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Ishaque AH, Alvi MA, Pedro K, Fehlings MG. Imaging protocols for non-traumatic spinal cord injury: current state of the art and future directions. Expert Rev Neurother 2024; 24:691-709. [PMID: 38879824 DOI: 10.1080/14737175.2024.2363839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 05/31/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Non-traumatic spinal cord injury (NTSCI) is a term used to describe damage to the spinal cord from sources other than trauma. Neuroimaging techniques such as computerized tomography (CT) and magnetic resonance imaging (MRI) have improved our ability to diagnose and manage NTSCIs. Several practice guidelines utilize MRI in the diagnostic evaluation of traumatic and non-traumatic SCI to direct surgical intervention. AREAS COVERED The authors review practices surrounding the imaging of various causes of NTSCI as well as recent advances and future directions for the use of novel imaging modalities in this realm. The authors also present discussions around the use of simple radiographs and advanced MRI modalities in clinical settings, and briefly highlight areas of active research that seek to advance our understanding and improve patient care. EXPERT OPINION Although several obstacles must be overcome, it appears highly likely that novel quantitative imaging features and advancements in artificial intelligence (AI) as well as machine learning (ML) will revolutionize degenerative cervical myelopathy (DCM) care by providing earlier diagnosis, accurate localization, monitoring for deterioration and neurological recovery, outcome prediction, and standardized practice. Some intriguing findings in these areas have been published, including the identification of possible serum and cerebrospinal fluid biomarkers, which are currently in the early phases of translation.
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Affiliation(s)
- Abdullah H Ishaque
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Karlo Pedro
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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Pfender N, Jutzeler CR, Hubli M, Scheuren PS, Pfyffer D, Zipser CM, Rosner J, Friedl S, Sutter R, Spirig JM, Betz M, Schubert M, Seif M, Freund P, Farshad M, Curt A, Hupp M. Potential thresholds of critically increased cardiac-related spinal cord motion in degenerative cervical myelopathy. Front Neurol 2024; 15:1411182. [PMID: 38978814 PMCID: PMC11228334 DOI: 10.3389/fneur.2024.1411182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024] Open
Abstract
Introduction New diagnostic techniques are a substantial research focus in degenerative cervical myelopathy (DCM). This cross-sectional study determined the significance of cardiac-related spinal cord motion and the extent of spinal stenosis as indicators of mechanical strain on the cord. Methods Eighty-four DCM patients underwent MRI/clinical assessments and were classified as MRI+ [T2-weighted (T2w) hyperintense lesion in MRI] or MRI- (no T2w-hyperintense lesion). Cord motion (displacement assessed by phase-contrast MRI) and spinal stenosis [adapted spinal canal occupation ratio (aSCOR)] were related to neurological (sensory/motor) and neurophysiological readouts [contact heat evoked potentials (CHEPs)] by receiver operating characteristic (ROC) analysis. Results MRI+ patients (N = 31; 36.9%) were more impaired compared to MRI- patients (N = 53; 63.1%) based on the modified Japanese Orthopedic Association (mJOA) subscores for upper {MRI+ [median (Interquartile range)]: 4 (4-5); MRI-: 5 (5-5); p < 0.01} and lower extremity [MRI+: 6 (6-7); MRI-: 7 (6-7); p = 0.03] motor dysfunction and the monofilament score [MRI+: 21 (18-23); MRI-: 24 (22-24); p < 0.01]. Both patient groups showed similar extent of cord motion and stenosis. Only in the MRI- group displacement identified patients with pathologic assessments [trunk/lower extremity pin prick score (T/LEPP): AUC = 0.67, p = 0.03; CHEPs: AUC = 0.73, p = 0.01]. Cord motion thresholds: T/LEPP: 1.67 mm (sensitivity 84.6%, specificity 52.5%); CHEPs: 1.96 mm (sensitivity 83.3%, specificity 65.6%). The aSCOR failed to show any relation to the clinical assessments. Discussion These findings affirm cord motion measurements as a promising additional biomarker to improve the clinical workup and to enable timely surgical treatment particularly in MRI- DCM patients. Clinical trial registration www.clinicaltrials.gov, NCT02170155.
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Affiliation(s)
- Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | | | - Michèle Hubli
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Paulina S Scheuren
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Dario Pfyffer
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- School of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA, United States
| | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jan Rosner
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurology, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Susanne Friedl
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - José M Spirig
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Michael Betz
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Maryam Seif
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Mazda Farshad
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- University Spine Center Zurich, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Markus Hupp
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Thompson K, Travers H, Ngan A, Reed T, Shahsavarani S, Verma RB. Updates in current concepts in degenerative cervical myelopathy: a systematic review. JOURNAL OF SPINE SURGERY (HONG KONG) 2024; 10:313-326. [PMID: 38974484 PMCID: PMC11224794 DOI: 10.21037/jss-23-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/20/2024] [Indexed: 07/09/2024]
Abstract
Background The incidence of degenerative cervical myelopathy (DCM) has increased over the years due to an increasing aging population, yet there is a dearth of recent comprehensive data evaluating the multiple facets of this degenerative condition. Recent publications have highlighted the biochemistry and biomechanics of DCM, which are paramount to understanding the degenerative nature of the condition and selecting the most optimal treatment options for improved patient outcomes. In addition, there have been recent studies establishing the superiority of surgical to non-surgical treatments for DCM, which until now was a poorly substantiated claim that has permeated the medical field for decades. The authors of this systematic review sought to collect and assess available high quality peer reviewed data to analyze the nature of DCM and gain a better understanding for its treatment choices. Methods PubMed and Cochrane Central Register of Controlled Trials were systematically searched on January 19, 2023 with date restrictions of 2015-2023 imposed. For initial data collection, five independent searches were completed using the following keywords: pathogenesis, pathophysiology, and epidemiology of DCM; cervical spondylotic myelopathy (CSM) and DCM recent developments; management and treatment for CSM and DCM; diagnosis and management of DCM; and pathophysiology of DCM. The results were screened for their application to DCM; any study that did not directly address DCM were identified and removed through abstract assessment, such studies included those pertaining to alternative fields including cardiology and psychiatry. Studies found relevant through full-text assessment and those published in English were included in this study and unpublished studies and studies found irrelevant based on titles and keywords were excluded from this study. The 115 articles that met criteria were critically appraised independently by the 2 reviewers and the principles of Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) were applied to assess the quality of evidence from each study. Results A total of 352 studies resulted from the original search. There were 71 duplicate articles that were removed and a total of 281 articles were screened. 166 articles were then removed based on the exclusion/inclusion criteria, title, and abstract. Of the 138 articles that remained, a final list of 115 articles was created based on the reporting measures. Conclusions DCM is a multifactorial disease that has the potential to impair neurological function and cause significant paralysis. Although the multiple facets of this disease have not been fully elucidated, there have been significant breakthroughs in understanding the mechanisms involved in this disease process. The use of complex imaging modalities, genetic sequencing, biomarkers, and pharmacological agents has provided insight into the factors involved in the progression of DCM, which has consequently cultivated more refined approaches for diagnosis and treatment of DCM.
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Affiliation(s)
- Kiara Thompson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Hannah Travers
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Alex Ngan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Orthopedic Surgery, North Shore University Hospital-Long Island Jewish Medical Center, Manhasset, NY, USA
| | - Tim Reed
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Orthopedic Surgery at Huntington Hospital, Huntington, NY, USA
| | - Shaya Shahsavarani
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Rohit B. Verma
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- Department of Orthopedic Surgery, North Shore University Hospital-Long Island Jewish Medical Center, Manhasset, NY, USA
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Karabacak M, Jagtiani P, Zipser CM, Tetreault L, Davies B, Margetis K. Mapping the Degenerative Cervical Myelopathy Research Landscape: Topic Modeling of the Literature. Global Spine J 2024:21925682241256949. [PMID: 38760664 DOI: 10.1177/21925682241256949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2024] Open
Abstract
STUDY DESIGN Topic modeling of literature. OBJECTIVES Our study has 2 goals: (i) to clarify key themes in degenerative cervical myelopathy (DCM) research, and (ii) to evaluate the current trends in the popularity or decline of these topics. Additionally, we aim to highlight the potential of natural language processing (NLP) in facilitating research syntheses. METHODS Documents were retrieved from Scopus, preprocessed, and modeled using BERTopic, an NLP-based topic modeling method. We specified a minimum topic size of 25 documents and 50 words per topic. After the models were trained, they generated a list of topics and corresponding representative documents. We utilized linear regression models to examine trends within the identified topics. In this context, topics exhibiting increasing linear slopes were categorized as "hot topics," while those with decreasing slopes were categorized as "cold topics". RESULTS Our analysis retrieved 3510 documents that were classified into 21 different topics. The 3 most frequently occurring topics were "OPLL" (ossification of the posterior longitudinal ligament), "Anterior Fusion," and "Surgical Outcomes." Trend analysis revealed the hottest topics of the decade to be "Animal Models," "DCM in the Elderly," and "Posterior Decompression" while "Morphometric Analyses," "Questionnaires," and "MEP and SSEP" were identified as being the coldest topics. CONCLUSIONS Our NLP methodology conducted a thorough and detailed analysis of DCM research, uncovering valuable insights into research trends that were otherwise difficult to discern using traditional techniques. The results provide valuable guidance for future research directions, policy considerations, and identification of emerging trends.
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Affiliation(s)
- Mert Karabacak
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Pemla Jagtiani
- School of Medicine, SUNY Downstate Health Sciences University, New York, NY, USA
| | - Carl Moritz Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Lindsay Tetreault
- Department of Neurology, New York University Langone, New York, NY, USA
| | - Benjamin Davies
- Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
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Horak T, Horakova M, Kerkovsky M, Dostal M, Hlustik P, Valosek J, Svatkova A, Bednarik P, Vlckova E, Bednarik J. Evidence-based commentary on the diagnosis, management, and further research of degenerative cervical spinal cord compression in the absence of clinical symptoms of myelopathy. Front Neurol 2024; 15:1341371. [PMID: 38798708 PMCID: PMC11116587 DOI: 10.3389/fneur.2024.1341371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/18/2024] [Indexed: 05/29/2024] Open
Abstract
Degenerative cervical myelopathy (DCM) represents the final consequence of a series of degenerative changes in the cervical spine, resulting in cervical spinal canal stenosis and mechanical stress on the cervical spinal cord. This process leads to subsequent pathophysiological processes in the spinal cord tissues. The primary mechanism of injury is degenerative compression of the cervical spinal cord, detectable by magnetic resonance imaging (MRI), serving as a hallmark for diagnosing DCM. However, the relative resilience of the cervical spinal cord to mechanical compression leads to clinical-radiological discordance, i.e., some individuals may exhibit MRI findings of DCC without the clinical signs and symptoms of myelopathy. This degenerative compression of the cervical spinal cord without clinical signs of myelopathy, potentially serving as a precursor to the development of DCM, remains a somewhat controversial topic. In this review article, we elaborate on and provide commentary on the terminology, epidemiology, natural course, diagnosis, predictive value, risks, and practical management of this condition-all of which are subjects of ongoing debate.
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Affiliation(s)
- Tomas Horak
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
| | - Magda Horakova
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
| | - Milos Kerkovsky
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, Czechia
| | - Marek Dostal
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, Czechia
- Department of Biophysics, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petr Hlustik
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- Department of Neurology, University Hospital Olomouc, Olomouc, Czechia
| | - Jan Valosek
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- Department of Neurosurgery, Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czechia
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, QC, Canada
- Mila—Quebec AI Institute, Montreal, QC, Canada
| | - Alena Svatkova
- Danish Research Center for Magnetic Resonance, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Petr Bednarik
- Danish Research Center for Magnetic Resonance, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
- Department of Radiology, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Copenhagen, Denmark
| | - Eva Vlckova
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
| | - Josef Bednarik
- Faculty of Medicine, Masaryk University, Brno, Czechia
- Department of Neurology, University Hospital Brno, Brno, Czechia
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Filimonova E, Abdaev M, Vasilenko I, Kubetskij Y, Prokhorov O, Rzaev J. Evaluation of the structural integrity of different spinal cord tracts with magnetization transfer ratio in degenerative cervical myelopathy. Neuroradiology 2024; 66:839-846. [PMID: 38441573 DOI: 10.1007/s00234-024-03327-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/27/2024] [Indexed: 04/21/2024]
Abstract
PURPOSE Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction. In this study, we explored the potential of magnetization transfer ratio (MTR) for evaluating the structural integrity of spinal cord tracts in patients with clinically significant DCM. METHODS Fifty-three patients with DCM and 41 patients with cervical radiculopathy were evaluated using high-resolution cervical spinal cord magnetic resonance imaging (MRI), which included the magnetization transfer technique. MRI data were analyzed with the Spinal Cord Toolbox (v5.5); MTR values in each spinal tract were calculated and compared between groups after correction for patient age and sex. Correlations between MTR values and patients' clinical disability rate were also evaluated. RESULTS A statistically significant reduction in the average MTR of the spinal cord white matter, as well as the MTR of the ventral columns and lateral funiculi, was revealed in the DCM group (adjusted p < 0.01 for all comparisons). Furthermore, reductions in MTR values in the fasciculus cuneatus, spinocerebellar, rubrospinal, and reticulospinal tracts were found in patients with DCM (adjusted p < 0.01 for all comparisons). Positive correlations between the JOA score and the MTR within the ventral columns of the spinal cord (R = 0.38, adjusted p < 0.05) and the ventral spinocerebellar tract (R = 0.41, adjusted p < 0.05) were revealed. CONCLUSION The findings of our study indicate that demyelination in patients with DCM primarily affects the spinal tracts of the extrapyramidal system, and the extent of these changes is related to the severity of the condition.
