Guidelines for the Management of Degenerative Cervical Myelopathy and Acute Spinal Cord Injury: Development Process and Methodology

A deep learning approach for cervical cord injury severity determination through axial and sagittal magnetic resonance imaging segmentation and classification

STUDY DESIGN

Cross-sectional Database Study.

OBJECTIVE

While the American Spinal Injury Association (ASIA) Impairment Scale is the standard for assessing spinal cord injuries (SCI), it has limitations due to subjectivity and impracticality. Advances in machine learning (ML) and image recognition have spurred research into their use for outcome prediction. This study aims to analyze deep learning techniques for identifying and classifying cervical SCI severity from MRI scans.

METHODS

The study included patients with traumatic and nontraumatic cervical SCI admitted from 2019 to 2022. MRI images were labeled by two senior resident physicians. A deep convolutional neural network was trained using axial and sagittal cervical MRI images from the dataset. Model performance was assessed using Dice Score and IoU to measure segmentation accuracy by comparing predicted and ground truth masks. Classification accuracy was evaluated with the F1 Score, balancing false positives and negatives.

RESULT

In the axial spinal cord segmentation, we achieved a Dice score of 0.94 for and IoU score of 0.89. In the sagittal spinal cord segmentation, we obtained Dice score up to 0.9201 and IoU scores up to 0.8541. The model for axial image score classification gave a satisfactory result with an F1 score of 0.72 and AUC of 0.79.

CONCLUSION

Our models successfully identified cervical SCI on T2-weighted MR images with satisfactory performance. Further research is needed to develop more advanced models for predicting patient outcomes in SCI cases.

[Cervical stenosis-Diagnostics and treatment of symptomatic spinal canal stenosis and neuroforaminal stenosis]

Cervical stenosis is a clinical picture that is regularly encountered by both hospital physicians and orthopedic surgeons in the daily clinical practice. While advanced cervical spinal canal stenosis may lead to myelopathic symptoms in cases of sufficient manifestation and spinal cord injury, neuroforaminal stenosis leads to radicular symptoms due to compression of the nerve roots. The clinical examination can provide initial clues as to the suspected cause of the patient's symptoms; however, reliable diagnostics are based only on sectional imaging of the cervical spine. Depending on the extent of the symptoms, the treatment options vary between nonsurgical treatment for moderate symptoms without neurological deficits and surgical decompression of the spinal cord or nerve roots. The surgical treatment can be performed from anterior or posterior depending on the findings. Surgery can lead to an improvement of the neurological symptoms; however, the primary aim of surgical treatment is to avoid deterioration of the neurological deficits.

A Critical Appraisal of the Congress of Neurological Surgeons Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma

Background and objective Thoracolumbar spine trauma (TST) is frequently associated with spinal cord injury and other soft tissue and bony injuries. The management of such injuries requires an evidence-based approach. This study used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to assess the methodological quality of clinical guidelines for the management of TST published by the Congress of Neurological Surgeons (CNS). Methods All clinical guidelines on TST published by CNS until 2020 were assessed. Five appraisers from three international centers evaluated the quality of eligible clinical guidelines by using AGREE II. Mean AGREE II scores for each domain were determined. In higher-quality domains, the scores for individual items were analyzed. Results A total of 12 guidelines published by CNS on TST were assessed. Mean scores for all six domains were as follows: Scope and Purpose (75.2%), Stakeholder Involvement (45.4%), Rigor of Development (57.0%), Clarity of Presentation (58.7%), Applicability (16.9%), and Editorial Independence (64.1%). The mean score for the overall quality of all CNS guidelines was 52.9% [95% confidence interval (CI): 52.2-53.5%]. The overall agreement among appraisers was excellent [intra-class correlation coefficients (ICCs) for each guideline ranged from 0.903 to 0.963]. Conclusions CNS guidelines for the management of TST demonstrated acceptable quality across most domains; however, the domains of Applicability and Stakeholder Involvement could be further improved in future guideline updates. The assessors concluded that all guidelines could still be recommended for clinical practice with or without modifications.

