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Baram A, Capo G, Riva M, Brembilla C, Rosellini E, De Robertis M, Servadei F, Pessina F, Fornari M. Monocentric Retrospective Analysis of Clinical Outcomes, Complications, and Adjacent Segment Disease in 507 Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Myelopathy. World Neurosurg 2024:S1878-8750(24)01219-1. [PMID: 39019433 DOI: 10.1016/j.wneu.2024.07.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 07/08/2024] [Accepted: 07/09/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Degenerative cervical myelopathy (DCM) is a leading cause of nontraumatic spinal cord injury. Surgery aims to arrest neurological decline and improve conditions, but controversies surround risks and benefits in elderly patients, outcomes in mild myelopathy, and the risk of adjacent segment disease (ASD). METHODS Retrospective data of patients who underwent anterior cervical discectomy and fusion for DCM in our hospital were collected. Patients were stratified by preoperative modified Japanese Orthopaedic Association (mJOA) (mild, moderate, severe) and age (under 70, over 70). Clinical outcomes, complications, and ASD rate were analyzed. We evaluated the relationship between mJOA recovery rate and the risk of complications and various preoperative parameters. RESULTS Five hundred seven consecutive patients were included in the study, with a mean follow-up of 43.52 months (12-71). Improvement in all outcome variables was observed in mild, moderate, and severe myelopathy categories, with elderly patients showing a lower improvement. Except for age, no other variable correlated with mJOA recovery rate. We observed 45 complications (11.1% of patients), with 14 in the U70 group and 31 in the O70 group (P value < 0.001). Age, Charlson comorbidity index, and ASA score were found to be predictors of complications. Fourteen patients (2.8% of total), mean age 54.2, developed radiological and clinical ASD. Most had cranial-level ASD with Pfirmann grade ≥ 2 before index surgery. CONCLUSIONS Most myelopathic patients improve after anterior cervical discectomy and fusion. Elderly patients show a lower improvement and higher complication rates than their younger counterparts. ASD rates are low, and younger patients with preexisting cranial level alterations are more susceptible.
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Affiliation(s)
- Ali Baram
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.
| | - Gabriele Capo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Marco Riva
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Carlo Brembilla
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Elena Rosellini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Mario De Robertis
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Franco Servadei
- Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Neurosurgery, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Maurizio Fornari
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Chernysh AA, Loftus DH, Zheng B, Arditi J, Leary OP, Fridley JS. Utility of Diffusion Tensor Imaging for Prognosis and Management of Cervical Spondylotic Myelopathy: A PRISMA Review. World Neurosurg 2024; 190:88-98. [PMID: 38986943 DOI: 10.1016/j.wneu.2024.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
OBJECTIVE As advances are made in quantitative magnetic resonance imaging, specifically diffusion tensor imaging, researchers have investigated its potential to serve as a biomarker of disease or prognosticator for postoperative recovery in the management of cervical spondylotic myelopathy. Here, we narratively review the current state of the emerging literature, describing areas of consensus and disagreement. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, we queried 2 large databases for original manuscripts published in English and systematically produced a narrative review of the use of diffusion tensor imaging in the management of cervical spondylotic myelopathy. RESULTS Of the 437 manuscripts initially returned in our query, 29 met the final inclusion criteria, and data were extracted regarding diffusion tensor imaging indices and their relationships with clinical outcomes following surgery. Preoperative fractional anisotropy was most commonly found to correlate closely with postsurgical clinical outcomes, though results were mixed. CONCLUSIONS Preoperative fractional anisotropy most frequently and best correlates with functional outcomes following surgery for cervical spondylotic myelopathy, according to a review of the current literature. The findings were not universal and at times contradictory, highlighting the need for high-quality future investigations to better define the utility of diffusion tensor imaging in spinal disease.
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Affiliation(s)
- Alexander A Chernysh
- Warren Alpert Medical School of Brown University, Rhode Island Hospital, Department of Neurosurgery, Providence, Rhode Island, USA.
