Is the type and/or co-existence of degenerative spinal pathology associated with the occurrence of degenerative cervical myelopathy? A single centre retrospective analysis of individuals with MRI defined cervical cord compression

BACKGROUND

Degenerative cervical myelopathy (DCM) arises from spinal degenerative changes injuring the cervical spinal cord. Most cord compression is incidental, referred to as asymptomatic spinal cord compression (ASCC). How and why ASCC differs from DCM is poorly understood. In this paper, we study a local cohort to identify specific types and groups of degenerative pathology more likely associated with DCM than ASCC.

METHODS

This study was a retrospective cohort analysis (IRB Approval ID: PRN10455). The frequency of degenerative findings between those with ASCC and DCM patients were compared using network analysis, hierarchical clustering, and comparison to existing literature to identify potential subgroups in a local cohort (N = 155) with MRI-defined cervical spinal cord compression. Quantitative measures of spinal cord compression (MSCC and MCC) were used to confirm their relevance.

RESULTS

ELF (8.7 %, 95 % CI 3.8-13.6 % vs 35.7 %, 95 % CI 27.4-44.0 %) Congenital Stenosis (3.9 %, 95 % CI 0.6-7.3 % vs 25.0 %, 95 % CI 17.5-32.5 %), and OPLL (0.0 %, 95 % CI 0.0-0.0 % vs 3.6 %, 95 % CI 0.3-6.8 %) were more likely in patients with DCM. Comparative network analysis indicated loss of lordosis was associated with ASCC, whilst ELF with DCM. Hierarchical Cluster Analysis indicated four sub-groups: multi-level disc disease with ELF, single-level disc disease without loss of lordosis and OPLL with DCM, and single-level disc disease with loss of lordosis with ASCC. Quantitative measures of cord compression were higher in groups associated with DCM, but similar in patients with single-level disc disease and loss of lordosis.

CONCLUSIONS

This study identified four subgroups based on degenerative pathology requiring further investigation.

Toward Shared Decision-Making in Degenerative Cervical Myelopathy: Protocol for a Mixed Methods Study

BACKGROUND

Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this.

OBJECTIVE

The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes.

METHODS

Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders.

RESULTS

Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway.

CONCLUSIONS

This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46809.

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.

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.

The Pre-Operative Duration of Symptoms: The Most Important Predictor of Post-Operative Efficacy in Patients with Degenerative Cervical Myelopathy

Objective. To explore the most important predictors of post-operative efficacy in patients with degenerative cervical myelopathy (DCM). Methods. From January 2013 to January 2019, 284 patients with DCM were enrolled. They were categorized based on the different surgical methods used: single anterior cervical decompression and fusion (ACDF) (n = 80), double ACDF (n = 56), three ACDF (n = 13), anterior cervical corpectomy and fusion (ACCF) (n = 63), anterior cervical hybrid decompression and fusion (ACHDF) (n = 25), laminoplasty (n = 38) and laminectomy and fusion (n = 9). The follow-up time was 2 years. The patients were divided into two groups based on the mJOA recovery rate at the last follow-up: Group A (the excellent improvement group, mJOA recovery rate >50%, n = 213) and Group B (the poor improvement group, mJOA recovery rate ≤50%, n = 71). The evaluated data included age, gender, BMI, duration of symptoms (months), smoking, drinking, number of lesion segments, surgical methods, surgical time, blood loss, the Charlson Comorbidity Index (CCI), CCI classification, imaging parameters (CL, T1S, C2-7SVA, CL (F), T1S (F), C2-7SVA (F), CL (E), T1S (E), C2-7SVA (E), CL (ROM), T1S (ROM) and C2-7SVA (ROM)), maximum spinal cord compression (MSCC), maximum canal compromise (MCC), Transverse area (TA), Transverse area ratio (TAR), compression ratio (CR) and the Coefficient compression ratio (CCR). The visual analog score (VAS), neck disability index (NDI), modified Japanese Orthopedic Association (mJOA) and mJOA recovery rate were used to assess cervical spinal function and quality of life. Results. We found that there was no significant difference in the baseline data among the different surgical groups and that there were only significant differences in the number of lesion segments, C2−7SVA, T1S (F), T1S (ROM), TA, CR, surgical time and blood loss. Therefore, there was comparability of the post-operative recovery among the different surgical groups, and we found that there were significant differences in age, the duration of symptoms, CL and pre-mJOA between Group A and Group B. A binary logistic regression analysis showed that the duration of the symptoms was an independent risk factor for post-operative efficacy in patients with DCM. Meanwhile, when the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196). Conclusion. For patients with DCM (regardless of the number of lesion segments and the proposed surgical methods), the duration of symptoms was an independent risk factor for the post-operative efficacy. When the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196).

Comparative intra- and inter-observer reliability of two methods for evaluating intraoperative ultrasonography-based spinal cord hyperechogenicity intensity in degenerative cervical myelopathy

Objectives

During French-door laminoplasty, a linear array transducer of IOUS was used to observe and record the spinal cord decompression. To acquire a higher-reliability method, and compare the in-observer and inter-observer reliability of two methods in evaluating the hyperechoic intensity of spinal cord ultrasound in degenerative cervical myelopathy (DCM).

Background

The intensity of spinal cord hyperechogenicity is considered as a potential predictor of neurological recovery in DCM after decompression, but the accuracy of gray value ratio (GVR) is affected by many factors.

Methods

Totally 28 patients (20 males and 8 females) who had been followed up for 12 months were included. Their mean age at surgery was 61.2 ± 10.8 years and the average symptom duration was 23.36 ± 22.11 months. The gray values of circles 1, 2 and 3 were recorded as Gcompression, Gnorml and Gsac, respectively. Circle 1 was drawn with the maximum brightness point within the spinal cord as the center, circle 2 with the same area was plotted on the spinal cord with uniform echogenicity, without compression and at least 1 cm away from the circle 1, and circle 3 was drawn on the dorsal dural sac at the same segment as circle 1. GVR was calculated as follows: GVR-A = G_compression/G_norml (method A), and GVR-B = G_compression/G_sac (method B). The in-observer and inter-observer reliabilities of the two methods were compared. It is generally believed a reliability coefficient < 0.40 and > 0.75 indicate poor and good reliability respectively. The images-based GVR-B using this protocol demonstrates higher inter- and intraobserver reliabilities than GVR-A, and can be used as the basis for prognostic prediction and future studies.