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Affiliation(s)
- Elena Filimonova
- FSBI "Federal Center of Neurosurgery", Novosibirsk, Russia.
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia.
| | - Mars Abdaev
- FSBI "Federal Center of Neurosurgery", Novosibirsk, Russia
| | - Ivan Vasilenko
- FSBI "Federal Center of Neurosurgery", Novosibirsk, Russia
| | | | | | - Jamil Rzaev
- FSBI "Federal Center of Neurosurgery", Novosibirsk, Russia
- Department of Neurosurgery, Novosibirsk State Medical University, Novosibirsk, Russia
- Novosibirsk State University, Novosibirsk, Russia
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LeClair N, Ejimone M, Lynch D, Dasika J, Rao D, Hoefnagel AL, Mongan PD. T2-weighted Imaging Hyperintensity and Transcranial Motor-evoked Potentials During Cervical Spine Surgery: Effects of Sevoflurane in 150 Consecutive Cases. J Neurosurg Anesthesiol 2024; 36:150-158. [PMID: 36805419 DOI: 10.1097/ana.0000000000000909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/11/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND There is debate on the impact of inhalational esthetic agents on transcranial motor evoked potentials (TcMEPs) during intraoperative neuromonitoring. Current guidelines advise their avoidance, which contrasts with common clinical practice. METHODS This retrospective cohort study of 150 consecutive cervical spine surgeries at a single institution compared stimulation voltages and TcMEP amplitudes in patients who did and did not receive sevoflurane as part of a balanced anesthetic technique. Patients were divided into 3 groups stratified by the presence or absence of increased signal intensity within the cervical spinal cord on T2-weighted magnetic resonance imaging (indicative or myelopathy/spinal cord injury [SCI]) and sevoflurane use. RESULTS Patients with no magnetic resonance imaging evidence of myelopathy/SCI that received sevoflurane (n=80) had the lowest stimulation voltages and largest TcMEP amplitude responses in the lower extremities compared with those with no magnetic resonance imaging evidence of myelopathy/SCI (n=30). In patients with evidence of myelopathy/SCI who did not receive sevoflurane (n=19), lower extremity TcMEP amplitudes were similar to patients with a myelopathy/SCI that received sevoflurane. Six of these 19 patients had initial low-dose sevoflurane discontinued because of concerns of low/absent baseline TcMEP amplitudes. CONCLUSIONS Balanced anesthesia with 0.5 MAC sevoflurane in patients with and without radiological evidence of myelopathy/SCI allows reliable TcMEP monitoring. However, in communication with surgical and neuromonitoring teams, it may be advisable in a subset of patients to avoid or discontinue sevoflurane in favor of a propofol/opioid-based anesthetic to ensure adequate and reproducible TcMEPs.
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Affiliation(s)
| | | | | | | | - Dinesh Rao
- Radiology, University of Florida-Jacksonville, Jacksonville, FL
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Brannigan JFM, Davies BM, Mowforth OD, Yurac R, Kumar V, Dejaegher J, Zamorano JJ, Murphy RKJ, Tripathi M, Anderson DB, Harrop J, Molliqaj G, Wynne-Jones G, Arbatin JJF, Kato S, Ito M, Wilson J, Romelean R, Dea N, Graves D, Tessitore E, Martin AR, Nouri A. Management of mild degenerative cervical myelopathy and asymptomatic spinal cord compression: an international survey. Spinal Cord 2024; 62:51-58. [PMID: 38129661 PMCID: PMC10853067 DOI: 10.1038/s41393-023-00945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 11/28/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023]
Abstract
STUDY DESIGN Cross-sectional survey. OBJECTIVE Currently there is limited evidence and guidance on the management of mild degenerative cervical myelopathy (DCM) and asymptomatic spinal cord compression (ASCC). Anecdotal evidence suggest variance in clinical practice. The objectives of this study were to assess current practice and to quantify the variability in clinical practice. METHODS Spinal surgeons and some additional health professionals completed a web-based survey distributed by email to members of AO Spine and the Cervical Spine Research Society (CSRS) North American Society. Questions captured experience with DCM, frequency of DCM patient encounters, and standard of practice in the assessment of DCM. Further questions assessed the definition and management of mild DCM, and the management of ASCC. RESULTS A total of 699 respondents, mostly surgeons, completed the survey. Every world region was represented in the responses. Half (50.1%, n = 359) had greater than 10 years of professional experience with DCM. For mild DCM, standardised follow-up for non-operative patients was reported by 488 respondents (69.5%). Follow-up included a heterogeneous mix of investigations, most often at 6-month intervals (32.9%, n = 158). There was some inconsistency regarding which clinical features would cause a surgeon to counsel a patient towards surgery. Practice for ASCC aligned closely with mild DCM. Finally, there were some contradictory definitions of mild DCM provided in the form of free text. CONCLUSIONS Professionals typically offer outpatient follow up for patients with mild DCM and/or asymptomatic ASCC. However, what this constitutes varies widely. Further research is needed to define best practice and support patient care.
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Affiliation(s)
- Jamie F M Brannigan
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| | - Oliver D Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ratko Yurac
- Spine unit, Department of Orthopedic and Traumatology, Clínica Alemana, Santiago, Chile
- Department of Orthopedic and Traumatology, School of Medicine, University del Desarrollo, Santiago, Chile
| | - Vishal Kumar
- Department of Orthopaedics, PGIMER, Chandigarh, India
| | - Joost Dejaegher
- Department of Neurosurgery, University Hospitals Leuven, Leuven, KU Leuven, Belgium
| | - Juan J Zamorano
- Spine unit, Department of Orthopedic and Traumatology, Clínica Alemana, Santiago, Chile
| | - Rory K J Murphy
- Department of Neurosurgery, St. Joseph's Hospital and Medical Center, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - David B Anderson
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - James Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Granit Molliqaj
- Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Guy Wynne-Jones
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - So Kato
- The University of Tokyo Hospital, Tokyo, Japan
| | - Manabu Ito
- Department of Orthopaedic Surgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Jefferson Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ronie Romelean
- Jayapalan Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Petaling Jaya, Kuala Lumpur, Malaysia
| | - Nicolas Dea
- Combined Neurosurgical and Orthopedic Spine Program. Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Daniel Graves
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Enrico Tessitore
- Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | | | - Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
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9
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Forodighasemabadi A. Editorial for "Predictive Value of the Diffusion Magnetic Resonance Imaging Technique for the Postoperative Outcome of Cervical Spondylotic Myelopathy". J Magn Reson Imaging 2024; 59:611-612. [PMID: 37204111 DOI: 10.1002/jmri.28786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/20/2023] Open
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10
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Gallagher DO, Taghlabi KM, Bondar K, Saifi C. Degenerative Cervical Myelopathy: A Concept Review and Clinical Approach. Clin Spine Surg 2024; 37:1-8. [PMID: 38285428 DOI: 10.1097/bsd.0000000000001463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 05/09/2023] [Indexed: 01/30/2024]
Abstract
STUDY DESIGN Narrative review. OBJECTIVE To provide an overview of the evaluation and diagnosis of degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA DCM describes several etiologies of degenerative, nontraumatic spinal cord impairment. Early diagnosis and intervention can decrease neurological decline. METHODS An extensive literature review was conducted. RESULTS The incidence and prevalence of DCM are increasing worldwide. Asymptomatic spinal cord compression can progress to cervical myelopathy. Static and dynamic factors contribute to spinal cord compression. Patients frequently present with decreased manual dexterity, gait instability, and neck pain. On physical exam, patients frequently present with upper motor neuron signs, a Lhermitte sign, a failed Romberg test, global proprioceptive dysfunction, and decreased pain sensation. Anatomic variation may complicate physical exam interpretation. The modified Japanese Orthopaedic Association Scale and Nurick Classification, based on functional impairment, provide diagnostic utility. Magnetic Resonance Imaging imaging is useful in narrowing the differential diagnosis, evaluating the severity of neurological impairment, and predicting disease progression. CONCLUSIONS Understanding the pathophysiology of DCM and the diagnostic utility of the signs and symptoms of DCM is critical. The decision for anterior cervical discectomy and fusion (ACDF), laminoplasty, or combined ACDF and posterior cervical fusion is individualized for each patient.
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Affiliation(s)
- Daniel O Gallagher
- Department of Education, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Kevin Bondar
- Department of Orthopedic Surgery and Sports Medicine, Houston Methodist Hospital, Houston, TX
| | - Comron Saifi
- Department of Orthopedic Surgery and Sports Medicine, Houston Methodist Hospital, Houston, TX
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Yu D, Chang MC, Jeon I, Kim SW. Diagnostic and prognostic significance of preoperative evoked potential tests in degenerative cervical myelopathy. Spine J 2024; 24:87-93. [PMID: 37704047 DOI: 10.1016/j.spinee.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND CONTEXT Decompression surgery is a treatment option for patients with degenerative cervical myelopathy (DCM). Surgical decisions primarily depend on clinical symptoms and radiological examinations. The diagnostic and prognostic significance of evoked potential tests for surgical outcomes in patients with DCM has not been thoroughly examined. PURPOSE To identify the diagnostic and prognostic significance of preoperative evoked potential tests in patients with DCM who underwent decompression surgery. STUDY DESIGN This was a retrospective observational study. PATIENT SAMPLE One hundred two consecutive patients who underwent evoked potential tests and surgical treatment between January 2016 and December 2020 in a single spine center and had a minimum follow-up of 6 months. OUTCOME MEASURES Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery. METHODS This study evaluated the preoperative central motor conduction time (CMCT), somatosensory evoked potentials, and Japanese Orthopedic Association (JOA) scores obtained preoperatively and 6 months after surgery. RESULTS Abnormal CMCT findings were observed in 94 patients (92.2%). Abnormal somatosensory evoked potentials were observed in 77 patients (75.5%). There was a statistically significant correlation between preoperative JOA score and abductor pollicis brevis (APB)-CMCT (r=-0.546, p=.001), tibialis anterior (TA)-CMCT (r=-0.517, p<.001), median nerve (MN)-SSEP (r=-0.353, p=.001), and tibial nerve (TN)-SSEP (r=-0.349, p=.003). There were significant differences in recovery rates associated with diabetes mellitus (DM), preoperative severity of myelopathy, TA-CMCT, MN-SSEP, and TN-SSEP. Stepwise multiple regression analysis showed that the major factors affecting the clinical outcomes were TN-SSEP (β=0.327, p=.004), preoperative JOA score (β=0.278, p=.012), and DM (β=0.241, p=.025). CONCLUSIONS Evoked potential testing is a functional diagnostic tool that can indicate the severity of myelopathic symptoms in patients with DCM. Additionally, preoperative TN-SSEP may have significant prognostic value in predicting postoperative clinical outcomes. Thus, preoperative evoked potential tests could be helpful for determining suitable surgical treatment candidates and forecasting postoperative prognosis.
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Affiliation(s)
- Dongwoo Yu
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, South Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, South Korea
| | - Ikchan Jeon
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, South Korea
| | - Sang Woo Kim
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, South Korea.
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12
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Khan AF, Mohammadi E, Haynes G, Hameed S, Rohan M, Anderson DB, Weber KA, Muhammad F, Smith ZA. Evaluating tissue injury in cervical spondylotic myelopathy with spinal cord MRI: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2024; 33:133-154. [PMID: 37926719 DOI: 10.1007/s00586-023-07990-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/02/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE Cervical Spondylotic Myelopathy (CSM) is a degenerative condition that leads to loss of cervical spinal cord (CSC) integrity. Various spinal cord Magnetic Resonance Imaging (MRI) methods can identify and characterize the extent of this damage. This systematic review aimed to evaluate the diagnostic, biomarker, and predictive utilities of different spinal cord MRI methods in clinical research studies of CSM. The aim was to provide a comprehensive understanding of the progress in this direction for future studies and effective diagnosis and management of CSM. METHODS A comprehensive literature search was conducted on PubMed and EMBASE from 2010 to 2022 according to PRISMA guidelines. Studies with non-human subjects, less than 3T magnetic field strength, non-clinical design, or not quantitatively focusing on the structural integrity of CSC were excluded. The extracted data from each study included demographics, disease severity, MRI machine characteristics, quantitative metrics, and key findings in terms of diagnostic, biomarker, and predictive utilities of each MRI method. The risk of bias was performed using the guide from AHRQ. The quality of evidence was assessed separately for each type of utility for different MRI methods using GRADE. RESULTS Forty-seven studies met the inclusion criteria, utilizing diffusion-weighted imaging (DTI) (n = 39), magnetization transfer (MT) (n = 6), MR spectroscopy (n = 3), and myelin water imaging (n = 1), as well as a combination of MRI methods (n = 12). The metric fractional anisotropy (FA) showed the highest potential in all facets of utilities, followed by mean diffusivity. Other promising metrics included MT ratio and intracellular volume fraction, especially in multimodal studies. However, the level of evidence for these promising metrics was low due to a small number of studies. Some studies, mainly DTI, also reported the usefulness of spinal cord MRI in mild CSM. CONCLUSIONS Spinal cord MRI methods can potentially facilitate the diagnosis and management of CSM by quantitatively interrogating the structural integrity of CSC. DTI is the most promising MRI method, and other techniques have also shown promise, especially in multimodal configurations. However, this field is in its early stages, and more studies are needed to establish the usefulness of spinal cord MRI in CSM.
