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Zhang JK, Javeed S, Greenberg JK, Yakdan S, Kaleem MI, Botterbush KS, Benedict B, Dibble CF, Sun P, Sherrod B, Dailey AT, Bisson EF, Mahan M, Mazur M, Song SK, Ray WZ. Diffusion MRI Metrics Characterize Postoperative Clinical Outcomes After Surgery for Cervical Spondylotic Myelopathy. Neurosurgery 2024:00006123-990000000-01226. [PMID: 38904404 DOI: 10.1227/neu.0000000000003037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 04/16/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Advanced diffusion-weighted MRI (DWI) modeling, such as diffusion tensor imaging (DTI) and diffusion basis spectrum imaging (DBSI), may help guide rehabilitation strategies after surgical decompression for cervical spondylotic myelopathy (CSM). Currently, however, postoperative DWI is difficult to interpret, owing to signal distortions from spinal instrumentation. Therefore, we examined the relationship between postoperative DTI/DBSI-extracted from the rostral C3 spinal level-and clinical outcome measures at 2-year follow-up after decompressive surgery for CSM. METHODS Fifty patients with CSM underwent complete clinical and DWI evaluation-followed by DTI/DBSI analysis-at baseline and 2-year follow-up. Clinical outcomes included the modified Japanese Orthopedic Association score and comprehensive patient-reported outcomes. DTI metrics included apparent diffusion coefficient, fractional anisotropy, axial diffusivity, and radial diffusivity. DBSI metrics evaluated white matter tracts through fractional anisotropy, fiber fraction, axial diffusivity, and radial diffusivity as well as extra-axonal pathology through restricted and nonrestricted fraction. Cross-sectional Spearman's correlations were used to compare postoperative DTI/DBSI metrics with clinical outcomes. RESULTS Twenty-seven patients with CSM, including 15, 7, and 5 with mild, moderate, and severe disease, respectively, possessed complete baseline and postoperative DWI scans. At 2-year follow-up, there were 10 significant correlations among postoperative DBSI metrics and postoperative clinical outcomes compared with 3 among postoperative DTI metrics. Of the 13 significant correlations, 7 involved the neck disability index (NDI). The strongest relationships were between DBSI axial diffusivity and NDI (r = 0.60, P < .001), DBSI fiber fraction and NDI (rs = -0.58, P < .001), and DBSI restricted fraction and NDI (rs = 0.56, P < .001). The weakest correlation was between DTI apparent diffusion coefficient and NDI (r = 0.35, P = .02). CONCLUSION Quantitative measures of spinal cord microstructure after surgery correlate with postoperative neurofunctional status, quality of life, and pain/disability at 2 years after decompressive surgery for CSM. In particular, DBSI metrics may serve as meaningful biomarkers for postoperative disease severity for patients with CSM.
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Affiliation(s)
- Justin K Zhang
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Saad Javeed
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Jacob K Greenberg
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Salim Yakdan
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Muhammad I Kaleem
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Kathleen S Botterbush
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Braeden Benedict
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Christopher F Dibble
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Peng Sun
- Department of Imaging Physics, UT MD Anderson Cancer Center, Houston, Texas, USA
| | - Brandon Sherrod
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Andrew T Dailey
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Erica F Bisson
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Mark Mahan
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Marcus Mazur
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Sheng-Kwei Song
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Wilson Z Ray
- Department of Neurological Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