| | - David H Loftus
- Warren Alpert Medical School of Brown University, Rhode Island Hospital, Department of Neurosurgery, Providence, Rhode Island, USA
| | - Bryan Zheng
- Warren Alpert Medical School of Brown University, Rhode Island Hospital, Department of Neurosurgery, Providence, Rhode Island, USA
| | - Jonathan Arditi
- Warren Alpert Medical School of Brown University, Rhode Island Hospital, Department of Neurosurgery, Providence, Rhode Island, USA
| | - Owen P Leary
- Warren Alpert Medical School of Brown University, Rhode Island Hospital, Department of Neurosurgery, Providence, Rhode Island, USA
| | - Jared S Fridley
- Warren Alpert Medical School of Brown University, Rhode Island Hospital, Department of Neurosurgery, Providence, Rhode Island, USA
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Treanor C, Gallagher C, Lenehan W, Gantly H, Bolger C, Malone A. Flipping the mJOA: Clinical utility of the modified Japanese Orthopaedic Association score as a tool for detecting degenerative cervical myelopathy. BRAIN & SPINE 2024; 4:102853. [PMID: 39040488 PMCID: PMC11261069 DOI: 10.1016/j.bas.2024.102853] [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: 02/06/2024] [Revised: 03/28/2024] [Accepted: 06/24/2024] [Indexed: 07/24/2024]
Abstract
Introduction People with Degenerative Cervical Myelopathy (DCM) often experience diagnostic delay. This could lead to poorer outcomes, including disability. Research question Does the modified Japanese Orthopaedic Association scale (mJOA) have clinical utility as an early detection tool for possible DCM? Materials and methods This is a prospective study of consecutive adult patients, referred to a National Neurosurgical Centre with a neck problem. Assessing clinicians undertook standard clinical examination and calculated the mJOA score. A consultant radiologist independently reported radiological findings, after which the assessing clinician determined the diagnosis. The sensitivity and specificity of mJOA for DCM at various cut-points was statistically analysed using Receiver Operating Characteristics (ROC) curves. Results Of 201 patients (98 male, mean age 52.6 ± 13y) assessed over 13 months, 21 were diagnosed with DCM (prevalence 10.4%). Fifteen (71.4%) had a mJOA score classifying disease severity as mild, 4/21 (19%) had moderate disease and two (9.5%) had severe disease. A mJOA score ≤17 (cutpoint ≥1) showed sensitivity of 95% and specificity of 71% for the clinical diagnosis of DCM. mJOA score ≤16 (cutpoint ≥2) had sensitivity of 62% and specificity of 90%. The ROC area under the curve was 0.885 (95% confidence interval: 0.82 to 0.95). 87% of patients were correctly classified. Discussion and conclusion mJOA score ≤16 is 90% specific for a subsequent diagnosis of DCM in people with neck problems and has potential to be used as an early detection tool. Further research is needed to replicate these findings and establish feasibility and acceptability in primary care.
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Affiliation(s)
- Caroline Treanor
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland
- School of Physiotherapy, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Conor Gallagher
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland
| | - Warren Lenehan
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland
| | - Hannah Gantly
- School of Physiotherapy, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Ciaran Bolger
- National Neurosurgical Centre, Beaumont Hospital, Dublin 9, Ireland
- Department of Clinical Neuroscience, RCSI University of Medicine and Health Sciences, Dublin 2, Ireland
| | - Ailish Malone
- School of Physiotherapy, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin 2, Ireland
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Jiang Z, Davies B, Zipser C, Margetis K, Martin A, Matsoukas S, Zipser-Mohammadzada F, Kheram N, Boraschi A, Zakin E, Obadaseraye OR, Fehlings MG, Wilson J, Yurac R, Cook CE, Milligan J, Tabrah J, Widdop S, Wood L, Roberts EA, Rujeedawa T, Tetreault L. The value of Clinical signs in the diagnosis of Degenerative Cervical Myelopathy - A Systematic review and Meta-analysis. Global Spine J 2024; 14:1369-1394. [PMID: 37903098 PMCID: PMC11289551 DOI: 10.1177/21925682231209869] [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: 11/01/2023] Open
Abstract
STUDY DESIGN Delayed diagnosis of degenerative cervical myelopathy (DCM) is likely due to a combination of its subtle symptoms, incomplete neurological assessments by clinicians and a lack of public and professional awareness. Diagnostic criteria for DCM will likely facilitate earlier referral for definitive management. OBJECTIVES This systematic review aims to determine (i) the diagnostic accuracy of various clinical signs and (ii) the association between clinical signs and disease severity in DCM? METHODS A search was performed to identify studies on adult patients that evaluated the diagnostic accuracy of a clinical sign used for diagnosing DCM. Studies were also included if they assessed the association between the presence of a clinical sign and disease severity. The QUADAS-2 tool was used to evaluate the risk of bias of individual studies. RESULTS This review identified eleven studies that used a control group to evaluate the diagnostic accuracy of various signs. An additional 61 articles reported on the frequency of clinical signs in a cohort of DCM patients. The most sensitive clinical tests for diagnosing DCM were the Tromner and hyperreflexia, whereas the most specific tests were the Babinski, Tromner, clonus and inverted supinator sign. Five studies evaluated the association between the presence of various clinical signs and disease severity. There was no definite association between Hoffmann sign, Babinski sign or hyperreflexia and disease severity. CONCLUSION The presence of clinical signs suggesting spinal cord compression should encourage health care professionals to pursue further investigation, such as neuroimaging to either confirm or refute a diagnosis of DCM.
