 0.034). The transverse area of the spinal cord was significantly larger in the anterior spondylectomy group than in the laminoplasty group on follow-up (p = 0.037). Preoperative neurological scores (assessed using the Japanese Orthopaedic Association scale) and improvement on follow-up ≥ 2 years after treatment (average 3.3 years) were not significantly different between the 2 groups; however, there was a significant difference in Japanese Orthopaedic Association score at 4–6 weeks postoperatively (p = 0.047).

Conclusions

Kyphotic deformity and mechanical stress in the cervical spine may play an important role in neurological dysfunction. In a select group of patients with kyphotic deformity ≥ 10°, adequate correction of local sagittal alignment may help to maximize the chance of neurological improvement.

High-resolution magnetic resonance imaging and 18FDG-PET findings of the cervical spinal cord before and after decompressive surgery in patients with compressive myelopathy

STUDY DESIGN

Evaluation of cervical spinal cord (CSC) of patients with compressive myelopathy by magnetic resonance imaging (MRI) and high-resolution (18F)fluoro-deoxyglucose (18FDG) positron emission tomography (PET).

OBJECTIVE

To determine changes in morphology, intramedullary signal intensity, and glucose metabolic rate in CSC after decompression, and to assess the utility of 18FDG-PET in evaluation of patients with cervical myelopathy.

SUMMARY OF BACKGROUND DATA

The significance of CSC enlargement after decompression and signal intensity changes within the cord remain elusive. No data are available on metabolic activity of the compressed CSC. Only a few studies have examined correlation between high-resolution MRI and 18FDG-PET neuroimaging in cervical myelopathy.

METHODS

We studied 24 patients who underwent cervical decompressive surgery in terms of postoperative neurologic improvement and changes in MRI and 18FDG-PET. Neurologic status was assessed by the Japanese Orthopedic Association scoring system (17-point scale). Signal intensity change in the cord was qualitatively assessed on both T1- and T2-weighted images. The transverse area of the CSC on MRIs and glucose metabolic rate (standardized uptake value [SUV]) from 18FDG-PET were measured digitally.

RESULTS

Neurologic improvement correlated with preoperative CSC transverse area at maximal compression (P < 0.01) and at follow-up (P < 0.001) and with mean SUV before surgery (P < 0.01) and at follow-up (P < 0.05). Preoperative signal intensity change on MRIs (low intramedullary signal intensity abnormality on T1-weighted image and high intramedullary on T2-weighted image) correlated negatively with neurologic improvement rate (P < 0.05). The transverse area of the CSC was significantly smaller after surgery in patients with preoperative MRI signal intensity changes (P < 0.05). The SUV at follow-up tended to normalize in association with neurologic improvement.

CONCLUSION

Our results showed that postoperative neurologic improvement in patients with cervical compressive myelopathy correlated with increased transverse area of the spinal cord, signal intensity change on both T1- and T2-weighted image, and the mean SUV.

Measurement of glucose metabolism in rat spinal cord slices with dynamic positron autoradiography

We attempted to measure the regional metabolic rate of glucose (MRglc) in sliced spinal cords in vitro. The thoracic spinal cord of a mature Wister rat was cut into 400-mum slices in oxygenated and cooled (1-4 degrees C) Krebs-Ringer solution. After at least 60 min of preincubation, the spinal cord slices were transferred into double polystyrene chambers and incubated in Krebs-Ringer solution at 36 degrees C, bubbled with 5% O(2)/5% CO(2) gas. To measure MRglc, we used the dynamic positron autoradiography technique (dPAT) with F-18-2-fluoro-2-deoxy-d-glucose ([(18)F]FDG) and the net influx constant of [(18)F]FDG as an index. Uptake curves of [(18)F]FDG were well fitted by straight lines for more than 7 h after the slicing of the spinal cord (linear regression coefficient, r=0.99), indicating a constant uptake of glucose by the spinal cord tissue. The slope (K), which denotes MRglc, is affected by tetrodotoxin, and high K(+) (50 mM) or Ca(2+)-free, high Mg(2+) solution. After 10 min of hypoxia, the K value following reoxygenation was similar to the unloaded control value, but after 45 min of hypoxia, the K value was markedly lower than the unloaded control value, and after >90 min of reoxygenation it was nearly 0. Our results indicate that the living spinal cord slices used retained an activity-dependent metabolism to some extent. This technique may provide a new approach for measuring MRglc in sliced living spinal cord tissue in vitro and for quantifying the dynamic changes in MRglc in response to various interventions such as hypoxia.

Ossification of the posterior longitudinal ligament of the cervical spine: histopathological findings around the calcification and ossification front

OBJECT

The authors studied the histological and immunohistochemical features of ossified posterior longitudinal ligament (PLL) of the cervical spine, especially in the calcification and ossification front.

METHODS

Samples of en bloc ossified PLL plaque obtained in 31 patients were stained with H & E and immunohistochemically prepared for collagens (types I and II), vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-beta, and bone morphogenetic protein (BMP)-2, and by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling method for apoptosis.