A Clinical Practice Guideline on the Timing of Surgical Decompression and Hemodynamic Management of Acute Spinal Cord Injury and the Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury: Introduction, Rationale, and Scope

STUDY DESIGN

Protocol for the development of clinical practice guidelines following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) standards.

OBJECTIVES

Acute SCI or intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. The treatment of SCI has dramatically evolved over the last century as a result of preclinical and clinical research that has addressed important knowledge gaps, including injury mechanisms, disease pathophysiology, medical management, and the role of surgery. In an acute setting, clinicians are faced with critical decisions on how to optimize neurological recovery in patients with SCI that include the role and timing of surgical decompression and the best strategies for hemodynamic management. The lack of consensus surrounding these treatments has prevented standardization of care across centers and has created uncertainty with respect to how to best manage patients with SCI. ISCI is a feared complication that can occur in the best of hands. Unfortunately, there are no systematic reviews or clinical practice guidelines to assist spine surgeons in the assessment and management of ISCI in adult patients undergoing spinal surgery. Given these limitations, it is the objective of this initiative to develop evidence-based recommendations that will inform the management of both SCI and ISCI. This protocol describes the rationale for developing clinical practice guidelines on (i) the timing of surgical decompression in acute SCI; (ii) the hemodynamic management of acute SCI; and (iii) the prevention, identification, and management of ISCI in patients undergoing surgery for spine-related pathology.

METHODS

Systematic reviews were conducted according to PRISMA standards in order to summarize the current body of evidence and inform the guideline development process. The guideline development process followed the approach proposed by the GRADE working group. Separate multidisciplinary, international groups were created to perform the systematic reviews and formulate the guidelines. All potential conflicts of interest were vetted in advance. The sponsors exerted no influence over the editorial process or the development of the guidelines.

RESULTS

This process resulted in both systematic reviews and clinical practice guidelines/care pathways related to the role and timing of surgery in acute SCI; the optimal hemodynamic management of acute SCI; and the prevention, diagnosis and management of ISCI.

CONCLUSIONS

The ultimate goal of this clinical practice guideline initiative was to develop evidence-based recommendations for important areas of controversy in SCI and ISCI in hopes of improving neurological outcomes, reducing morbidity, and standardizing care across settings. Throughout this process, critical knowledge gaps and future directions were also defined.

An Overview of the Methodology Used to Develop Clinical Practice Guidelines for the Management of Acute and Intraoperative Spinal Cord Injury

STUDY DESIGN

An overview of the methods used to develop clinical practice guidelines (CPGs).

OBJECTIVES

Acute spinal cord injury (SCI) and intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. To date, there are several studies that have discussed the diagnostic and management strategies for both SCI and ISCI. CPGs in SCI help to distill and translate the current evidence into actionable recommendations, standardize care across centers, optimize patient outcomes, and reduce costs and unnecessary interventions. Furthermore, they can be used by patients to assist in making decisions about certain treatments and by policy makers to inform allocation of resources. The objective of this article is to summarize the methods used to develop CPGs for the timing of surgery and hemodynamic management of acute SCI, as well as the identification and treatment of ISCI.

METHODS

The CPGs were developed using standards established by the Institute of Medicine (now the National Academy of Medicine), the Guideline International Network and several other organizations. Systematic reviews were conducted according to accepted methodological standards (eg, Institute of Medicine, Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute) in order to summarize the current body of evidence and inform the guideline development process. Protocols for each guideline were created. A multidisciplinary guideline development group (GDG) was formed that included individuals living with SCI as well as clinicians from the broad range of specialties that encounter patients with SCI: spine or trauma surgeons, critical care physicians, rehabilitation specialists, neurologists, anesthesiologists and other healthcare professionals. Individuals living with SCI were also included in the GDG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to rate the certainty of the evidence for each critical outcome. The "evidence to recommendation" framework was then used to translate the evidence obtained from the systematic review to an actionable recommendation. This framework provides structure when assessing the body of evidence and considers several additional factors when rating the strength of the recommendation, including the magnitude of benefits and harms, patient preferences, resource use, health equities, acceptability and feasibility. Finally, the CPGs were appraised both internally and externally.