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Affiliation(s)
- Zhilin Jiang
- King’s College Hospital, NHS Foundation Trust, London, UK
| | | | - Carl Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
| | | | - Allan Martin
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Najmeh Kheram
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Andrea Boraschi
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Elina Zakin
- New York University Langone, Department of Neurology, New York, NY, USA
| | | | - Michael G. Fehlings
- University of Toronto Division of Neurosurgery and Spinal Program, Toronto, ON, Canada
| | - Jamie Wilson
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Ratko Yurac
- University del Desarrollo, Clinica Alemana de Santiago, Chile
| | | | - Jamie Milligan
- Department of Family Medicine, McMaster University, Hamilton, ON, USA
| | - Julia Tabrah
- Hounslow and Richmond Community Healthcare, Teddington, UK
| | | | - Lianne Wood
- Nottingham University Hospital, Nottingham, UK
| | | | | | - Lindsay Tetreault
- New York University Langone, Department of Neurology, New York, NY, USA
| | - AO Spine RECODE-DCM Diagnostic Criteria Incubator
- King’s College Hospital, NHS Foundation Trust, London, UK
- University of Cambridge, Cambridge, UK
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
- New York University Langone, Department of Neurology, New York, NY, USA
- Department of Surgery, Asaba Specialist Hospital, Asaba, Nigeria
- University of Toronto Division of Neurosurgery and Spinal Program, Toronto, ON, Canada
- University of Nebraska Medical Center, Omaha, NE, USA
- University del Desarrollo, Clinica Alemana de Santiago, Chile
- Duke University Medical Center, Durham, NC
- Department of Family Medicine, McMaster University, Hamilton, ON, USA
- Hounslow and Richmond Community Healthcare, Teddington, UK
- Myelopathy.org, Cambridge, UK
- Nottingham University Hospital, Nottingham, UK
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5
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Agarwal N, DiGiorgio A, Michalopoulos GD, Letchuman V, Chan AK, Shabani S, Lavadi RS, Lu DC, Wang MY, Haid RW, Knightly JJ, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Upadhyaya C, Potts EA, Tumialán LM, Fu KMG, Asher AL, Bisson EF, Chou D, Bydon M, Mummaneni PV. Impact of Educational Background on Preoperative Disease Severity and Postoperative Outcomes Among Patients With Cervical Spondylotic Myelopathy. Clin Spine Surg 2024; 37:E137-E146. [PMID: 38102749 DOI: 10.1097/bsd.0000000000001557] [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: 10/31/2022] [Accepted: 10/03/2023] [Indexed: 12/17/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively maintained database. OBJECTIVE Assess differences in preoperative status and postoperative outcomes among patients of different educational backgrounds undergoing surgical management of cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA Patient education level (EL) has been suggested to correlate with health literacy, disease perception, socioeconomic status (SES), and access to health care. METHODS The CSM data set of the Quality Outcomes Database (QOD) was queried for patients undergoing surgical management of CSM. EL was grouped as high school or below, graduate-level, and postgraduate level. The association of EL with baseline disease severity (per patient-reported outcome measures), symptoms >3 or ≤3 months, and 24-month patient-reported outcome measures were evaluated. RESULTS Among 1141 patients with CSM, 509 (44.6%) had an EL of high school or below, 471 (41.3%) had a graduate degree, and 161 (14.1%) had obtained postgraduate education. Lower EL was statistically significantly associated with symptom duration of >3 months (odds ratio=1.68), higher arm pain numeric rating scale (NRS) (coefficient=0.5), and higher neck pain NRS (coefficient=0.79). Patients with postgraduate education had statistically significantly lower Neck Disability Index (NDI) scores (coefficient=-7.17), lower arm pain scores (coefficient=-1), and higher quality-adjusted life-years (QALY) scores (coefficient=0.06). Twenty-four months after surgery, patients of lower EL had higher NDI scores, higher pain NRS scores, and lower QALY scores ( P <0.05 in all analyses). CONCLUSIONS Among patients undergoing surgical management for CSM, those reporting a lower educational level tended to present with longer symptom duration, more disease-inflicted disability and pain, and lower QALY scores. As such, patients of a lower EL are a potentially vulnerable subpopulation, and their health literacy and access to care should be prioritized.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony DiGiorgio
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | | | - Vijay Letchuman
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Andrew K Chan
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | | | | | | | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Brenton Pennicooke
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Cheerag Upadhyaya
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Eric A Potts
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Luis M Tumialán
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, AZ
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Dean Chou
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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Johansen TO, Holmberg ST, Danielsen E, Rao V, Salvesen ØO, Andresen H, Carmen VLLA, Solberg TK, Gulati S, Nygaard ØP. Long-Term Results After Surgery for Degenerative Cervical Myelopathy. Neurosurgery 2024; 94:454-460. [PMID: 37823669 PMCID: PMC10846761 DOI: 10.1227/neu.0000000000002712] [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: 01/23/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Degenerative cervical myelopathy (DCM) is a frequent cause of spinal cord dysfunction, and surgical treatment is considered safe and effective. Long-term results after surgery are limited. This study investigated long-term clinical outcomes through data from the Norwegian registry for spine surgery. METHODS Patients operated at the university hospitals serving Central and Northern Norway were approached for long-term follow-up after 3 to 8 years. The primary outcome was change in the Neck Disability Index, and the secondary outcomes were changes in the European Myelopathy Scale score, quality of life (EuroQoL EQ-5D); numeric rating scales (NRS) for headache, neck pain, and arm pain; and perceived benefit of surgery assessed by the Global Perceived Effect scale from 1 year to long-term follow-up. RESULTS We included 144 patients operated between January 2013 and June 2018. In total, 123 participants (85.4%) provided patient-reported outcome measures (PROMs) at long-term follow-up. There was no significant change in PROMs from 1 year to long-term follow-up, including Neck Disability Index (mean 1.0, 95% CI -2.1-4.1, P = .53), European Myelopathy Scale score (mean -0.3, 95% CI -0.7-0.1, P = .09), EQ-5D index score (mean -0.02, 95% CI -0.09-0.05, P = .51), NRS neck pain (mean 0.3 95% CI -0.2-0.9, P = .22), NRS arm pain (mean -0.1, 95% CI -0.8-0.5, P = .70), and NRS headache (mean 0.4, 95% CI -0.1-0.9, P = .11). According to Global Perceived Effect assessments, 106/121 patients (87.6%) reported to be stable or improved ("complete recovery," "much better," "slightly better," or "unchanged") at long-term follow-up compared with 88.1% at 1 year. Dichotomizing the outcome data based on severity of DCM did not demonstrate significant changes either. CONCLUSION Long-term follow-up of patients undergoing surgery for DCM demonstrates persistence of statistically significant and clinically meaningful improvement across a wide range of PROMs.
