Predictors of surgical outcome in cervical spondylotic myelopathy

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.

Would the one-stage combined approach lead to better long-term neurological outcomes than the posterior approach alone in multilevel degenerative cervical myelopathy patients with T2-Weighted increased signal intensity? An 8-year follow-up results and propensity score matching analysis

BACKGROUND

T2-weighted increased signal intensity (ISI) is commonly recognized as a sign of more severe spinal cord lesions, usually accompanied by worse neurological deficits and possibly worse postoperative neurological recovery. The combined approach could achieve better decompression and better neurological recovery for multilevel degenerative cervical myelopathy (MDCM). The choice of surgical approach for MDCM with intramedullary T2-weighted ISI remains disputed. This study aimed to compare the neurological outcomes of posterior and one-stage combined posteroanterior approaches for MDCM with T2-weighted ISI.

METHODS

A total of 83 consecutive MDCM patients with confirmed ISI with at least three intervertebral segments operated between 2012 and 2014 were retrospectively enrolled. Preoperative demographic, radiological and clinical condition variables were collected, and neurological conditions were evaluated by the Japanese Orthopedic Assessment score (JOA) and Neck Disability Index (NDI). Propensity score matching analysis was conducted to produce pairs of patients with comparable preoperative conditions from the posterior-alone and combined groups. Both short-term and mid-term surgical outcomes were evaluated, including the JOA recovery rate (JOARR), NDI improvements, complications, and reoperations.

RESULTS

A total of 83 patients were enrolled, of which 38 and 45 patients underwent posterior surgery alone and one-stage posteroanterior surgery, respectively. After propensity score matching, 38 pairs of comparable patients from the posterior and combined groups were matched. The matched groups presented similar preoperative clinical and radiological features and the mean follow-up duration were 111.6 ± 8.9 months. The preoperative JOA scores of the posterior and combined groups were 11.5 ± 2.2 and 11.1 ± 2.3, respectively (p = 0.613). The combined group presented with prolonged surgery duration(108.8 ± 28.0 and 186.1 ± 47.3 min, p = 0.028) and greater blood loss(276.3 ± 139.1 and 382.1 ± 283.1 ml, p<0.001). At short-term follow-up, the combined group presented a higher JOARR than the posterior group (posterior group: 50.7%±46.6%, combined group: 70.4%±20.3%, p = 0.024), while no significant difference in JOARR was observed between the groups at long-term follow-up (posterior group: 49.2%±48.5%, combined group: 59.6%±47.6%, p = 0.136). No significant difference was found in the overall complication and reoperation rates.

CONCLUSIONS

For MDCM patients with ISI, both posterior and one-stage posteroanterior approaches could achieve considerable neurological alleviations in short-term and long-term follow-up. With greater surgical trauma, the combined group presented better short-term JOARR but did not show higher efficacy in long-term neurological function preservation in patients with comparable preoperative conditions.

Assessment of Surgical Outcomes in Patients with Degenerative Cervical Myelopathy Using the 25-Question Geriatric Locomotive Function Scale: A Longitudinal Observational Study

Introduction

Locomotive syndrome caused by degenerative musculoskeletal diseases is reported to improve with surgical treatment. However, it is unclear whether surgical treatment is effective for the locomotive syndrome developing in patients with degenerative cervical myelopathy (DCM). Thus, this study primarily aimed to longitudinally assess the change in locomotive syndrome stage before and after cervical spinal surgery for patients with DCM using the 25-question geriatric locomotive function scale (GLFS-25). A secondary objective was to identify factors associated with the postoperative improvement in the locomotive syndrome stage.

Methods

We retrospectively reviewed clinical data of patients undergoing cervical spine surgery at our institution from April 2020 to May 2022 who had answered the Japanese Orthopaedic Association Cervical Myelopathy Assessment Questionnaire, visual analog scale, and GLFS-25 preoperatively and at 6 months and 1 year postoperatively. We collected demographic data, medical history, preoperative radiographic parameters, presence or absence of posterior longitudinal ligament ossification, and surgical data.

Results

We enrolled 115 patients (78 men and 37 women) in the present study. Preoperatively, using the GLFS-25, 73.9% of patients had stage 3, 10.4% had stage 2, 9.6% had stage 1, 6.1% had no locomotive syndrome. The stage distribution of locomotive syndrome improved significantly at 6-months and 1-year postoperatively. The multivariable Poisson regression analysis revealed that better preoperative lower extremity function (relative risk: 3.0; 95% confidence interval: 1.01-8.8) was significantly associated with postoperative improvement in the locomotive syndrome stage.

Conclusions

This is the first study to longitudinally assess the locomotive syndrome stage in patients with DCM using GLFS-25. Our results indicated that patients with DCM experienced significant improvement in the locomotive syndrome stage following cervical spine surgery. Particularly, the preoperative lower extremity function was significant in postoperative improvement in the locomotive syndrome stage.

Fractional amplitude of low-frequency fluctuation alterations in patients with cervical spondylotic myelopathy: a resting-state fMRI study

PURPOSE

We sought to use the fractional amplitude of low-frequency fluctuation (fALFF) method to investigate the changes in spontaneous brain activity in CSM patients and their relationships with clinical features.

METHODS

We recruited 20 patients with CSM, and 20 healthy controls (HCs) matched for age, sex, and education status. The fALFF method was used to evaluate the altered spontaneous brain activities. The Pearson correlation analysis of fALFF and the clinical features were carried out.

RESULTS

Compared with HC, CSM group showed increased fALFF values in the left middle frontal gyrus, inferior parietal lobule, and right angular gyrus. Decreased fALFF values were found in the right lingual gyrus, cuneus (P < 0.05). Pearson correlation analysis shows that the fALFF values of all CSM were positively correlated with JOA score in the right angular gyrus (r = 0.518, P < 0.05).

CONCLUSION

CSM patients have abnormal fALFF distribution in multiple brain regions and might be an appealing alternative approach for further exploration of the pathological and neuropsychological states in CSM.

Comparison of the patient-derived modified Japanese Orthopaedic Association scale and the European myelopathy score

PURPOSE

To compare the patient-derived modified Japanese Orthopaedic Association (P-mJOA) scale with the European myelopathy score (EMS) for the assessment of patients with degenerative cervical myelopathy (DCM).

METHODS

In this register-based cohort study with prospectively collected data, included patients were surgically treated for DCM and had reported both P-mJOA and EMS scores at baseline, 1-year follow-up, and/or 2-year follow-up to the Swedish Spine Register. P-mJOA and EMS scores were defined as severe (P-mJOA 0-11 and EMS 5-8), moderate (P-mJOA 12-14 and EMS 9-12), or mild (P-mJOA 15-18 and EMS 13-18). P-mJOA and EMS mean scores were compared, and agreement was evaluated with Spearman's rank correlation coefficient (ρ), the intraclass correlation coefficient (ICC), and kappa (κ) statistics.

RESULTS

Included patients (n = 714, mean age 63.2 years, 42.2% female) completed 937 pairs of the P-mJOA and the EMS. The mean P-mJOA and EMS scores were 13.9 ± 3.0 and 14.5 ± 2.7, respectively (mean difference -0.61 [95% CI -0.72 to -0.51; p < 0.001]). Spearman's ρ was 0.84 (p < 0.001), and intra-rater agreement measured with ICC was 0.83 (p < 0.001). Agreement of severity level measured with unweighted and weighted κ was fair (κ = 0.22 [p < 0.001]; κ = 0.34 [p < 0.001], respectively). Severity levels were significantly higher using the P-mJOA (p < 0.001).

CONCLUSION

The P-mJOA and the EMS had similar mean scores, and intra-rater agreement was high, whereas severity levels only demonstrated fair agreement. The EMS has a lower sensitivity for detecting severe myelopathy but shows an increasing agreement with the P-mJOA for milder disease severity. A larger interval to define severe myelopathy with the EMS is recommended.

Predictive Value of the Diffusion Magnetic Resonance Imaging Technique for the Postoperative Outcome of Cervical Spondylotic Myelopathy

BACKGROUND

Diffusion magnetic resonsance imaging (dMRI) can potentially predict the postoperative outcome of cervical spondylotic myelopathy (CSM).

PURPOSE

To explore preoperative dMRI parameters to predict the postoperative outcome of CSM through multifactor correlation analysis.

STUDY TYPE

Prospective.

POPULATION

Post-surgery CSM patients; 102 total, 73 male (52.42 ± 10.60 years old) and 29 female (52.0 ± 11.45 years old).

FIELD STRENGTH/SEQUENCE

3.0 T/Turbo spin echo T1/T2-weighted, T2*-weighted multiecho gradient echo and dMRI.

ASSESSMENT

Spinal cord function was evaluated using modified Japanese Orthopedic Association (mJOA) scoring at different time points: preoperative and 3, 6, and 12 months postoperative. Single-factor correlation and t test analyses were conducted based on fractional anisotropy (FA), mean diffusivity, intracellular volume fraction, isotropic volume fraction, orientation division index, increased signal intensity, compression ratio, age, sex, symptom duration and operation method, and multicollinearity was calculated. The linear quantile mixed model (LQMM) and the linear mixed-effects regression model (LMER) were used for multifactor correlation analysis using the combinations of the above variables.

STATISTICAL TESTS

Distance correlation, Pearson's correlation, multiscale graph correlation and t tests were used for the single-factor correlation analyses. The variance inflation factor (VIF) was used to calculate multicollinearity. LQMM and LMER were used for multifactor correlation analyses. P < 0.05 was considered statistically significant.

RESULTS

The single-factor correlation between all variables and the postoperative mJOA score was weak (all r < 0.3). The linear relationship was stronger than the nonlinear relationship, and there was no significant multicollinearity (VIF = 1.10-1.94). FA values in the LQMM and LMER models had a significant positive correlation with the mJOA score (r = 5.27-6.04), which was stronger than the other variables.

DATA CONCLUSION

The FA value based on dMRI significantly positively correlated with CSM patient postoperative outcomes, helping to predict the surgical outcome and formulate a treatment plan before surgery.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Systematic investigation of cerebellar functional alterations and their association with surgical outcomes in patients with degenerative cervical myelopathy: a resting-state fMRI study

OBJECTIVE

The aim of this study was to systematically investigate the changes in cerebellar neural activity and cerebellar-cortical functional connectivity (FC) in patients with degenerative cervical myelopathy (DCM) using resting-state functional magnetic resonance imaging (fMRI).