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Affiliation(s)
- Ali Fahim Khan
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Esmaeil Mohammadi
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Grace Haynes
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, USA
| | - Sanaa Hameed
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Michael Rohan
- Laureate Institute for Brain Research, Tulsa, OK, USA
| | - David B Anderson
- School of Health Sciences, The University of Sydney, Sydney, Australia
| | - Kenneth A Weber
- Systems Neuroscience and Pain Laboratory, Division of Pain Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Fauziyya Muhammad
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA
| | - Zachary A Smith
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, 1000 N Lincoln Blvd, Suite 4000, Oklahoma City, OK, 73104, USA.
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13
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Sun SP, Phang CR, Tzou SC, Chen CM, Ko LW. Integration of MRI and somatosensory evoked potentials facilitate diagnosis of spinal cord compression. Sci Rep 2023; 13:7861. [PMID: 37188786 DOI: 10.1038/s41598-023-34832-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/09/2023] [Indexed: 05/17/2023] Open
Abstract
This study aimed to integrate magnetic resonance imaging (MRI) and related somatosensory evoked potential (SSEP) features to assist in the diagnosis of spinal cord compression (SCC). MRI scans were graded from 0 to 3 according to the changes in the subarachnoid space and scan signals to confirm differences in SCC levels. The amplitude, latency, and time-frequency analysis (TFA) power of preoperative SSEP features were extracted and the changes were used as standard judgments to detect neurological function changes. Then the patient distribution was quantified according to the SSEP feature changes under the same and different MRI compression grades. Significant differences were found in the amplitude and TFA power between MRI grades. We estimated three degrees of amplitude anomalies and power loss under each MRI grade and found the presence or absence of power loss occurs after abnormal changes in amplitude only. For SCC, few integrated approach combines the advantages of both MRI and evoked potentials. However, integrating the amplitude and TFA power changes of SSEP features with MRI grading can help in the diagnosis and speculate progression of SCC.
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Affiliation(s)
- Shu-Pin Sun
- International Ph.D. Program in Interdisciplinary Neuroscience (UST), College of Biological Science and Technology, National Yang Ming Chiao Tung University, 734, Engineering Bldg. 5, 1001 Daxue Road, Hsinchu, 30010, Taiwan, ROC
- Department of Medical Research, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, 300, Taiwan, ROC
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, 300, Taiwan, ROC
| | - Chun-Ren Phang
- International Ph.D. Program in Interdisciplinary Neuroscience (UST), College of Biological Science and Technology, National Yang Ming Chiao Tung University, 734, Engineering Bldg. 5, 1001 Daxue Road, Hsinchu, 30010, Taiwan, ROC
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, 300, Taiwan, ROC
| | - Shey-Cherng Tzou
- Institute of Molecular Medicine and Bioengineering, National Yang Ming Chiao Tung University, Hsinchu, 300, Taiwan, ROC
- Department of Biomedical Science and Environment Biology, and the Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung, 807, Taiwan, ROC
| | - Chang-Mu Chen
- Department of Surgery, College of Medicine and Hospital, National Taiwan University, No. 7, Zhongshan South Road, Taipei, 10002, Taiwan, ROC.
| | - Li-Wei Ko
- International Ph.D. Program in Interdisciplinary Neuroscience (UST), College of Biological Science and Technology, National Yang Ming Chiao Tung University, 734, Engineering Bldg. 5, 1001 Daxue Road, Hsinchu, 30010, Taiwan, ROC.
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, 300, Taiwan, ROC.
- Institute of Electrical and Control Engineering, Department of Electronics and Electrical Engineering, National Yang Ming Chiao Tung University, Hsinchu, 300, Taiwan, ROC.
- Department of Biomedical Science and Environment Biology, and the Drug Development and Value Creation Research Center, Kaohsiung Medical University, Kaohsiung, 807, Taiwan, ROC.
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14
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Hejrati N, Pedro K, Alvi MA, Quddusi A, Fehlings MG. Degenerative cervical myelopathy: Where have we been? Where are we now? Where are we going? Acta Neurochir (Wien) 2023; 165:1105-1119. [PMID: 37004568 DOI: 10.1007/s00701-023-05558-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/06/2023] [Indexed: 04/04/2023]
Abstract
Degenerative cervical myelopathy (DCM), a recently coined term, encompasses a group of age-related and genetically associated pathologies that affect the cervical spine, including cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL). Given the significant contribution of DCM to global disease and disability, there are worldwide efforts to promote research and innovation in this area. An AO Spine effort termed 'RECODE-DCM' was initiated to create an international multistakeholder consensus group, involving patients, caregivers, physicians and researchers, to focus on launching actionable discourse on DCM. In order to improve the management, treatment and results for DCM, the RECODE-DCM consensus group recently identified ten priority areas for translational research. The current article summarizes recent advancements in the field of DCM. We first discuss the comprehensive definition recently refined by the RECODE-DCM group, including steps taken to arrive at this definition and the supporting rationale. We then provide an overview of the recent advancements in our understanding of the pathophysiology of DCM and modalities to clinically assess and diagnose DCM. A focus will be set on advanced imaging techniques that may offer the opportunity to improve characterization and diagnosis of DCM. A summary of treatment modalities, including surgical and nonoperative options, is then provided along with future neuroprotective and neuroregenerative strategies. This review concludes with final remarks pertaining to the genetics involved in DCM and the opportunity to leverage this knowledge toward a personalized medicine approach.
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Affiliation(s)
- Nader Hejrati
- Division of Genetics and Development, Krembil Research Institute, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Suite 4WW-449, Toronto, ON, M5T 2S8, Canada
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Karlo Pedro
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mohammed Ali Alvi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Ayesha Quddusi
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Suite 4WW-449, Toronto, ON, M5T 2S8, Canada.
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada.
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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15
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Schading S, David G, Max Emmenegger T, Achim C, Thompson A, Weiskopf N, Curt A, Freund P. Dynamics of progressive degeneration of major spinal pathways following spinal cord injury: A longitudinal study. Neuroimage Clin 2023; 37:103339. [PMID: 36758456 PMCID: PMC9939725 DOI: 10.1016/j.nicl.2023.103339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/23/2022] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Following spinal cord injury (SCI), disease processes spread gradually along the spinal cord forming a spatial gradient with most pronounced changes located at the lesion site. However, the dynamics of this gradient in SCI patients is not established. OBJECTIVE This study tracks the spatiotemporal dynamics of remote anterograde and retrograde spinal tract degeneration in the upper cervical cord following SCI over two years utilizing quantitative MRI. METHODS Twenty-three acute SCI patients (11 paraplegics, 12 tetraplegics) and 21 healthy controls were scanned with a T1-weighted sequence for volumetry and a FLASH sequence for myelin-sensitive magnetization transfer saturation (MTsat) of the upper cervical cord. We estimated myelin content from MTsat maps within the corticospinal tracts (CST) and dorsal columns (DC) and measured spinal cord atrophy by means of left-right width (LRW) and anterior-posterior width (APW) on the T1-weighted images across cervical levels C1-C3. MTsat in the CST and LRW were considered proxies for retrograde degeneration, while MTsat in the DC and APW provided evidence for anterograde degeneration, respectively. Using regression models, we compared the temporal and spatial trajectories of these MRI readouts between tetraplegics, paraplegics, and controls over a 2-year period and assessed their associations with clinical improvement. RESULTS Linear rates and absolute differences in myelin-sensitive MTsat indicated retrograde and anterograde neurodegeneration in the CST and DC, respectively. Changes in MTsat within the CST and in LRW progressively developed over time forming a gradient towards lower cervical levels by 2 years after injury, especially in tetraplegics (change per cervical level in MTsat: -0.247 p.u./level, p = 0.034; in LRW: -0.323 mm/level, p = 0.024). MTsat within the DC was already decreased at cervical levels C1-C3 at baseline (1.5 months after injury) in both tetra- and paraplegics, while linear decreases in APW over time were similar across C1-C3, preserving the spatial gradient. The relative improvement in light touch score was associated with MTsat within the DC at baseline (rs = 0.575, p = 0.014). CONCLUSION Rostral and remote to the injury, the CST and DC show ongoing structural changes, indicative of myelin reductions and atrophy within 2 years after SCI. While anterograde degeneration in the DC was already detectable uniformly at C1-C3 early following SCI, retrograde degeneration in the CST developed over time revealing specific spatial and temporal neurodegenerative gradients. Disentangling and quantifying such dynamic pathological processes may provide biomarkers for regenerative and remyelinating therapies along entire spinal pathways.
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Affiliation(s)
- Simon Schading
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Gergely David
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Tim Max Emmenegger
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Cristian Achim
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Alan Thompson
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Nikolaus Weiskopf
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Felix Bloch Institute for Solid State Physics, Faculty of Physics and Earth Sciences, Leipzig University, Leipzig, Germany
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland; Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Wellcome Trust Centre for Neuroimaging, UCL Queen Square Institute of Neurology, University College London, London, UK.
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Nozawa K, Maki S, Furuya T, Okimatsu S, Inoue T, Yunde A, Miura M, Shiratani Y, Shiga Y, Inage K, Eguchi Y, Ohtori S, Orita S. Magnetic resonance image segmentation of the compressed spinal cord in patients with degenerative cervical myelopathy using convolutional neural networks. Int J Comput Assist Radiol Surg 2023; 18:45-54. [PMID: 36342593 DOI: 10.1007/s11548-022-02783-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 10/20/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE Spinal cord segmentation is the first step in atlas-based spinal cord image analysis, but segmentation of compressed spinal cords from patients with degenerative cervical myelopathy is challenging. We applied convolutional neural network models to segment the spinal cord from T2-weighted axial magnetic resonance images of DCM patients. Furthermore, we assessed the correlation between the cross-sectional area segmented by this network and the neurological symptoms of the patients. METHODS The CNN architecture was built using U-Net and DeepLabv3 + and PyTorch. The CNN was trained on 2762 axial slices from 174 patients, and an additional 517 axial slices from 33 patients were held out for validation and 777 axial slices from 46 patients for testing. The performance of the CNN was evaluated on a test dataset with Dice coefficients as the outcome measure. The ratio of CSA at the maximum compression level to CSA at the C2 level, as segmented by the CNN, was calculated. The correlation between the spinal cord CSA ratio and the Japanese Orthopaedic Association score in DCM patients from the test dataset was investigated using Spearman's rank correlation coefficient. RESULTS The best Dice coefficient was achieved when U-Net was used as the architecture and EfficientNet-b7 as the model for transfer learning. Spearman's rs between the spinal cord CSA ratio and the JOA score of DCM patients was 0.38 (p = 0.007), showing a weak correlation. CONCLUSION Using deep learning with magnetic resonance images of deformed spinal cords as training data, we were able to segment compressed spinal cords of DCM patients with a high concordance with expert manual segmentation. In addition, the spinal cord CSA ratio was weakly, but significantly, correlated with neurological symptoms. Our study demonstrated the first steps needed to implement automated atlas-based analysis of DCM patients.
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Affiliation(s)
- Kyohei Nozawa
- Department of Medical Engineering, Graduate School of Science and Engineering, Chiba University, Chiba, Japan
| | - Satoshi Maki
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.
- Center for Frontier Medical Engineering, Chiba University, Chiba, Japan.
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sho Okimatsu
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takaki Inoue
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Atsushi Yunde
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masataka Miura
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuki Shiratani
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
- Center for Frontier Medical Engineering, Chiba University, Chiba, Japan
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Chen X, Schädelin S, Lu PJ, Ocampo-Pineda M, Weigel M, Barakovic M, Ruberte E, Cagol A, Marechal B, Kober T, Kuhle J, Kappos L, Melie-Garcia L, Granziera C. Personalized maps of T1 relaxometry abnormalities provide correlates of disability in multiple sclerosis patients. Neuroimage Clin 2023; 37:103349. [PMID: 36801600 PMCID: PMC9958406 DOI: 10.1016/j.nicl.2023.103349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVES AND AIMS Quantitative MRI (qMRI) has greatly improved the sensitivity and specificity of microstructural brain pathology in multiple sclerosis (MS) when compared to conventional MRI (cMRI). More than cMRI, qMRI also provides means to assess pathology within the normal-appearing and lesion tissue. In this work, we further developed a method providing personalized quantitative T1 (qT1) abnormality maps in individual MS patients by modeling the age dependence of qT1 alterations. In addition, we assessed the relationship between qT1 abnormality maps and patients' disability, in order to evaluate the potential value of this measurement in clinical practice. METHODS We included 119 MS patients (64 relapsing-remitting MS (RRMS), 34 secondary progressive MS (SPMS), 21 primary progressive MS (PPMS)), and 98 Healthy Controls (HC). All individuals underwent 3T MRI examinations, including Magnetization Prepared 2 Rapid Acquisition Gradient Echoes (MP2RAGE) for qT1 maps and High-Resolution 3D Fluid Attenuated Inversion Recovery (FLAIR) imaging. To calculate personalized qT1 abnormality maps, we compared qT1 in each brain voxel in MS patients to the average qT1 obtained in the same tissue (grey/white matter) and region of interest (ROI) in healthy controls, hereby providing individual voxel-based Z-score maps. The age dependence of qT1 in HC was modeled using linear polynomial regression. We computed the average qT1 Z-scores in white matter lesions (WMLs), normal-appearing white matter (NAWM), cortical grey matter lesions (GMcLs) and normal-appearing cortical grey matter (NAcGM). Lastly, a multiple linear regression (MLR) model with the backward selection including age, sex, disease duration, phenotype, lesion number, lesion volume and average Z-score (NAWM/NAcGM/WMLs/GMcLs) was used to assess the relationship between qT1 measures and clinical disability (evaluated with EDSS). RESULTS The average qT1 Z-score was higher in WMLs than in NAWM. (WMLs: 1.366 ± 0.409, NAWM: -0.133 ± 0.288, [mean ± SD], p < 0.001). The average Z-score in NAWM in RRMS patients was significantly lower than in PPMS patients (p = 0.010). The MLR model showed a strong association between average qT1 Z-scores in white matter lesions (WMLs) and EDSS (R2 = 0.549, β = 0.178, 97.5 % CI = 0.030 to 0.326, p = 0.019). Specifically, we measured a 26.9 % increase in EDSS per unit of qT1 Z-score in WMLs in RRMS patients (R2 = 0.099, β = 0.269, 97.5 % CI = 0.078 to 0.461, p = 0.007). CONCLUSIONS We showed that personalized qT1 abnormality maps in MS patients provide measures related to clinical disability, supporting the use of those maps in clinical practice.