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Hohenhaus M, Klingler JH, Scholz C, Volz F, Hubbe U, Beck J, Reisert M, Würtemberger U, Kremers N, Wolf K. Automated signal intensity analysis of the spinal cord for detection of degenerative cervical myelopathy - a matched-pair MRI study. Neuroradiology 2023; 65:1545-1554. [PMID: 37386202 PMCID: PMC10497437 DOI: 10.1007/s00234-023-03187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/16/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE Detection of T2 hyperintensities in suspected degenerative cervical myelopathy (DCM) is done subjectively in clinical practice. To gain objective quantification for dedicated treatment, signal intensity analysis of the spinal cord is purposeful. We investigated fully automated quantification of the T2 signal intensity (T2-SI) of the spinal cord using a high-resolution MRI segmentation. METHODS Matched-pair analysis of prospective acquired cervical 3D T2-weighted sequences of 114 symptomatic patients and 88 healthy volunteers. Cervical spinal cord was segmented automatically through a trained convolutional neuronal network with subsequent T2-SI registration slice-by-slice. Received T2-SI curves were subdivided for each cervical level from C2 to C7. Additionally, all levels were subjectively classified concerning a present T2 hyperintensity. For T2-positive levels, corresponding T2-SI curves were compared to curves of age-matched volunteers at the identical level. RESULTS Forty-nine patients showed subjective T2 hyperintensities at any level. The corresponding T2-SI curves showed higher signal variabilities reflected by standard deviation (18.51 vs. 7.47 a.u.; p < 0.001) and range (56.09 vs. 24.34 a.u.; p < 0.001) compared to matched controls. Percentage of the range from the mean absolute T2-SI per cervical level, introduced as "T2 myelopathy index" (T2-MI), was correspondingly significantly higher in T2-positive segments (23.99% vs. 10.85%; p < 0.001). ROC analysis indicated excellent differentiation for all three parameters (AUC 0.865-0.920). CONCLUSION This fully automated T2-SI quantification of the spinal cord revealed significantly increased signal variability for DCM patients compared to healthy volunteers. This innovative procedure and the applied parameters showed sufficient diagnostic accuracy, potentially diagnosing radiological DCM more objective to optimize treatment recommendation. TRIAL REGISTRATION DRKS00012962 (17.01.2018) and DRKS00017351 (28.05.2019).
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Affiliation(s)
- Marc Hohenhaus
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Department of Radiology, Medical Physics, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Urs Würtemberger
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nico Kremers
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Wolf
- Department of Neurology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Evaniew N, Coyle M, Rampersaud YR, Bailey CS, Jacobs WB, Cadotte DW, Thomas KC, Attabib N, Paquet J, Nataraj A, Christie SD, Weber MH, Phan P, Charest-Morin R, Fisher CG, Hall H, McIntosh G, Dea N. Timing of Recovery After Surgery for Patients With Degenerative Cervical Myelopathy: An Observational Study From the Canadian Spine Outcomes and Research Network. Neurosurgery 2023; 92:271-282. [PMID: 36637265 DOI: 10.1227/neu.0000000000002213] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/31/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The time course over which postoperative neurological recovery occurs after surgery for degenerative cervical myelopathy occurs is poorly understood. OBJECTIVE To determine the time point at which patients experience significant neurological improvement. METHODS We reviewed data from an ongoing prospective multicenter cohort study. We measured neurological function at 3 months, 1 year, and 2 years after surgery using the modified Japanese Orthopedic Association (mJOA) scale. We implemented minimal clinical important differences (MCIDs) to guide interpretation of mJOA scores, and we used 1-way analysis of variance to compare changes between follow-up intervals. RESULTS Among 330 patients, the mean overall mJOA improved from 12.9 (SD 2.6) to 14.6 (SD 2.4) at 3 months, 14.7 (SD 2.4) at 1 year, and 14.8 (SD 2.5) at 2 years. The difference in means was statistically significant (P < .01) at the interval from baseline to 3 months postoperatively, but not from 3 months to 1 year or 1 year to 2 years. The MCID was reached by 161 patients at 3 months, 32 more at 1 year, and 15 more at 2 years, with a statistically significant difference only at 3 months. Patients with moderate or severe disease reached the MCID more frequently than those with mild disease. CONCLUSION Among patients who underwent surgery for degenerative cervical myelopathy, most significant neurological improvement occurred by 3 months after surgery. These findings will facilitate valid discussions about postoperative expectations during shared clinical decision making between patients and their surgeons.
