Management of Cervical Spondylotic Radiculopathy: A Systematic review

Prediction of additional hospital days in patients undergoing cervical spine surgery with machine learning methods

BACKGROUND

Machine learning (ML), a subset of artificial intelligence (AI), uses algorithms to analyze data and predict outcomes without extensive human intervention. In healthcare, ML is gaining attention for enhancing patient outcomes. This study focuses on predicting additional hospital days (AHD) for patients with cervical spondylosis (CS), a condition affecting the cervical spine. The research aims to develop an ML-based nomogram model analyzing clinical and demographic factors to estimate hospital length of stay (LOS). Accurate AHD predictions enable efficient resource allocation, improved patient care, and potential cost reduction in healthcare.

METHODS

The study selected CS patients undergoing cervical spine surgery and investigated their medical data. A total of 945 patients were recruited, with 570 males and 375 females. The mean number of LOS calculated for the total sample was 8.64 ± 3.7 days. A LOS equal to or <8.64 days was categorized as the AHD-negative group (n = 539), and a LOS > 8.64 days comprised the AHD-positive group (n = 406). The collected data was randomly divided into training and validation cohorts using a 7:3 ratio. The parameters included their general conditions, chronic diseases, preoperative clinical scores, and preoperative radiographic data including ossification of the anterior longitudinal ligament (OALL), ossification of the posterior longitudinal ligament (OPLL), cervical instability and magnetic resonance imaging T2-weighted imaging high signal (MRI T2WIHS), operative indicators and complications. ML-based models like Lasso regression, random forest (RF), and support vector machine (SVM) recursive feature elimination (SVM-RFE) were developed for predicting AHD-related risk factors. The intersections of the variables screened by the aforementioned algorithms were utilized to construct a nomogram model for predicting AHD in patients. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve and C-index were used to evaluate the performance of the nomogram. Calibration curve and decision curve analysis (DCA) were performed to test the calibration performance and clinical utility.

RESULTS

For these participants, 25 statistically significant parameters were identified as risk factors for AHD. Among these, nine factors were obtained as the intersection factors of these three ML algorithms and were used to develop a nomogram model. These factors were gender, age, body mass index (BMI), American Spinal Injury Association (ASIA) scores, magnetic resonance imaging T2-weighted imaging high signal (MRI T2WIHS), operated segment, intraoperative bleeding volume, the volume of drainage, and diabetes. After model validation, the AUC was 0.753 in the training cohort and 0.777 in the validation cohort. The calibration curve exhibited a satisfactory agreement between the nomogram predictions and actual probabilities. The C-index was 0.788 (95% confidence interval: 0.73214-0.84386). On the decision curve analysis (DCA), the threshold probability of the nomogram ranged from 1 to 99% (training cohort) and 1 to 75% (validation cohort).

CONCLUSION

We successfully developed an ML model for predicting AHD in patients undergoing cervical spine surgery, showcasing its potential to support clinicians in AHD identification and enhance perioperative treatment strategies.

(Cost-)effectiveness of personalised multimodal physiotherapy compared to surgery in patients with cervical radiculopathy: A systematic review

RATIONALE

Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking.

AIM/OBJECTIVES

To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy.

METHODS

PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported.

CONCLUSION

Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.

[Influence of preoperative symptom duration on effectiveness of cervical disc arthroplasty in cervical spondylotic radiculopathy patients]

Objective

To investigate the influence of preoperative symptom duration on effectiveness of cervical disc arthroplasty (CDA) in cervical spondylotic radiculopathy (CSR) patients.

Methods

The clinical data of 90 CSR patients who underwent single-segment CDA between January 2008 and March 2020 and met the selection criteria were retrospectively analyzed. Based on preoperative symptom duration, patients were divided into an early intervention group (preoperative symptom duration <24 months) and a late intervention group (preoperative symptom duration ≥24 months). There was no significant difference in baseline data between the two groups ( P>0.05), including age, gender, body mass index, smoking status, surgical segment, preoperative neck disability index (NDI), visual analogue scale (VAS) score, cervical lordosis (CL), C 2-C 7 range of motion (ROM), disc angle (DA), disc ROM (DROM), and disc intervertebral height (DIH). The early intervention group had a slightly higher preoperative Japan Orthopedic Association (JOA) score than the late intervention group ( P<0.05). Perioperative indicators such as operation time, intraoperative blood loss, and postoperative hospital stay were recorded. The changes of JOA score, NDI, and VAS score at last follow-up compared with those before operation were used to evaluate the clinical efficacy, and the imaging evaluation of CL, C 2-C 7 ROM, DA, DROM, and DIH was performed before operation, immediately after operation, and at last follow-up. The incidence of prosthesis-related complications, including heterotopic ossification (HO), anterior bone loss (ABL), and prosthesis subsidence, was also assessed at last follow-up.