Results

All examination acquisitions were successfully completed. GVR-A averaged 2.043 (0.318–5.56), and GVR-B averaged 0.578(0.06–1.41). GVR-B has better repeatability of gray value measurement, smaller relative standard deviation (RSD%) (0.298 vs. 0.32) and larger inter-group correlation coefficient compared with GVR-A. The mean value (MD) of the GVR difference calculated by GVR-B between the two clinicians was closer to 0.

Conclusions

For DCM patients routinely using ultrasound for real-time cord visualization during spinal cord decompression by French-door laminoplasty, the images-based GVR-B using this protocol demonstrates better inter- and intraobserver reliabilities compared with GVR-A.

Assessment of acute traumatic cervical spinal cord injury using conventional magnetic resonance imaging in combination with diffusion tensor imaging-tractography: a retrospective comparative study

PURPOSE

The application of conventional magnetic resonance imaging (MRI) in combination with diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) to diagnose acute traumatic cervical SCI has not been studied. This study explores the role of MRI with DTI-DTT in the diagnosis of acute traumatic cervical spinal cord injury (SCI).

METHODS

Thirty patients with acute traumatic cervical SCI underwent conventional MRI and DTI-DTT. Conventional MRI was used to detect the intramedullary lesion length (IMLL) and intramedullary hemorrhage length (IMHL). DTI was used to detect the spinal cord's fractional anisotropy (FA) and apparent diffusion coefficient value, and DTT detected the imaginary white matter fiber volume and the connection rates of fiber tractography (CRFT). Patients' neurological outcome was determined using the American Spinal Injury Association (ASIA) Impairment Scale (AIS) grades.

RESULTS

Patients were divided into group A (without AIS grade conversion) and group B (with AIS grade conversion). The IMLL and IMHL of group A were significantly higher than those of group B. The FA and CRFT of group A were significantly lower than those of group B. The final AIS grade was negatively correlated with the IMLL and IMHL, and positively correlated with the FA and CRFT. According to imaging features based on conventional MRI and DTI-DTT, we propose a novel classification and diagnostic procedure.

CONCLUSIONS

The combination of conventional MRI with DTI-DTT is a valid diagnostic approach for SCI. Lower IMLL and IMHL, and higher FA value and CRFT are linked to better neurological outcomes.

Improving Awareness Could Transform Outcomes in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 1]

STUDY DESIGN

Literature Review (Narrative).

OBJECTIVE

To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness.

METHODS

Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM.

RESULTS

DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness.

CONCLUSION

Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.

First neurological symptoms in degenerative cervical myelopathy: does it predict the outcome?

PURPOSE

Degenerative cervical myelopathy (DCM) is the most common non-traumatic cause of spinal cord dysfunction. Prediction of the neurological outcome after surgery is important. The aim of this study was to analyze the relationship between first symptoms of DCM and the neurological outcome after surgery.

METHODS

A retrospective analysis over a period of 10 years was performed. First symptoms such as cervicobrachial neuralgia, sensory and motor deficits and gait disturbances were evaluated regarding the postoperative neurological outcome. The modified Japanese Orthopedic Association Score (mJOA Score) was used to evaluate neurological outcome.

RESULTS

In total, 411 patients (263 males, 64%) with a median age of 62.6 ± 12.1 years were included. Cervicobrachial neuralgia was described in 40.2%, gait disturbance in 31.6%, sensory deficits in 19% and motor deficits in 9.2% as first symptom. Patients with cervicobrachial neuralgia were significantly younger (median age of 58 years, p = 0.0005) than patients with gait disturbances (median age of 68 years, p = 0.0005). Patients with gait disturbances and motor deficits as first symptom showed significantly lower mJOA Scores than other patients (p = 0.0005). Additionally, motor deficits and gait disturbance were negative predictors for postoperative outcome according to the mJOA Score.

CONCLUSION

Motor deficits and gait disturbances as the first symptom of DCM are negative predictors for postoperative neurological outcome. Nevertheless, patients with motor deficits and gait disturbance significantly profit from the surgical treatment despite poor preoperative mJOA Score.

The associations between radiological and neurological findings of degenerative cervical myelopathy: radiological analysis based on kinematic CT myelography and evoked potentials of the spinal cord

OBJECTIVE

Neurological and imaging findings play significant roles in the diagnosis of degenerative cervical myelopathy (DCM). Consistency between neurological and imaging findings is important for diagnosing DCM. The reasons why neurological findings exhibit varying sensitivity for DCM and their associations with radiological findings are unclear. This study aimed to identify associations between radiological parameters and neurological findings in DCM and elucidate the utility of concordance between imaging and neurological findings for diagnosing DCM.

METHODS

One hundred twenty-one patients with DCM were enrolled. The Japanese Orthopaedic Association (JOA) score, radiological parameters, MRI and kinematic CT myelography (CTM) parameters, and the affected spinal level (according to multimodal spinal cord evoked potential examinations) were assessed. Kinematic CTM was conducted with neutral positioning or at maximal extension or flexion of the cervical spine. The cross-sectional area (CSA) of the spinal cord, dynamic change in the CSA, C2-7 range of motion, and C2-7 angle were measured. The associations between radiological parameters and hyperreflexia, the Hoffmann reflex, the Babinski sign, and positional sense were analyzed via multiple logistic regression analysis.

RESULTS

In univariate analyses, the upper- and lower-limb JOA scores were found to be significantly associated with a positive Hoffmann reflex and a positive Babinski sign, respectively. In the multivariate analysis, a positive Hoffmann reflex was associated with a higher MRI grade (p = 0.026, OR 2.23) and a responsible level other than C6-7 (p = 0.0017, OR 0.061). A small CSA during flexion was found to be significantly associated with a positive Babinski sign (p = 0.021, OR 0.90). The presence of ossification of the posterior longitudinal ligament (p = 0.0045, OR 0.31) and a larger C2-7 angle during flexion (p = 0.01, OR 0.89) were significantly associated with abnormal great toe proprioception (GTP).

CONCLUSIONS

This study found that the Hoffmann reflex is associated with chronic and severe spinal cord compression but not the dynamic factors. The Babinski sign is associated with severe spinal cord compression during neck flexion. The GTP is associated with large cervical lordosis. These imaging features can help us understand the characteristics of the neurological findings.

Impact of various MRI signal intensity changes on radiological parameters, the neurological status, and surgical outcomes in degenerative cervical myelopathy

STUDY DESIGN

A retrospective study of prospectively collected date.

PURPOSE

The present study aimed to identify patient characteristics, radiological factors, the neurological status, and postoperative outcomes associated with MRI signal intensity changes in degenerative cervical myelopathy (DCM).