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Affiliation(s)
- Nathan Evaniew
- Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Coyle
- Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - Y Raja Rampersaud
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Bailey
- London Health Science Centre Combined Orthopaedic and Neurosurgery Spine Program, Schulich School of Medicine, Western University, London, Ontario, Canada
| | | | - David W Cadotte
- Spine Program, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Jérôme Paquet
- Department of Surgery, Université Laval, Québec, Québec, Canada
| | - Andrew Nataraj
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sean D Christie
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael H Weber
- Division of Orthopaedics, McGill University, Montreal, Quebec, Canada
| | - Philippe Phan
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Raphaële Charest-Morin
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles G Fisher
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hamilton Hall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Nicolas Dea
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
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Tsitsopoulos PP, Mondello S, Holmström U, Marklund N. Cerebrospinal fluid biomarkers of white matter injury and astrogliosis are associated with the severity and surgical outcome of degenerative cervical spondylotic myelopathy. Spine J 2022; 22:1848-1856. [PMID: 35753639 DOI: 10.1016/j.spinee.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/09/2022] [Accepted: 06/16/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Degenerative cervical spondylotic myelopathy (DCM) is the commonest form of spinal cord injury in adults. However, a limited number of clinical reports have assessed the role of biomarkers in DCM. PURPOSE We evaluated cerebrospinal fluid (CSF) biomarkers in patients scheduled for DCM surgery and hypothesized that CSF biomarkers levels (1) would reflect the severity of preoperative neurological status; and (2) correlate with radiological appearance; and (3) correlate with clinical outcome. STUDY DESIGN/SETTING Prospective clinical and laboratory study. PATIENT SAMPLE Twenty-three DCM patients, aged 66.4±12.8 years and seven controls aged 45.4±5.3 years were included. OUTCOME MEASURES The American Spinal Injury Association Impairment Scale, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire and EuroQol 5-dimensions were assessed preoperatively and at 3 months post-surgery. METHODS We measured preoperative biomarkers (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], phosphorylated neurofilament-H [pNF-H] and Ubiquitin C-terminal hydrolase L1) in CSF samples collected from patients with progressive clinical DCM who underwent surgical treatment. Biomarker concentrations in DCM patients were compared with those of cervical radiculopathy controls. RESULTS The median symptom duration was 10 (interquartile range 6) months. The levels of GFAP, NFL, pNF-H, Ubiquitin C-terminal hydrolase L1 were significantly higher in the DCM group compared to controls (p=.044, p=.002, p=.016, and p=.006, respectively). Higher pNF-H levels were found in patients with low signal on T1 Magnetic Resonance Imaging sequence compared to those without (p=.022, area under the receiver operating characteristic curve [AUC] 0.780, 95% Confidence Interval: 0.59-0.98). Clinical improvement following surgery correlated mainly with NFL and GFAP levels (p<.05). CONCLUSIONS Our results suggest that CSF biomarkers of white matter injury and astrogliosis may be a useful tool to assess myelopathy severity and predict outcome after surgery, while providing valuable information on the underlying pathophysiology.
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Affiliation(s)
- Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokratio General Hospital, Constantinoupoleos 49, 54642, Aristotle University School of Medicine, Thessaloniki, Greece; Department of Neuroscience, Neurosurgery, Sjukhusvägen 3, 751 85, Uppsala University Hospital, Uppsala, Sweden.