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Affiliation(s)
- Tonje O. Johansen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Siril T. Holmberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Elisabet Danielsen
- Department of Clinical Medicine, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Vidar Rao
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Øyvind O. Salvesen
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Hege Andresen
- National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim, Norway
| | | | - Tore K. Solberg
- Institute for Clinical Medicine, UNN The Arctic University of Norway, Tromsø, Norway
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Øystein P. Nygaard
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
- National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim, Norway
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7
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Davies BM, Khan DZ, Barzangi K, Ali A, Mowforth OD, Nouri A, Harrop JS, Aarabi B, Rahimi-Movaghar V, Kurpad SN, Guest JD, Tetreault L, Kwon BK, Boerger TF, Rodrigues-Pinto R, Furlan JC, Chen R, Zipser CM, Curt A, Milligan J, Kalsi-Rayn S, Sarewitz E, Sadler I, Widdop S, Fehlings MG, Kotter MR. We Choose to Call it 'Degenerative Cervical Myelopathy': Findings of AO Spine RECODE-DCM, an International and Multi-Stakeholder Partnership to Agree a Standard Unifying Term and Definition for a Disease. Global Spine J 2024; 14:503-512. [PMID: 35769029 PMCID: PMC10802519 DOI: 10.1177/21925682221111780] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Modified DELPHI Consensus Process. OBJECTIVE To agree a single unifying term and definition. Globally, cervical myelopathy caused by degenerative changes to the spine is known by over 11 different names. This inconsistency contributes to many clinical and research challenges, including a lack of awareness. METHOD AO Spine RECODE-DCM (Research objectives and Common Data Elements Degenerative Cervical Myelopathy). To determine the index term, a longlist of candidate terms and their rationale, was created using a literature review and interviews. This was shared with the community, to select their preferred terms (248 members (58%) including 149 (60%) surgeons, 45 (18%) other healthcare professionals and 54 (22%) People with DCM or their supporters) and finalized using a consensus meeting. To determine a definition, a medical definition framework was created using inductive thematic analysis of selected International Classification of Disease definitions. Separately, stakeholders submitted their suggested definition which also underwent inductive thematic analysis (317 members (76%), 190 (59%) surgeons, 62 (20%) other healthcare professionals and 72 (23%) persons living with DCM or their supporters). Using this definition framework, a working definition was created based on submitted content, and finalized using consensus meetings. RESULTS Degenerative Cervical Myelopathy was selected as the unifying term, defined in short, as a progressive spinal cord injury caused by narrowing of the cervical spinal canal. CONCLUSION A consistent term and definition can support education and research initiatives. This was selected using a structured and iterative methodology, which may serve as an exemplar for others in the future.