MATERIAL AND METHOD

One hundred and fourteen DCM patients who underwent posterior decompression surgeries were enrolled. Pre- and postoperative (12 months) Japanese Orthopedic Association (JOA) scores, cervical alignment and balance on X rays, the cross-sectional area of the spinal cord (CSA) in kinematic CT myelography (CTM). The recovery rate (RR) of the total JOA score and those specific for the upper and lower limb items were evaluated. MRI included T1-weighted imaging (WI) and T2WI. Patients were classified into two groups for a univariate analysis according to the presence or absence of a high signal intensity (HIS) in the sagittal view on T2WI, a low signal intensity (LSI) in the sagittal view on T1WI, the distribution of HSI at a single or multiple levels, and the presence or absence of the snake eye appearance. A multiple logistic regression analysis (MLRA) was performed to identify factors associated with signal intensity changes on MRI.

RESULTS

Ninety-six patients (84.3%) were classified into HIS changes in the sagittal view on T2WI. The group with multilevel HSI showed significantly lower RR specific for the lower extremity JOA score (30.8% vs 47.7%; P = 0.016). The snake eye-positive group showed a significantly inferior RR specific for the upper extremity JOA score (40.1% vs 53.2%; P = 0.04). In MLRA, LSI changes on T1WI revealed small CSAF (P = 0.02, Odds ratio; 0.77, 95%CI:0.61-0.97), while HSI changes on T2WI revealed a small CSAF (P = 0.008, Odds ratio;1.36, 95%CI:1.08-1.72) and large C2-7 angle during extension (P = 0.009, Odds ratio;0.73, 95%CI:0.58-0.92). CSAF correlated with multilevel HSI changes (P = 0.006, Odds ratio;0.78, 95%CI:0.66-0.93). The snake eye appearance correlated with CSAF (P = 0.006, Odds ratio;0.78, 95%CI:0.66-0.93) and the duration of disease (P = 0.05, Odds ratio;1.01, 95%CI:1.0-1.03).

CONCLUSION

Severe and poorly compensated spinal cord compression during neck flexion may cause signal intensity changes. The snake eye appearance may be useful as a sign of the inferior postoperative recovery of upper limb function, and multilevel HSI as a sign of the inferior postoperative recovery of lower limb function.

Evaluating the Severity and Prognosis of Acute Traumatic Cervical Spinal Cord Injury: A Novel Classification Using Diffusion Tensor Imaging and Diffusion Tensor Tractography

STUDY DESIGN

Retrospective observational cohort study.

OBJECTIVE

We explored the relationship between diffusion tensor imaging (DTI) parameters and prognosis in patients with acute traumatic cervical spinal cord injury (ATCSCI).

SUMMARY OF BACKGROUND DATA

DTI has been used to diagnose spinal cord injury; nevertheless, its role remains controversial.

METHODS

We analyzed retrospectively 24 patients with ATCSCI who were examined using conventional T2-weighted imaging and DTI. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were recorded at the injured site. Diffusion tensor tractography (DTT) was used to measure the spinal cord white matter fiber volume (MWFV). American Spinal Injury Association (ASIA) grades were recorded. Correlations between DTI parameters and ASIA scores were evaluated using Spearman correlation coefficients.

RESULTS

FA values at injured sites were significantly lower than those of the control group, whereas ADC values in injured and control groups were not significantly different. DTT revealed that ATCSCI could be divided into four types: Type A1-complete rupture of spinal cord white matter fiber (MWF); Type A2-partial rupture of MWF; Type B-most MWF retained with severe compression or abnormal fiber conduction direction; and Type C-MWF basically complete with slight compression. Preoperative physical examinations revealed complete injury (ASIA A) in patients with A1 (n = 4) and A2 (n = 4). The ASIA grades or scores of A2 were improved to varying degrees, whereas there was no significant improvement in A1. FA values and MWFV of ASIA B, C, and D were significantly higher than those of ASIA A. FA and MWFV were correlated with ASIA motor score preoperatively and at final follow-up.

CONCLUSION

We propose a classification for the severity of ATCSCI based on DTI and DTT that may explain why some patients with ASIA A recover, whereas others do not.Level of Evidence: 4.

Inadequate spinal cord expansion in intraoperative ultrasound after decompression may predict neurological recovery of degenerative cervical myelopathy

OBJECTIVE

To compare the neurological recovery between patients with adequate and inadequate immediate spinal cord expansion after sufficient decompression in degenerative cervical myelopathy (DCM).

METHODS

Twenty-seven patients subjected to French-door laminoplasty underwent the guidance of intraoperative ultrasound (IOUS) and were prospectively included. The modified Japanese Orthopedic Association (mJOA) score was evaluated before surgery and at 12 months postoperatively. The maximum spinal cord compression (MSCC) after sufficient decompression was calculated on the IOUS image; patients were divided into adequate (MSCC ≥ 0.95) and inadequate (MSCC < 0.95) expansion groups according to the MSCC. The mJOA score, spinal cord hyperechogenicity, age at surgery, symptom duration, occupational rate of the spinal canal, and the minimum anteroposterior diameter of the spinal cord between the two groups were compared.

RESULTS

Initially, 2 cases showed residual compression on IOUS; after further decompression, all patients acquired sufficient decompression. All patients achieved improvements in mJOA scores with an average recovery rate of 68.6 ± 20.3%. The recovery rate of the mJOA score of the inadequate expansion group was significantly inferior to that of the adequate expansion group (59.2 ± 21.7% versus 76.2 ± 16.2%, p = 0.028). The spinal cord hyperechogenicity was more common in the inadequate expansion group, while the spinal cord anteroposterior diameter of the inadequate expansion group was significantly smaller than that of the adequate expansion group.

CONCLUSIONS

The application of IOUS in French-door laminoplasty could help to confirm sufficient decompression for the treatment of DCM. Inadequate spinal cord expansion after sufficient decompression had the high possibility of predicting less satisfactory neurological recovery of DCM.

KEY POINTS

• The intraoperative ultrasound revealed that not all degenerative cervical myelopathy patients acquired adequate spinal cord expansion after sufficient decompression. • Patients who failed to acquire adequate spinal cord expansion commonly combined with spinal cord hyperechogenicity and trended to achieve less satisfactory neurological recovery after surgical decompression. • Inadequate spinal cord expansion after sufficient decompression had the high possibility of predicting less satisfactory neurological recovery of patients with degenerative cervical myelopathy.