METHODS

In this study, we collected clinical data and resting-state fMRI data from 54 DCM patients and 50 healthy controls (HCs). We analyzed voxel-wise regional fMRI metrics, including amplitude of low frequency fluctuation (ALFF), fractional ALFF, regional homogeneity, functional connectivity density, and voxel-mirrored homotopic connectivity. In analysis 1, we examined the differences in regional fMRI metrics within the cerebellum between the DCM patient group and the healthy control group, as well as their correlation with preoperative neurological status and prognosis. In analysis 2, we investigated cerebellar-cortical functional connectivity differences between the two groups and their correlation with preoperative neurological status and prognosis. Lastly, in analysis 3, we explored the internetwork connectivity between the 'cerebellar-SMN' (sensorimotor network) system, examined the between-group differences, and investigated its correlation with preoperative neurological status and prognosis.

RESULTS

(1) Relative to HCs, DCM patients exhibited functional alterations in wide-spread cerebellar regions; (2) DCM patients exhibited altered cerebellar-cortical FC which was associated with the preoperative neurological status and prognosis; (3) DCM patients exhibited altered internetwork connectivity between 'cerebellar-SMN' system which was associated with duration of symptom.

CONCLUSION

Wide-spread cerebellar functional alterations occur in DCM pathogenesis and the deficits in cerebellar-SMN functional connectivity may be beneficial in future studies for predicting surgical outcomes in patients with DCM.

Classification and prognostic factors of patients with cervical spondylotic myelopathy after surgical treatment: a cluster analysis

Identifying potential prognostic factors of CSM patients could improve doctors' clinical decision-making ability. The study retrospectively collected the baseline data of population characteristics, clinical symptoms, physical examination, neurological function and quality of life scores of patients with CSM based on the clinical big data research platform. The modified Japanese Orthopedic Association (mJOA) score and SF-36 score from the short-term follow-up data were entered into the cluster analysis to characterize postoperative residual symptoms and quality of life. Four clusters were yielded representing different patterns of residual symptoms and quality of patients' life. Patients in cluster 2 (mJOA RR 55.8%) and cluster 4 (mJOA RR 55.8%) were substantially improved and had better quality of life. The influencing factors for the better prognosis of patients in cluster 2 were young age (50.1 ± 11.8), low incidence of disabling claudication (5.0%) and pathological signs (63.0%), and good preoperative SF36-physiological function score (73.1 ± 24.0) and mJOA socre (13.7 ± 2.8); and in cluster 4 the main influencing factor was low incidence of neck and shoulder pain (11.7%). We preliminarily verified the reliability of the clustering results with the long-term follow-up data and identified the preoperative features that were helpful to predict the prognosis of the patients. This study provided reference and research basis for further study with a larger sample data, extracting more patient features, selecting more follow-up nodes, and improving clustering algorithm.

Time course of symptomatic improvement after open-door laminoplasty for cervical spondylotic myelopathy

BACKGROUND

Postoperative outcomes following cervical spondylotic myelopathy (CSM) are excellent overall, but there are few prospective studies using patient-reported outcome measures that have explored how long improvement can be expected after surgery. The aim of this prospective study was to investigate from when and until when symptoms improve after open-door laminoplasty in patients with CSM and the factors that affect surgical outcomes.

METHODS

The subjects were 115 CSM patients who underwent laminoplasty. The Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) was used for longitudinal evaluation, and surveys on cervical spine function, upper extremity function, lower extremity function, bladder function, and quality of life were conducted before surgery and at 3, 6, 12, 18, and 24 months after surgery. The patients were classified into 'effective' and 'ineffective' groups based on the points obtained for each domain, and the factors affecting the outcome of surgery were examined by multivariate analysis.

RESULTS

JOACMEQ scores improved significantly at 3 months postoperatively compared to preoperatively for all four domains except cervical spine function, but there was no significant improvement after 3 months postoperatively. Multivariate analysis showed that the preoperative score (cervical spine function and upper extremity function) and the points obtained at 3 months postoperatively (upper and lower extremity function, bladder function, and quality of life) were the factors associated with membership of the effective group at 24 months postoperatively.

CONCLUSIONS

Although upper and lower extremity function, bladder function, and quality of life domains improved in the relatively early postoperative period, improvement after 3 months postoperatively was limited. The results suggest that the preoperative score and the superiority of the improvement obtained up to 3 months after surgery may be indicators of postoperative outcomes, and this may provide new insights into the selection of surgical indications and patient explanations.

Indication as a predictor for outcomes in anterior cervical discectomy and fusion: The impact of myelopathy on disposition

BACKGROUND

While the indication for Anterior Cervical Discectomy and Fusion (ACDF) may influence the expected postoperative course, there is limited data comparing how length of stay (LOS) and disposition for patients with myelopathy differ from those with radiculopathy. This study aimed to compare LOS and discharge disposition, in patients undergoing ACDF for cervical radiculopathy versus those for myelopathy.

METHODS

A retrospective review of all adult ACDF cases between 2013 and 2019 was conducted analyzing sex, age, race, comorbidities, level of surgery, myelopathy measures when applicable, complications, dysphagia, hospital LOS, and discharge disposition.

RESULTS

A total of 157 patients were included in the study with 73 patients undergoing an ACDF for radiculopathy and 84 for myelopathy. Univariate analysis determined older age (p < 0.01), male sex (p = 0.03), presence of CKD (p < 0.01) or COPD (p = 0.01), surgery at C3/4 level (p = 0.01), and indication (p < 0.01) as predictors for a discharge to either acute rehabilitation or a skilled nursing facility rather than to home. Multivariate logistic regression demonstrated age and indication as the only independent predictors of disposition, with home disposition being more likely with decreased age (OR 0.92, 95 % CI 0.86-0.98) and radiculopathy as the diagnosis (OR 6.72, 95 % CI 1.22- 37.02).

CONCLUSIONS

Myelopathic patients, as compared to those with radiculopathy at presentation, had significantly longer LOS, increased dysphagia, and were more often discharged to a facility. Understanding these two distinct populations as separate entities will streamline the pre and post-surgical care as the current DRG codes and ICD 10 PCS do not differentiate the expected post-operative course in patients undergoing ACDF for myelopathy versus radiculopathy.

Spinal Cord Signal Intensity Predicts Functional Outcomes in the Operative Management of Degenerative Cervical Myelopathy

STUDY DESIGN

Prospective single institutional cohort study on degenerative cervical myelopathy (DCM) from 2009 to 2022.

OBJECTIVE

This study aims to assess the relationship among preoperative spinal cord signal change, postoperative signal change evolution, and functional outcome in patients undergoing surgery for DCM.

SUMMARY OF BACKGROUND DATA

There is conflicting evidence on whether spinal cord signal intensity influences functional outcomes in patients with DCM.

PATIENTS AND METHODS

This prospective study investigated 104 patients with DCM that underwent both preoperative and routine postoperative cervical spine magnetic resonance imaging (MRI) as part of a research protocol. Signal intensity/grade, modified Japanese Orthopedic Association (mJOA) scores, signal resolution, and patient demographics were assessed.

RESULTS

Sixty-eight of the subjects were found to have abnormal T2 spinal cord signal intensity changes on their preoperative MRI. The total mean preoperative mJOA score was 13.6, increasing postoperatively to 16 (P < 0.001). The presence or absence of preoperative spinal cord signal change was not associated with the change in mJOA score or neurological recovery rate after surgery. Of the 68 patients with preoperative T2 signal change, 36 were found to have an improvement in the T2-weighted signal grade after surgery and 32 had no change in postoperative signal grade. The mean improvement in mJOA score (3.7) and neurological recovery rate (70.3%) was significantly higher in the patients with preoperative signal change whose postoperative MRI signal change grade improved by at least one point compared with those that did not (2.0, 50.5%), (P < 0.001, P < 0.003).

CONCLUSIONS

The presence of preoperative T2-weighted signal change was associated with lower preoperative mJOA scores, but no change in mJOA after surgery or postoperative neurological recovery rate. However, improvement in T2-weighted spinal cord signal grade on postoperative MRI was significantly associated with a degree of neurological improvement after surgery.

Clinicoradiological Risk Factors Associated with Inability to Achieve Minimum Clinically Important Difference in Operated Cases of Cervical Spondylotic Myelopathy

STUDY DESIGN

This is a retrospective cohort study.

PURPOSE

This study aimed to identify the clinicoradiological risk factors associated with the inability to achieve minimum clinically important difference (MCID) on the modified Japanese Orthopaedic Association (mJOA) Scale in operated cases of cervical spondylotic myelopathy (CSM).

OVERVIEW OF LITERATURE

Only a few studies have evaluated the outcomes of surgery performed for CSM using MCID on the mJOA scale.

METHODS

We analyzed 124 operated CSM cases from March 2019 to April 2021 for preoperative clinical features, cervical sagittal radiographic parameters, and magnetic resonance imaging (MRI) signal intensities (SI). The risk factors associated with missing the MCID (poor outcome) on mJOA at the final follow-up were identified using binary logistic regression. Multivariate analysis was used to find significant risk factors, and odds ratios (OR) were computed.

RESULTS

A total of 110 men (89.2%) and 14 women (10.8%) with an average age of 53.5±13.2 years were included in the analysis. During the last follow-up, 89 cases (72.1%) achieved MCID (meaningful gains following surgery) while 35 (27.9%) could not. The final model identified the following parameters as significant risk factors for poor outcome: increased duration of symptoms (OR, 6.77; p=0.001), lower preoperative mJOA scale (OR, 0.75; p=0.029), the presence of multilevel T2-weighted (T2W) MRI SI (OR, 4.79; p=0.004), and larger change in cervical sagittal vertical axis (ΔcSVA) (OR, 1.06; p=0.013). Also, an increase in cSVA postoperatively correlated with a reduced functional recovery rate (r=-0.4, p<0.001).

CONCLUSIONS

Surgery for CSM leads to significant functional benefits. However, poorer outcomes are observed in cases of greater duration of symptoms, higher preoperative severity with multilevel T2W MRI SI, and a larger increase in the postoperative cSVA (sagittal imbalance).

The Deterioration of Cervical Kyphosis During Neck Flexion after Laminoplasty Affects the Surgical Outcome of Cervical Spondylotic Myelopathy

STUDY DESIGN

A retrospective single-center study.