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Affiliation(s)
- Benjamin M. Davies
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
| | - Danyal Z Khan
- Department of Neurosurgery, Walton Centre, UK
- Wellcome / EPSRC Centre for Interventional and Surgical Sciences, University College London, UK
| | - Kara Barzangi
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
| | - Ahmad Ali
- Department of Neurosurgery, Walton Centre, UK
| | - Oliver D. Mowforth
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
| | - Aria Nouri
- Department of Neurosurgery, Geneva University Hospital, University of Geneva, Switzerland
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, 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
| | - 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
| | - Lindsay Tetreault
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Brian K. Kwon
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto - Hospital de Santo António, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Portugal
| | - Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | | | - Armin Curt
- University Spine Center, Balgrist University Hospital, Switzerland
| | | | | | | | | | | | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Mark R.N. Kotter
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, UK
- Myelopathy.org, UK
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8
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Partha Sarathi CI, Sinha A, Rafati Fard A, Bhatti F, Rujeedawa T, Ahmed S, Akhbari M, Bhatti A, Nouri A, Kotter MR, Davies BM, Mowforth OD. The significance of metabolic disease in degenerative cervical myelopathy: a systematic review. Front Neurol 2024; 15:1301003. [PMID: 38375465 PMCID: PMC10876002 DOI: 10.3389/fneur.2024.1301003] [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: 09/23/2023] [Accepted: 01/09/2024] [Indexed: 02/21/2024] Open
Abstract
Introduction Degenerative cervical myelopathy (DCM) is a form of chronic spinal cord injury, with a natural history of potential for progression over time. Whilst driven by mechanical stress on the spinal cord from degenerative and congenital pathology, the neurological phenotype of DCM is likely to be modified by multiple systemic factors. The role of metabolic factors is therefore of interest, particularly given that ischaemia is considered a key pathological mechanism of spinal cord injury. The objective was therefore to synthesise current evidence on the effect of metabolism on DCM susceptibility, severity, and surgical outcomes. Methods A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English, with a focus on DCM and metabolism, including diabetes, cardiovascular disease, anaemia, and lipid profile, were eligible for inclusion. Risk of methodological bias was assessed using the Joanna Briggs Institute (JBI) critical assessment tools. Quality assessments were performed using the GRADE assessment tool. Patient demographics, metabolic factors and the relationships between metabolism and spinal cord disease, spinal column disease and post-operative outcomes were assessed. Results In total, 8,523 papers were identified, of which 57 met criteria for inclusion in the final analysis. A total of 91% (52/57) of included papers assessed the effects of diabetes in relation to DCM, of which 85% (44/52) reported an association with poor surgical outcomes; 42% of papers (24/57) discussed the association between cardiovascular health and DCM, of which 88% (21/24) reported a significant association. Overall, DCM patients with diabetes or cardiovascular disease experienced greater perioperative morbidity and poorer neurological recovery. They were also more likely to have comorbidities such as obesity and hyperlipidaemia. Conclusion Metabolic factors appear to be associated with surgical outcomes in DCM. However, evidence for a more specific role in DCM susceptibility and severity is uncertain. The pathophysiology and natural history of DCM are critical research priorities; the role of metabolism is therefore a key area for future research focus. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268814.
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Affiliation(s)
- Celine Iswarya Partha Sarathi
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Amil Sinha
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Amir Rafati Fard
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Faheem Bhatti
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Tanzil Rujeedawa
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Shahzaib Ahmed
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Melika Akhbari
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Aniqah Bhatti
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Mark R. Kotter
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin M. Davies
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Oliver D. Mowforth
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
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9
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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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10
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Elliott L, Li M, Gharooni AA, Davies BM, Mowforth OD. Respiratory dysfunction in degenerative cervical myelopathy: A systematic review. J Clin Neurosci 2024; 120:94-101. [PMID: 38237493 DOI: 10.1016/j.jocn.2024.01.001] [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: 10/15/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Degenerative cervical myelopathy is a condition of symptomatic cervical spinal cord compression secondary to a range of degenerative spinal pathology. Respiratory symptoms such as shortness of breath are not uncommonly reported by people with DCM and respiratory dysfunction has been described in several DCM studies. The objective of this review was therefore to systematically synthesise the current evidence on the relationship between DCM and respiratory function. METHODS The review was registered on PROSPERO and adhered to PRISMA guidelines. Ovid MEDLINE and Embase were searched from inception to 14th March 2023. DCM studies reporting on any measure or outcome relating to respiratory function or disease were eligible. Reference lists of included studies and relevant reviews articles were hand searched. Title, abstract and full text screening, risk of bias and GRADE assessments were completed in duplicate. A quantitative synthesis is presented. RESULTS Of 1991 studies identified by literature searching, 13 met inclusion criteria: 3 cohort studies, 5 case-control studies, 1 case series and 4 case studies. Forced vital capacity (FVC), peak expiratory flow rate (PEFR) and maximal voluntary ventilation (MVV) were reported to be lower in DCM patients than controls; there was inconsistency in comparisons of forced expiratory volume in 1 s (FEV1). There was conflicting evidence on whether surgical decompression was associated with improvements in respiratory parameters and on the relationship between level of spinal cord compression and respiratory dysfunction. CONCLUSION DCM may be associated with respiratory dysfunction. However, consistency and quality of evidence is currently low. Further work should characterise respiratory dysfunction in DCM patients more rigorously and investigate putative mechanisms such as disruption to cervical nerve roots responsible for diaphragmatic innervation and damage to descending spinal projections from brainstem respiratory centres.