Intensity of Intraoperative Spinal Cord Hyperechogenicity as a Novel Potential Predictive Indicator of Neurological Recovery for Degenerative Cervical Myelopathy

OBJECTIVE

To analyze the correlations between intraoperative ultrasound and MRI metrics of the spinal cord in degenerative cervical myelopathy and identify novel potential predictive ultrasonic indicators of neurological recovery for degenerative cervical myelopathy.

MATERIALS AND METHODS

Twenty-two patients who underwent French-door laminoplasty for multilevel degenerative cervical myelopathy were followed up for 12 months. The Japanese Orthopedic Association (JOA) scores were assessed preoperatively and 12 months postoperatively. Maximum spinal cord compression and compression rates were measured and calculated using both intraoperative ultrasound imaging and preoperative T2-weight (T2W) MRI. Signal change rates of the spinal cord on preoperative T2W MRI and gray value ratios of dorsal and ventral spinal cord hyperechogenicity on intraoperative ultrasound imaging were measured and calculated. Correlations between intraoperative ultrasound metrics, MRI metrics, and the recovery rate JOA scores were analyzed using Spearman correlation analysis.

RESULTS

The postoperative JOA scores improved significantly, with a mean recovery rate of 65.0 ± 20.3% (p < 0.001). No significant correlations were found between the operative ultrasound metrics and MRI metrics. The gray value ratios of the spinal cord hyperechogenicity was negatively correlated with the recovery rate of JOA scores (ρ = -0.638, p = 0.001), while the ventral and dorsal gray value ratios of spinal cord hyperechogenicity were negatively correlated with the recovery rate of JOA-motor scores (ρ = -0.582, p = 0.004) and JOA-sensory scores (ρ = -0.452, p = 0.035), respectively. The dorsal gray value ratio was significantly higher than the ventral gray value ratio (p < 0.001), while the recovery rate of JOA-motor scores was better than that of JOA-sensory scores at 12 months post-surgery (p = 0.028).

CONCLUSION

For degenerative cervical myelopathy, the correlations between intraoperative ultrasound and preoperative T2W MRI metrics were not significant. Gray value ratios of the spinal cord hyperechogenicity and dorsal and ventral spinal cord hyperechogenicity were significantly correlated with neurological recovery at 12 months postoperatively.

Cervical arteriosclerosis is associated with preoperative clinical symptoms in patients with cervical spondylotic myelopathy

PURPOSE

This study aims to clarify the association between cervical spondylotic myelopathy (CSM) and cervical arteriosclerosis using ultrasonography that comprehensively includes spinal cord stenosis.

METHODS

Eighty-two consecutive patients aged over 60 years who underwent spine surgery were divided into those with CSM (n = 31; CSM group) and those with lumbar spinal stenosis without cervical myelopathy (n = 51; LSS group). Maximum spinal cord compression (MSCC) was evaluated for cervical stenosis severity using magnetic resonance (MR) images. The intima-media thickness (IMT) of the common carotid artery (CCA) and pulsatility index (PI) of the bilateral internal carotid artery (ICA) and vertebral artery (VA) were evaluated for cervical arteriosclerosis using pulsed-wave Doppler ultrasonography. Symptom severity was evaluated using the Japanese Orthopaedic Association (JOA) score. Spearman's correlation coefficient was used to determine the relationship between the JOA score and MSCC or IMT and PI in each group. Stepwise multiple linear regression analyses were conducted with the JOA score as a dependent variable and age, sex, body mass index, cervical arteriosclerosis assessment, and MSCC as independent variables.

RESULTS

Bilateral IMT and left-side ICA-PI were significantly negatively correlated with JOA scores in the CSM group (Right-CCA-IMT: R =  - 0.412, Left-IMT: R =  - 0.549, Left-ICA -PI: R =  - 0.205, P < 0.05), but not in the LSS group. Multiple linear regression analyses showed that CCA-IMT was the strongest independent factor associated with the preoperative JOA score.

CONCLUSIONS

Cervical arteriosclerosis was associated with preoperative clinical symptoms in CSM patients.

Study protocol for an observational study of cerebrospinal fluid pressure in patients with degenerative cervical myelopathy undergoing surgical deCOMPression of the spinal CORD: the COMP-CORD study

INTRODUCTION

Degenerative cervical myelopathy (DCM) is a disabling spinal disorder characterised by sensorimotor deficits of upper and lower limbs, neurogenic bladder dysfunction and neuropathic pain. When suspected, cervical MRI helps to reveal spinal cord compression and rules out alternative diagnoses. However, the correlation between radiological findings and symptoms is weak. Cerebrospinal fluid pressure (CSFP) analysis may complement the appreciation of cord compression and be used for intraoperative and postoperative monitorings in patients undergoing surgical decompression.

METHODS AND ANALYSIS

Twenty patients diagnosed with DCM undergoing surgical decompression will receive standardised lumbar CSFP monitoring immediately before, during and 24 hours after operation. Rest (ie, opening pressure, CSF pulsation) and stimulated (ie, Valsalva, Queckenstedt's) CSFP-findings in DCM will be compared with 20 controls and results from CSFP monitoring will be related to clinical and neurophysiological findings. Arterial blood pressure will be recorded perioperatively and postoperatively to calculate spinal cord perfusion pressure and spinal vascular reactivity index. Furthermore, measures of CSFP will be compared with markers of spinal cord compression by means of MR imaging.

ETHICS AND DISSEMINATION

The study protocol conformed to the latest revision of the Declaration of Helsinki and was approved by the local Ethics Committee of the University Hospital of Zurich (KEK-ZH number PB-2016-00623). The main publications from this study will cover the CSFP fluid dynamics and pressure analysis preoperative, perioperative and postoperative correlated with imaging, clinical scores and neurophysiology. Other publications will deal with preoperative and postoperative spinal perfusion. Furthermore, we will disseminate an analysis on waveform morphology and the correlation with blood pressure and ECG. Parts of the data will be used for computational modelling of cervical stenosis.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02170155).

Short-term predictive potential of quantitative assessment of spinal cord impairment in patients undergoing French-door Laminoplasty for degenerative cervical myelopathy: preliminary results of an exploratory study exploiting intraoperative ultrasound data

BACKGROUND

To study the correlation of neurological function in degenerative cervical myelopathy (DCM) patients with quantitative assessment of spinal cord compression and impairment by intraoperative ultrasound imaging (IOUSI).