OBJECTIVE

The present study investigated whether postoperative cervical alignment changes, in addition to preoperative patient backgrounds, imaging parameters, and disease severity, affect outcomes 1 year after laminoplasty.

METHODS

One hundred and three cervical spondylotic myelopathy (CSM) patients who underwent laminoplasty were enrolled. Preoperative and postoperative (1-year) Japanese Orthopedic Association (JOA) scores, cervical alignment, and balance on X-rays were assessed. Patients were classified into 2 groups for a univariate analysis according to the status of the recovery rate (RR) of the JOA score ≥50%. A multiple logistic regression analysis was performed to identify factors associated with good surgical outcomes a.

RESULTS

The mean RR of the JOA score was 47.5% and the loss of cervical lordosis in the neutral position was 5.5°. The univariate analysis revealed slight differences in age, sex, and the duration of disease. Preoperative C2-7 angles were not significantly different. The C2-7 angle during flexion after surgery was significantly smaller in Group F. In the multiple logistic regression analysis, significant factors associated with the status of RR≥50% were a younger age (OR: .75, 95%CI: .59-.96), shorter duration of disease (OR: .94, 95%CI: .89-.99), and a lordotic C2-7 angle during neck flexion after surgery (OR: 1.47, 95%CI: 1.1-1.95).

CONCLUSION

We retrospectively assessed the surgical outcomes of laminoplasty in 103 CSM cases. In addition to an older age and longer duration of disease, postoperative deteriorations in cervical kyphosis during neck flexion had a negative impact on outcomes.

A clinical model to predict postoperative improvement in sub-domains of the modified Japanese Orthopedic Association score for degenerative cervical myelopathy

PURPOSE

The modified Japanese Orthopedic Association (mJOA) score consists of six sub-domains and is used to quantify the severity of cervical myelopathy. The current study aimed to assess for predictors of postoperative mJOA sub-domains scores following elective surgical management for patients with cervical myelopathy and develop the first clinical prediction model for 12-month mJOA sub-domain scores.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Byron F.] Last name [Stephens], Author 2 Given name: [Lydia J.] Last name [McKeithan], Author 3 Given name: [W. Hunter] Last name [Waddell], Author 4 Given name: [Anthony M.] Last name [Steinle], Author 5 Given name: [Wilson E.] Last name [Vaughan], Author 6 Given name: [Jacquelyn S.] Last name [Pennings], Author 7 Given name: [Jacquelyn S.] Last name [Pennings], Author 8 Given name: [Scott L.] Last name [Zuckerman], Author 9 Given name: [Kristin R.] Last name [Archer], Author 10 Given name: [Amir M.] Last name [Abtahi] Also, kindly confirm the details in the metadata are correct.Last Author listed should be Kristin R. Archer METHODS: A multivariable proportional odds ordinal regression model was developed for patients with cervical myelopathy. The model included patient demographic, clinical, and surgery covariates along with baseline sub-domain scores. The model was internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

RESULTS

The model identified mJOA baseline sub-domains to be the strongest predictors of 12-month scores, with numbness in legs and ability to walk predicting five of the six mJOA items. Additional covariates predicting three or more items included age, preoperative anxiety/depression, gender, race, employment status, duration of symptoms, smoking status, and radiographic presence of listhesis. Surgical approach, presence of motor deficits, number of surgical levels involved, history of diabetes mellitus, workers' compensation claim, and patient insurance had no impact on 12-month mJOA scores.

CONCLUSION

Our study developed and validated a clinical prediction model for improvement in mJOA scores at 12 months following surgery. The results highlight the importance of assessing preoperative numbness, walking ability, modifiable variables of anxiety/depression, and smoking status. This model has the potential to assist surgeons, patients, and families when considering surgery for cervical myelopathy.

LEVEL OF EVIDENCE

Level III.

Predictors of poor clinical outcome in patients with cervical spondylotic myelopathy undergoing cervical laminectomy and fusion

BACKGROUND

Cervical spondylotic myelopathy (CSM) is a common degenerative disease that arises from spinal cord compression and injury. Laminectomy with posterior spinal fusion (LPSF) is one of the most common approaches used to treat patients with CSM. The present study aimed to evaluate predictors of poor clinical outcome in patients with CSM undergoing LPSF.

METHODS

We retrospectively evaluated 157 patients with CSM who underwent LPSF at our center between April 2014 and June 2019. The neurological outcome was assessed using the modified Japanese Orthopaedic Association (mJOA) scale before the surgery and at the last follow-up visit. Based on the clinical outcomes, all patients were divided into two groups [the good group (recovery rates ≥ 75%) and the poor group (recovery rates < 75%)]. The following suggested variables as potential predictors for the poor clinical outcome were compared between the two groups:age, gender, body mass index (BMI), smoking, diabetes, number of laminectomy levels, presence of signal changes in Magnetic Resonance Imaging (MRI), duration of symptoms, preoperative JOA scale, preoperative Pavlov ratio, preoperative cervical curvature, and preoperative cervical range of motion (ROM).

RESULTS

There were 86 males (54.8%) and 71 females (45.2%) with the mean follow-up time of 24.96 ± 1.67 months. Overall, 114 patients (72.6%) had a good clinical outcome. However, 43 subjects (27.4%) failed to achieve a good outcome. According to the binary logistic regression analysis, age (odds ratio [OR], 2.14; 95% confidence interval [95% CI], 1.87-2.63; P = 0.014) and preoperative JOA scale (OR, 3.73; 95% CI 2.96-4.87; p < 0.001) were independent predictors of poor clinical outcome.

CONCLUSIONS

The results of the present study showed that age and preoperative JOA scale were predictors of poor clinical outcome in patients with CSM undergoing LPSF. These findings will be of great value in preoperative counseling and management of postoperative expectations.

Depression and anxiety in cervical degenerative disc disease: Who are susceptible?

Background

Pre-operative depression and anxiety are associated with poorer patient-reported outcomes following cervical spine surgery. Identification of and interventions for these disorders are key to preventing related negative effects. However, most spine surgeons do not routinely evaluate mental health disorders. Few studies have investigated which patients with cervical degenerative disc diseases (CDDD) are susceptible to depression and anxiety.

Objective

To determine the factors associated with depression and anxiety in patients with CDDD.

Methods

Three hundred twelve patients with CDDD were recruited in this cross-sectional case-control study. Patients underwent a structured interview to acquire demographic and clinical characteristic information, which included the Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA), and Visual Analog Scale (VAS) for neck/arm pain. Depression and anxiety were evaluated using the Zung Self-Rating Depression and Anxiety Scales. Univariate and multivariate logistic regression analyses were used to identify factors associated with depression and anxiety.

Results

Of all patients, 102 (32.7%) had depression and 92 (29.5%) had anxiety. Two hundred six (66.0%) patients with neither depression nor anxiety were defined as the control group. Univariate analysis indicated that gender, educational level, occupation type, Charlson comorbidity index, symptom duration, symptomatology, surgery history, NDI, mJOA, VAS-neck, and VAS-arm scores were associated with depression and anxiety (except for symptom duration for anxiety). Multivariate logistic regression analysis indicated that females [odds ratio (OR) 1.81, 95% confidence interval (CI) 1.01-3.23], physical work (OR 2.06, 95% CI 1.16-3.65), poor mJOA score (ORmoderate 2.67, 95% CI 1.40-5.07; ORsevere 7.63, 95% CI 3.85-15.11), and high VAS-neck score (OR 1.24, 95% CI 1.11-1.39) were independent risk factors for depression. Physical work (OR 1.84, 95% CI 1.01-3.35), poor mJOA score (ORmoderate 2.66, 95% CI 1.33-5.33; ORsevere 9.26, 95% CI 4.52-18.99), and high VAS-neck score (OR 1.34, 95% CI 1.19-1.51) were independent risk factors for anxiety.

Conclusion

Approximately one-third of patients with CDDD had depression or anxiety. Patients who engaged in heavy work and had severe symptoms (poor mJOA and high VAS-neck scores) are susceptible to depression and anxiety. Additionally, female patients are susceptible to depression. Our findings may help identify CDDD patients with depression and anxiety in clinical practice.

Influence of clinical and radiological parameters on the likelihood of neurological improvement after surgery for degenerative cervical myelopathy

OBJECTIVE

Degenerative cervical myelopathy (DCM) is routinely treated with surgical decompression, but disparate postoperative outcomes are frequently observed, ranging from complete neurological recovery to persistent decline. Although numerous clinical and radiological factors have been independently associated with failure to improve, the relative impact of these proposed risk factors remains obscure. In this study, the authors assess the combined role of clinical and radiographic parameters in contributing to failure to attain neurological improvement after surgery.

METHODS

A consecutive series of patients who underwent surgery for DCM between July 2013 and August 2018 at a single institution was identified from a prospectively maintained database. Retrospective chart review was undertaken to record perioperative clinical and radiographic parameters. Failure to improve on the last follow-up evaluation after surgery, defined as a change in modified Japanese Orthopaedic Association (mJOA) score less than 2, was the primary outcome in univariate and multivariate analyses.

RESULTS

The authors included 183 patients in the final cohort. In total, 109 (59.6%) patients improved (i.e., responders with ΔmJOA score ≥ 2) after surgery and 74 (40.4%) were nonresponders with ΔmJOA score < 2. Baseline demographic variables and comorbidity rates were similar, whereas baseline Nurick score was the only clinical variable that differed between responders and nonresponders (2.7 vs 3.0, p = 0.02). In contrast, several preoperative radiographic variables differed between the groups, including presence and degree of cervical kyphosis, number of levels with bidirectional cord compression, presence and number of levels with T2-weighted signal change, intramedullary lesion (IML) length, Torg ratio, and both narrowest spinal canal and cord diameter. On multivariate analysis, preoperative degree of kyphosis at C2-7 (OR 1.19, p = 0.004), number of levels with bidirectional compression (OR 1.83, p = 0.003), and IML length (OR 1.14, p < 0.001) demonstrated the highest predictive power for nonresponse (area under the receiver operating characteristic curve 0.818). A risk factor point system that predicted failure of improvement was derived by incorporating these 3 variables.

CONCLUSIONS

When a large spectrum of both clinical and radiographic variables is considered, the degree of cervical kyphosis, number of levels with bidirectional compression, and IML length are the most predictive of nonresponse after surgery for DCM. Assessment of these radiographic factors can help guide surgical decision-making and more appropriately stratify patients in clinical trials.