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, A.O.U. "Policlinico G. Martino" Via Consolare Valeria, 98125, University of Messina, Messina, Italy
| | - Ulrika Holmström
- Department of Neuroscience, Neurosurgery, Sjukhusvägen 3, 751 85, Uppsala University Hospital, Uppsala, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hospital Klinikgatan 17A, 221 85 Lund, Sweden
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Dijkman MD, van Bilsen MWT, Fehlings MG, Bartels RHMA. Long-term functional outcome of surgical treatment for degenerative cervical myelopathy. J Neurosurg Spine 2022; 36:830-840. [PMID: 34826817 DOI: 10.3171/2021.8.spine21651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/23/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Mark D Dijkman
- 1Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
- 2Department of Neurosurgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; and
| | - Martine W T van Bilsen
- 1Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
- 2Department of Neurosurgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; and
| | | | - Ronald H M A Bartels
- 1Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
- 2Department of Neurosurgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands; and
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Funaba M, Imajo Y, Suzuki H, Nishida N, Nagao Y, Sakamoto T, Fujimoto K, Sakai T. Impact of various MRI signal intensity changes on radiological parameters, the neurological status, and surgical outcomes in degenerative cervical myelopathy. Clin Neurol Neurosurg 2021; 207:106802. [PMID: 34273664 DOI: 10.1016/j.clineuro.2021.106802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/24/2022]
Abstract
STUDY DESIGN A retrospective study of prospectively collected date. PURPOSE The present study aimed to identify patient characteristics, radiological factors, the neurological status, and postoperative outcomes associated with MRI signal intensity changes in degenerative cervical myelopathy (DCM). MATERIAL AND METHOD One hundred and fourteen DCM patients who underwent posterior decompression surgeries were enrolled. Pre- and postoperative (12 months) Japanese Orthopedic Association (JOA) scores, cervical alignment and balance on X rays, the cross-sectional area of the spinal cord (CSA) in kinematic CT myelography (CTM). The recovery rate (RR) of the total JOA score and those specific for the upper and lower limb items were evaluated. MRI included T1-weighted imaging (WI) and T2WI. Patients were classified into two groups for a univariate analysis according to the presence or absence of a high signal intensity (HIS) in the sagittal view on T2WI, a low signal intensity (LSI) in the sagittal view on T1WI, the distribution of HSI at a single or multiple levels, and the presence or absence of the snake eye appearance. A multiple logistic regression analysis (MLRA) was performed to identify factors associated with signal intensity changes on MRI. RESULTS Ninety-six patients (84.3%) were classified into HIS changes in the sagittal view on T2WI. The group with multilevel HSI showed significantly lower RR specific for the lower extremity JOA score (30.8% vs 47.7%; P = 0.016). The snake eye-positive group showed a significantly inferior RR specific for the upper extremity JOA score (40.1% vs 53.2%; P = 0.04). In MLRA, LSI changes on T1WI revealed small CSAF (P = 0.02, Odds ratio; 0.77, 95%CI:0.61-0.97), while HSI changes on T2WI revealed a small CSAF (P = 0.008, Odds ratio;1.36, 95%CI:1.08-1.72) and large C2-7 angle during extension (P = 0.009, Odds ratio;0.73, 95%CI:0.58-0.92). CSAF correlated with multilevel HSI changes (P = 0.006, Odds ratio;0.78, 95%CI:0.66-0.93). The snake eye appearance correlated with CSAF (P = 0.006, Odds ratio;0.78, 95%CI:0.66-0.93) and the duration of disease (P = 0.05, Odds ratio;1.01, 95%CI:1.0-1.03). CONCLUSION Severe and poorly compensated spinal cord compression during neck flexion may cause signal intensity changes. The snake eye appearance may be useful as a sign of the inferior postoperative recovery of upper limb function, and multilevel HSI as a sign of the inferior postoperative recovery of lower limb function.
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Affiliation(s)
- Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.
| | - Yasuaki Imajo
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Hidenori Suzuki
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Norihiro Nishida
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yuji Nagao
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Takuya Sakamoto
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kazuhiro Fujimoto
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Takashi Sakai
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
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Increased signal intensity on postoperative T2-weighted axial images in cervical spondylotic myelopathy: Patterns of changes and associated impact on outcomes. J Clin Neurosci 2021; 90:244-250. [PMID: 34275557 DOI: 10.1016/j.jocn.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/26/2021] [Accepted: 06/06/2021] [Indexed: 11/23/2022]
Abstract
Although T2-weighted axial magnetic resonance imaging (MRI) has strength in demonstrating morphologic characteristics of the spinal cord in cervical spondylotic myelopathy (CSM), no study has investigated postoperative changes. We aimed to assess postoperative changes on T2-weighted axial MRI using the classification system based on axial imaging in cervical compressive myelopathy (Ax-CCM) and associated impact on outcome in CSM. In total, 250 patients with CSM who underwent decompressive surgery with preoperative and postoperative MRI were included. At first, we investigated the presence of increased signal intensity (SI) in cervical spinal cord on T2-weighted sagittal images. Next, the increased SI was assessed using Ax-CCM on T2weighted axial images. The classifications were type 0, no-signal abnormality; single-level type 1, diffuse; single-level type 2, fuzzy focal; single-level type 3, discrete focal; and two-level. The recovery rates (RRs) of modified Japanese Orthopaedic Association (mJOA) score were evaluated from 5 to 10 months postoperatively. Eighty-seven patients (34.8%) exhibited postoperative changes. Most of postoperative changes were in single-level type 1 and 2. Patterns of changes were resolution, reduced extent, or transition to discrete margin. The most common pattern was resolution in type 1 (23.9%) and transition to discrete margin in type 2 (46.5%). In each group, resolution showed the best RR, but insignificantly (p > 0.05).