METHODS

Twenty-three patients who underwent French-Door laminoplasty for multilevel DCM were followed for 6 months. Modified Japanese Orthopaedic Association (mJOA) score and cervical MRI were assessed before surgery and at postoperative 6 months. IOUS, used to guide decompression, were recorded. The anteroposterior diameter (APD) and the gray values of the IOUSI hyperechogenicity of the midsagittal IOUSI at the narrowest level and at the lesion-free level, and the APD and traverse diameter at the traverse maximum compression level of IOUSI were measured. Maximum spinal cord compression (MSCC), compression rate (CR), and IOUSI gray value ratio (R_gray) were calculated. The appearance of preoperative T2W MRI increased signal intensity (ISI), and the signal change rate (SCR) on postoperative T2W MRI of 9 patients were also measured and calculated, and compared with that of IOUSI hyperechogenicity.

RESULTS

Average mJOA score increased significantly from 11.57 ± 2.67 before surgery to 15.39 ± 1.50 at 6 months after surgery, with an average recovery rate (RR) of 71.11 ± 22.81%. The difference between the appearance of preoperative T2W MRI ISI and IOUSI hyperechogenicity was not significant. Spearman correlation analysis found that the IOUSI R_gray were negatively correlated with the RR of mJOA score with a coefficient of - 0.77, and the IOUSI R_gray was not correlated with the postoperative MRI SCR.

CONCLUSIONS

In DCM patients, the gray values of IOUSI can be measured accurately. The IOUSI R_gray correlated with postoperative neurological recovery significantly.

Ten-Year Surgical Outcomes and Prognostic Factors for French-Door Laminoplasty in the Treatment of Multilevel Cervical Spondylotic Myelopathy

Objective

To analyze the ten-year surgical outcomes and postoperative complications of French-Door laminoplasty (FDL) in the management of multilevel cervical spondylotic myelopathy (MCSM) and analyze the prognostic factors for FDL in treating MCSM.

Methods

64 patients with MCSM, who were operated by FDL, were included in this study and followed up for at least 10 years. Clinical assessments including modified Japanese Orthopaedic Association (mJOA) score, age at surgery, preoperative symptom duration, operative time, blood loss and postoperative complications, radiological assessments including Cobb angle, cervical range of motion (ROM), intramedullary signal intensity on T2W MRI, canal narrowing ratio (CNR), and maximum spinal cord compression (MSCC). mJOA score, Cobb angle, cervical ROM, intramedullary signal intensity on T2W MRI, and CNR were assessed before surgery and at the final follow-up.

Results

The average mJOA score was significantly improved from preoperative 10.32 ± 1.63 points to 15.10 ± 0.62 points at the final follow-up (p < 0.05). The average RR of the mJOA score at the final follow-up was 69.10 ± 7.32%. The cervical Cobb angle and ROM decreased significantly at the final follow-up. Patients with high intramedullary signal intensity of T2W MRI or CNR more than 50% showed a lower RR of the mJOA score. Correlation analysis revealed that preoperative symptom duration and intramedullary signal intensity of T2W MRI, CNR, MSCC, and blood loss were significantly correlated with the RR of the mJOA score. Gender, operative method, and age at surgery were significantly correlated with the preservation rate of ROM. Operative time was significantly correlated with the incidence of axial symptoms.

Conclusions

The ten-year clinical outcomes of FDL were satisfactory. Higher intramedullary signal intensity of T2W MRI and a greater CNR predicted poorer prognoses.

The Relationship Between Gastrointestinal Comorbidities, Clinical Presentation and Surgical Outcome in Patients with DCM: Analysis of a Global Cohort

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord impairment in adults, presenting most frequently in patients 50 years or older. Gastrointestinal comorbidities (GICs) commonly occur in this group; however, their relationship with DCM has not been thoroughly investigated. It is the objective of the present study to investigate the difference between patients with or without GICs who are surgically treated for DCM. A cohort of 757 patients with clinical data and 458 with magnetic resonance imaging (MRI) data from the AOSpine North America and AOSpine International studies on DCM was evaluated. GICs were obtained at presentation and included gastric, intestinal, hepatic, and pancreatic conditions. Patients were dichotomized into 2 groups: those with GICs and those without GICs. Both clinical and MRI presentation, as well as baseline neurological and functional status, were compared. Neurological and functional outcomes at 2-year follow-up were also compared. GICs were present in 121 patients (16%). These patients were less commonly male (48.76% vs. 65.4%, p = 0.001) and were slightly less neurologically impaired based on the Nurick grade (3.05 ± 1.10 vs. 3.28 ± 1.16, p = 0.044) but not based on mJOA (12.74 ± 2.62 vs. 12.48 ± 2.76, p = 0.33). They also had a worse physical health score (32.80 ± 8.79 vs. 34.65 ± 9.38 p = 0.049), worse neck disability (46.31 ± 20.04 vs. 38.23 ± 20.44, p < 0.001), a lower prevalence of upper motor neuron signs (hyperreflexia, 70.2% vs. 78.9%, p = 0.037; Babinski’s sign 24.8% vs. 37.3%, p = 0.008), and a higher rate of psychiatric comorbidities (31.4% vs. 10.4%, p < 0.0001). On MRI, GIC patients less commonly exhibited signal intensity changes (T2 hyperintensity, 49.2% vs. 75.6%, p < 0.001; T1 hypointensity, 9.7% vs. 21.1%, p = 0.036), and had a lower number of T2 hyperintensity levels (0.82 ± 0.98 vs. 1.3 ± 1.11, p = 0.001). There was no difference in surgical outcome between the groups. DCM patients with GICs are more likely to be female and have significantly more general health impairment and neck disability. However, these patients have less clinical and MRI features typical of more severe neurological impairment. This constellation of symptoms is considerably different than those typically observed in DCM, and it is therefore plausible that nutritional factors may contribute to this unique observation.

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.

Recovery priorities in degenerative cervical myelopathy: a cross-sectional survey of an international, online community of patients

OBJECTIVES

To establish the recovery priorities of individuals suffering with degenerative cervical myelopathy (DCM).

DESIGN

A cross-sectional, observational study.

SETTING

Patients from across the world with a diagnosis of DCM accessed the survey over an 18-month period on Myelopathy.org, an international myelopathy charity.

PARTICIPANTS

481 individuals suffering from DCM completed the online survey fully.

MAIN OUTCOME MEASURES

Functional recovery domains were established through qualitative interviews and a consensus process. Individuals were asked about their disease characteristics, including limb pain (Visual Analogue Scale) and functional disability (patient-derived version of the modified Japanese Orthopaedic Association score). Individuals ranked recovery domains (arm and hand function, walking, upper body/trunk function, sexual function, elimination of pain, sensation and bladder/bowel function) in order of priority. Priorities were analysed as the modal first priority and mean ranking. The influence of demographics on selection was analysed, with significance p<0.05.