RESULTS

Enchondral ossification was evident between the ligamentous enthesis and deep layer of the ligament, with irregularly disorganized arrangement of elastic fibers in association with advancement of the degenerative process. In the ossification front, many hypertrophic metaplastic chondrocytes were noted in the ossifying plaque immediately contiguous to the ligament fibers, together with a considerable degree of neovascularization. Both TGFbeta and BMP-2 were highly expressed in metaplastic hypertrophic chondrocytes in the ossification front, and BMP-2 was also expressed in fibroblastic cells near the ossified PLL plaque. Expression of type I collagen was significant in the matrix of the ossified PLL lesion, whereas that of type II was marked in metaplastic chondrocytes in the ossification front. Apoptotic hypertrophic chondrocytes were observed mainly in the fibrocartilaginous area near the calcification front.

CONCLUSIONS

The enchondral ossification process in the ossified PLL was closely associated with degenerative changes of elastic fibers and cartilaginous cartilage formation, together with the appearance of metaplastic hypertrophic cartilage cells and neovascularization. The authors also found that VEGF-positive metaplastic chondrocytes in the ossification front and different expression patterns of collagens probably play some role in the extension of the ossified PLL from the ossification front.

Metabolic neuroimaging of the cervical spinal cord in patients with compressive myelopathy: a high-resolution positron emission tomography study

OBJECT

The authors conducted a study to examine whether high-resolution [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET) could be used to visualize deterioration of cervical spinal cord function associated with various degrees of compression and to determine its potential usefulness during assessment of compressive myelopathy.

METHODS

In 23 patients requiring decompressive surgery for myelopathy FDG-PET was performed. The preoperative findings of high-resolution FDG-PET were compared with the neurological scores and magnetic resonance (MR) imaging findings. The preoperative standardized uptake value (SUV) of FDG utilization rate of the cervical cord correlated with the pre- (r = 0.497, p = 0.016) and postoperative neurological scores (r = 0.595, p = 0.003), as well as with the rate of neurological improvement postoperatively (r = 0.538, p = 0.008). The FDG utilization rate did not correlate with the high signal intensity on T2-weighted MR images.

CONCLUSIONS

Analysis of these results indicates that high-resolution FDG-PET imaging provides useful qualitative and quantitative estimates of impaired metabolic activity of the compromised cervical cord that correlate closely with the severity of neurological dysfunction.

Increased expression of neurotrophins and their receptors in the mechanically compressed spinal cord of the spinal hyperostotic mouse (twy/twy)

The purpose of the present study was to identify any compensatory changes at the site of chronic compression of the spinal cord and neighboring segments. For this purpose, serial immunohistochemical and immunoblot analyses were performed for the expression levels of endogenous brain-derived neurotrophic factor (BDNF), neurotrophin (NT)-3, and their receptors, trkB and trkC in 24 tip-toe walking Yoshimura mice (twy/twy) aged 12-24 weeks. The twy mouse exhibits spontaneous calcified deposits posteriorly at the C1-C2 level, compressing the spinal cord. Immunoreactivities for BDNF, NT-3, trkB and trkC were preferentially localized in the gray matter, particularly in the anterior horn cells. In 24-week-old twy mice with severe compression, expression levels of these neurotrophins at the site of maximal compression were significantly lower than at the less- or non-compressed sites. In contrast, the expression levels of BDNF, NT-3, trkB and trkC were significantly higher at the rostral and caudal sites immediately adjacent to the maximal compression site. No such changes were noted in 12-week-old twy mice or in control Institute of Cancer Research mice. Our results suggest that overexpression of BDNF, NT-3, trkB and trkC in motoneuron areas neighboring the site of mechanical compression may represent compensatory changes in response to the compromised neuronal function at the level of compression, and that these proteins possibly contribute to neuronal survival and plasticity.

Progressive changes in neurofilament proteins and growth-associated protein-43 immunoreactivities at the site of cervical spinal cord compression in spinal hyperostotic mice

STUDY DESIGN

Immunohistochemical examination of the expression and localization of neurofilament (NF) proteins and growth-associated protein (GAP)-43 in spinal hyperostotic (twy/twy) mice with progressive compression of the cervical spinal cord.

OBJECTIVE

To determine the biologic functions of NF proteins and GAP-43 in the mouse cervical spinal cord during chronic mechanical compression.

SUMMARY OF BACKGROUND DATA

The pathologic and repair process in the chronically compressed spinal cord are understood poorly. The present authors hypothesized that there existed an increased expression of NF proteins and GAP-43 in twy/twy mice during the lengthy period of spinal cord compression, which resembles compressive myelopathy.

METHODS

The cervical spinal cords of 54 twy mice (aged 8 weeks [n = 18], 14 weeks [n = 18], and 20 weeks [n = 18]) and 18 control animals were examined histologically. Using appropriate antibodies, sections were also stained immunohistochemically for NF proteins and GAP-43.

RESULTS

Separation of the myelin sheath from the axon and axonal swelling with deformation were detected in the anterior and lateral funiculi of the spinalcords of 20-week-old twy/twy mice. No such changes were noted in 8-week-old twy mice. In twy/twy mice aged 8 and 14 weeks with mild-to-moderate compression, weak immunoreactivities (mainly in the white matter) for NF proteins and GAP-43 were noted; however, in 20-week-old twy/twy mice, these axons stained strongly positive and immunoreactive swollen axons were present. The relative area of GAP-43 immunoreactive axons gradually increased between 8 and 20 weeks in each column, particularly in the anterior and lateral funiculi in the contralateral side of compression.

CONCLUSIONS

The results showed that the expression of NF proteins and GAP-43 in the white matter increased proportionally with the magnitude of spinal cord compression, and indicated the possible involvement of GAP-43 in both axonal degeneration and repair processes in the chronically compressed spinal cord.