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Zipser CM, Pfender N, Spirig JM, Betz M, Aguirre J, Hupp M, Farshad M, Curt A, Schubert M. Study protocol for an observational study of cerebrospinal fluid pressure in patients with degenerative cervical myelopathy undergoing surgical deCOMPression of the spinal CORD: the COMP-CORD study. BMJ Open 2020; 10:e037332. [PMID: 32958488 PMCID: PMC7507854 DOI: 10.1136/bmjopen-2020-037332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Degenerative cervical myelopathy (DCM) is a disabling spinal disorder characterised by sensorimotor deficits of upper and lower limbs, neurogenic bladder dysfunction and neuropathic pain. When suspected, cervical MRI helps to reveal spinal cord compression and rules out alternative diagnoses. However, the correlation between radiological findings and symptoms is weak. Cerebrospinal fluid pressure (CSFP) analysis may complement the appreciation of cord compression and be used for intraoperative and postoperative monitorings in patients undergoing surgical decompression. METHODS AND ANALYSIS Twenty patients diagnosed with DCM undergoing surgical decompression will receive standardised lumbar CSFP monitoring immediately before, during and 24 hours after operation. Rest (ie, opening pressure, CSF pulsation) and stimulated (ie, Valsalva, Queckenstedt's) CSFP-findings in DCM will be compared with 20 controls and results from CSFP monitoring will be related to clinical and neurophysiological findings. Arterial blood pressure will be recorded perioperatively and postoperatively to calculate spinal cord perfusion pressure and spinal vascular reactivity index. Furthermore, measures of CSFP will be compared with markers of spinal cord compression by means of MR imaging. ETHICS AND DISSEMINATION The study protocol conformed to the latest revision of the Declaration of Helsinki and was approved by the local Ethics Committee of the University Hospital of Zurich (KEK-ZH number PB-2016-00623). The main publications from this study will cover the CSFP fluid dynamics and pressure analysis preoperative, perioperative and postoperative correlated with imaging, clinical scores and neurophysiology. Other publications will deal with preoperative and postoperative spinal perfusion. Furthermore, we will disseminate an analysis on waveform morphology and the correlation with blood pressure and ECG. Parts of the data will be used for computational modelling of cervical stenosis. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02170155).