Results

Patients in both groups were followed up 24-120 months, with an average of 53.4 months. There was no significant difference in operation time, intraoperative blood loss, or follow-up duration between the groups ( P>0.05). However, the late intervention group had significantly longer postoperative hospital stay compared to the early intervention group ( P<0.05). At last follow-up, there was no significant difference in the changes of JOA score, NDI, and VAS score between the two groups before and after operation ( P>0.05). During the follow-up, there was no surgical revision in the two groups, and there was no significant difference in the incidence of HO, ABL, and prosthesis subsidence between the two groups at last follow-up ( P>0.05). Imaging evaluation showed that there was no significant difference in CL, C 2-C 7 ROM, DA, DROM, and DIH between the two groups at each time point before and after operation ( P>0.05). The intra-group comparison showed that the early intervention group could maintain the immediate postoperative CL at last follow-up, while the late intervention group had recovered to the preoperative level. Additionally, the C 2-C 7 ROM, DROM, and DA had all recovered to preoperative levels at last follow-up in both groups; meanwhile, the DIH significantly increased immediately after operation and sustained until the last follow-up.

Conclusion

Preoperative symptom duration significantly affects the effectiveness of CDA in CSR patients. Patients with preoperative symptom duration ≥24 months have longer postoperative hospital stays and potentially poorer ability to maintain CL compared with patients with preoperative symptom duration <24 months.

Investigating the brain functional abnormalities underlying pain hypervigilance in chronic neck and shoulder pain: a resting-state fMRI study

PURPOSE

To investigate pain hypervigilance in individuals suffering from chronic neck and shoulder pain (CNSP) and its underlying brain mechanism.

METHODS

The evaluation of pain vigilance was conducted through the utilization of pain vigilance and awareness questionnaires. Voxel-wise regional homogeneity (ReHo) from 60 CNSP patients and 60 healthy controls (HCs) using resting-state fMRI data. Voxel-wise two-sample T-test was conducted to reveal the ReHo variations between CNSP and HC. Correlation analyses were utilized to reveal the connection between brain abnormalities and medical measurements. Furthermore, a mediation analysis was conducted to elucidate the pathway-linking changes in brain function with medical measurements.

RESULTS

Our present study revealed three main findings. Firstly, patients with CSNP demonstrated a heightened vigilance of pain in comparison to healthy adults, a common occurrence among individuals with chronic pain conditions. Secondly, we observed brain abnormalities in various brain regions in CSNP patients, and these alterations were associated with the extent of pain vigilance. Lastly, the pain hypervigilance impact on the severity of pain was found to be controlled by regional neural activity in the anterior cingulate cortex (ACC) in subjects with CSNP.

CONCLUSION

Our findings suggested that long-term repetitive nociceptive input caused by chronic pain further aggravates the pain intensity by impairing the vigilance-related pain processing within the anterior cingulate cortex in CNSP patients.

Evaluation of Safety and Efficacy of Preoperative Coronal MRI-Guided Minimally Invasive Surgery for Cervical Spondylotic Radiculopathy

BACKGROUND Key-hole surgery is a minimally invasive technique that has shown promise in various surgical procedures. This study aimed to assess the clinical effectiveness of preoperative coronal MRI-assisted key-hole surgery for the treatment of patients with cervical spondylotic radiculopathy (CSR). MATERIAL AND METHODS A total of 30 patients diagnosed with CSR and undergoing key-hole surgery with CMRI assistance were included in the study. Various parameters, including surgical segments, incision length, disease duration, operative time, intraoperative fluoroscopy times, intraoperative blood loss, complications, and length of hospitalization, were recorded. Precise measurements of Cobb angles and intervertebral space height were taken before and after the surgical procedure. Surgical outcomes were evaluated using modified Macnab criteria, visual analogue scale (VAS), Japanese Orthopaedic Association Scores (JOA), and neck disability index (NDI). RESULTS The average duration of disease was 6.47±3.29 months, with an average incision length of 1.94±0.15 cm and operative time of 57.83±4.34 minutes. The average intraoperative blood loss was 33.70±9.28 ml, with an average of 3.50±0.73 intraoperative fluoroscopies. The average duration of hospitalization was 4.10±1.27 days. Preoperative and postoperative measurements showed no statistically significant difference in C2-C7 Cobb angles and intervertebral space height. However, there were significant improvements in postoperative VAS, NDI, and JOA scores compared to preoperative scores. The surgical effectiveness rate was 100%, with a high rate of good and excellent outcomes. CONCLUSIONS The findings of this study suggest that preoperative CMRI-assisted key-hole surgery for single-segment CSR is a safe and effective treatment option with low complication rates. The clinical benefits include high security and good outcomes. Further research and larger studies are warranted to validate these findings.