Surgical results for cervical spondylotic myelopathy with inconsistent between deep tendon reflex findings and magnetic resonance imaging findings

BACKGROUND

To evaluate the surgical results of patients with cervical spondylotic myelopathy (CSM) with inconsistency between deep tendon reflex findings and cervical magnetic resonance imaging (MRI) findings and to analyze the differences between patients with good and poor surgical outcomes.

METHODS

We evaluated 50 subjects with CSM (30 males, 20 females; mean age: 70.4 years) who underwent posterior surgery and were followed for at least 1 year postoperatively. Matched CSM was defined as a consistent preoperative neurological pattern determined by deep tendon reflex and cervical MRI T2-weighted high-signal intramedullary area or stenosis in the most cranial compression levels. A lack of consistency was classified as unmatched CSM. Recovery rate (RR) according to Japanese Orthopaedic Association (JOA) scoring preoperatively and at 1 year postoperatively were compared between the groups.

RESULTS

The matched and unmatched CSM group included 27 subjects (13 males, 14 females; mean age: 68.2 years) and 23 subjects (17 males, 6 females; mean age: 72.8 years), respectively. RR was significantly higher in the matched CSM group (56.1 ± 3.7 % vs 36.8 ± 2.7 %; p = 0.002). Unmatched CSM was significantly associated with a lower RR independently of sex, patient age, surgical procedure, preoperative JOA score, diagnosis levels, and complication of diabetes.

CONCLUSIONS

Postoperative JOA score RR was significantly diminished among unmatched CSM patients comprising of 46% of cases. Some patients with unmatched CSM had multiple levels of spinal canal stenosis, foraminal stenosis, and peripheral neuropathy, suggesting that surgical results were poorer than those of matched CSM.

The Natural History of Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is the most frequent cause of spinal cord dysfunction and injury in the adult population and leads to significant loss of quality of life and economic impact from its associated medical care expenditures and loss of work. Surgical intervention is recommended for patients manifesting progressing neurological signs and symptoms of myelopathy, but the optimal management in individuals who have mild and clinically stable disease manifestations is controversial. Understanding the natural history of DCM is, thus, important in assessing patients and identifying those most appropriately indicated for surgical management. Despite the attempts to rigorously perform studies of the natural history of these patients, most published investigations suffer from methodological weaknesses or are underpowered to provide definitive answers. Investigations of particular patient subsets, however, provide some clinical guidance as to which patients stand most to benefit from surgery, and these may include those with lower baseline mJOA scores, evidence of segmental hypermobility, cord signal changes on MRI, abnormal somatosensory or motor-evoked potentials, or the presence of certain inflammatory markers. Clinicians should assess patients with mild myelopathy and those harboring asymptomatic cervical spinal cord compression individually when making treatment decisions and an understanding of the various factors that may influence natural history may aid in identifying those best indicated for surgery. Further investigations will likely identify how variables that affect natural history can be used in devising more precise treatment algorithms.

Analysis of combined clinical and diffusion basis spectrum imaging metrics to predict the outcome of chronic cervical spondylotic myelopathy following cervical decompression surgery

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is the most common cause of chronic spinal cord injury, a significant public health problem. Diffusion tensor imaging (DTI) is a neuroimaging technique widely used to assess CNS tissue pathology and is increasingly used in CSM. However, DTI lacks the needed accuracy, precision, and recall to image pathologies of spinal cord injury as the disease progresses. Thus, the authors used diffusion basis spectrum imaging (DBSI) to delineate white matter injury more accurately in the setting of spinal cord compression. It was hypothesized that the profiles of multiple DBSI metrics can serve as imaging outcome predictors to accurately predict a patient's response to therapy and his or her long-term prognosis. This hypothesis was tested by using DBSI metrics as input features in a support vector machine (SVM) algorithm.

METHODS

Fifty patients with CSM and 20 healthy controls were recruited to receive diffusion-weighted MRI examinations. All spinal cord white matter was identified as the region of interest (ROI). DBSI and DTI metrics were extracted from all voxels in the ROI and the median value of each patient was used in analyses. An SVM with optimized hyperparameters was trained using clinical and imaging metrics separately and collectively to predict patient outcomes. Patient outcomes were determined by calculating changes between pre- and postoperative modified Japanese Orthopaedic Association (mJOA) scale scores.

RESULTS

Accuracy, precision, recall, and F1 score were reported for each SVM iteration. The highest performance was observed when a combination of clinical and DBSI metrics was used to train an SVM. When assessing patient outcomes using mJOA scale scores, the SVM trained with clinical and DBSI metrics achieved accuracy and an area under the curve of 88.1% and 0.95, compared with 66.7% and 0.65, respectively, when clinical and DTI metrics were used together.

CONCLUSIONS

The accuracy and efficacy of the SVM incorporating clinical and DBSI metrics show promise for clinical applications in predicting patient outcomes. These results suggest that DBSI metrics, along with the clinical presentation, could serve as a surrogate in prognosticating outcomes of patients with CSM.

Social risk factors predicting outcomes of cervical myelopathy surgery

OBJECTIVE

Combinations of certain social risk factors of race, sex, education, socioeconomic status (SES), insurance, education, employment, and one's housing situation have been associated with poorer pain and disability outcomes after lumbar spine surgery. To date, an exploration of such factors in patients with cervical spine surgery has not been conducted. The objective of the current work was to 1) define the social risk phenotypes of individuals who have undergone cervical spine surgery for myelopathy and 2) analyze their predictive capacity toward disability, pain, quality of life, and patient satisfaction-based outcomes.

METHODS

The Cervical Myelopathy Quality Outcomes Database was queried for the period from January 2016 to December 2018. Race/ethnicity, educational attainment, SES, insurance payer, and employment status were modeled into unique social phenotypes using latent class analyses. Proportions of social groups were analyzed for demonstrating a minimal clinically important difference (MCID) of 30% from baseline for disability, neck and arm pain, quality of life, and patient satisfaction at the 3-month and 1-year follow-ups.

RESULTS

A total of 730 individuals who had undergone cervical myelopathy surgery were included in the final cohort. Latent class analysis identified 2 subgroups: 1) high risk (non-White race and ethnicity, lower educational attainment, not working, poor insurance, and predominantly lower SES), n = 268, 36.7% (class 1); and 2) low risk (White, employed with good insurance, and higher education and SES), n = 462, 63.3% (class 2). For both 3-month and 1-year outcomes, the high-risk group (class 1) had decreased odds (all p < 0.05) of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Being in the low-risk group (class 2) resulted in an increased odds of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Neither group had increased or decreased odds of being satisfied with surgery.

CONCLUSIONS

Although 2 groups underwent similar surgical approaches, the social phenotype involving non-White race/ethnicity, poor insurance, lower SES, and poor employment did not meet MCIDs for a variety of outcome measures. This finding should prompt surgeons to proactively incorporate socially conscience care pathways within healthcare systems, as well as to optimize community-based resources to improve outcomes and personalize care for populations at social risk.

Prognostic Factors for the Postoperative Improvement of Spinal Cord-Related Neuropathic Pain in Patients with Degenerative Cervical Myelopathy

Introduction

The number of patients with degenerative cervical myelopathy (DCM) requiring surgical treatment has markedly increased in today's aging society. Such patients often exhibit impaired activities of daily living because of motor dysfunction as well as neuropathic pain (NeP). Although many studies have demonstrated the safety and efficacy of surgical treatment for DCM, residual postoperative NeP has not been well described. Therefore, this study aimed to identify the predictors of postoperative NeP improvement in patients with DCM.

Methods

This retrospective study included 92 outpatients with postoperative chronic NeP (≥3 months) related to DCM. Data were obtained from clinical information, magnetic resonance imaging (MRI) findings, and patient-based questionnaires using the Neuropathic Pain Symptom Inventory (NPSI) and the Brief Scale for Psychiatric Problems in Orthopaedic Patients. Univariate and multivariate analyses were performed for patients with NPSI improvement rates <30% and ≥30% to identify prognostic factors.

Results

Among 92 patients, 61 (66.3%) had residual NeP, with a low improvement rate even after surgery. The independent negative prognostic factors for NeP improvement after surgery were older age at operation (odds ratio (OR): 0.932), longer symptom duration before surgery (OR: 0.589), and higher preoperative NPSI score (OR: 0.932). The cut-off value of symptom duration before surgery for postoperative NeP improvement was 1 year. By contrast, the preoperative Japanese Orthopaedic Association score and MRI findings, including signal intensity change and the degree of spinal cord compression, were not associated with postoperative NeP improvement. Moreover, even in patients with an NPSI improvement rate ≥30%, the NPSI subscores for deep pain and paresthesia/dysesthesia remained high.

Conclusions

Discrepancies between physician- and image-based assessments and patient-based assessments were identified as factors associated with improvement in postoperative NeP. Our findings are important for both spine surgeons and patients to manage patient expectations with respect to recovery during the postoperative course.

Quantitative Romberg using a force plate: an objective measure for cervical myelopathy

BACKGROUND CONTEXT

Surgical decision making for cervical spondylotic myelopathy (CSM) relies on evaluation of symptoms and physical examination. The Romberg test is a clinical exam used to identify balance issues with CSM. However, the Romberg test has a subjective interpretation and has a binary (positive or negative) result.

PURPOSE

This study aims to compare force plate pressure readings during a standard Romberg test in patients with CSM to age-matched normal healthy volunteers.

STUDY DESIGN/SETTING

Prospective cross sectional observational comparative cohort from a single multi-surgeon spine center.

PATIENT SAMPLE

Patients who were clinically diagnosed with CSM were compared to age-matched healthy volunteers without a clinical history of spine pathology.

OUTCOME MEASURES

Quantitative Romberg Force Plate Measurements METHODS: Patients with CSM requiring surgery and healthy normal volunteers were asked to perform the Romberg test while on a force plate measuring the center of pressure (COP): standing up straight with arms extended for 30 seconds with eyes open, followed by 30 seconds with eyes closed. The change for total sway area, sway frequency and sway speed with eyes closed and eyes open were calculated and compared between patients with CSM and healthy volunteers.

RESULTS

Thirty-four CSM patients were age-matched to 34 healthy volunteers. There was a larger change in quantitative Romberg measurements with eyes open versus eyes closed in CSM patients compared to normal volunteers for maximum lateral movement (10.79 cm vs. 0.94 cm, p=.003), maximum anterior-posterior movement (15.06 cm vs. 10.00 cm p=.201), total lateral CoP movement (89.82cm vs. 18.71cm, p=.007), total AP CoP movement (154.68 cm vs. 87.47 cm, p=.601), total CoP trace movement (199.79 cm vs. 88.44 cm, p=.014), sway area (284.74 cm² vs. 57.76 cm², p=.006), and average speed (7.00 cm/s vs. 2.91 cm/s, p=.006).