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Affiliation(s)
- Xinjie Chen
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Sabine Schädelin
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Po-Jui Lu
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Mario Ocampo-Pineda
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Matthias Weigel
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland; Division of Radiological Physics, Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Muhamed Barakovic
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Esther Ruberte
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Alessandro Cagol
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Benedicte Marechal
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Lausanne, Switzerland
| | - Tobias Kober
- Advanced Clinical Imaging Technology, Siemens Healthineers International AG, Lausanne, Switzerland
| | - Jens Kuhle
- Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Ludwig Kappos
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Lester Melie-Garcia
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland
| | - Cristina Granziera
- Translational Imaging in Neurology (ThINK) Basel, Department of Biomedical Engineering, Faculty of Medicine, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland.
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Zipser CM, Fehlings MG, Margetis K, Curt A, Betz M, Sadler I, Tetreault L, Davies BM. Proposing a Framework to Understand the Role of Imaging in Degenerative Cervical Myelopathy: Enhancement of MRI Protocols Needed for Accurate Diagnosis and Evaluation. Spine (Phila Pa 1976) 2022; 47:1259-1262. [PMID: 35857708 PMCID: PMC9365266 DOI: 10.1097/brs.0000000000004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Carl M. Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michael G. Fehlings
- Division of Neurosurgery and Spinal Program, University of Toronto and Krembil Brain Institute, University Health Network, Toronto, ON, Canada
| | | | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Iwan Sadler
- Myelopathy Support, Myelopathy.org, Cambridge, UK
| | - Lindsay Tetreault
- Department of Neurology, NYU Langone Health, Graduate Medical Education, New York, NY
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A scoping review of information provided within degenerative cervical myelopathy education resources: Towards enhancing shared decision making. PLoS One 2022; 17:e0268220. [PMID: 35588126 PMCID: PMC9119544 DOI: 10.1371/journal.pone.0268220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/25/2022] [Indexed: 11/19/2022] Open
Abstract
Background Degenerative cervical myelopathy (DCM) is a chronic neurological condition estimated to affect 1 in 50 adults. Due to its diverse impact, trajectory and management options, patient-centred care and shared decision making are essential. In this scoping review, we aim to explore whether information needs in DCM are currently being met in available DCM educational resources. This forms part of a larger Myelopathy.org project to promote shared decision making in DCM. Methods A search was completed encompassing MEDLINE, Embase and grey literature. Resources relevant to DCM were compiled for analysis. Resources were grouped into 5 information types: scientific literature, videos, organisations, health education websites and patient information leaflets. Resources were then further arranged into a hierarchical framework of domains and subdomains, formed through inductive analysis. Frequency statistics were employed to capture relative popularity as a surrogate marker of potential significance. Results Of 2674 resources, 150 information resources addressing DCM were identified: 115 scientific literature resources, 28 videos, 5 resources from health organisations and 2 resources from health education websites. Surgical management was the domain with the largest number of resources (66.7%, 100/150). The domain with the second largest number of resources was clinical presentation and natural history (28.7%, 43/150). Most resources (83.3%, 125/150) were designed for professionals. A minority (11.3% 17/150) were written for a lay audience or for a combined audience (3.3%, 5/150). Conclusion Educational resources for DCM are largely directed at professionals and focus on surgical management. This is at odds with the needs of stakeholders in a lifelong condition that is often managed without surgery, highlighting an unmet educational need.
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Valošek J, Bednařík P, Keřkovský M, Hluštík P, Bednařík J, Svatkova A. Quantitative MR Markers in Non-Myelopathic Spinal Cord Compression: A Narrative Review. J Clin Med 2022; 11:2301. [PMID: 35566426 PMCID: PMC9105390 DOI: 10.3390/jcm11092301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 02/01/2023] Open
Abstract
Degenerative spinal cord compression is a frequent pathological condition with increasing prevalence throughout aging. Initial non-myelopathic cervical spinal cord compression (NMDC) might progress over time into potentially irreversible degenerative cervical myelopathy (DCM). While quantitative MRI (qMRI) techniques demonstrated the ability to depict intrinsic tissue properties, longitudinal in-vivo biomarkers to identify NMDC patients who will eventually develop DCM are still missing. Thus, we aim to review the ability of qMRI techniques (such as diffusion MRI, diffusion tensor imaging (DTI), magnetization transfer (MT) imaging, and magnetic resonance spectroscopy (1H-MRS)) to serve as prognostic markers in NMDC. While DTI in NMDC patients consistently detected lower fractional anisotropy and higher mean diffusivity at compressed levels, caused by demyelination and axonal injury, MT and 1H-MRS, along with advanced and tract-specific diffusion MRI, recently revealed microstructural alterations, also rostrally pointing to Wallerian degeneration. Recent studies also disclosed a significant relationship between microstructural damage and functional deficits, as assessed by qMRI and electrophysiology, respectively. Thus, tract-specific qMRI, in combination with electrophysiology, critically extends our understanding of the underlying pathophysiology of degenerative spinal cord compression and may provide predictive markers of DCM development for accurate patient management. However, the prognostic value must be validated in longitudinal studies.
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Affiliation(s)
- Jan Valošek
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (J.V.); (P.H.)
- Department of Radiology, Faculty of Medicine and Dentistry, Palacký University Olomouc, 779 00 Olomouc, Czech Republic
- Department of Biomedical Engineering, University Hospital Olomouc, 779 00 Olomouc, Czech Republic
| | - Petr Bednařík
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark;
- Department of Radiology, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
| | - Miloš Keřkovský
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic; (M.K.); (J.B.)
- Department of Radiology and Nuclear Medicine, University Hospital Brno, 625 00 Brno, Czech Republic
| | - Petr Hluštík
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University Olomouc, 779 00 Olomouc, Czech Republic; (J.V.); (P.H.)
- Department of Neurology, University Hospital Olomouc, 779 00 Olomouc, Czech Republic
| | - Josef Bednařík
- Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic; (M.K.); (J.B.)
- Department of Neurology, University Hospital Brno, 625 00 Brno, Czech Republic
- Central European Institute of Technology, Masaryk University, 625 00 Brno, Czech Republic
| | - Alena Svatkova
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark;
- Department of Radiology, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, 2650 Hvidovre, Denmark
- Department of Medicine III, Clinical Division of Endocrinology and Metabolism, Medical University of Vienna, 1090 Vienna, Austria
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How Is Spinal Cord Function Measured in Degenerative Cervical Myelopathy? A Systematic Review. J Clin Med 2022; 11:jcm11051441. [PMID: 35268533 PMCID: PMC8910882 DOI: 10.3390/jcm11051441] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 12/10/2022] Open
Abstract
Degenerative cervical myelopathy (DCM) is a prevalent condition in which spinal degeneration causes cord compression and neurological dysfunction. The spinal cord is anatomically complex and operates in conjunction with the brain, the musculoskeletal system, and numerous organs to control numerous functions, including simple and coordinated movement, sensation, and autonomic functions. As a result, accurate and comprehensive measurement of spinal cord function in patients with DCM and other spinal pathologies is challenging. This project aimed to summarize the neurological, functional, and quality of life (QoL) outcome measures currently in use to quantify impairment in DCM. A systematic review of the literature was performed to identify prospective studies with at least 100 DCM subjects that utilized one or more quantitative neurological, functional, or QoL outcome measures. A total of 148 studies were identified. The most commonly used instruments were subjective functional scales including the Japanese Orthopedic Association (JOA) (71 studies), modified JOA (mJOA) (66 studies), Neck Disability Index (NDI) (54 studies), and Nurick (39 studies), in addition to the QoL measure Short-Form-36 (SF-36, 52 studies). A total of 92% (320/349) of all outcome measures were questionnaires, whereas objective physical testing of neurological function (strength, gait, balance, dexterity, or sensation) made up 8% (29/349). Studies utilized an average of 2.36 outcomes measures, while 58 studies (39%) utilized only a single outcome measure. No studies were identified that specifically assessed the dorsal column sensory pathway or respiratory, bowel, or sexual function. In the past five years, there were no significant differences in the number of total, functional, or QoL outcome measures used, but physical testing of neurological function has increased (p = 0.005). Prior to 2017, cervical spondylotic myelopathy (CSM) was the most frequently used term to describe the study population, whereas in the last five years, DCM has become the preferred terminology. In conclusion, clinical studies of DCM typically utilize limited data to characterize impairment, often relying on subjective, simplistic, and non-specific measures that do not reflect the complexity of the spinal cord. Although accurate measurement of impairment in DCM is challenging, it is necessary for early diagnosis, monitoring for deterioration, and quantifying recovery after therapeutic interventions. Clinical decision-making and future clinical studies in DCM should employ a combination of subjective and objective assessments to capture the multitude of spinal cord functions to improve clinical management and inform practice guidelines.
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Martin AR, Tetreault L, Nouri A, Curt A, Freund P, Rahimi-Movaghar V, Wilson JR, Fehlings MG, Kwon BK, Harrop JS, Davies BM, Kotter MRN, Guest JD, Aarabi B, Kurpad SN. Imaging and Electrophysiology for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 9]. Global Spine J 2022; 12:130S-146S. [PMID: 34797993 PMCID: PMC8859711 DOI: 10.1177/21925682211057484] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The current review aimed to describe the role of existing techniques and emerging methods of imaging and electrophysiology for the management of degenerative cervical myelopathy (DCM), a common and often progressive condition that causes spinal cord dysfunction and significant morbidity globally. METHODS A narrative review was conducted to summarize the existing literature and highlight future directions. RESULTS Anatomical magnetic resonance imaging (MRI) is well established in the literature as the key imaging tool to identify spinal cord compression, disc herniation/bulging, and inbuckling of the ligamentum flavum, thus facilitating surgical planning, while radiographs and computed tomography (CT) provide complimentary information. Electrophysiology techniques are primarily used to rule out competing diagnoses. However, signal change and measures of cord compression on conventional MRI have limited utility to characterize the degree of tissue injury, which may be helpful for diagnosis, prognostication, and repeated assessments to identify deterioration. Early translational studies of quantitative imaging and electrophysiology techniques show potential of these methods to more accurately reflect changes in spinal cord microstructure and function. CONCLUSION Currently, clinical management of DCM relies heavily on anatomical MRI, with additional contributions from radiographs, CT, and electrophysiology. Novel quantitative assessments of microstructure, perfusion, and function have the potential to transform clinical practice, but require robust validation, automation, and standardization prior to uptake.
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Affiliation(s)
- Allan R. Martin
- Department of Neurological Surgery, University of California Davis, Davis, CA, USA
| | - Lindsay Tetreault
- Department of Neurology, New York University, Langone Health, Graduate Medical Education, New York, NY, USA
| | - Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Armin Curt
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Patrick Freund
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
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Nouri A, Tessitore E, Molliqaj G, Meling T, Schaller K, Nakashima H, Yukawa Y, Bednarik J, Martin AR, Vajkoczy P, Cheng JS, Kwon BK, Kurpad SN, Fehlings MG, Harrop JS, Aarabi B, Rahimi-Movaghar V, Guest JD, Davies BM, Kotter MRN, Wilson JR. Degenerative Cervical Myelopathy: Development and Natural History [AO Spine RECODE-DCM Research Priority Number 2]. Global Spine J 2022; 12:39S-54S. [PMID: 35174726 PMCID: PMC8859703 DOI: 10.1177/21925682211036071] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES To discuss the current understanding of the natural history of degenerative cervical myelopathy (DCM). METHODS Literature review summarizing current evidence pertaining to the natural history and risk factors of DCM. RESULTS DCM is a common condition in which progressive arthritic disease of the cervical spine leads to spinal cord compression resulting in a constellation of neurological symptoms, in particular upper extremity dysfunction and gait impairment. Anatomical factors including cord-canal mismatch, congenitally fused vertebrae and genetic factors may increase individuals' risk for DCM development. Non-myelopathic spinal cord compression (NMSCC) is a common phenomenon with a prevalence of 24.2% in the healthy population, and 35.3% among individuals >60 years of age. Clinical radiculopathy and/or electrophysiological signs of cervical cord dysfunction appear to be risk factors for myelopathy development. Radiological progression of incidental Ossification of the Posterior Longitudinal Ligament (OPLL) is estimated at 18.3% over 81-months and development of myelopathy ranges between 0-61.5% (follow-up ranging from 40 to 124 months between studies) among studies. In patients with symptomatic DCM undergoing non-operative treatment, 20-62% will experience neurological deterioration within 3-6 years. CONCLUSION Current estimates surrounding the natural history of DCM, particularly those individuals with mild or minimal impairment, lack precision. Clear predictors of clinical deterioration for those treated with non-operative care are yet to be identified. Future studies are needed on this topic to help improve treatment counseling and clinical prognostication.