RESULTS

The results of the CPGs for SCI are provided in separate articles in this focus issue.

CONCLUSIONS

Development of these CPGs for SCI followed the methodology proposed by the Institute of Medicine the Guideline International Network and the GRADE Working Group. It is anticipated that these CPGs will assist clinicians implement the best evidence into practice and facilitate shared-decision making with patients.

Myelopathy disability index: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy

PURPOSE

To find the cut-off values in the Myelopathy Disability Index (MDI) that will allow us to classify the severity of Degenerative Cervical Myelopathy (DCM) into mild, moderate and severe.

METHODS

Cross-sectional study with prospective data collection, with a total of 64 patients diagnosed with Degenerative Cervical Myelopathy (DCM). Anthropometric, diagnostic, neurological, functional and quality of life variables were collected. A Receiver Operating Curve (ROC) was performed. The cut-off points were validated by comparing the functional status of patients in the 3 groups and their Nurick scores.

RESULTS

Sixty-four patients (23 women) with a mean age of 61.97 (SD 11.57) participated in this study. The majority of patients were Nurick I (28.13%) and Nurick II (32.81%). The medium MDI was 7.36 (SD 6.66) and the mJOA was 14.08 (SD 2.57). The mild-moderate cut-off value was between 4 and 5, with an Area Under the Curve (AUC) of 0.805, sensitivity of 0.853 and specificity of 0.6. For moderate-severe, the cut-off value obtained was between 7 and 8, with an AUC of 0.862, sensitivity of 0.857 and specificity of 0.684. Patients with greater severity had significantly lower functionality, with a P-value of 0.004 in the 30 Metre Walking Test and 0.005 in the Nine-Hole Peg Test. Established severity groups were also significantly related to the different categories of the Nurick score (P-value = 0.000).

CONCLUSION

MDI values between 0 and 4 correspond to mild DCM, between 5 and 7 would be moderate DCM and from 8 to 30 indicate severe DCM.

Update of the Natural History, Pathophysiology, and Treatment Strategies of Degenerative Cervical Myelopathy: A Narrative Review

Cervical myelopathy is a clinical syndrome resulting in symptoms of neurologic deficits due to prolonged spinal cord compression or ischemia in the cervical spine. Spinal cord compression can be caused by ossification of the posterior longitudinal ligament and hypertrophy of ligamentun flavum in addition to degenerative cervical spondylosis, degenerative disc disease, and progressive cervical kyphosis. Degenerative cervical myelopathy (DCM) is a series of disease entities caused by spinal cord compression by various nontraumatic and non-infectious causes. The pathophysiology of DCM includes spinal cord structure and function abnormalities caused by both static and dynamic factors. Surgical decompression for patients with moderate to severe cervical myelopathy not only inhibits the progression of neurological deterioration, but also improves functional status, pain, and quality of life. However, the role of nonsurgical treatment in patients with mild spinal cord compression is controversial. In general, patients with cervical myelopathies who do not undergo surgery have a poor prognosis. Appropriate surgical treatment is recommended when spinal cord compression is confirmed on image study in patients with reasonable symptoms of cervical myelopathy. The patient's overall health, degree of compression, presence of concurrent cervical radiculopathy, and cervical spine alignment, in addition to lesion location and etiology, should be considered when determining an appropriate surgical procedure. This review covers the updated issues, including pathophysiology, clinical manifestations, differential diagnosis, and available treatments for DCM.

Predictors of home discharge after scheduled surgery for degenerative cervical myelopathy

OBJECTIVE

Degenerative cervical myelopathy (DCM) is an important public health issue. Surgery is the mainstay of treatment for moderate and severe DCM. Delayed discharge of patients after DCM surgery is associated with increased healthcare costs. There is a paucity of data regarding predictive factors for discharge destination after scheduled surgery for patients with DCM. The purpose of this study was to identify factors predictive of home versus nonhome discharge after DCM surgery.