DISCUSSION

Poor standing balance can be quantified in patients with CSM. Quantifying standing balance in patients with CSM shows significantly worse objective measures than age-matched healthy volunteers. The Romberg test on a force plate may help diagnose and evaluate patients with CSM, guide patient management and potentially grade the severity of spinal pathology. Further studies are needed to determine its utility in monitoring disease progression and measure treatment effectiveness.

The influence of carotid atherosclerosis on surgical outcomes of patients with cervical spondylotic myelopathy: A retrospective study

The appearance of atherosclerosis in the carotid artery may be suggest the possibility of atherosclerosis in the spinal cord artery, which can cause spinal cord ischemia and further lead to neural element damage.According to the inclusion and exclude standard, there are 137 patients with cervical spondylotic myelopathy (CSM) incorporating retrospective analysis. These patients were consecutively admitted into The Second Hospital- Cheeloo College of Medicine-Shandong University from January 2016 to December 2018 and have accepted surgical treatment. All patients were examined by color Doppler ultrasound to detect carotid atherosclerosis before surgery. All patients were divided into 2 groups according to the presence or absence of carotid atherosclerosis: carotid atherosclerosis group (n = 88) and noncarotid atherosclerosis group (n = 49). All patients were followed up for at least 12 months after surgery. Demographic and surgery-related data were collected and analyzed to identify potential factors that affect the surgical outcomes in CSM.The average age of carotid atherosclerosis group (51 males and 37 females), and noncarotid atherosclerosis group (24 males and 25 females) were 62.02 ± 10.34 years (range, 38-85 years) and 49.61 ± 10.28 years (range, 26-67 years), respectively.In carotid atherosclerosis group: pre and postoperative modify Japanese Orthopedic Association Scores (mJOA score) were 11.58 ± 1.82 and 14.36 ± 1.64; the recovery rate of mJOA score was 45.57% ± 13.28%. In noncarotid atherosclerosis group: pre and postoperative mJOA score were 12.00 ± 2.11 and 15.04 ± 1.70; the recovery rate of mJOA score was 53.90% ± 13.22%. Univariate logistic regression analysis demonstrated that gender (P = .004), age ≥65 years (P = .001), duration of symptoms ≥12 months (P = .040), smoking history (P < .001), preoperative mJOA score ≤11 (P = .007) and carotid atherosclerosis (P = .004) were related to poor surgical outcomes. Multivariate logistic regression analysis showed significant correlations between poor surgical outcomes and age ≥65 years (P = .047), smoking history (P = .010), preoperative mJOA score ≤11 (P = .008) or carotid atherosclerosis (P = .047).Carotid atherosclerosis may be a risk factor for poor surgical outcomes in CSM.

Optimal machine learning methods for radiomic prediction models: Clinical application for preoperative T2*-weighted images of cervical spondylotic myelopathy

INTRODUCTION

Predicting the postoperative neurological function of cervical spondylotic myelopathy (CSM) patients is generally based on conventional magnetic resonance imaging (MRI) patterns, but this approach is not completely satisfactory. This study utilized radiomics, which produced advanced objective and quantitative indicators, and machine learning to develop, validate, test, and compare models for predicting the postoperative prognosis of CSM.

MATERIALS AND METHODS

In total, 151 CSM patients undergoing surgical treatment and preoperative MRI was retrospectively collected and divided into good/poor outcome groups based on postoperative modified Japanese Orthopedic Association (mJOA) scores. The datasets obtained from several scanners (an independent  scanner) for the training (testing) cohort were used for cross-validation (CV). Radiological models based on the intramedullary hyperintensity and compression ratio were constructed with 14 binary classifiers. Radiomic models based on 237 robust radiomic features were constructed with the same 14 binary classifiers in combination with 7 feature reduction methods, resulting in 98 models. The main outcome measures were the area under the receiver operating characteristic curve (AUROC) and accuracy.

RESULTS

Forty-one (11) radiomic models were superior to random guessing during CV (testing), with significant increased AUROC and/or accuracy (P AUROC < .05 and/or P accuracy < .05). One radiological model performed better than random guessing during CV (P accuracy < .05). In the testing cohort, the linear SVM preprocessor + SVM, the best radiomic model (AUROC: 0.74 ± 0.08, accuracy: 0.73 ± 0.07), overperformed the best radiological model (P AUROC = .048).

CONCLUSION

Radiomic features can predict postoperative spinal cord function in CSM patients. The linear SVM preprocessor + SVM has great application potential in building radiomic models.

Disruption of human brain connectivity networks in patients with cervical spondylotic myelopathy

Background

Brain functional plasticity and reorganization in patients with cervical spondylotic myelopathy (CSM) is increasingly being explored and validated. However, specific topological alterations in functional networks and their role in CSM brain functional reorganization remain unclear. This study investigates the topological architecture of intrinsic brain functional networks in CSM patients using graph theory.

Methods

Functional MRI was conducted on 67 CSM patients and 60 healthy controls (HCs). The topological organization of the whole-brain functional network was then calculated using theoretical graph analysis. The difference in categorical variables between groups was compared using a chi-squared test, while that between continuous variables was evaluated using a two-sample t-test. Nonparametric permutation tests were used to compare network measures between the two groups.

Results

Small-world architecture in functional brain networks were identified in both CSM patients and HCs. Compared with HCs, CSM patients showed a decreased area under the curve (AUC) of the characteristic path length (FDR q=0.040), clustering coefficient (FDR q=0.037), and normalized characteristic path length (FDR q=0.038) of the network. In contrast, there was an increased AUC of normalized clustering coefficient (FDR q=0.014), small-worldness (FDR q=0.009), and global network efficiency (FDR q=0.027) of the network. In local brain regions, nodal topological properties revealed group differences which were predominantly in the default-mode network (DMN), left postcentral gyrus, bilateral putamen, lingual gyrus, and posterior cingulate gyrus.

Conclusions

This study reported altered functional topological organization in CSM patients. Decreased nodal centralities in the visual cortex and sensory-motor regions may indicate sensory-motor dysfunction and blurred vision. Furthermore, increased nodal centralities in the cerebellum may be compensatory for sensory-motor dysfunction in CSM, while the increased DMN may indicate increased psychological processing in CSM patients.

A Bibliometric Analysis and Visualization of Current Research Trends in the Treatment of Cervical Spondylotic Myelopathy

STUDY DESIGN

Bibliometric analysis.

OBJECTIVE

Cervical spondylotic myelopathy (CSM) has become the most common cause of spinal cord dysfunction. Many topics of CSM still remain controversial. This study aimed to illustrate the overall knowledge structure and development trends of CSM.

METHODS

Research data sets were acquired from the Web of Science database and the time span was defined as "2000 to 2019." VOS viewer and Citespace software was used to analyze the data and generate visualization knowledge maps. Annual trends of publications, distribution, H-index status, co-authorship status, and research hotspots were analyzed.

RESULTS

A total of 2367 publications met the requirement. The largest number of articles was from the United States, followed by Japan, China, Canada, and India. The highest H-index was found for articles from the United States. The highest number of articles was published in Spine. The cooperation between the countries, institutes, and authors were relatively weak. Cervical sagittal alignment, predictive factor, diffusion tensor imaging, and the natural history of CSM may become a frontier in this research field.

CONCLUSION

The number of publications showed an upward trend with a stable rise. Most of the publications are limited to a few countries and institutions with relatively weak interaction. The United States, Canada, Japan, China, and India have made significant contributions to the field of CSM. The United States is the country with the highest productivity, not only in quality but also in quantity. Cervical sagittal alignment, predictive factor, diffusion tensor imaging, and the natural history of CSM are the research hotspots in the recent years.

Role of Diffuse Tensor Imaging in Predicting Outcomes of Decompressive Surgery in Degenerative Cervical Myelopathy—A Prospective Analysis

Background Cervical spondylotic myelopathy is a common degenerative disorder of the cervical spine. Assessing the severity of the disease objectively remains a challenge. Advances in magnetic resonance imaging (MRI), especially diffusion tensor imaging (DTI), elucidate the damaged or compressed fiber tracts in the cord. This study is our endeavor to correlate the relationship between clinical features, radiological features with special reference to DTI, and surgical outcome in patients with degenerative cervical myelopathy.

Methods All consecutive patients of cervical spondylotic myelopathy and cord intensity changes in MRI, admitted and treated in the department of neurosurgery during the period of 2016 to 2018, were included and evaluated clinically and radiologically. The clinical evaluation included motor assessment scale (MAS), 30 meters walking, and hand grip. Radiological investigations included additional DTI in 3T MRI and clinical outcome was measured postoperatively after 12 months by modified Japanese Orthopedic Association (mJOA) recovery ratio and MAS scores.

Results The patients age ranged from 30 to 80 years and the mean age of the study population was 55.95 ± 10 years. Patients with fractional anisotropy (FA) < 0.5 had higher grade of Nurick, that is, grade 5 in 4.3%, grade 4 in 65.2%, and grade 3 in 27.1% compared with grade 5 in 0%, grade 4 in 23.5%, and grade 3 in 47.1% in FA > 0.5. Mean mJOA recovery ratio in the group FA > 0.5 was 57.32 whereas it was 38.78 in FA < 0.5.

Conclusion DTI serves as a potential biomarker for predicting the surgical outcome in degenerative cervical myelopathy cases and thereby making the surgical decision precise. FA can be a potential quantitative tool to predict the functional outcome following decompressive surgery for degenerative cervical myelopathy conditions, in particular lower FA values carries poor prognosis.

Predictors of neurologic outcome after surgery for cervical ossification of the posterior longitudinal ligament differ based on myelopathy severity: a multicenter study

OBJECTIVE

The purpose of this retrospective multicenter study was to compare prognostic factors for neurological recovery in patients undergoing surgery for cervical ossification of the posterior longitudinal ligament (OPLL) based on their presenting mild, moderate, or severe myelopathy.