RESULTS

Of 659 survey responses obtained, 481 were complete. Overall, pain was the most popular recovery priority (39.9%) of respondents, followed by walking (20.2%), sensation (11.9%) and arm and hand function (11.5%). Sexual function (5.7%), bladder and bowel (3.7%) and trunk function (3.5%) were chosen less frequently. When considering the average ranking of symptoms, while pain remained the priority (2.6±2.0), this was closely followed by walking (2.9±1.7) and arm/hand function (3.0±1.4). Sensation ranked lower (4.3±2.1). With respect to disease characteristics, overall pain remained the recovery priority, with the exception of patients with greater walking impairment (p<0.005) who prioritised walking, even among patients with lower pain scores.

CONCLUSIONS

This is the first study investigating patient priorities in DCM. The patient priorities reported provide an important framework for future research and will help to ensure that it is aligned with patient needs.

What Has Been Learned from Magnetic Resonance Imaging Examination of the Injured Human Spinal Cord: A Canadian Perspective

Magnetic resonance imaging (MRI) has transformed the way surgeons and researchers study and treat spinal cord injury. In this narrative review, we explore the historical context of imaging the human spinal cord and describe how MRI has evolved from providing the first visualization of the human spinal cord in the 1980s to a remarkable set of imaging tools today. The article focuses in particular on the role of Canadian researchers to this field. We begin by outlining the clinical context of traumatic injury to the human spinal cord and describe why current MRI standards fall short when it comes to treating this disabling condition. Parts 2 and 3 of this work explore an exciting and dramatic shift in the use of MRI technology to aid in our understanding and treatment of traumatic injury to the spinal cord. We explore the use of functional imaging (part 2) and structural imaging (part 3) and explore how these techniques have evolved, how they are used, and the challenges that we face for continued refinement and application to patients who live with the neurological and functional deficits caused by injury to the delicate spinal cord.

Cervical Spondylotic Myelopathy: Natural Course and the Value of Diagnostic Techniques -WFNS Spine Committee Recommendations

Objective

This study presents the results of a systematic literature review conducted to determine most up-to-date information on the natural outcome of cervical spondylotic myelopathy (CSM) and the most reliable diagnostic techniques.

Methods

A literature search was performed for articles published during the last 10 years.

Results

The natural course of patients with cervical stenosis and signs of myelopathy is quite variable. In patients with no symptoms, but significant stenosis, the risk of developing myelopathy with cervical stenosis is approximately 3% per year. Myelopathic signs are useful for the clinical diagnosis of CSM. However, they are not highly sensitive and may be absent in approximately one-fifth of patients with myelopathy. The electrophysiological tests to be used in CSM patients are motor evoked potential (MEP), spinal cord evoked potential, somatosensory evoked potential, and electromyography (EMG). The differential diagnosis of CSM from other neurological conditions can be accomplished by those tests. MEP and EMG monitoring are useful to reduce C5 root palsy during CSM surgery. Notable spinal cord T2 hyperintensity on cervical magnetic resonance imaging (MRI) is correlated with a worse outcome, whereas lighter signal changes may predict better outcomes. T1 hypointensity should be considered a sign of more advanced disease.

Conclusion

The natural course of CSM is quite variable. Signal changes on MRI and some electrophysiological tests are valuable adjuncts to diagnosis.

Recent advances in the management of cervical spondylotic myelopathy: bibliometric analysis and surgical perspectives

OBJECTIVE

Cervical spondylotic myelopathy (CSM) has become a prevalent cause of spinal cord dysfunction among the aging population worldwide. Although great strides have been made in spine surgery in past decades, the optimal timing and surgical strategy to treat CSM have remained controversial. In this article the authors aimed to analyze the current trends in studies of CSM and to summarize the recent advances of surgical techniques in its treatment.

METHODS

The PubMed database was searched using the keywords pertaining to CSM in human studies that were published between 1975 and 2018. Analyses of both the bibliometrics and contents, including the types of papers, authors, affiliations and countries, number of patients, and the surgical approaches were conducted. A systematic review of the literature was also performed with emphasis on the diagnosis and treatment of mild CSM.

RESULTS

A total of 1008 papers published during the span of 44 years were analyzed. These CSM studies mainly focused on the natural history, diagnosis, and treatment, and only a few prospective randomized trials were reported. For the authors and affiliations, there was a shift of clustering of papers toward Asian countries in the past decades. Regarding the treatment for CSM, there was an exponential growth of surgical series published, and there was a trend toward slightly more anterior than posterior approaches through the past decade. Patients with CSM had increased risks of neurological deterioration or spinal cord injury with nonoperative management. Because surgery might reduce the risks, and early surgery was likely to be correlated with better outcomes, there was a trend toward attention to mildly symptomatic CSM.

CONCLUSIONS

There is emerging enthusiasm for research on CSM worldwide, with more publications originating in Asian countries over the past few decades. The surgical management of CSM is evolving continuously toward early and anterior approaches. More prospective investigations on the optimal timing and choices of surgery are therefore needed.

The relationship between preoperative factors and the presence of intramedullary increased signal intensity on T2-weighted magnetic resonance imaging in patients with cervical spondylotic myelopathy

OBJECTIVE

To investigate preoperative factors affecting the presence of intramedullary increased signal intensity (ISI) on T2-weighted magnetic resonance imaging (MRI) in patients with cervical spondylotic myelopathy (CSM) and the impact of ISI on clinical manifestations.

PATIENTS AND METHODS

Eighty-nine patients with CSM were retrospectively reviewed from January 2013 to December 2016 in our hospital. Based on the presence or absence of ISI on axial and sagittal T2-weighted MRI, patients were divided into ISI group (48 cases) and non-ISI group (41 cases). Factors such as age, sex, body mass index (BMI), duration of symptoms, clinical symptoms and signs, number and distribution of spinal cord compression levels, preoperative Japanese Orthopedic Association (JOA) score, preoperative C2-C7 lordotic angle, preoperative C2-C7 range of motion (ROM), maximal canal compromise (MCC) and maximal spinal cord compression (MSCC) were initially compared using univariate analysis. Factors with significant result in univariate analysis were included in multivariate logistic regression analysis. Receiver operating characteristic (ROC) curve and the area under the curve (AUC) were applied to evaluate the reliability of multivariate logistic regression model.