METHODS

Patients undergoing scheduled DCM surgery who had been enrolled in a prospective DCM substudy of the Canadian Spine Outcomes and Research Network registry between January 2015 and October 2020 were included in this retrospective analysis. Patient data were evaluated to identify potential factors predictive of home discharge after surgery. Logistic regression was used to identify independent factors predictive of home discharge. A multivariable model was then used as a final model.

RESULTS

Overall, 639 patients were included in the initial analysis, 543 (85%) of whom were discharged home. The mean age of the entire cohort was 60 years (SD 11.8 years), with a BMI of 28.9 (SD 5.7). Overall, 61.7% of the patients were female. The mean length of stay was 2.72 days (SD 1.7 days). The final internally validated bootstrapped multivariable model revealed that younger age, higher 9-Item Patient Health Questionnaire score, lower Neck Disability Index scores, fewer operated levels, mJOA scores indicating mild disease, anterior cervical discectomy and fusion procedure, and no perioperative adverse effects were predictive of home discharge.

CONCLUSIONS

Younger age, less neck-related disability, fewer operated levels, more significant depression, less severe myelopathy, anterior cervical discectomy and fusion procedure, and no perioperative adverse effects are predictive of home discharge after surgery for DCM. These factors can help to guide clinical decision-making and optimize postoperative care pathways.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Development and Implementation of Clinical Practice Guidelines: An Update and Synthesis of the Literature With a Focus in Application to Spinal Conditions

STUDY DESIGN

Review.

OBJECTIVES

The objectives of this review are to (a) summarize the role of clinical practice guidelines (CPGs), (b) outline the methodology involved in formulating CPGs, (c) provide an illustration of these principles using a CPG developed for degenerative cervical myelopathy, and (d) highlight the importance of knowledge translation.

METHODS

A review of the literature was conducted to summarize current standards in CPG development and implementation.

RESULTS

CPGs are systematically developed statements intended to affect decisions made by health care providers, policy makers, and patients. The main objectives of CPGs are to synthesize and translate evidence into recommendations, optimize patient outcomes, standardize care, and facilitate shared decision making among physicians, patients, and their caregivers. The main steps involved in the development of CPGs include defining the clinical problem, assembling a multidisciplinary guideline development group and systematic review team, conducting a systematic review of the literature, translating the evidence to recommendations, critically appraising the CPG and updating the document when new studies arise. The final step in developing a CPG is to implement it into clinical practice; this step requires an assessment of the barriers to implementation and the formulation of effective dissemination strategies.

CONCLUSION

CPGs are an important component in the teaching and practice of medicine and are available for a wide spectrum of diseases. CPGs, however, can only be used to influence clinical practice if the recommendations are informed by a systematic review of the literature and developed using rigorous methodology. The opportunity to transform clinical management of spinal conditions is an attractive outcome of the application of high-quality CPGs.

Development of the Portuguese Version of the Modified Japanese Orthopaedic Association Score: Cross-Cultural Adaptation, Reliability, Validity, and Responsiveness

BACKGROUND

Spondylotic cervical myelopathy (SCM) is a common cause of spinal-related disability in elderly patients. The assessment of this disability is a challenging task and depends on the subjective evaluation of the investigator. As a widespread-used scale, the modified version of the Japanese Orthopaedic Association score (mJOA) should be translated and culturally adapted in the Brazilian Portuguese language (i.e., mJOA-Br) to provide its clinical and research use. This study aimed to perform translation, transcultural adaptation, and validation of the mJOA into Brazilian Portuguese.

METHODS

Following the transcultural adaptation model described by Guillemin et al., the scale as translated into Brazilian Portuguese and back-translated to English. Afterwards, questionnaires were applied in consecutive patients with SCM and compared with a control group (without SCM). The final scale was compared with the Brazilian version of Neck Disability Index for validation.

RESULTS

Sixty patients were submitted to the translated version of mJOA. There was a strong correlation between mJOA-Br scores and Neck Disability Index scores to evaluate SCM symptoms (R = -0.75).

CONCLUSIONS

mJOA-Br was considered a valid and reliable tool to evaluate patients with SCM.