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Affiliation(s)
- Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Enrico Tessitore
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Granit Molliqaj
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Torstein Meling
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Karl Schaller
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Hiroaki Nakashima
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasutsugu Yukawa
- Department of Orthopedic Surgery, Wakayama Medical University, Wakayama, Japan
| | - Josef Bednarik
- Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Allan R. Martin
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin, Berlin, Germany
| | - Joseph S. Cheng
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto, Ontario, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, Baltimore, MD, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, FL, USA
| | - Benjamin M. Davies
- Department of Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, United Kingdom
| | - Mark R. N. Kotter
- Department of Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, United Kingdom
| | - Jefferson R. Wilson
- Division of Neurosurgery and Spine Program, University of Toronto, Ontario, Canada
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Rodrigues-Pinto R, Montenegro TS, Davies BM, Kato S, Kawaguchi Y, Ito M, Zileli M, Kwon BK, Fehlings MG, Koljonen PA, Kurpad SN, Guest JD, Aarabi B, Rahimi-Movaghar V, Wilson JR, Kotter MRN, Harrop JS. Optimizing the Application of Surgery for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 10]. Global Spine J 2022; 12:147S-158S. [PMID: 35174733 PMCID: PMC8859702 DOI: 10.1177/21925682211062494] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
STUDY DESIGN Literature Review (Narrative). OBJECTIVE To introduce the number 10 research priority for Degenerative Cervical Myelopathy: Individualizing Surgery. METHODS This article summarizes the current recommendations and indications for surgery, including how known prognostic factors such as injury time, age, disease severity, and associated comorbidities impact surgical outcome. It also considers key areas of uncertainty that should be the focus of future research. RESULTS While a small proportion of conservatively managed patients may remain stable, the majority will deteriorate over time. To date, surgical decompression is the mainstay of treatment, able to halt disease progression and improve neurologic function and quality of life for most patients. Whilst this recognition has led to recommendations on when to offer surgery, there remain many uncertainties including the type of surgery, or timing in milder and/or asymptomatic cases. Their clarification has the potential to transform outcomes, by ensuring surgery offers each individual its maximum benefit. CONCLUSION Developing the evidence to better guide surgical decision-making at the individual patient level is a research priority for Degenerative Cervical Myelopathy.
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Affiliation(s)
- Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto - Hospital de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Thiago S. Montenegro
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - So Kato
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | | | - Manabu Ito
- Department of Orthopaedic Surgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Mehmet Zileli
- Neurosurgery Department, Ege University, Bornova, Izmir, Turkey
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, ON, Canada
| | - Paul A. Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Iran
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, ON, Canada
| | | | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
Degenerative cervical myelopathy (DCM) is a recently coined term encompassing a variety of age-related and genetically associated pathologies, including cervical spondylotic myelopathy, degenerative disc disease, and ligamentous aberrations such as ossification of the posterior longitudinal ligament. All of these pathologies produce chronic compression of the spinal cord causing a clinical syndrome characterized by decreased hand dexterity, gait imbalance, and potential genitourinary or sensorimotor disturbances. Substantial variability in the underlying etiology of DCM and its natural history has generated heterogeneity in practice patterns. Ongoing debates in DCM management most commonly center around clinical decision-making, timing of intervention, and the ideal surgical approach. Pivotal basic science studies during the past two decades have deepened our understanding of the pathophysiologic mechanisms surrounding DCM. Growing knowledge of the key pathophysiologic processes will help us tailor personalized approaches in an increasingly heterogeneous patient population. This article focuses on summarizing the most exciting approaches in personalizing DCM patient treatments including biomarkers, factors affecting clinical decision-making, and choice of the optimal surgical approach. Throughout we provide a concise review on the conditions encompassing DCM and discuss the underlying pathophysiology of chronic spinal cord compression. We also provide an overview on clinical-radiologic diagnostic modalities as well as operative and nonoperative treatment strategies, thereby addressing knowledge gaps and controversies in the field of DCM.
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Generic acquisition protocol for quantitative MRI of the spinal cord. Nat Protoc 2021; 16:4611-4632. [PMID: 34400839 PMCID: PMC8811488 DOI: 10.1038/s41596-021-00588-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 06/10/2021] [Indexed: 02/08/2023]
Abstract
Quantitative spinal cord (SC) magnetic resonance imaging (MRI) presents many challenges, including a lack of standardized imaging protocols. Here we present a prospectively harmonized quantitative MRI protocol, which we refer to as the spine generic protocol, for users of 3T MRI systems from the three main manufacturers: GE, Philips and Siemens. The protocol provides guidance for assessing SC macrostructural and microstructural integrity: T1-weighted and T2-weighted imaging for SC cross-sectional area computation, multi-echo gradient echo for gray matter cross-sectional area, and magnetization transfer and diffusion weighted imaging for assessing white matter microstructure. In a companion paper from the same authors, the spine generic protocol was used to acquire data across 42 centers in 260 healthy subjects. The key details of the spine generic protocol are also available in an open-access document that can be found at https://github.com/spine-generic/protocols . The protocol will serve as a starting point for researchers and clinicians implementing new SC imaging initiatives so that, in the future, inclusion of the SC in neuroimaging protocols will be more common. The protocol could be implemented by any trained MR technician or by a researcher/clinician familiar with MRI acquisition.
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Martin AR, Jentzsch T, Wilson JRF, Moghaddamjou A, Jiang F, Rienmueller A, Badhiwala JH, Akbar MA, Nater A, Oitment C, Ganau M, Massicotte EM, Fehlings MG. Inter-rater Reliability of the Modified Japanese Orthopedic Association Score in Degenerative Cervical Myelopathy: A Cross-sectional Study. Spine (Phila Pa 1976) 2021; 46:1063-1069. [PMID: 33492085 DOI: 10.1097/brs.0000000000003956] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cross-sectional blinded-assessor cohort study. OBJECTIVE The aim of this study was to determine the inter-rater reliability of the modified Japanese Orthopaedic Association (mJOA) score in a large cohort of degenerative cervical myelopathy (DCM) patients. SUMMARY OF BACKGROUND DATA The mJOA score is widely accepted as the primary outcome measure in DCM; it has been utilized in clinical practice guidelines and directly influences treatment recommendations, but its reliability has not been established. METHODS A refined version of the mJOA was administered to DCM patients by two or more blinded clinicians. Inter-rater reliability was measured using intraclass correlation coefficient (ICC), agreement, and mean difference for mJOA total score and subscores. Data were also analyzed with analysis of variance for differences by mJOA severity (mild: 15-17, moderate: 12-14, severe: <12), assessor, assessment order, previous surgery, age, and sex. RESULTS One hundred fifty-four DCM patients underwent 322 mJOA assessments (183 paired assessments). ICC was 0.88 for total mJOA, 0.79 for upper extremity (UE) motor, 0.84 for lower extremity (LE) motor, 0.63 for UE sensation, and 0.78 for urinary function subscores. Paired assessments were identical across all four subscores in 25%. The mean difference in mJOA was 0.93 points between assessors, and this differed by severity (mild: 0.68, moderate: 1.24, severe: 0.87, P = 0.001). Differences of ≥ 2 points occurred in 19%. Disagreement between mild and moderate severity occurred in 12% of patients. Other variables did not demonstrate significant relationships with mJOA scores. CONCLUSION The inter-rater reliability of total mJOA and its subscores is good, except for UE sensory function (moderate). However, the vast majority of assessments differed between observers, indicating that this measure should be interpreted carefully, particularly when near the threshold between severity categories, or when a patient is reassessed for deterioration. Further efforts to educate clinicians on administration and to refine the UE sensory subscore may enhance the reliability of this tool.Level of Evidence: 1.
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Affiliation(s)
- Allan R Martin
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Neurological Surgery, University of California - Davis, Sacramento, CA
| | - Thorsten Jentzsch
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Jamie R F Wilson
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- University of Nebraska Medical Center, Omaha, NE
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ali Moghaddamjou
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Fan Jiang
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anna Rienmueller
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jetan H Badhiwala
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad A Akbar
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anick Nater
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Colby Oitment
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mario Ganau
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Eric M Massicotte
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Spinal Program, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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28
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Vallotton K, David G, Hupp M, Pfender N, Cohen-Adad J, Fehlings MG, Samson RS, Wheeler-Kingshott CAMG, Curt A, Freund P, Seif M. Tracking White and Gray Matter Degeneration along the Spinal Cord Axis in Degenerative Cervical Myelopathy. J Neurotrauma 2021; 38:2978-2987. [PMID: 34238034 DOI: 10.1089/neu.2021.0148] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This study aims to determine tissue-specific neurodegeneration across the spinal cord in patients with mild-moderate degenerative cervical myelopathy (DCM). Twenty-four mild-moderate DCM and 24 healthy subjects were recruited. In patients, a T2-weighted scan was acquired at the compression site, whereas in all participants a T2*-weighted and diffusion-weighted scan was acquired at the cervical level (C2-C3) and in the lumbar enlargement (i.e., rostral and caudal to the site of compression). We quantified intramedullary signal changes, maximal canal and cord compression, white (WM) and gray matter (GM) atrophy, and microstructural indices from diffusion-weighted scans. All patients underwent clinical (modified Japanese Orthopaedic Association; mJOA) and electrophysiological assessments. Regression analysis assessed associations between magnetic resonance imaging (MRI) readouts and electrophysiological and clinical outcomes. Twenty patients were classified with mild and 4 with moderate DCM using the mJOA scale. The most frequent site of compression was at the C5-C6 level, with maximum cord compression of 38.73% ± 11.57%. Ten patients showed imaging evidence of cervical myelopathy. In the cervical cord, WM and GM atrophy and WM microstructural changes were evident, whereas in the lumbar cord only WM showed atrophy and microstructural changes. Remote cervical cord WM microstructural changes were pronounced in patients with radiological myelopathy and associated with impaired electrophysiology. Lumbar cord WM atrophy was associated with lower limb sensory impairments. In conclusion, tissue-specific neurodegeneration revealed by quantitative MRI is already apparent across the spinal cord in mild-moderate DCM before the onset of severe clinical impairments. WM microstructural changes are particularly sensitive to remote pathologically and clinically eloquent changes in DCM.
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Affiliation(s)
- Kevin Vallotton
- Spinal Cord Injury Center Balgrist, University of Zurich, Zurich, Switzerland
| | - Gergely David
- Spinal Cord Injury Center Balgrist, University of Zurich, Zurich, Switzerland
| | - Markus Hupp
- Spinal Cord Injury Center Balgrist, University of Zurich, Zurich, Switzerland
| | - Nikolai Pfender
- Spinal Cord Injury Center Balgrist, University of Zurich, Zurich, Switzerland
| | - Julien Cohen-Adad
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, Quebec, Canada.,Functional Neuroimaging Unit, CRIUGM, University of Montreal, Montreal, Quebec, Canada.,Mila-Quebec AI Institute, Montreal, Quebec, Canada
| | - Michael G Fehlings
- Department of Surgery and Spine Program, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Rebecca S Samson
- NMR Research Unit, Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, London, United Kingdom
| | - Claudia A M Gandini Wheeler-Kingshott
- NMR Research Unit, Queen Square MS Centre, UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, London, United Kingdom.,Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.,Brain Connectivity Centre, IRCCS Mondino Foundation, Pavia, Italy
| | - Armin Curt
- Spinal Cord Injury Center Balgrist, University of Zurich, Zurich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center Balgrist, University of Zurich, Zurich, Switzerland.,Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, United Kingdom.,Wellcome Trust Centre for Neuroimaging, Institute of Neurology, University College London, London, United Kingdom
| | - Maryam Seif
- Spinal Cord Injury Center Balgrist, University of Zurich, Zurich, Switzerland.,Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
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29
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Valošek J, Labounek R, Horák T, Horáková M, Bednařík P, Keřkovský M, Kočica J, Rohan T, Lenglet C, Cohen-Adad J, Hluštík P, Vlčková E, Kadaňka Z, Bednařík J, Svatkova A. Diffusion magnetic resonance imaging reveals tract-specific microstructural correlates of electrophysiological impairments in non-myelopathic and myelopathic spinal cord compression. Eur J Neurol 2021; 28:3784-3797. [PMID: 34288268 PMCID: PMC8530898 DOI: 10.1111/ene.15027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/16/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND PURPOSE Non-myelopathic degenerative cervical spinal cord compression (NMDC) frequently occurs throughout aging and may progress to potentially irreversible degenerative cervical myelopathy (DCM). Whereas standard clinical magnetic resonance imaging (MRI) and electrophysiological measures assess compression severity and neurological dysfunction, respectively, underlying microstructural deficits still have to be established in NMDC and DCM patients. The study aims to establish tract-specific diffusion MRI markers of electrophysiological deficits to predict the progression of asymptomatic NMDC to symptomatic DCM. METHODS High-resolution 3 T diffusion MRI was acquired for 103 NMDC and 21 DCM patients compared to 60 healthy controls to reveal diffusion alterations and relationships between tract-specific diffusion metrics and corresponding electrophysiological measures and compression severity. Relationship between the degree of DCM disability, assessed by the modified Japanese Orthopaedic Association scale, and tract-specific microstructural changes in DCM patients was also explored. RESULTS The study identified diffusion-derived abnormalities in the gray matter, dorsal and lateral tracts congruent with trans-synaptic degeneration and demyelination in chronic degenerative spinal cord compression with more profound alterations in DCM than NMDC. Diffusion metrics were affected in the C3-6 area as well as above the compression level at C3 with more profound rostral deficits in DCM than NMDC. Alterations in lateral motor and dorsal sensory tracts correlated with motor and sensory evoked potentials, respectively, whereas electromyography outcomes corresponded with gray matter microstructure. DCM disability corresponded with microstructure alteration in lateral columns. CONCLUSIONS Outcomes imply the necessity of high-resolution tract-specific diffusion MRI for monitoring degenerative spinal pathology in longitudinal studies.