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Affiliation(s)
- Lorcan Elliott
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Michael Li
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Aref-Ali Gharooni
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Oliver D Mowforth
- Division of Academic Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
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11
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Ni M, Li S, Wen X, Wang B, Jiang C, Zhang X, Lang N, Jiang L, Yuan H. A matched case-control study of early cervical spondylotic myelopathy based on diffusion magnetic resonance imaging. Insights Imaging 2024; 15:25. [PMID: 38270768 PMCID: PMC10811301 DOI: 10.1186/s13244-023-01579-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/29/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Early cervical spondylotic myelopathy (CSM) is challenging to diagnose and easily missed. Diffusion MRI (dMRI) has the potential to identify early CSM. METHODS Using diffusion tensor imaging (DTI), diffusion kurtosis imaging (DKI), and neurite orientation dispersion and density imaging (NODDI), a 1:1 matched case-control study was conducted to evaluate the potential of dMRI in identifying early CSM and assessing uncompressed segments of CSM patients. CSM patients and volunteers were matched by age and spinal location. The differences in dMRI parameters between groups were assessed by the paired t-test, the multicollinearity of the dMRI parameters was evaluated by the variance inflation factor (VIF), and the value of dMRI parameters in distinguishing controls from CSM patients was determined by logistic regression. The univariate t-test was used to analyse differences between CSM patients and volunteers in adjacent uncompressed areas. RESULTS In total, 56 CSM patients and 56 control volunteers were included. Paired t-tests revealed significant differences in nine dMRI parameters between groups. Multicollinearity calculated through VIF and combined with logistic regression showed that the orientation division index (ODI) was significantly positively correlated (r = 2.12, p = 0.035), and the anisotropic water fraction (AWF) was significantly negatively correlated (r = -0.98, p = 0.015). The fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), isotropic volume fraction (ISOVF), ODI, and AWF were significantly different in the upper and lower uncompressed areas at all ages. CONCLUSION dMRI can noninvasively identify early CSM patients and potentially identify the extent of CSM lesions involving the cervical spinal cord. CRITICAL RELEVANCE STATEMENT Diffusion MRI (dMRI) can identify early cervical spondylotic myelopathy (CSM) and has the potential to help determine the extent of CSM involvement. The application of dMRI can help screen for early CSM and develop clinical surgical and rehabilitation treatment plans. KEY POINTS • Diffusion MRI can differentiate between normal and early-stage cervical spondylotic myelopathy patients. • Diffusion MRI has the ability to identify the extent of spinal cord involvement in cervical spondylotic myelopathy. • Diffusion MRI enables the early screening of cervical spondylotic myelopathy and helps guide clinical treatment.
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Affiliation(s)
- Ming Ni
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Shujing Li
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Xiaoyi Wen
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Ben Wang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China
| | - Chenyu Jiang
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | | | - Ning Lang
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Liang Jiang
- Department of Orthopedics, Peking University Third Hospital, Beijing, China.
- Engineering Research Center of Bone and Joint Precision Medicine, Beijing, China.
- Beijing Key Laboratory of Spinal Disease Research, Beijing, China.
| | - Huishu Yuan
- Department of Radiology, Peking University Third Hospital, Beijing, China.
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12
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Friesen AC, Detombe SA, Doyle-Pettypiece P, Ng W, Gurr K, Bailey C, Rasoulinejad P, Siddiqi F, Bartha R, Duggal N. Characterizing mJOA-defined post-surgical recovery patterns in patients with degenerative cervical myelopathy. World Neurosurg X 2024; 21:100267. [PMID: 38193094 PMCID: PMC10772397 DOI: 10.1016/j.wnsx.2023.100267] [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: 12/29/2022] [Revised: 07/11/2023] [Accepted: 11/28/2023] [Indexed: 01/10/2024] Open
Abstract
Background Degenerative cervical myelopathy is a spinal disorder resulting in progressive cord compression and neurological deficits that are assessed using the modified Japanese Orthopedic Association (mJOA) questionnaire. It is difficult to predict which patients will recover neurological function after surgery, making it challenging for clinicians to set postoperative patient expectations. In this study, we used mJOA subscores to identify patterns of recovery and recovery timelines in patients with moderate and severe myelopathy. Methods Fifty-three myelopathy patients were enrolled and completed the mJOA questionnaire both pre-surgery, and six weeks and six months post-surgery. Pearson chi-square tests were performed to assess relationships of both recovery patterns and recovery timelines with severity of disease. Results Moderate myelopathy patients were significantly more likely than severe myelopathy patients to experience full recovery of upper extremity, lower extremity, and sensory domains. Disease severity did not significantly impact the timeline during which recovery occurs. Overall, >90% of patients experienced at least partial recovery by six months post surgery, 80% of which demonstrated it within the first six weeks. Conclusions This study shows the more severe the disease experienced by myelopathy patients, the more likely they will be left with permanent disabilities despite surgery. Early identification and treatment are therefore necessary to prevent worsening quality of life and increased costs of functional dependence. The recovery timelines for each subscore are similar and provide new values to guide patient expectations in their potential post-operative recovery. The overall recovery timeline is more generalizable though potentially lacking the specificity patients seek.