Ultrasound-guided injection acupotomy as a minimally invasive intervention therapy for cervical spondylotic radiculopathy: a randomized control trial

OBJECTIVE

To explore the efficacy and safety of ultrasound-guided injection acupotomy as a minimally invasive intervention treatment of cervical spondylotic radiculopathy (CSR).

METHODS

160 CSR subjects were recruited who met the inclusion criteria in our hospital from October 2019 to December 2021. The subjects were randomly divided into the experimental and control group, with 80 cases in each. The experimental group received ultrasound-guided injection acupotomy as a minimally invasive intervention therapy. The control group received ultrasound-guided selective nerve root block (SNRB). The Odom's criteria clinical curative effect, visual analogue scale (VAS), neck disability index (NDI), and 36-Item Short Form Health Survey questionnaire (SF-36) were used to evaluate the outcome of subjects at several different points in time.

RESULTS

At 30 min and 1 month after the end of treatment, there was no significant difference in any scores. However, after six months, the excellent and good rate was better in the experimental group compared to the control (RD = 0.175; 95% CI, 0.044-0.300, p = 0.009). The total effective rate was also better in the experimental group (RD = 0.126; 95% CI, 0.021-0.232, p = 0.018). In contrast, the VAS score (MD = -0.500; 95% CI, -1.000-0.000, p = 0.030) and NDI score (MD = -6.460; 95% CI, -11.067 to -1.852, p = 0.006) were lower in the experimental group compared to the control. The total SF-36 score was higher in the experimental group (MD = 7.568; 95% CI, 2.459-12.677, p = 0.004).

CONCLUSION

Ultrasound-guided injection acupotomy minimally invasive interventional treatment of CSR has no significant difference in short-term curative effect compared with ultrasound-guided SNRB, but the data indicators are significantly better than the latter at 6 months after the end of the course of treatment, showing better long-term efficacy.

The effects of modified Guizhi plus Gegen decoction combined with the blade needle therapy on TCM syndromes, cervical curvature and levels of inflammatory factors in patients with cervical spondylotic radiculopathy

OBJECTIVE

To explore the effect of modified Guizhi plus Gegen decoction combined with the blade needle therapy on traditional Chinese medicine (TCM) syndromes, cervical curvature, and inflammatory factor levels in patients with cervical spondylotic radiculopathy.

METHODS

In this retrospective study, 114 patients with cervical spondylotic radiculopathy who visited Pain Clinic, Hangzhou Fuyang Hospital of TCM Orthopedics and Traumatology from January 2020 to December 2022 were selected as the study subjects. According to different treatment methods, these patients were divided into an observation group (n=57, treated with blade needle therapy) and a control group (n=57, treated with modified Guizhi plus Gegen decoction combined with the blade needle therapy). Patients in both groups were treated for 3 courses. The treatment effects, TCM syndrome scores, cervical curvature, hemorheology indexes, inflammatory factors and adverse reactions were analyzed and compared between the two groups.

RESULTS

The effective rate of patients in the observation group was 94.74%, which was significantly higher than 82.46% in the control group (P<0.05). After treatment, TCM syndrome scores, hemorheology indexes, and inflammatory factors levels in both of groups were significantly decreased in contrast to before treatment, while the cervical curvature was obviously increased. Compared with the control group, after the treatment, TCM syndrome scores, hemorheology indexes, inflammatory factors levels after treatment in the observation group were obviously lower, while the cervical curvature in the observation group being significantly increased (all P<0.05). No statistical differences were found for the incidence of adverse reactions between two the groups.

CONCLUSION

Modified Guizhi plus Gegen decoction combined with the blade needle therapy effectively improved the TCM syndrome scores, restored the curvature of the cervical spine, improved the hemorheology of patients, inhibited the levels of inflammatory factors and it also has few adverse reactions, with a significant treatment effect in patients with cervical spondylotic radiculopathy.

Electroacupuncture Attenuates Neuropathic Pain in a Rat Model of Cervical Spondylotic Radiculopathy: Involvement of Spinal Cord Synaptic Plasticity

Purpose

Cervical spondylotic radiculopathy (CSR) is a common neurologic condition that causes chronic neck pain and motor functions, with neuropathic pain (NP) being the primary symptom. Although it has been established that electroacupuncture (EA) can yield an analgesic effect in clinics and synaptic plasticity plays a critical role in the development and maintenance of NP, the underlying mechanisms have not been fully elucidated. In this study, we explored the potential mechanisms underlying EA's effect on synaptic plasticity in CSR rat models.

Materials and Methods

The CSR rat model was established by spinal cord compression (SCC). Electroacupuncture stimulation was applied to LI4 (Hegu) and LR3 (Taichong) acupoints for 20 min once a day for 7 days. Pressure pain threshold (PPT) and mechanical pain threshold (MPT) were utilized to detect the pain response of rats. A gait score was used to evaluate the motor function of rats. Enzyme-linked immunosorbent assay (ELISA), Western blot (WB), immunohistochemistry (IHC), immunofluorescence (IF), and transmission electron microscopy (TEM) were performed to investigate the effects of EA.