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Affiliation(s)
- Jan Valošek
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czechia.,Department of Biomedical Engineering, University Hospital, Olomouc, Czechia
| | - René Labounek
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czechia.,Division of Clinical Behavioral Neuroscience, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tomáš Horák
- Central European Institute of Technology, Masaryk University, Brno, Czechia.,Department of Neurology, University Hospital Brno, Brno, Czechia.,Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Magda Horáková
- Department of Neurology, University Hospital Brno, Brno, Czechia.,Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petr Bednařík
- Central European Institute of Technology, Masaryk University, Brno, Czechia.,High Field MR Centre, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Miloš Keřkovský
- Faculty of Medicine, Masaryk University, Brno, Czechia.,Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, Czechia
| | - Jan Kočica
- Department of Neurology, University Hospital Brno, Brno, Czechia.,Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Tomáš Rohan
- Faculty of Medicine, Masaryk University, Brno, Czechia.,Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, Czechia
| | - Christophe Lenglet
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Julien Cohen-Adad
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, Quebec, Canada.,Functional Neuroimaging Unit, CRIUGM, University of Montreal, Montreal, Quebec, Canada.,Mila - Quebec AI Institute, Montreal, Quebec, Canada
| | - Petr Hluštík
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czechia
| | - Eva Vlčková
- Department of Neurology, University Hospital Brno, Brno, Czechia.,Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Zdeněk Kadaňka
- Department of Neurology, University Hospital Brno, Brno, Czechia.,Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Josef Bednařík
- Central European Institute of Technology, Masaryk University, Brno, Czechia.,Department of Neurology, University Hospital Brno, Brno, Czechia.,Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Alena Svatkova
- Central European Institute of Technology, Masaryk University, Brno, Czechia.,Department of Medicine III, Clinical Division of Endocrinology and Metabolism, Medical University of Vienna, Vienna, Austria
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30
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Therapeutic repetitive Transcranial Magnetic stimulation (rTMS) for neurological dysfunction in Degenerative cervical Myelopathy: An unexplored opportunity? Findings from a systematic review. J Clin Neurosci 2021; 90:76-81. [PMID: 34275584 DOI: 10.1016/j.jocn.2021.05.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/10/2021] [Indexed: 01/18/2023]
Abstract
Degenerative Cervical Myelopathy (DCM) is one of the commonest causes of non-traumatic Spinal Cord Injury (SCI) leading to significant neurological impairments and reduced health-related quality of life. Guidelines recommend surgical intervention to halt disease progression in moderate-to-severe cases, and whilst many do experience neurological recovery, this is incomplete leading to lifelong disability. A James Lind Alliance (JLA) research priority setting partnership for DCM highlighted novel therapies and rehabilitation as top 10 research priority in DCM. Neurological recovery following decompressive surgery in DCM has been attributed neuroplasticity, and therapies influencing neuroplasticity are of interest. Electrical neuromodulation interventions such as repetitive Transcranial Magnetic Stimulation (rTMS), are being increasingly explored in related fields such as spinal cord injury to improve recovery and symptoms. The aim of this systematic review was to determine the role and efficacy of rTMS as a therapeutic tool in managing neurological dysfunction in DCM. We searched the databases of Medline, EMBASE, CINAHIL and Cochrane Central Register of Controlled Trials (CENTRAL). No studies were identified that had investigated the therapeutic use of rTMS in DCM. A significant number of studies had explored TMS based neurophysiological assessments indicating its role as a screening and prognostication tool in DCM. Post-operative rehabilitation interventions including TMS and non-operative management of DCM is a field which requires further investigation, as required in the AO Spine JLA DCM research priorities. rTMS is a safe neuromodulatory intervention and may have a role in enhancing recovery in DCM. Further research in these fields are required.
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31
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Jimenez KA, Kwon JW, Yoon J, Lee HM, Moon SH, Suk KS, Kim HS, Lee BH. Handgrip Strength Correlated with Falling Risk in Patients with Degenerative Cervical Myelopathy. J Clin Med 2021; 10:jcm10091980. [PMID: 34062994 PMCID: PMC8125546 DOI: 10.3390/jcm10091980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/30/2021] [Accepted: 04/30/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Few studies have investigated associations between hand grip strength (HGS) and the surgical outcomes of degenerative cervical myelopathy (DCM). Methods: This study was designed as a prospective observational study of 203 patients who had undergone fusion surgery for DCM. We divided the patients according to sex and HGS differences. Clinical outcome parameters, including HGS, a fall diary and four functional mobility tests (alternative step test, six-meter walk test, timed up and go test, and sit-to-stand test) were measured preoperatively, at 3 months and 1 year after surgery. Results: Mean patient ages were 59.93 years in the male group and 67.33 years in the female group (p = 0.000; independent t-test). The mean HGS of both hands improved significantly at postoperative 3 months and 1 year in all patients (p = 0.000 for both; ANOVA). In male patients, preoperative risk of falls was negatively correlated with HGS (p = 0.000). In female patients, pre- and postoperative risk of falls were correlated negatively with HGS (p = 0.000). The postoperative incidence of falls decreased in both groups (p = 0.000) Conclusions: Postoperative HGS in patients with DCM is correlated with postoperative falls and functional outcome differently, when comparing male and female patients, for predicting favorable outcomes and neurologic deficit recovery after surgery in DCM patients.
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Affiliation(s)
- Kathryn Anne Jimenez
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Ji-Won Kwon
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Jayeong Yoon
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Hwan-Mo Lee
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Seong-Hwan Moon
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Kyung-Soo Suk
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Hak-Sun Kim
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
| | - Byung Ho Lee
- Orthopedic Department, College of Medicine, Yonsei University, Seoul 03722, Korea
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32
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Martin AR, Kalsi-Ryan S, Akbar MA, Rienmueller AC, Badhiwala JH, Wilson JR, Tetreault LA, Nouri A, Massicotte EM, Fehlings MG. Clinical outcomes of nonoperatively managed degenerative cervical myelopathy: an ambispective longitudinal cohort study in 117 patients. J Neurosurg Spine 2021:1-9. [PMID: 33836502 DOI: 10.3171/2020.9.spine201395] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/16/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Degenerative cervical myelopathy (DCM) is among the most common pathologies affecting the spinal cord but its natural history is poorly characterized. The purpose of this study was to investigate functional outcomes in patients with DCM who were managed nonoperatively as well as the utility of quantitative clinical measures and MRI to detect deterioration. METHODS Patients with newly diagnosed DCM or recurrent myelopathic symptoms after previous surgery who were initially managed nonoperatively were included. Retrospective chart reviews were performed to analyze clinical outcomes and anatomical MRI scans for worsening compression or increased signal change. Quantitative neurological assessments were collected prospectively, including modified Japanese Orthopaedic Association (mJOA) score; Quick-DASH; graded redefined assessment of strength, sensation, and prehension-myelopathy version (GRASSP-M: motor, sensory, and dexterity); grip dynamometer; Berg balance scale score; gait stability ratio; and gait variability index. A deterioration of 10% was considered significant (e.g., a 2-point decrease in mJOA score). RESULTS A total of 117 patients were included (95 newly diagnosed, 22 recurrent myelopathy), including 74 mild, 28 moderate, and 15 severe cases. Over a mean follow-up of 2.5 years, 57% (95% CI 46%-67%) of newly diagnosed patients and 73% (95% CI 50%-88%) of patients with recurrent DCM deteriorated neurologically. Deterioration was best detected with grip strength (60%), GRASSP dexterity (60%), and gait stability ratio (50%), whereas the mJOA score had low sensitivity (33%) in 50 patients. A composite score had a sensitivity of 81% and a specificity of 82%. The sensitivity of anatomical MRI was 28% (83 patients). CONCLUSIONS DCM appears to have a poor natural history; however, prospective studies are needed for validation. Serial assessments should include mJOA score, grip strength, dexterity, balance, and gait analysis. The absence of worsening on anatomical MRI or in mJOA scores is not sufficient to determine clinical stability.
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Affiliation(s)
- Allan R Martin
- 1Division of Neurosurgery, Department of Surgery, University of Toronto.,2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto
| | - Sukhvinder Kalsi-Ryan
- 3KITE Research Institute, University Health Network, Toronto.,4Department of Physical Therapy, University of Toronto, Ontario, Canada
| | - Muhammad A Akbar
- 1Division of Neurosurgery, Department of Surgery, University of Toronto.,2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto
| | - Anna C Rienmueller
- 2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto
| | - Jetan H Badhiwala
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
| | | | - Lindsay A Tetreault
- 2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto.,5Graduate Entry Medicine, University College Cork, Ireland; and
| | - Aria Nouri
- 6Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
| | - Eric M Massicotte
- 1Division of Neurosurgery, Department of Surgery, University of Toronto.,2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto
| | - Michael G Fehlings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto.,2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto
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33
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Ost K, Jacobs WB, Evaniew N, Cohen-Adad J, Anderson D, Cadotte DW. Spinal Cord Morphology in Degenerative Cervical Myelopathy Patients; Assessing Key Morphological Characteristics Using Machine Vision Tools. J Clin Med 2021; 10:jcm10040892. [PMID: 33672259 PMCID: PMC7926672 DOI: 10.3390/jcm10040892] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 02/16/2021] [Accepted: 02/18/2021] [Indexed: 11/29/2022] Open
Abstract
Despite Degenerative Cervical Myelopathy (DCM) being the most common form of spinal cord injury, effective methods to evaluate patients for its presence and severity are only starting to appear. Evaluation of patient images, while fast, is often unreliable; the pathology of DCM is complex, and clinicians often have difficulty predicting patient prognosis. Automated tools, such as the Spinal Cord Toolbox (SCT), show promise, but remain in the early stages of development. To evaluate the current state of an SCT automated process, we applied it to MR imaging records from 328 DCM patients, using the modified Japanese Orthopedic Associate scale as a measure of DCM severity. We found that the metrics extracted from these automated methods are insufficient to reliably predict disease severity. Such automated processes showed potential, however, by highlighting trends and barriers which future analyses could, with time, overcome. This, paired with findings from other studies with similar processes, suggests that additional non-imaging metrics could be added to achieve diagnostically relevant predictions. Although modeling techniques such as these are still in their infancy, future models of DCM severity could greatly improve automated clinical diagnosis, communications with patients, and patient outcomes.
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Affiliation(s)
- Kalum Ost
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - W. Bradley Jacobs
- Department of Clinical Neurosciences, Section of Neurosurgery, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
- Combined Orthopedic and Neurosurgery Spine Program, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Nathan Evaniew
- Combined Orthopedic and Neurosurgery Spine Program, University of Calgary, Calgary, AB T2N 1N4, Canada;
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Julien Cohen-Adad
- NeuroPoly Lab, Institute of Biomedical Engineering, Polytechnique Montrèal, Montrèal, QC H3T 1J4, Canada;
- Functional Neuroimaging Unit, CRIUGM, Universitè de Montrèal, Montrèal, QC H3T 1J4, Canada
- Mila-Quebec AI Institute, Montrèal, QC T2N 1N4, Canada
| | - David Anderson
- Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - David W. Cadotte
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
- Combined Orthopedic and Neurosurgery Spine Program, University of Calgary, Calgary, AB T2N 1N4, Canada;
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada;
- Correspondence: ; Tel.: +403-944-3490
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34
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Hupp M, Pfender N, Vallotton K, Rosner J, Friedl S, Zipser CM, Sutter R, Klarhöfer M, Spirig JM, Betz M, Schubert M, Freund P, Farshad M, Curt A. The Restless Spinal Cord in Degenerative Cervical Myelopathy. AJNR Am J Neuroradiol 2021; 42:597-609. [PMID: 33541903 DOI: 10.3174/ajnr.a6958] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 10/12/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The spinal cord is subject to a periodic, cardiac-related movement, which is increased at the level of a cervical stenosis. Increased oscillations may exert mechanical stress on spinal cord tissue causing intramedullary damage. Motion analysis thus holds promise as a biomarker related to disease progression in degenerative cervical myelopathy. Our aim was characterization of the cervical spinal cord motion in patients with degenerative cervical myelopathy. MATERIALS AND METHODS Phase-contrast MR imaging data were analyzed in 55 patients (37 men; mean age, 56.2 [SD,12.0] years; 36 multisegmental stenoses) and 18 controls (9 men, P = .368; mean age, 62.2 [SD, 6.5] years; P = .024). Parameters of interest included the displacement and motion pattern. Motion data were pooled on the segmental level for comparison between groups. RESULTS In patients, mean craniocaudal oscillations were increased manifold at any level of a cervical stenosis (eg, C5 displacement: controls [n = 18], 0.54 [SD, 0.16] mm; patients [n = 29], monosegmental stenosis [n = 10], 1.86 [SD, 0.92] mm; P < .001) and even in segments remote from the level of the stenosis (eg, C2 displacement: controls [n = 18], 0.36 [SD, 0.09] mm; patients [n = 52]; stenosis: C3, n = 21; C4, n = 11; C5, n = 18; C6, n = 2; 0.85 [SD, 0.46] mm; P < .001). Motion at C2 differed with the distance to the next stenotic segment and the number of stenotic segments. The motion pattern in most patients showed continuous spinal cord motion throughout the cardiac cycle. CONCLUSIONS Patients with degenerative cervical myelopathy show altered spinal cord motion with increased and ongoing oscillations at and also beyond the focal level of stenosis. Phase-contrast MR imaging has promise as a biomarker to reveal mechanical stress to the cord and may be applicable to predict disease progression and the impact of surgical interventions.