METHODS

The study included 372 consecutive patients with OPLL who underwent surgery for cervical myelopathy between 2006 and 2016 in East Asian countries with a high OPLL prevalence. Baseline and postoperative clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) myelopathy score and recovery ratio. Radiographic assessment included occupying ratio, cervical range of motion, and sagittal alignment parameters. Patient myelopathy was classified as mild, moderate, or severe based on the preoperative JOA score. Linear and multivariate regression analyses were performed to identify patient and surgical factors associated with neurological recovery stratified by baseline myelopathy severity.

RESULTS

The mean follow-up period was 45.4 months (range 25-140 months). The mean preoperative and postoperative JOA scores and recovery ratios for the total cohort were 11.7 ± 3.0, 14.5 ± 2.7, and 55.2% ± 39.3%, respectively. In patients with mild myelopathy, only age and diabetes correlated with recovery. In patients with moderate to severe myelopathy, older age and preoperative increased signal intensity on T2-weighted imaging were significantly correlated with a lower likelihood of recovery, while female sex and anterior decompression with fusion (ADF) were associated with better recovery.

CONCLUSIONS

Various patient and surgical factors are correlated with likelihood of neurological recovery after surgical treatment for cervical OPLL, depending on the severity of presenting myelopathy. Older age, male sex, intramedullary high signal intensity, and posterior decompression are associated with less myelopathy improvement in patients with worse baseline function. Therefore, myelopathy-specific preoperative counseling regarding prognosis for postoperative long-term neurological improvement should include consideration of these individual and surgical factors.

Cerebrospinal fluid biomarkers of glial and axonal injury in cervical spondylotic myelopathy

OBJECTIVE

Degenerative cervical spondylotic myelopathy (CSM) is a major cause of spinal cord dysfunction with an unpredictable prognosis. Βiomarkers reflecting pathophysiological processes in CSM have been insufficiently investigated. It was hypothesized that preoperative cerebrospinal fluid (CSF) biomarker levels are altered in patients with CSM and correlate with neurological status and outcome.

METHODS

CSF biomarkers from patients with CSM and controls were analyzed with immunoassays. Spinal cord changes were evaluated with MRI. The American Spinal Cord Injury Association Impairment Scale, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), and the EQ-5D questionnaire were applied prior to and 3 months after surgery. A p value < 0.05 was considered statistically significant.

RESULTS

Twenty consecutive CSM patients with a mean age of 67.7 ± 13 years and 63 controls with a mean age of 65.2 ± 14.5 years (p > 0.05) were included in the study. In the CSM subjects, CSF neurofilament light subunit (NF-L) and glial fibrillary acidic protein (GFAP) concentrations were higher (p < 0.05), whereas fatty acid-binding protein 3 (FABP3), soluble amyloid precursor proteins (sAPPα and sAPPβ), and amyloid β (Aβ) peptide (Aβ38, Aβ40, and Aβ42) concentrations were lower than in controls (p < 0.05). Aβ peptide levels correlated positively with symptom duration. Preoperative JOACMEQ lower extremity function and CSF NF-L levels correlated positively, and the JOACMEQ bladder function correlated negatively with sAPPα and sAPPβ (p < 0.05). CSF NF-L and FABP3 levels were higher in patients with improved outcome (EQ-5D visual analog scale difference > 20).

CONCLUSIONS

CSF biomarkers of glial and axonal damage, inflammation, and synaptic changes are altered in symptomatic CSM patients, indicating that axonal injury, astroglial activation, and Aβ dysmetabolism may be present in these individuals. These findings reflect CSM pathophysiology and may aid in prognostication. However, future studies including larger patient cohorts, postoperative biomarker data and imaging, and longer follow-up times are required to validate the present findings.

Pattern and Rate of Functional Recovery After Surgery for Cervical Spondylotic Myelopathy: Egyptian Prospective Study

OBJECTIVE

To study pattern and rate of neurological functional recovery after surgery for cervical spondylotic myelopathy (CSM).

METHODS

This prospective study comprised 25 patients with CSM who underwent surgical decompression at our institution. Upper limb, lower limb, and sphincter functions were assessed using the modified Japanese Orthopaedic Association score (mJOA). Assessment was done before the operation and at 1 month, 3 months, and 1 year after surgery.

RESULTS

The mJOA score did not significantly increase at 1 month after surgery (P = 0.051); however, increase in mJOA score was statistically significant at 3 and 1 year after surgery (P < 0.001 and P < 0.001, respectively). Upper limb motor dysfunction improved in 65% of patients, lower limb motor dysfunction improved in 52% of patients, upper limb sensory dysfunction improved in 48% of patients, and sphincter dysfunction improved in 14.2% of patients. There was a significant positive correlation between preoperative and postoperative mJOA score at 1 month, 3 months, and 1 year after surgery.

CONCLUSIONS

Minimal improvement occurred in the first month after CSM surgery to reach a peak at 3 months after surgery and steady improvement up to 1 year after surgery. Upper limbs recovered better and earlier than lower limbs and sphincter function. Preoperative severity of CSM is one of the main predictors of postoperative neurological outcome.

Surgical Outcomes of Postural Instability in Patients With Cervical Myelopathy

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

The objective of this study was to investigate the surgical outcomes of postural instability and its predictors in patients with cervical myelopathy (CM).

SUMMARY OF BACKGROUND DATA

Although several studies have shown impaired postural stability in CM patients, there remains a paucity of literature examining its surgical outcome.

MATERIALS AND METHODS

Postural stability was assessed using a stabilometer preoperatively, at the early phase (3-6 months postoperatively), and 1-year postoperatively, employing 2 stabilometric parameters: sway area [SwA (cm): the amount of sway of gravity center assessed by the outer peripheral area of the stabilogram] and sway density [SwD (/cm): the indicator of proprioceptive reflexes calculated by the locus length of the stabilogram per SwA]. Twenty-seven healthy age-matched, sex-matched, and body mass index-matched subjects were recruited as controls. To investigate the predictors of postoperative postural instability, univariate, and multivariate analyses were performed, including demographic data, preoperative neurological symptom severity, radiographic findings, and preoperative stabilometric parameters as independent variables.

RESULTS

Altogether, 54 CM patients were included in the present study. SwA was 7.89±0.84, 4.78±0.68, and 4.85±0.49, and SwD was 14.63±0.85, 20.41±1.23, and 19.36±1.40 preoperatively, at the early phase, and 1-year postoperatively, respectively, and significant improvement was found in both parameters postoperatively. However, at all timepoints, these parameters were significantly worse in CM patients than in the healthy subjects (SwA: 2.68±0.24, SwD: 24.91±1.83). Multivariate analyses showed that worse preoperative stabilometric parameters were significantly related to worse postoperative stabilometric parameters.

CONCLUSIONS

Surgery significantly improved postural stability in CM patients; however, it did not reach the level observed in healthy controls, even postoperatively. A predictor of greater residual postoperative postural instability was a greater level of preoperative postural instability. In CM patients, to achieve better surgical outcome of postural stability, surgical intervention is recommended before the symptoms related to bodily imbalance deteriorate.

LEVEL OF EVIDENCE

Level III.

Development and Validation of Cervical Prediction Models for Patient-Reported Outcomes at 1 Year After Cervical Spine Surgery for Radiculopathy and Myelopathy

STUDY DESIGN

Retrospective analysis of prospectively collected registry data.

OBJECTIVE

To develop and validate prediction models for 12-month patient-reported outcomes of disability, pain, and myelopathy in patients undergoing elective cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Predictive models have the potential to be utilized preoperatively to set expectations, adjust modifiable characteristics, and provide a patient-centered model of care.

METHODS

This study was conducted using data from the cervical module of the Quality Outcomes Database. The outcomes of interest were disability (Neck Disability Index:), pain (Numeric Rating Scale), and modified Japanese Orthopaedic Association score for myelopathy. Multivariable proportional odds ordinal regression models were developed for patients with cervical radiculopathy and myelopathy. Patient demographic, clinical, and surgical covariates as well as baseline patient-reported outcomes scores were included in all models. The models were internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

RESULTS

Four thousand nine hundred eighty-eight patients underwent surgery for radiculopathy and 2641 patients for myelopathy. The most important predictor of poor postoperative outcomes at 12-months was the baseline Neck Disability Index score for patients with radiculopathy and modified Japanese Orthopaedic Association score for patients with myelopathy. In addition, symptom duration, workers' compensation, age, employment, and ambulatory and smoking status had a statistically significant impact on all outcomes (P < 0.001). Clinical and surgical variables contributed very little to predictive models, with posterior approach being associated with higher odds of having worse 12-month outcome scores in both the radiculopathy and myelopathy cohorts (P < 0.001). The full models overall discriminative performance ranged from 0.654 to 0.725.

CONCLUSIONS

These predictive models provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical disease. Predictive models have the potential to be used as a shared decision-making tool for evidence-based preoperative counselling.

LEVEL OF EVIDENCE

2.

Analysis of the impact of spinopelvic radiographic parameters on the severity of cervical spondylotic myelopathy

BACKGROUND

The correlation between spinal radiographic parameters and severity of cervical spondylotic myelopathy (CSM) is controversial. This study aimed to investigate the associations between spinal radiographic parameters and CSM severity, as well as between cervical and other spinopelvic radiographic parameters.

METHODS

Patients diagnosed with CSM (N = 118; 77 men) at our hospital from March 2013 to February 2017 were included. The patients' demographic data and the following radiographic parameters were investigated: cervical lordosis (CL), C2-C7 sagittal vertical axis (C2-C7 SVA), T1 slope, thoracic kyphosis, lumbar lordosis, pelvic incidence, sacral slope, pelvic tilt, and sagittal vertical axis (SVA). Cervical cord compression ratio (CCCR) was evaluated on sagittal magnetic resonance imaging. The Japanese Orthopaedic Association (JOA) scoring system was used for clinical evaluation. Correlation analyses were performed among the clinical and radiographic parameters.

RESULTS

The JOA score had the strongest correlation with SVA (r = -0.46, p < 0.01), followed by CCCR (r = -0.33, p < 0.01), CL (r = -0.29, p < 0.01), T1 slope (r = -0.29, p = 0.01), and C2-C7 SVA (r = -0.20, p = 0.03). Multivariate linear regression analysis revealed a model predicting the JOA score; JOA = 13.6 - 0.24 × SVA - 4.2 × CCCR (r = 0.51, p < 0.01). Although there was no significant correlation between the cervical and lumbopelvic radiographic parameters, the sequential correlation among the investigated spinopelvic parameters was identified.