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Affiliation(s)
- Alexander C. Friesen
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Sarah A. Detombe
- Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
| | - Pat Doyle-Pettypiece
- Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
| | - Wai Ng
- Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
| | - Kevin Gurr
- Department of Orthopedics, London Health Sciences Centre, London, Ontario, Canada
| | - Chris Bailey
- Department of Orthopedics, London Health Sciences Centre, London, Ontario, Canada
| | - Parham Rasoulinejad
- Department of Orthopedics, London Health Sciences Centre, London, Ontario, Canada
| | - Fawaz Siddiqi
- Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
- Department of Orthopedics, London Health Sciences Centre, London, Ontario, Canada
| | - Robert Bartha
- Centre for Functional and Metabolic Mapping, Robarts Research Institute, Western University, London, Ontario, Canada
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Neil Duggal
- Department of Clinical Neurological Sciences, London Health Sciences Centre, London, Ontario, Canada
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13
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Rujeedawa T, Mowforth OD, Brannigan J, Magee J, Francis JJ, Laing RJ, Davies BM, Kotter MR. A single centre service evaluation of degenerative cervical and thoracic myelopathy. J Clin Neurosci 2023; 117:168-172. [PMID: 37826868 DOI: 10.1016/j.jocn.2023.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/23/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Degenerative cervical myelopathy (DCM) and degenerative thoracic myelopathy (DTM) present with leg, bladder and bowel symptoms. If imaging confirms spinal cord compression both conditions are usually managed surgically. Surgical timing is important in patient management as it affects post-operative recovery and long-term outcomes. This service evaluation aims to explore whether that patients with DTM are more likely to be treated urgently than those with DCM and to examine whether any differences in management are justified. METHODS A retrospective service evaluation was registered and approved by the Cambridge University Hospitals NHS Foundation Trust (CUH) Clinical Audit Department (Clinical Project ID4455 PRN10455). All patients who had undergone surgery for DTM at CUH from January 2015 until April 2022 were included. Comparison was made to a cohort of DCM patients who underwent surgery at CUH from June 2016 to January 2019. Data analysis was conducted in R. RESULTS A total of 130 DCM patients and 78 DTM patients were included. Our DCM and DTM patient cohorts had comparable demographics, but DTM patients had fewer spinal levels affected. Despite equivalent disease severity, DTM patients had a shorter time to diagnosis, shorter wait for surgery and were more likely to be operated on as an emergency case. CONCLUSIONS Despite comparable demographics and pathophysiology, DTM was diagnosed and managed more quickly than DCM. Better defined diagnostic pathways for degenerative spinal myelopathy may hold opportunities to optimise diagnosis and management, ensuring consistent high quality, efficient and equitable care.
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Affiliation(s)
- Tanzil Rujeedawa
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Oliver D Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.
| | - Jamie Brannigan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Joe Magee
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Jibin J Francis
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Rodney J Laing
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin M Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Mark R Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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14
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Kim HW, Yong H, Shea GKH. Blood-spinal cord barrier disruption in degenerative cervical myelopathy. Fluids Barriers CNS 2023; 20:68. [PMID: 37743487 PMCID: PMC10519090 DOI: 10.1186/s12987-023-00463-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/12/2023] [Indexed: 09/26/2023] Open
Abstract
Degenerative cervical myelopathy (DCM) is the most prevalent cause of spinal cord dysfunction in the aging population. Significant neurological deficits may result from a delayed diagnosis as well as inadequate neurological recovery following surgical decompression. Here, we review the pathophysiology of DCM with an emphasis on how blood-spinal cord barrier (BSCB) disruption is a critical yet neglected pathological feature affecting prognosis. In patients suffering from DCM, compromise of the BSCB is evidenced by elevated cerebrospinal fluid (CSF) to serum protein ratios and abnormal contrast-enhancement upon magnetic resonance imaging (MRI). In animal model correlates, there is histological evidence of increased extravasation of tissue dyes and serum contents, and pathological changes to the neurovascular unit. BSCB dysfunction is the likely culprit for ischemia-reperfusion injury following surgical decompression, which can result in devastating neurological sequelae. As there are currently no therapeutic approaches specifically targeting BSCB reconstitution, we conclude the review by discussing potential interventions harnessed for this purpose.
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Affiliation(s)
- Hyun Woo Kim
- Department of Orthopaedics and Traumatology, LKS Faulty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Hu Yong
- Department of Orthopaedics and Traumatology, LKS Faulty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Graham Ka Hon Shea
- Department of Orthopaedics and Traumatology, LKS Faulty of Medicine, The University of Hong Kong, Hong Kong, China.