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Affiliation(s)
- M Hupp
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.)
| | - N Pfender
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.)
| | - K Vallotton
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.)
| | - J Rosner
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.).,Department of Neurology (J.R.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - S Friedl
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.)
| | - C M Zipser
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.)
| | | | - M Klarhöfer
- Siemens Healthcare AG (M.K.), Zurich, Switzerland
| | - J M Spirig
- University Spine Center Zurich (J.M.S., M.B., M.F., A.C.), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - M Betz
- University Spine Center Zurich (J.M.S., M.B., M.F., A.C.), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - M Schubert
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.)
| | - P Freund
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.)
| | - M Farshad
- University Spine Center Zurich (J.M.S., M.B., M.F., A.C.), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - A Curt
- From the Spinal Cord Injury Center (M.H., N.P., K.V., J.R., S.F., C.M.Z., M.S., P.F., A.C.).,University Spine Center Zurich (J.M.S., M.B., M.F., A.C.), Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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35
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Fischer T, Stern C, Freund P, Schubert M, Sutter R. Wallerian degeneration in cervical spinal cord tracts is commonly seen in routine T2-weighted MRI after traumatic spinal cord injury and is associated with impairment in a retrospective study. Eur Radiol 2020; 31:2923-2932. [PMID: 33125565 PMCID: PMC8043949 DOI: 10.1007/s00330-020-07388-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 08/09/2020] [Accepted: 10/07/2020] [Indexed: 11/17/2022]
Abstract
Objectives Wallerian degeneration (WD) is a well-known process after nerve injury. In this study, occurrence of remote intramedullary signal changes, consistent with WD, and its correlation with clinical and neurophysiological impairment were assessed after traumatic spinal cord injury (tSCI). Methods In 35 patients with tSCI, WD was evaluated by two radiologists on T2-weighted images of serial routine MRI examinations of the cervical spine. Dorsal column (DC), lateral corticospinal tract (CS), and lateral spinothalamic tract (ST) were the analyzed anatomical regions. Impairment scoring according to the American Spinal Injury Association Impairment Scale (AIS, A–D) as well as a scoring system (0–4 points) for motor evoked potential (MEP) and sensory evoked potential (SEP) was included. Mann-Whitney U test was used to test for differences. Results WD in the DC occurred in 71.4% (n = 25), in the CS in 57.1% (n = 20), and in 37.1% (n = 13) in the ST. With WD present, AIS grades were worse for all tracts. DC: median AIS B vs D, p < 0.001; CS: B vs D, p = 0.016; and ST: B vs D, p = 0.015. More pathological MEP scores correlated with WD in the DC (median score 0 vs 3, p < 0.001) and in the CS (0 vs 2, p = 0.032). SEP scores were lower with WD in the DC only (1 vs 2, p = 0.031). Conclusions WD can be detected on T2-weighted scans in the majority of cervical spinal cord injury patients and should be considered as a direct effect of the trauma. When observed, it is associated with higher degree of impairment. Key Points • Wallerian degeneration is commonly seen in routine MRI after traumatic spinal cord injury. • Wallerian degeneration is visible in the anatomical regions of the dorsal column, the lateral corticospinal tract, and the lateral spinothalamic tract. • Presence of Wallerian degeneration is associated with higher degree of impairment.
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Affiliation(s)
- Tim Fischer
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Christoph Stern
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
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Labounek R, Valošek J, Horák T, Svátková A, Bednařík P, Vojtíšek L, Horáková M, Nestrašil I, Lenglet C, Cohen-Adad J, Bednařík J, Hluštík P. HARDI-ZOOMit protocol improves specificity to microstructural changes in presymptomatic myelopathy. Sci Rep 2020; 10:17529. [PMID: 33067520 PMCID: PMC7567840 DOI: 10.1038/s41598-020-70297-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/21/2020] [Indexed: 12/12/2022] Open
Abstract
Diffusion magnetic resonance imaging (dMRI) proved promising in patients with non-myelopathic degenerative cervical cord compression (NMDCCC), i.e., without clinically manifested myelopathy. Aim of the study is to present a fast multi-shell HARDI-ZOOMit dMRI protocol and validate its usability to detect microstructural myelopathy in NMDCCC patients. In 7 young healthy volunteers, 13 age-comparable healthy controls, 18 patients with mild NMDCCC and 15 patients with severe NMDCCC, the protocol provided higher signal-to-noise ratio, enhanced visualization of white/gray matter structures in microstructural maps, improved dMRI metric reproducibility, preserved sensitivity (SE = 87.88%) and increased specificity (SP = 92.31%) of control-patient group differences when compared to DTI-RESOLVE protocol (SE = 87.88%, SP = 76.92%). Of the 56 tested microstructural parameters, HARDI-ZOOMit yielded significant patient-control differences in 19 parameters, whereas in DTI-RESOLVE data, differences were observed in 10 parameters, with mostly lower robustness. Novel marker the white-gray matter diffusivity gradient demonstrated the highest separation. HARDI-ZOOMit protocol detected larger number of crossing fibers (5–15% of voxels) with physiologically plausible orientations than DTI-RESOLVE protocol (0–8% of voxels). Crossings were detected in areas of dorsal horns and anterior white commissure. HARDI-ZOOMit protocol proved to be a sensitive and practical tool for clinical quantitative spinal cord imaging.
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Affiliation(s)
- René Labounek
- Department of Biomedical Engineering, University Hospital Olomouc, 779 00, Olomouc, Czech Republic.,Department of Neurology, Palacký University, 779 00, Olomouc, Czech Republic.,Division of Clinical Behavioral Neuroscience, Department of Pediatrics, University of Minnesota, Minneapolis, MN, 55414, USA
| | - Jan Valošek
- Department of Biomedical Engineering, University Hospital Olomouc, 779 00, Olomouc, Czech Republic.,Department of Neurology, Palacký University, 779 00, Olomouc, Czech Republic
| | - Tomáš Horák
- Central European Institute of Technology, Masaryk University, 625 00, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, 625 00, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Alena Svátková
- Central European Institute of Technology, Masaryk University, 625 00, Brno, Czech Republic.,Department of Medicine III, Clinical Division of Endocrinology and Metabolism, Medical University of Vienna, 1090, Vienna, Austria.,Department of Imaging Methods, Faculty of Medicine, University of Ostrava, 701 03, Ostrava, Czech Republic
| | - Petr Bednařík
- Central European Institute of Technology, Masaryk University, 625 00, Brno, Czech Republic.,High Field MR Centre, Medical University of Vienna, Vienna, Austria
| | - Lubomír Vojtíšek
- Central European Institute of Technology, Masaryk University, 625 00, Brno, Czech Republic
| | - Magda Horáková
- Central European Institute of Technology, Masaryk University, 625 00, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, 625 00, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Igor Nestrašil
- Division of Clinical Behavioral Neuroscience, Department of Pediatrics, University of Minnesota, Minneapolis, MN, 55414, USA.,Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, 55414, USA
| | - Christophe Lenglet
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, 55414, USA
| | - Julien Cohen-Adad
- Institute of Biomedical Engineering, Polytechnique Montreal, Montreal, Canada
| | - Josef Bednařík
- Central European Institute of Technology, Masaryk University, 625 00, Brno, Czech Republic.,Department of Neurology, University Hospital Brno, 625 00, Brno, Czech Republic.,Faculty of Medicine, Masaryk University, 625 00, Brno, Czech Republic
| | - Petr Hluštík
- Department of Neurology, Palacký University, 779 00, Olomouc, Czech Republic. .,Department of Neurology, University Hospital Olomouc, 779 00, Olomouc, Czech Republic.
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Moghaddamjou A, Wilson JRF, Martin AR, Gebhard H, Fehlings MG. Multidisciplinary approach to degenerative cervical myelopathy. Expert Rev Neurother 2020; 20:1037-1046. [PMID: 32683993 DOI: 10.1080/14737175.2020.1798231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Degenerative cervical myelopathy (DCM) is a prevalent condition causing significant impairment spanning several domains of health. A multidisciplinary approach to the care of DCM would be ideal in utilizing complex treatments from different disciplines to address broad patient needs. AREAS COVERED In this article the authors will discuss the importance of multidisciplinary care and establish a general framework for its use. The authors will then highlight the potential role of a multidisciplinary team in each aspect of DCM care including assessment, diagnosis, decision-making, surgical intervention, non-operative therapy, monitoring, and postoperative care. EXPERT OPINION In order to provide comprehensive personalized care to DCM patients, it is necessary to have a multidisciplinary team composed by a combination of the patient, surgeon, primary care practitioner, neurologist, anesthesiologist, radiologist, physiatrist, nurses, physiotherapist, occupational therapist, pain specialist, and social workers all functioning independently and communicating to achieve a common goal.
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Affiliation(s)
- Ali Moghaddamjou
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto , Toronto, Ontario, Canada
| | - Jamie R F Wilson
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto , Toronto, Ontario, Canada.,Spinal Program, Toronto Western Hospital, University Health Network , Toronto, Ontario, Canada
| | - Allan R Martin
- Spinal Program, Toronto Western Hospital, University Health Network , Toronto, Ontario, Canada
| | - Harry Gebhard
- Department of Surgery, Canton Hospital Baden , Baden, Switzerland.,Department of Trauma, University Hospital Zurich, University of Zurich , Zurich, Switzerland
| | - Michael G Fehlings
- Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto , Toronto, Ontario, Canada.,Spinal Program, Toronto Western Hospital, University Health Network , Toronto, Ontario, Canada
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Jannelli G, Nouri A, Molliqaj G, Grasso G, Tessitore E. Degenerative Cervical Myelopathy: Review of Surgical Outcome Predictors and Need for Multimodal Approach. World Neurosurg 2020; 140:541-547. [PMID: 32389875 DOI: 10.1016/j.wneu.2020.04.233] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/12/2022]
Abstract
Degenerative cervical myelopathy is the most common cause of spinal cord injury in the elderly population in the developed world, and it significantly affects the quality of life of patients and their caregivers. Surgery remains the only treatment option able to halt disease progression and provide neurological recovery for most patients. Although it has remained challenging to predict exactly who will experience improvement after surgery, increasingly it has been shown that clinical, imaging, and electrophysiological factors can predict, with relatively good capacity, those more likely to benefit. Clinically, the baseline neurological impairment appears to be strongly related to the outcome, and the magnetic resonance imaging findings of T1-weighted hypointensity and the length of T2-weighted hyperintensity appear to be the most prognostic. In this context, electrophysiology findings (both motor and sensory evoked potentials) have shown some predictive capacity. However, large studies are lacking. Although multivariate models have been conducted using clinical and magnetic resonance imaging data, no multimodal prediction models are available that encompass the predictive capacity of clinical, imaging, and electrophysiological data. In the present review, we examined the rationale for clinical, imaging, and electrophysiological usage in clinical practice and discussed a model of multimodal assessment for the management of degenerative cervical myelopathy.
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Affiliation(s)
- Gianpaolo Jannelli
- Neurosurgical Unit, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland.
| | - Aria Nouri
- Neurosurgical Unit, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Granit Molliqaj
- Neurosurgical Unit, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Giovanni Grasso
- Section of Neurosurgery, Department of Biomedicine, Neurosciences and Advanced Diagnostics, University of Palermo, Palermo, Italy
| | - Enrico Tessitore
- Neurosurgical Unit, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland
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Degenerative Cervical Myelopathy: A Brief Review of Past Perspectives, Present Developments, and Future Directions. J Clin Med 2020; 9:jcm9020535. [PMID: 32079075 PMCID: PMC7073521 DOI: 10.3390/jcm9020535] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/30/2020] [Accepted: 02/13/2020] [Indexed: 01/15/2023] Open
Abstract
Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord injury in developed countries; its prevalence is increasing due to the ageing of the population. DCM causes neurological dysfunction and is a significant cause of disability in the elderly. It has important negative impacts on the quality of life of those affected, as well as on their caregivers. DCM is triggered by a variety of degenerative changes in the neck, which affect one or more anatomical structures, including intervertebral discs, vertebrae, and spinal canal ligaments. These changes can also lead to structural abnormalities, leading to alterations in alignment, mobility, and stability. The principle unifying problem in this disease, regardless of the types of changes present, is injury to the spinal cord due to compression by static and/or dynamic forces. This review is partitioned into three segments that focus on key elements of the past, the present, and the future in the field, which serve to introduce the focus issue on "Degenerative Cervical Myelopathy and the Aging Spine". Emerging from this review is that tremendous progress has been made in the field, particularly in recent years, and that there are exciting possibilities for further advancements of patient care.