CONCLUSIONS

CSM severity worsened with spinal malalignment, such as a larger SVA. Though lumbopelvic radiographic parameters did not significantly impact cervical alignment and CSM severity, the sequential correlations among cervical-thoracic-lumbopelvic radiographic parameters were observed. Therefore, SVA is the most relevant radiographic parameter for CSM, but we cannot preclude the possibility that lumbopelvic alignment also affects cervical alignment and CSM severity.

Assessment of standing balance in normal versus cervical spondylotic myelopathy patients

Background

The Romberg test is used to identify balance issues in patients with Cervical Spondylotic Myelopathy (CSM), but has subjective interpretation. The purpose of this study is to evaluate force plate pressure readings during a Romberg test to quantify postural control.

Methods

Quantitative Romberg force plate readings with eyes open and closed in patients with CSM were obtained and changes in balance measurements were compared to a normal population (N = 28, mean age 39 ± 7 years).

Results

We identified 30 CSM patients with a mean age of 58 ± 10 years. Majority of patients presented with pain (90%) and neurologic symptoms (83%). Cord compression on imaging was identified in 90%. Mean eyes closed Romberg measurements were larger compared to eyes open measurements in CSM patients (p < 0.01). There was a larger change in Romberg (∆R) measurements in CSM compared to normals for total sway area (TSA, 14.18 vs 0.02 cm², p < 0.001) and average speed (AS, 2.07 vs 0.23 cm/s, p < 0.001). The presence of long tract signs produced larger ∆R (TSA, 15.35 vs 0.02 cm², p = 0.003; AS, 2.21 vs 0.23 cm/s, p = 0.001), and those with identified cord compression on imaging also had larger ∆R (TSA, 15.1 vs 0.02 cm², p < 0.001; AS, 2.17 vs 0.23 cm/s, p < 0.001).

Conclusions

Standing balance can be quantified in patients with CSM and is worse when compared to a normal population. Long tract signs and cord compression in imaging translates to worse balance in myelopathic patients. The use of quantitative Romberg measurements help evaluate balance in CSM.

The prediction of intraoperative cervical cord function changes by different motor evoked potentials phenotypes in cervical myelopathy patients

Background

Surgery is usually the treatment of choice for patients with cervical compressive myelopathy (CCM). Motor evoked potential (MEP) has proved to be helpful tool in evaluating intraoperative cervical spinal cord function change of those patients. This study aims to describe and evaluate different MEP baseline phenotypes for predicting MEP changes during CCM surgery.

Methods

A total of 105 consecutive CCM patients underwent posterior cervical spine decompression were prospectively collected between December 2012 and November 2016. All intraoperative MEP baselines recorded before spinal cord decompression were classified into 5 types (I to V) that were carefully designed according to the different MEP parameters. The postoperative neurologic status of each patient was assessed immediately after surgery.

Results

The mean intraoperative MEP changes range were 10.2% ± 5.8, 14.7% ± 9.2, 54.8% ± 31.9, 74.1% ± 24.3, and 110% ± 40 in Type I, II, III, IV, and V, respectively. There was a significant correlation of the intraoperative MEP change rate with different MEP baseline phenotypes (r = 0.84, P < 0.01). Postoperative transient new spinal deficits were found 0/31 case in Type I, 0/21 in Type II, 1/14 in Type III, 2/24 in Type IV, and 4/15 in Type V. No permanent neurological injury was found in our cases series.

Conclusions

The MEP baselines categories for predicting intraoperative cervical cord function change is proposed through this work. The more serious the MEP baseline abnormality, the higher the probability of intraoperative MEP changes, which is beneficial to early warning for the cervical cord injury.

The value of dynamic MRI in the treatment of cervical spondylotic myelopathy: a protocol for a prospective randomized clinical trial

Background

Cervical spondylotic myelopathy (CSM) is the most severe type of cervical spondylosis and the most common cause of spinal cord dysfunction among adults over 55 years old. MRI plays an important role in the diagnosis and evaluation of CSM, which can directly demonstrate the correlation between disc, spinal cord, posterior structures and abnormal signal in spinal cord. Static MRI can only show the static and neutral position of spinal cord, which is not enough to understand the pathogenesis of CSM. Dynamic MRI demonstrating the extension and flexion position of spinal cord can be a better tool for the treatment of CSM, especially the surgical decision making.

Method

A total of 180 CSM patients who have indications for surgery will be recruited in outpatient of Peking University Third Hospital and assigned to three groups (Group A, B and C) based on their static MRI after consent. Group A (incomplete dura compression) means the signal of cerebral spinal fluid (CSF) is still visible. Group B (complete dura compression) means no CSF signal and no shape change of spinal cord. Group C (spinal cord compression) means shape change of spinal cord. Two surgical plans will be made for each participant by one professional surgeon according to the static MRI and dynamic MRI respectively and we will randomly choose one to perform via a random number system. Follow-up will be maintained at 3, 6, and 12 months after surgery through outpatient or telephone interview, including mJOA score, 10-s G&R (grip and release) and 10-s step test, SF-36 score, radiographic examination and complications. Finally, data collection and statistical analysis will be finished by researchers who are blinded to recruitment and treatment.

Discussion

This study will help us to explore the indication of dynamic MRI and the value of dynamic MRI in the treatment of CSM, especially the surgical decision making. Dynamic MRI can be a useful tool in the treatment of CSM patients.

Trial registration

ChiCTR1900023014. Registered on May 7th, 2019.

Degenerative cervical myelopathy - update and future directions

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.

The change of cervical sagittal parameters plays an important role in clinical outcomes of cervical spondylotic myelopathy after multi-level anterior cervical discectomy and fusion

BACKGROUND

Cervical sagittal parameters were closely related with clinical outcomes after multi-level ACDF. Our purpose was to evaluate the clinical outcomes and cervical sagittal parameters in patients with MCSM after ACDF and to identify the risk factors of poor clinical outcomes.

MATERIAL AND METHODS

ACDF was performed in 89 patients with MCSM. Based on average JOA recovery rate, patients were divided good-outcome group (group GO) and poor-outcome group (group PO). The cervical sagittal parameters including Cobb angle, SVA, T1S, cranial tilt and cervical tilt were measured. Multivariate logistic regression was used to identify risk factors.

RESULTS

Fifty-four patients (60.67%) were divided into group GO, while 35 patients (39.33%) were divided into group PO. Cobb angle, SVA and T1S was corrected from preoperative average 11.80° ± 9.63°, 23.69 mm ± 11.69 mm and 24.43° ± 11.78° to postoperative average 15.08° ± 9.05°, 18.79 mm ± 10.78 mm and 26.92° ± 11.94° respectively (p < 0.001). △Cobb angle (p = 0.008) and △SVA (p = 0.009) showed significantly statistical differences between two groups. Longer symptom duration, lower preoperative JOA score, smaller △Cobb angle and larger △SVA were identified as risk factors of poor clinical outcomes.

CONCLUSION

Multi-level ACDF is an effective surgical method to treat patients with MCSM. However, long duration of preoperative symptoms, lower preoperative JOA score, smaller △Cobb angle and larger △SVA are risk factors for poor outcomes in patients with MCSM after ACDF. Sagittal parameters should be paid attention to in surgery.

Effect of depression and anxiety on health-related quality of life outcomes and patient satisfaction after surgery for cervical compressive myelopathy

OBJECTIVE

Preoperative mood disorders such as depression and anxiety are known to be associated with poor health-related quality of life (HRQOL) outcomes after lumbar spine surgery. However, the effects of preoperative depression and anxiety on postoperative HRQOL outcomes and patient satisfaction in cervical compressive myelopathy are yet to be clarified. This study aimed to investigate the effect of depression and anxiety on HRQOL outcomes and patient satisfaction following surgery for cervical compressive myelopathy.

METHODS

The authors reviewed the cases of all consecutive patients with cervical compressive myelopathy who had undergone surgical treatment in the period between January 2012 and March 2017 at their institution. Using the Hospital Anxiety and Depression Scale (HADS), the authors classified patients as depressed (HADS-D+) or not depressed (HADS-D-) and anxious (HADS-A+) or not anxious (HADS-A-). Patient HRQOL was evaluated preoperatively and at the end of at least 1 year after surgery using the physical and mental component summaries of the SF-12 Health Survey, EQ-5D (EuroQol health survey of five dimensions), Neck Disability Index, and Japanese Orthopaedic Association scale. Patient satisfaction was evaluated on the basis of a seven-item questionnaire and divided into two categories: satisfied and dissatisfied. Preoperative HRQOL statuses, postoperative improvements in HRQOL outcomes, and patient satisfaction were compared between the groups.

RESULTS

Among the 121 patients eligible for inclusion in the study, there were 69 patients (57.0%) without depression (HADS-D-) and 52 (43.0%) with depression (HADS-D+) and 82 patients (67.8%) without anxiety (HADS-A-) and 39 (32.2%) with anxiety (HADS-A+). All patients who completed both the preoperative and postoperative questionnaires had significant postoperative improvements in all HRQOL outcomes. The HADS-D+ and HADS-A+ patients had poorer preoperative HRQOL statuses than the HADS-D- and HADS-A- patients, respectively. However, statistically significant improvements in all HRQOL outcomes were observed in both HADS-D+ and HADS-A+ patients. Patient satisfaction was comparable between the HADS-D or HADS-A groups.

CONCLUSIONS

Cervical compressive myelopathy patients with preoperative depression or anxiety according to the HADS tool had worse preoperative HRQOL statuses. However, patients with cervical compressive myelopathy showed significant improvements in HRQOL outcomes and had sufficient levels of satisfaction after surgery regardless of the presence of preoperative depression or anxiety.