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Affiliation(s)
- Carl Moritz Zipser
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Nikolai Pfender
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Jose Miguel Spirig
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Jose Aguirre
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Markus Hupp
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
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Postoperative Resolution of MR T2 Increased Signal Intensity in Cervical Spondylotic Myelopathy: The Impact of Signal Change Resolution on the Outcomes. Spine (Phila Pa 1976) 2019; 44:E1241-E1247. [PMID: 31232980 DOI: 10.1097/brs.0000000000003128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective comparative imaging study. OBJECTIVE This study investigated whether postoperative resolution of spinal cord increased signal intensity (ISI) reflected symptom improvement and surgical outcomes in cervical spondylotic myelopathy (CSM) patients. SUMMARY OF BACKGROUND DATA Although some CSM patients exhibit magnetic resonance imaging (MRI) ISI, its alteration and resolution have not been investigated. The association between postoperative ISI resolution and surgical outcomes in CSM patients remains controversial. METHODS A total of 505 consecutive CSM patients (311 males; 194 females) aged a mean of 66.6 years (range, 41-91) were enrolled. All were treated with laminoplasty and underwent MRI scans preoperatively and after an average of 26.5 months postoperatively (range 12-66 months). ISI was classified pre- and postoperatively based on sagittal T2-weighted magnetic resonance images into Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The patients' pre- and postoperative neurological statuses were evaluated using the Japanese Orthopedic Association scoring system for cervical myelopathy [Japanese Orthopedic Association (JOA) score] and other quantifiable tests, including the 10-s grip and release (10-s G&R) test and 10-s step test. RESULTS A total of 337 patients showed preoperative ISI. Among these, 42 (12.5%) showed postoperative ISI resolution, associated with better postoperative JOA score and recovery rate, 10-s G&R and 10-s step test scores than those who retained it. Patients with preoperative Grade 2 ISI had no postoperative ISI resolution. Patients with ISI improvement from Grade 1 to Grade 0 had better outcomes than those with ISI worsening from Grade 1 to Grade 2. CONCLUSION Postoperative ISI resolution in CSM patients reflects postoperative symptoms and surgical outcomes. Patients who exhibit ISI resolution have better clinical outcomes. LEVEL OF EVIDENCE 3.
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Wei L, Cao P, Xu C, Wu H, Hua D, Tian Y, Yuan W. Comparison of Three Anterior Techniques in the Surgical Treatment of Three-Level Cervical Spondylotic Myelopathy with Intramedullary T2-Weighted Increased Signal Intensity. World Neurosurg 2019; 126:e842-e852. [DOI: 10.1016/j.wneu.2019.02.182] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 11/25/2022]
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The relationship between preoperative factors and the presence of intramedullary increased signal intensity on T2-weighted magnetic resonance imaging in patients with cervical spondylotic myelopathy. Clin Neurol Neurosurg 2019; 178:1-6. [PMID: 30660852 DOI: 10.1016/j.clineuro.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/03/2019] [Accepted: 01/13/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To investigate preoperative factors affecting the presence of intramedullary increased signal intensity (ISI) on T2-weighted magnetic resonance imaging (MRI) in patients with cervical spondylotic myelopathy (CSM) and the impact of ISI on clinical manifestations. PATIENTS AND METHODS Eighty-nine patients with CSM were retrospectively reviewed from January 2013 to December 2016 in our hospital. Based on the presence or absence of ISI on axial and sagittal T2-weighted MRI, patients were divided into ISI group (48 cases) and non-ISI group (41 cases). Factors such as age, sex, body mass index (BMI), duration of symptoms, clinical symptoms and signs, number and distribution of spinal cord compression levels, preoperative Japanese Orthopedic Association (JOA) score, preoperative C2-C7 lordotic angle, preoperative C2-C7 range of motion (ROM), maximal canal compromise (MCC) and maximal spinal cord compression (MSCC) were initially compared using univariate analysis. Factors with significant result in univariate analysis were included in multivariate logistic regression analysis. Receiver operating characteristic (ROC) curve and the area under the curve (AUC) were applied to evaluate the reliability of multivariate logistic regression model. RESULTS Univariate analysis showed that the number of spinal cord compression levels, preoperative JOA score, MCC and MSCC might be related to the presence of ISI (P < 0.05). Furthermore, multivariate logistic regression analysis revealed that the number of spinal cord compression levels (OR = 0.203, P < 0.05), preoperative JOA score (OR = 4.274, P < 0.05) and MSCC (OR = 0.250, P < 0.05) were independent preoperative risk factors associated with the presence of ISI, yielding an AUC of 0.9558. Patients with ISI showed a trend of increasing clinical symptoms and signs, and also exhibited statistically significantly increased frequencies of clumsy hands, lower limb spasticity, impairment of gait, broad-based, unstable gait, weakness and motor deficits (P < 0.05). CONCLUSION Multilevel spinal cord compression, lower preoperative JOA score and greater MSCC are independent preoperative risk factors related to the presence of ISI on T2-weighted MRI in patients with CSM. Patients with ISI tend to have more clinical symptoms and signs, especially in lower limb manifestations and motor deficits.
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