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Lévy S, Rapacchi S, Massire A, Troalen T, Feiweier T, Guye M, Callot V. Intravoxel Incoherent Motion at 7 Tesla to quantify human spinal cord perfusion: limitations and promises. Magn Reson Med 2020; 84:1198-1217. [DOI: 10.1002/mrm.28195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/16/2019] [Accepted: 01/10/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Simon Lévy
- Aix‐Marseille Univ, CNRS, CRMBM Marseille France
- APHM, Hopital Universitaire Timone, CEMEREM Marseille France
- Aix‐Marseille Univ, IFSTTAR, LBA Marseille France
- iLab‐Spine International Associated Laboratory Marseille‐Montreal France‐Canada
| | - Stanislas Rapacchi
- Aix‐Marseille Univ, CNRS, CRMBM Marseille France
- APHM, Hopital Universitaire Timone, CEMEREM Marseille France
| | - Aurélien Massire
- Aix‐Marseille Univ, CNRS, CRMBM Marseille France
- APHM, Hopital Universitaire Timone, CEMEREM Marseille France
- iLab‐Spine International Associated Laboratory Marseille‐Montreal France‐Canada
| | | | | | - Maxime Guye
- Aix‐Marseille Univ, CNRS, CRMBM Marseille France
- APHM, Hopital Universitaire Timone, CEMEREM Marseille France
| | - Virginie Callot
- Aix‐Marseille Univ, CNRS, CRMBM Marseille France
- APHM, Hopital Universitaire Timone, CEMEREM Marseille France
- iLab‐Spine International Associated Laboratory Marseille‐Montreal France‐Canada
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41
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Degenerative cervical myelopathy - update and future directions. Nat Rev Neurol 2020; 16:108-124. [PMID: 31974455 DOI: 10.1038/s41582-019-0303-0] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2019] [Indexed: 11/09/2022]
Abstract
Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.
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Seif M, David G, Huber E, Vallotton K, Curt A, Freund P. Cervical Cord Neurodegeneration in Traumatic and Non-Traumatic Spinal Cord Injury. J Neurotrauma 2019; 37:860-867. [PMID: 31544628 PMCID: PMC7071087 DOI: 10.1089/neu.2019.6694] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This study aimed to compare macrostructural and microstructural neurodegenerative changes remote from a cervical spinal cord injury in traumatic spinal cord injury (tSCI) and degenerative cervical myelopathy (DCM) patients using quantitative magnetic resonance imaging (MRI). Twenty-nine tSCI patients, 20 mild/moderate DCM patients, and 22 healthy controls underwent a high-resolution MRI protocol at the cervical cord (C2/C3). High-resolution T2*-weighted and diffusion-weighted scans provided data to calculate tissue-specific cross-sectional areas of the spinal cord and tract-specific diffusion indices of cord white matter, respectively. Regression analysis determined associations between neurodegeneration and clinical impairment. tSCI patients showed more impairment in upper limb strength and manual dexterity when compared with DCM patients. While macrostructural MRI measures revealed a similar extent of remote cord atrophy at cervical level, microstructural measures (diffusion indices) were able to distinguish more pronounced tract-specific neurodegeneration in tSCI patients when compared with DCM patients. Tract-specific neurodegeneration was associated with upper limb impairment. Despite clinical differences between severely impaired tSCI compared with mildly affected DCM patient, extensive cord atrophy is present remotely from the focal spinal cord injury. Diffusion indices revealed greater tract-specific alterations in tSCI patients. Therefore, diffusion indices are more sensitive than macrostructural MRI measures as these are able to distinguish between traumatic and non-traumatic spinal cord injury. Neuroimaging biomarkers of cervical cord integrity hold potential as predictors of recovery and might be suitable biomarkers for interventional trials both in traumatic and non-traumatic SCI.
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Affiliation(s)
- Maryam Seif
- Spinal Cord Injury Center, Balgrist University Hospital, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Gergely David
- Spinal Cord Injury Center, Balgrist University Hospital, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Eveline Huber
- Spinal Cord Injury Center, Balgrist University Hospital, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Kevin Vallotton
- Spinal Cord Injury Center, Balgrist University Hospital, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Patrick Freund
- Spinal Cord Injury Center, Balgrist University Hospital, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London, United Kingdom.,Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Cadotte DW, Akbar MA, Fehlings MG, Stroman PW, Cohen-Adad J. What Has Been Learned from Magnetic Resonance Imaging Examination of the Injured Human Spinal Cord: A Canadian Perspective. J Neurotrauma 2019; 35:1942-1957. [PMID: 30074873 DOI: 10.1089/neu.2018.5903] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- David W Cadotte
- 1 University of Calgary Spine Program, Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary , Foothills Medical Centre, Calgary, Alberta, Canada
| | - M Ali Akbar
- 2 Department of Surgery, Division of Neurosurgery and Spinal Program, Toronto Western Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Michael G Fehlings
- 2 Department of Surgery, Division of Neurosurgery and Spinal Program, Toronto Western Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Patrick W Stroman
- 3 Centre for Neuroscience Studies, Queens University , Kingston, Ontario, Canada
| | - Julien Cohen-Adad
- 4 NeuroPoly Lab, Institute of Biomedical Engineering , Polytechnique Montreal, Montreal, Quebéc, Canada .,5 Functional Neuroimaging Unit, CRIUGM, Université de Montréal , Montreal, Quebéc, Canada
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Duration of symptoms in the quantification of upper limb disability and impairment for individuals with mild degenerative cervical myelopathy (DCM). PLoS One 2019; 14:e0222134. [PMID: 31498813 PMCID: PMC6733515 DOI: 10.1371/journal.pone.0222134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/22/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives Degenerative cervical myelopathy (DCM) involves spinal cord compression, which causes neurological decline. Neurological impairment in DCM is variable and can involve complex upper limb dysfunction including loss of manual dexterity, hyper-reflexia, focal weakness, and sensory impairment. DCM can cause progressive loss of manual dexterity, reduced upper limb (UL) function and disability. The purpose of this study was to define relationships between impairment and disability of the UL and determine the impact of duration of symptoms on disease severity. Design An observational cross-sectional study quantifying disease severity, UL impairment and disability at time of diagnosis was conducted. A second observational longitudinal cohort was studied at the time of diagnosis and 1 year later. Setting Toronto Western Hospital, Spine Program. Subjects The cross sectional study included 140 study subjects diagnosed with mild, moderate or severe DCM. For the longitudinal study, 61 study subjects with mild DCM were enrolled and split into two groups, one group with less than 12 months of symptom duration and more than 12 months. Main measures Modified Japanese Orthopaedic Assessment (mJOA); Graded Redefined Assessment of Sensation, Strength and Prehension (GRASSP); Quick Disability of the Arm, Shoulder and Hand (QuickDASH). Results Pearson correlation coefficients between GRASSP and QuickDASH revealed significant relationships between strength, sensation and dexterity for all patients to varying degrees. The covariate (mJOA) was significantly related to QuickDASH, indicating duration of symptoms has an important effect on UL disability in the mild severity group. Conclusions Strength, sensation and dexterity play a defining role in disability of the UL across all severities of DCM and are discriminant measures. Duration of symptoms has a significant impact on self-perceived disability, where a longer duration in mild patients results in diminished disability, suggesting adaptation. Duration of symptoms is an important factor to consider in the treatment plan for patients with mild disease.
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Freund P, Thompson A, Curt A, Hupp M, Weiskopf N, Grabher P, Altmann D, Friston K, Ashburner J, Ziegler G. Author response: Progressive neurodegeneration following spinal cord injury: Implications for clinical trials. Neurology 2019; 91:985. [PMID: 30455260 DOI: 10.1212/wnl.0000000000006540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Segmental differences of cervical spinal cord motion: advancing from confounders to a diagnostic tool. Sci Rep 2019; 9:7415. [PMID: 31092891 PMCID: PMC6520379 DOI: 10.1038/s41598-019-43908-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/02/2019] [Indexed: 01/01/2023] Open
Abstract
Increased cranio-caudal spinal cord motion is associated with clinical impairment in degenerative cervical myelopathy. However, whether spinal cord motion holds potential as a neuroimaging biomarker requires further validation. Different confounders (i.e. subject characteristics, methodological problems such as phase drift, etc.) on spinal cord motion readouts have to be considered. Twenty-two healthy subjects underwent phase contrast MRI, a subset of subjects (N = 9) had repeated scans. Parameters of interest included amplitude of velocity signal, maximum cranial respectively maximum caudal velocity, displacement (=area under curve of the velocity signal). The cervical spinal cord showed pulse synchronic oscillatory motions with significant differences in all readouts across cervical segments, with a maximum at C5. The Inter-rater reliability was excellent for all readouts. The test-retest reliability was excellent for all parameters at C2 to C6, but not for maximum cranial velocity at C6 and all readouts at C7. Spinal cord motion was correlated with spinal canal size, heart rate and body size. This is the first study to propose a standardized MRI measurement of spinal cord motion for further clinical implementation based on satisfactory phase drift correction and excellent reliability. Understanding the influence of confounders (e.g. structural conditions of the spine) is essential for introducing cord motion into the diagnostic work up.
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Abstract
Persistent spinal (traumatic and nontraumatic) pain is common and contributes to high societal and personal costs globally. There is an acknowledged urgency for new and interdisciplinary approaches to the condition, and soft tissues, including skeletal muscles, the spinal cord, and the brain, are rightly receiving increased attention as important biological contributors. In reaction to the recent suspicion and questioned value of imaging-based findings, this paper serves to recognize the promise that the technological evolution of imaging techniques, and particularly magnetic resonance imaging, is allowing in characterizing previously less visible morphology. We emphasize the value of quantification and data analysis of several contributors in the biopsychosocial model for understanding spinal pain. Further, we highlight emerging evidence regarding the pathobiology of changes to muscle composition (eg, atrophy, fatty infiltration), as well as advancements in neuroimaging and musculoskeletal imaging techniques (eg, fat-water imaging, functional magnetic resonance imaging, diffusion imaging, magnetization transfer imaging) for these important soft tissues. These noninvasive and objective data sources may complement known prognostic factors of poor recovery, patient self-report, diagnostic tests, and the "-omics" fields. When combined, advanced "big-data" analyses may assist in identifying associations previously not considered. Our clinical commentary is supported by empirical findings that may orient future efforts toward collaborative conversation, hypothesis generation, interdisciplinary research, and translation across a number of health fields. Our emphasis is that magnetic resonance imaging technologies and research are crucial to the advancement of our understanding of the complexities of spinal conditions. J Orthop Sports Phys Ther 2019;49(5):320-329. Epub 26 Mar 2019. doi:10.2519/jospt.2019.8793.
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Papinutto N, Henry RG. Evaluation of Intra- and Interscanner Reliability of MRI Protocols for Spinal Cord Gray Matter and Total Cross-Sectional Area Measurements. J Magn Reson Imaging 2019; 49:1078-1090. [PMID: 30198209 PMCID: PMC6620602 DOI: 10.1002/jmri.26269] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND In vivo quantification of spinal cord atrophy in neurological diseases using MRI has attracted increasing attention. PURPOSE To compare across different platforms the most promising imaging techniques to assess human spinal cord atrophy. STUDY TYPE Test/retest multiscanner study. SUBJECTS Twelve healthy volunteers. FIELD STRENGTH/SEQUENCE Three different 3T scanner platforms (Siemens, Philips, and GE) / optimized phase sensitive inversion recovery (PSIR), T1 -weighted (T1 -w), and T2 *-weighted (T2 *-w) protocols. ASSESSMENT On all images acquired, two operators assessed contrast-to-noise ratio (CNR) between gray matter (GM) and white matter (WM), and between WM and cerebrospinal fluid (CSF); one experienced operator measured total cross-sectional area (TCA) and GM area using JIM and the Spinal Cord Toolbox (SCT). STATISTICAL TESTS Coefficient of variation (COV); intraclass correlation coefficient (ICC); mixed effect models; analysis of variance (t-tests). RESULTS For all the scanners, GM/WM CNR was higher for PSIR than T2 *-w (P < 0.0001) and WM/CSF CNR for T1 -w was the highest (P < 0.0001). For TCA, using JIM, median COVs were smaller than 1.5% and ICC >0.95, while using SCT, median COVs were in the range 2.2-2.75% and ICC 0.79-0.95. For GM, despite some failures of the automatic segmentation, median COVs using SCT on T2 *-w were smaller than using JIM manual PSIR segmentations. In the mixed effect models, the subject was always the main contributor to the variance of area measurements and scanner often contributed to TCA variance (P < 0.05). Using JIM, TCA measurements on T2 *-w were different than on PSIR (P = 0.0021) and T1 -w (P = 0.0018), while using SCT, no notable differences were found between T1 -w and T2 *-w (P = 0.18). JIM and SCT-derived TCA were not different on T1 -w (P = 0.66), while they were different for T2 *-w (P < 0.0001). GM area derived using SCT/T2 *-w versus JIM/PSIR were different (P < 0.0001). DATA CONCLUSION The present work sets reference values for the magnitude of the contribution of different effects to cord area measurement intra- and interscanner variability. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 4 J. Magn. Reson. Imaging 2019;49:1078-1090.
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Affiliation(s)
- Nico Papinutto
- Department of NeurologyUniversity of California San Francisco94158San FranciscoCAUSA
| | - Roland G. Henry
- Department of NeurologyUniversity of California San Francisco94158San FranciscoCAUSA
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