RESULTS

Univariate analysis showed that the number of spinal cord compression levels, preoperative JOA score, MCC and MSCC might be related to the presence of ISI (P <  0.05). Furthermore, multivariate logistic regression analysis revealed that the number of spinal cord compression levels (OR = 0.203, P <  0.05), preoperative JOA score (OR = 4.274, P <  0.05) and MSCC (OR = 0.250, P <  0.05) were independent preoperative risk factors associated with the presence of ISI, yielding an AUC of 0.9558. Patients with ISI showed a trend of increasing clinical symptoms and signs, and also exhibited statistically significantly increased frequencies of clumsy hands, lower limb spasticity, impairment of gait, broad-based, unstable gait, weakness and motor deficits (P <  0.05).

CONCLUSION

Multilevel spinal cord compression, lower preoperative JOA score and greater MSCC are independent preoperative risk factors related to the presence of ISI on T2-weighted MRI in patients with CSM. Patients with ISI tend to have more clinical symptoms and signs, especially in lower limb manifestations and motor deficits.

The Relation between Cord Signal and Clinical Outcome after Anterior Cervical Discectomy in Patients with Degenerative Cervical Disc Herniation

Introduction

Cervical spondylotic myelopathy is a cervical cord compressive lesion that occurs as a result of the normal degenerative process which may cause magnetic resonance imaging (MRI) cord intensity changes that may worsen the clinical outcome even after successful anterior cervical decompression.

Objective

To assess the relation between MRI T2 Weighted images (T2 WI) hyperintense cord signal and clinical outcome after anterior cervical discectomy in patients with degenerative cervical disc herniation.

Materials and Methods

This is a retrospective observational study that was conducted on twenty-five patients with degenerative cervical disc prolapse associated with MRI T2WI hyperintense cord signal, at the Department of Neurosurgery, Qena University Hospital, South Valley University from August 2014 to December 2016. A complete clinical and radiological evaluation of the patients was done. Anterior cervical discectomy and fusion was done for all patients. Patients were clinically assessed preoperatively and postoperatively at 3, 6, and 12 months using Modified Japanese Orthopedic Association (MJOA) score. Radiographic assessment was done by preoperative and postoperative T2WI MRI. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software (version 22.0).

Results

There were 25 patients included in the study; 16 (64%) females and 9 (36%) males. The mean age was 46.89 ± 7.52 standard deviation (SD) years with range from 26 to 64 years, 3 (12%) patients had worsened in the form of postoperative motor power deterioration, and 14 (56%) patients has no improvement and remain as preoperative condition. The remaining 8 (32%) patients had a reported postoperative improvement of symptoms and signs according to MJOA score. The mean follow-up period (in months) was 11 ± 2.34 (SD).

Conclusion

The presence of T2W hyperintense signal on preoperative MRI predicts a poor surgical outcome in patients with cervical disc prolapse. The regression of T2W ISI postoperatively correlates with better functional outcomes.

Value of conventional MRI and diffusion tensor imaging parameters in predicting surgical outcome in patients with degenerative cervical myelopathy

BACKGROUND

In addition to conventional magnetic resonance imaging (cMRI), diffusion tensor imaging (DTI) has been investigated as a potential diagnostic and prognostic tool for patients with degenerative cervical myelopathy (DCM).

OBJECTIVE

To assess the efficacy of cMRI and DTI parameters in prediction of surgical outcome in DCM patients.

METHODS

One hundred and forty-two patients with DCM who underwent presurgical cMRI and DTI of the cervical spine were included. Quantitative parameters obtained by cMRI included compression ratio (CR), transverse area (TA), and signal intensity ratio (SIR). DTI was evaluated for apparent diffusion coefficient (ADC) and fractional anisotropy (FA). The Japanese Orthopaedic Association (JOA) score and recovery rate were used to evaluate clinical outcomes. A JOA recovery rate < 50% was defined as a poor surgical outcome. The relationship of surgical outcome with various imaging parameters was examined. Receiver operating characteristic (ROC) curves were used to measure the predictive ability and determine the best cut-off values of the quantitative parameters.

RESULTS

By ROC curve analyses of imaging parameters, the largest area under the ROC curve (AUC) was for FA (0.750), followed by ADC (0.719), TA (0.716), SIR (0.673), and CR (0.591). The cut-off values with the best compromise between sensitivity and specificity were set at 0.390 for FA, 1.344 × 10-3 mm2/s for ADC, 46.02 mm2 for TA, 1.556 for SIR, and 26.56% for CR. Multivariate logistic regression model revealed that JOA score ⩽ 8 points, TA ⩽ 46.02 mm2, and FA ⩽ 0.390 were independently associated with poor surgical outcome. The AUC value for the three-predictor model was 0.871, indicating strong predictive discrimination, and was significantly higher than the AUC value for the model containing only the JOA score (0.763; P= 0.003).

CONCLUSIONS

JOA score is a reasonable predictor of surgical outcome in DCM. However, a model inclusive of TA and FA provides superior predictive ability. Thus, quantitative analysis of cMRI and DTI is useful for predicting surgical outcome in DCM.

Comparison of the Prognostic Value of Different Quantitative Measurements of Increased Signal Intensity on T2-Weighted MRI in Cervical Spondylotic Myelopathy

OBJECTIVE

To investigate whether different quantitative measurements of increased signal intensity (ISI) on T2-weighted magnetic resonance imaging are useful for predicting surgical outcome in patients with cervical spondylotic myelopathy (CSM).

METHODS

We retrospectively reviewed 108 patients with ISI who underwent surgery for CSM. Clinical outcome was evaluated via the Japanese Orthopaedic Association (JOA) score and the recovery rate. Patients were divided into 2 groups based on the JOA recovery rate: good (≥50%) and fair (<50%). The quantitative measurements of ISI included the maximum vertical length and the signal change ratio (SCR). C2-C7 sagittal alignment, C2-C7 sagittal vertical axis, C2-C7 range of motion, maximum spinal cord compression, and maximum canal compromise also were assessed.

RESULTS

There were no significant differences in cervical sagittal alignment parameters between the groups. Multivariate analysis showed that a longer duration of symptoms, a lower preoperative JOA score, a longer preoperative ISI length, and a greater preoperative SCR were negatively associated with clinical outcomes. Receiver operating characteristic curve analysis showed that the best cutoff values of ISI length and SCR as negative predictors of surgical outcome were 15.50 mm and 1.56, respectively, and the areas under the receiver operating characteristic curve of preoperative ISI length, SCR that discriminate recovery rate of JOA score (≥50%, <50%) were 0.8507, 0.8422, respectively, and was 0.8903 for a combination of the 2.