Results

Our results showed that EA alleviated SCC-induced spontaneous pain and gait disturbance. ELISA showed that EA could decrease the concentration of pain mediators in the cervical nerve root. WB, IHC, and IF results showed that EA could downregulate the expression of synaptic proteins in spinal cord tissues and promote synaptic plasticity. TEM revealed that the EA could reverse the synaptic ultrastructural changes induced by CSR.

Conclusion

Our findings reveal that EA can inhibit SCC-induced NP by modulating the synaptic plasticity in the spinal cord and provide the foothold for the clinical treatment of CSR with EA.

The Efficacy of Cervical Lordosis Rehabilitation for Nerve Root Function and Pain in Cervical Spondylotic Radiculopathy: A Randomized Trial with 2-Year Follow-Up

Sagittal cervical alignment is a clinically related feature in patients suffering from chronic cervical spondylotic radiculopathy (CSR). We designed this randomized trial to explore the effects of cervical lordosis (CL) correction in thirty chronic lower CSR patients with CL < 20°. Patients were assigned randomly into two equal groups, study (SG) and control (CG). Both groups received neck stretching and exercises and infrared radiation; additionally, the SG received cervical extension traction. Treatments were applied 3× per week for 10 weeks after which groups were followed for 3 months and 2 years. The amplitude of dermatomal somatosensory evoked potentials (DSSEPS), CL C2−C7, and pain scales (NRS) were measured. The SG had an increase in CL post-treatment (p < 0.0001), this was maintained at 3 months and 2 years. No statistical improvement in CL was found for the CG. A significant reduction in NRS for SG after 10 weeks of treatment with non-significant loss of change at 3 months and continued improvement at 2 years was found. CG had less significant improvement in post-treatment NRS; the 3-month and 2-year measures revealed significant worsening in NRS. An inverse linear correlation between increased CL and NRS was found (r = −0.49; p = 0.005) for both groups initially and maintained in SG at the final 2-year follow-up (r = −0.6; p = 0.01). At 10 weeks, we found significant improvements in DSSEPS for both groups (p < 0.0001). We identified a linear correlation between initial DSSEPs and CL for both groups (p < 0.0001), maintained only in the SG at the final follow-up for all levels (p < 0.0001). Improved CL in the SG correlated with significant improvements in nerve root function and pain rating in patients with CSR at short and long-term follow-up. These observed effects indicate that clinicians involved in the treatment of patients with symptoms of cervical degenerative disorders should add sagittal curve correction to their armamentarium of rehabilitation procedures for relevant patient populations.

Cervical Radiculopathy as a Hidden Cause of Angina: Cervicogenic Angina

Patients presenting with chest pain to the emergency department constitute a diagnostic challenge as 77% of the patients' symptoms are not cardiac. Diagnostic uncertainty is a pervasive issue in primary care. A 56-year-old man presented with non-traumatic chest pain and chronic neck pain for 2 years, as well as numbness in his right third and fourth fingers for 6 months. It was not associated with palpitation, orthopnea or pedal edema. Except for hyperglycemia, no abnormal findings were found in diagnostic tests. At that time, he was being treated for type 2 diabetes using glucose-lowering drugs in order to lower his blood glucose and lessen his risk of heart disease. The cause of his chest pain remained unknown. Following a second opinion from an orthopedist, the patient was diagnosed with cervical radiculopathy and was treated with analgesics and physical therapy. Because the treatments had only provided temporary pain relief for the previous 6 months, he sought chiropractic care for pain relief. The patient's vital signs were stable and within normal limits during the assessment. A restricted neck movement, a positive Spurling test, and hypoesthesia in the right C7 dermatome were seen. Cervical radiographs revealed degenerative spondylosis with right C5/C6 neuroforaminal stenoses and bilateral C6/C7 neuroforaminal stenoses. A provisional diagnosis of cervical spondylotic radiculopathy associated with cervicogenic angina (CA) was made. Chiropractic procedures, including cervical manipulation, instrumented soft tissue mobilization, and motorized intermittent neck traction, were performed two to three times per week. After 3 months, the patient reported that the chest pain, neck pain, and radicular symptoms had completely resolved. Repeated radiographs taken during the 11th month follow-up revealed a comparable improvement in the increased spacing of the restricted neuroforamina, which could signify a beneficial alteration related to cervical function retrieval. CA is an angina-like chest pain caused by cervical spine disorders. This study adds to our understanding of the biomechanical impact of cervical radiculopathy on chest pain, which has largely been overlooked during diagnostic workups. Once cervical radiculopathy has been identified, CA symptoms can be eased by alleviating the noxious input stemming from the pinched nerve roots.