The Impact of Older Age on Functional Recovery and Quality of Life Outcomes after Surgical Decompression for Degenerative Cervical Myelopathy: Results from an Ambispective, Propensity-Matched Analysis from the CSM-NA and CSM-I International, Multi-Center Studies

Background: The effect on functional and quality of life (QOL) outcomes of surgery in elderly degenerative cervical myelopathy (DCM) patients has not been definitively established. Objective: To evaluate the effect of older age on the functional and QOL outcomes after surgery in an international, multi-center cohort of patients with DCM. Methods: 107 patients aged over 70 years old (mean 75.6 ± 4.4 years) were enrolled in the AOSpine CSM-North America and International studies. A propensity-matched cohort of 107 patients was generated from the remaining 650 adults aged <70 years old (mean 56.3 ± 9.6 years), matched to gender, complexity of surgery, co-morbidities, and baseline functional impairment (modified Japanese Orthopedic Association scale (mJOA). Functional, disability, and QOL outcomes were compared at baseline and at two years post-operatively, along with peri-operative adverse events. Results: Both cohorts were equivalently matched. At two years, both cohorts showed significant functional improvement from the baseline but the magnitude was greater in the younger cohort (mJOA 3.8 (3.2–4.4) vs. 2.6 (2.0–3.3); p = 0.007). This difference between groups was also observed in the SF-36 physical component summary (PCS) and mental component summary (MCS) outcomes (p = <0.001, p = 0.007), but not present in the neck disability index (NDI) scores (p = 0.094). Adverse events were non-significantly higher in the elderly cohort (22.4% vs. 15%; p = 0.161). Conclusions: Elderly patients showed an improvement in functional and QOL outcomes after surgery for DCM, but the magnitude of improvement was less when compared to the matched younger adult cohort. An age over 70 was not associated with an increased risk of adverse events.

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick’s grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski’s sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

Does the Neurological Examination Correlate with Patient-Perceived Outcomes in Degenerative Cervical Myelopathy?

BACKGROUND

In patients with neurological disorders, a divergence can exist between patients' perceptions regarding the outcomes and the objective neurological findings. Degenerative cervical myelopathy (DCM), a prevalent condition characterized by progressive compression of the cervical spinal cord, can produce debilitating symptoms and profound neurological findings. The purpose of the present study was to determine whether the physician-derived neurological examination findings, as recorded by American Spine Injury Association (ASIA) summary score, correlated with the patient-derived outcome measures for DCM.

METHODS

A total of 78 patients underwent surgical management of DCM with completion of preoperative and 6-month follow-up assessments. Surgical management consisted of either anterior or posterior cervical decompression. All patients underwent a neurological evaluation, including an ASIA assessment before surgery and 6 months after surgery, and completed the modified Japanese Orthopaedic Association (mJOA), neck disability index (NDI), and Short-Form 36-item (SF-36) scales pre- and postoperatively to measure both disease-specific and general perceived outcomes.

RESULTS

The objective physician-derived neurological testing (ASIA) did not correlate with the patient-derived scales (mJOA, NDI, and SF-36) pre- or postoperatively. Patients reported significant improvements (P < 0.001) at 6 months postoperatively in extremity functioning (mJOA), neck pain (NDI), overall physical health (SF-36), and objective strength and sensory functioning (ASIA). All patient-perceived outcome measures correlated with each other pre- and postoperatively (P < 0.01).

CONCLUSIONS

Objective scoring of postoperative neurological function did not correlate with patient-perceived outcomes before and after surgery for DCM. Traditional testing of motor and sensory function as part of the neurological assessment may not be sensitive enough to assess the scope of neurological changes experienced by patients with DCM.

Effect of Modified Japanese Orthopedic Association Severity Classifications on Satisfaction With Outcomes 12 Months After Elective Surgery for Cervical Spine Myelopathy

STUDY DESIGN

This study retrospectively analyzes prospectively collected data.

OBJECTIVE

Here, we aim to determine the influence of preoperative and 12-month modified Japanese Orthopedic Association (mJOA) on satisfaction and understand the change in mJOA severity classification after surgical management of degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

DCM is a progressive degenerative spine disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The mJOA is commonly used to grade and categorize myelopathy symptoms, but its association with postoperative satisfaction has not been previously explored.

METHODS

The quality and outcomes database (QOD) was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9 to 13), or severe (<9) categories on the mJOA scores. A McNemar-Bowker test was used to assess whether a significant proportion of patients changed mJOA category between preoperative and 12 months postoperative. A multivariable proportional odds ordinal logistic regression model was fitted with 12-month satisfaction as the outcome of interest.

RESULTS

We identified 1963 patients who underwent elective surgery for DCM and completed 12-months follow-ups. Comparing mJOA severity level preoperatively and at 12 months revealed that 55% remained in the same category, 37% improved, and 7% moved to a worse category. After adjusting for baseline and surgery-specific variables, the 12-month mJOA category had the highest impact on patient satisfaction (P < 0.001).

CONCLUSION

Patient satisfaction is an indispensable tool for measuring quality of care after spine surgery. In this sample, 12-month mJOA category, regardless of preop mJOA, was significantly correlated with satisfaction. Given these findings, it is important to advise patients of the probability that surgery will change their mJOA severity classification and the changes required to achieve postoperative satisfaction.

LEVEL OF EVIDENCE

3.

Trends in Nonoperative Treatment Modalities Prior to Cervical Surgery and Impact on Patient-Derived Outcomes: Two-Year Analysis of 1522 Patients From the Prospective Spine Treatment Outcome Study

Background

Effects of nonoperative treatments on surgical outcomes for patients who failed conservative management for cervical spine pathologies remain unknown. The objective is to describe conservative modality use in patients indicated for surgery for degenerative cervical spine conditions and its impact on perioperative outcomes.

Methods

The current study comprises a retrospective review of a prospective multicenter database. A total of 1522 patients with 1- to 2-level degenerative cervical pathology who were undergoing surgical intervention were included. Outcome measures used were health-related quality-of-life scores, length of hospitalization, estimated blood loss, length of surgery, and return-to-work status at 2 weeks, 6 months, 1 year, and 2 years postoperatively. Patients were grouped by diagnosis (radiculopathy vs. myelopathy), then divided based on epidural injection(s), physical therapy (PT), or opioid use prior to enrollment. Univariate t-tests and χ² tests were performed to determine differences between groups and impact on outcomes.

Results

Among 1319 radiculopathy patients, 25.7% received preoperative epidural injections, 35.3% received PT, and 35.5% received opioids. Radiculopathy patients who received epidurals and PT had higher 1-year postoperative return-to-work rates (P < .05). Radiculopathy patients without preoperative PT had longer hospitalization times, whereas those who received PT had higher 36-Item Short Form Health Survey (SF-36) physical functioning and physical component scores, lower 2-year visual analog scale (VAS) neck/arm pain scores, and higher 2-year return-to-work incidence (P < .05). Of myelopathy patients (n = 203), 14.8% received epidural injections, 25.1% received opioids, and 41.5% received PT. Myelopathy patients with preoperative PT had worse VAS arm pain scores 2 years postoperatively (P < .05). Patients receiving opioids were younger and had greater baseline-2-year Neck Disability Index improvement (P < .05).

Conclusions

Radiculopathy patients receiving epidurals returned to work after 1 year more frequently. PT was associated with shorter hospitalizations, greater SF-36 bodily pain norm and physical component score improvements, and increased return-to-work rates after 1 and 2 years. No statistically significant nonoperative treatment was associated with return-to-work rate in myelopathy patients.

Clinical Relevance

These findings suggest certain preoperative conservative treatment modalities are associated with improved outcomes in radiculopathy patients.

Outcome factors in surgically treated patients for cervical spondylotic myelopathy

Context/Objective: To investigate prospectively preoperative parameters that might be related to the outcome of surgically treated patients for cervical spondylotic myelopathy (CSM).Design: Prospective study.Setting: Single Center in Ioannina, Greece.Participants: Thirty-six patients were included in the study. There were 21 males and 15 females, mean age 50.8 years, range 39-70 years. The mean BMI was 27.3.Outcome measures: From each patient, we recorded age, sex, BMI, symptoms, duration of symptoms, comorbidities, lifestyle, myelopathy grade based on MRI and levels of compression. All patients completed the modified JOA (mJOA) and NPE questionnaires preoperatively and at 1, 3, 12 months and 5-years postoperatively.Results: The mean mJOA score significant improved from 10.8 ± 1.9 points preoperatively to 16.6 ± 2.2 points at 12 months postoperatively. The mean mJOA score at 5-years postoperatively was 15.5 ± 3 points. The difference was still highly significant. The mean NPE score significant improved from 59.8 ± 12.2 points preoperatively to 28.2 ± 8.5 points at 1 month, to 35.8 ± 8.1 points at 3 month and to 28.2 ± 8.8 points at 12 months postoperatively. Younger patients had significant higher baseline mJOA scores and significant higher mJOA scores 5-year postoperatively. No correlation was found between sex, BMI, symptom duration, baseline mJOA or myelopathy grade and outcome at 12 months or 5-year postoperatively.Conclusion: Age was highly predictive factor of outcome for patients undergoing surgical treatment of CSM.

Cervical Sagittal Range of Motion as a Predictor of Symptom Severity in Cervical Spondylotic Myelopathy

STUDY DESIGN

A retrospective review of radiographic data and functional outcomes.

OBJECTIVE

The aim of this study was to evaluate whether myelopathy symptom severity upon presentation corresponds to sagittal plane alignment or nonmyelopathy symptoms, such as pain, in patients with cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

Cervical sagittal balance is an important parameter in the outcome of surgical reconstruction. However, the effect of sagittal alignment on symptom severity in patients who have not undergone spine surgery is not well defined.

METHODS

A consecutive series of CSM patients was identified at an academic institution. Preoperative radiographs were analyzed for sagittal vertical axis (C2SVA), C7 slope (C7S), C2-C7 angle in neutral (C27N), flexion (C27F), and extension (C27E), and range of motion (C27ROM). Neutral alignment was categorized as lordotic, kyphotic, or sigmoid/straight. Outcomes collected were SF-12, neck disability index, arm pain, neck pain, and modified JOA (mJOA). Pearson coefficients determined correlations between radiographic and outcome parameters. Multivariate regression evaluated predictive factors of mJOA.

RESULTS

Radiographic parameters did not correlate with pain. Increasing age, smaller C27ROM, and smaller flexion angles correlated to lower (more severe) baseline mJOA scores. ROM (and not static alignment) was the only significant predictor of mJOA in the multivariate regression. Despite significant radiographic differences between lordotic, kyphotic, and sigmoid/straight alignment groups, myelopathy severity did not differ between these groups.

CONCLUSION

Static, neutral alignment, including SVA and lordosis, did not correlate with myelopathy or pain symptoms. Greater C27ROM and increased maximal flexion corresponded to milder myelopathy symptoms, suggesting that patients with myelopathy may compensate for cervical stenosis with hyperflexion, similar to that which is observed in the lumbar spine. In a CSM patient population, dynamic motion and compensatory deformities may play a more significant role in myelopathy symptom severity than what can be discerned from standard, neutral position radiographs.

LEVEL OF EVIDENCE

3.