CONCLUSIONS

Duration of symptoms, preoperative JOA score, preoperative ISI length, and SCR can reflect surgical outcome in patients with CSM; however, cervical sagittal alignment may not affect surgical outcome. Combining ISI length and SCR to depict ISI on T2-weighted magnetic resonance imaging is optimal and accurate. Patients with ISI length >15.50 mm and SCR >1.56 have fair surgical recovery.

Postoperative Resolution of Magnetic Resonance Imaging Signal Intensity Changes and the Associated Impact on Outcomes in Degenerative Cervical Myelopathy: Analysis of a Global Cohort of Patients

STUDY DESIGN

Subanalysis of the prospective AOSpine CSM North America and International studies.

OBJECTIVE

To describe the postoperative changes in magnetic resonance imaging (MRI) spinal cord signal intensity in degenerative cervical myelopathy (DCM) patients and to investigate the impact of its postoperative resolution on clinical outcomes.

SUMMARY OF BACKGROUND DATA

When examining the spinal cord, hyperintensity found in MRI T2-weighted images and hypointensity in T1-weighted images are known to correlate with preoperative severity of DCM and to predict postoperative neurological recovery. However, the clinical importance of these signal intensity changes in postoperative images has not been established.

METHODS

Among 757 surgical DCM patients enrolled in two prospective multicenter studies, postoperative MRI images obtained between 6 and 24 months after the operation were examined with a focus on T2 hyper- and T1 hypointensity in the spinal cord. The 2-year postoperative Nurick grade, modified Japanese Orthopaedic Association score and modified Japanese Orthopaedic Association recovery rate (RR) were analyzed between patients with or without resolution of signal intensity changes.

RESULTS

A total of 167 patients with preoperative T2 hyperintensity were included with complete postoperative MRI images. Of these patients, 11% showed resolution of signal intensity changes, 70% retained T2 hyperintensity only, and 19% showed both T2 hyper- and T1 hypointensity postoperatively. There was a stepwise trend toward worse postoperative outcomes, with the no signal intensity change group showing the best outcome and the T1 hypointensity group showing the worst (mean RR: 72% vs. 51% vs. 36%, P = 0.02). Patients who exhibited resolution of T2 hyperintensity showed better outcomes than those who retained it (RR: 72% vs. 47%, P = 0.04), but the resolution of T1 hypointensity was not associated with improved outcomes (RR: 38% vs. 26%, P = 0.36).

CONCLUSION

Postoperative resolution of T2 hyperintensity in patients with DCM was associated with the best clinical outcomes, whereas those with T1 hypointensity showed the worst.

LEVEL OF EVIDENCE

3.

High field structural MRI in the management of degenerative cervical myelopathy

Introduction: This is a narrative overview of the pathophysiology, investigation and management of Degenerative Cervical Myelopathy (DCM). This review article also takes a look ahead to the impact high resolution MRI may have on treatment.Background: DCM is the most common cause of spinal dysfunction and yet it remains poorly understood. It is becoming increasingly common in our ageing population. Disc and facet joint abnormalities, osteophytes, spondylothisthesis and ligamentous hypertrophy all act together to produce spinal canal and neuronal foramina stenosis which in turn causes neural compromise. Its impact on the quality of life of this patient group and the wider economy is vast. Some patients with overt cord compression and MRI signal change in their cervical cord may only have subtle clinical signs whilst others with less striking imaging may be profoundly myelopathic. Who to operate on and when remains a neurosurgical dilemma in this group of patients.Methods: A number of articles with a broad variation in methodology were reviewed and referenced during the production of this paper.Results: This paper is a narrative review. The results presented in all the referenced articles were considered.Conclusion: The process of developing new imaging techniques will give a greater understanding of the causes of the symptoms of DCM and in a wider context facilitate further surgical and medical strategies that are more cost effective and beneficial to patients. The advent of 7T MRI or further optimisation of safer 3T MRI sequences may soon provide this opportunity and the diagnostic gap in spinal cord imaging can begin to close.

The Relationship Between MRI Signal Intensity Changes, Clinical Presentation, and Surgical Outcome in Degenerative Cervical Myelopathy: Analysis of a Global Cohort

STUDY DESIGN

Retrospective analysis of prospective data.

OBJECTIVE

To assess the relationship between MRI signal intensity changes, clinical presentation, and surgical outcome in degenerative cervical myelopathy (DCM).

SUMMARY OF BACKGROUND DATA

Several studies have sought to assess the extent of spinal cord dysfunction and the potential for postoperative neurological recovery through the evaluation of spinal cord signal change on T2-weighted (T2WI) and T1-weighted images (T1WI). There remains ambiguity if T2WI and T1WI signal changes (1) relate to baseline severity, and (2) predict neurological recovery after surgical treatment.

METHODS

Four hundred nineteen MRIs from two prospective multicenter studies were examined. Images were assessed for the presence, levels, and location of spinal cord signal intensity changes and compared with clinical data. Signal changes were also evaluated for the prediction of 2-year postoperative outcome using mJOA parameters.

RESULTS

MRIs were categorized by T1WI and T2WI signal change: no signal change (28.9%), T2WI hyperintensity-only (T2WI-only, 51.8%), and T2WI-hyperintensity and T1WI-hypointensity (T1WI+T2WI, 19.3%). T2WI-hyperintensity was present at multiple levels in 27% of patients overall. Baseline severity increased from no signal change to T2WI-only to T2WI+T1WI (P < 0.0001), and there was an incremental increase in the frequency of signs/symptoms. There were no differences in outcomes between no signal change and T2WI-only groups. The presence of T1WI-hypointensity correlated with reduced recovery ratio (P = 0.03) and likelihood of an optimal surgical outcome (P = 0.005), adjusting for baseline mJOA. A greater number of T2WI-hyperintensity levels was also associated with worse baseline severity (P < 0.0001) and recovery ratio (P = 0.001).

CONCLUSION

This analysis of a global cohort of DCM patients shows a stepwise trend toward increasing impairment from no signal change to T2WI-hypertensity to T1WI-hypointensity. T1WI signal change indicates more permanent injury, portending decreased functional recovery. T2WI-hyperintensity alone does not predict outcomes. Multiple levels of T2WI-hyperintensity suggest additional tissue injury, correlating with worse clinical impairment and recovery potential.

LEVEL OF EVIDENCE

2.