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15
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Brannigan JFM, Mowforth OD, Rogers M, Wood H, Karimi Z, Kotter MRN, Davies BM. Osteopathy in the Early Diagnosis and Management of Degenerative Cervical Myelopathy: National Survey. JMIR Form Res 2023; 7:e45248. [PMID: 37159244 DOI: 10.2196/45248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/23/2023] [Accepted: 04/07/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Degenerative cervical myelopathy (DCM) is a common and disabling neurodegenerative condition. Surgical decompression is the only evidence-based treatment to halt disease progression; however, diagnosis and access to timely treatment are often delayed, which contribute to significant disability and dependence. Supporting early diagnosis and access to timely treatment is a critical priority. Exploring these challenges, Myelopathy.org has observed that people with DCM may seek osteopathy care for their symptoms, both before and after diagnosis. OBJECTIVE This study aimed to describe the current interaction between osteopaths and people with DCM and understand how this may be targeted to enhance the DCM diagnostic pathway. METHODS Registered osteopaths in the United Kingdom completed a web-based survey hosted by the Institute of Osteopathy, as part of their institute's 2021 census. Responses were collected from February to May 2021. Demographic information about the respondents was captured, including age, gender, and ethnicity. Professional information captured included the year of qualification; region of practice; type of practice; and number of undiagnosed, operated diagnosed, and unoperated diagnosed DCM cases encountered per year. The completion of the survey was voluntary; however, a prize draw incentive was offered to participants. RESULTS The demographics were heterogenous for the 547 practitioners who completed the survey. There was representation from a wide range of demographic groups, including the level of experience, gender, age, and the region of United Kingdom. At least 68.9% (377/547) of osteopaths reported encounters with DCM each year. Osteopaths most frequently encountered patients with undiagnosed DCM, with a mean of 3 patient encounters per year. This compares to 2 encounters per year with patients with diagnosed DCM. The level of practitioner experience was positively correlated with the detection of undiagnosed DCM (P<.005). The influence of practitioner experience was corroborated by a subgroup analysis looking at the relationship between practitioner age on the detection of undiagnosed DCM. Osteopaths older than 54 years encountered an average of 4.2 cases per year, whereas those younger than 35 years detected 2.9 cases per year. Osteopaths in private clinics reported encounters with a greater mean number (4.4) of undiagnosed DCM cases per year than osteopaths in other clinic types (3.0). CONCLUSIONS Osteopaths reported that they frequently consult people with DCM, including those suspected to have undiagnosed or presurgical DCM. Given this concentrated presentation of early DCM and a workforce professionally trained to examine musculoskeletal disease, osteopaths could have an important role in accelerating access to timely treatment. We included a decision support tool and specialist referral template as a tool to support onward care.
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Affiliation(s)
- Jamie F M Brannigan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Oliver D Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | | | - Helen Wood
- Myelopathy.org, Cambridge, United Kingdom
| | | | - Mark R N Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin M Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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16
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Lee YG, Kim SR. Predictors of Quality of Life in Patients With Degenerative Cervical Myelopathy Receiving Nonsurgical Management Due to Chronic Pain. Pain Manag Nurs 2023:S1524-9042(23)00035-8. [PMID: 36959040 DOI: 10.1016/j.pmn.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Most patients with degenerative cervical myelopathy (DCM) experience pain, and their quality of life (QoL) is poor. AIMS This study aimed to identify predictors of QoL, including demographic, clinical, physical, and psychosocial characteristics, in chronic pain patients with DCM receiving non-surgical management. DESIGN A descriptive study design was used. SETTING Participants were recruited at the pain clinic at a university hospital in Seoul, South Korea. PARTICIPANTS/SUBJECTS The subjects included 157 inpatients and outpatients with DCM receiving non-surgical management. METHODS We administered a written, structured, self-reported questionnaire, which included standard validated measures for the main variables of interest. RESULTS The median number of pain sites was two, and the average and most pain severities were 4.63 ± 2.35 and 5.71 ± 2.32 out of 10 within one month, respectively. Stepwise multiple regression analysis revealed that depression, education level, and headache were factors influencing physical QoL. Depression, education level, and marital status were factors influencing psychological QoL, whereas depression and education level were factors influencing social relationships QoL. Finally, the factors influencing environmental QoL were depression, educational level, and marital status. CONCLUSIONS Demographic characteristics, including educational level and marital status, clinical characteristics, including pain site, and psychological characteristics, including depression, were identified as factors influencing QoL in chronic pain patients with DCM receiving non-surgical management. CLINICAL IMPLICATIONS Healthcare professionals should consider demographic, clinical, and psychological characteristics when evaluating patients... QoL. In addition, it is necessary to pay attention to the QoL of participants who are single and have lower levels of education, headache pain, and high levels of depression. These patients are likely to have low QoL and strategies to improve their QoL should be developed.
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Affiliation(s)
- Yeong Gi Lee
- Department of Nursing, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Sung Reul Kim
- College of Nursing, Korea University, Seoul, Republic of Korea.
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17
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Lønne VV, Hara S, Gulati S, Aasdahl L, Salvesen Ø, Nygaard ØP, Solberg T, Hara KW. Return to work after surgery for degenerative cervical myelopathy: a nationwide registry-based observational study. Acta Neurochir (Wien) 2023; 165:779-787. [PMID: 36795223 PMCID: PMC10006038 DOI: 10.1007/s00701-023-05521-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/01/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Few studies of high quality exist on return to work (RTW) rate after surgery for degenerative cervical myelopathy (DCM). This study aims to examine the RTW rate in patients undergoing surgery for DCM. METHODS Nationwide prospectively collected data were obtained from the Norwegian Registry for Spine Surgery and the Norwegian Labour and Welfare Administration. The primary outcome was return to work, defined as being at work at a given time postoperatively without any medical income-compensation benefits. Secondary endpoints included the neck disability index (NDI) and quality of life measured by EuroQol-5D (EQ-5D). RESULTS Among 439 patients operated for DCM between 2012 and 2018, 20% of the patients received a medical income-compensation benefit one year before surgery. This number increased steadily towards the operation at which timepoint 100% received benefits. By 12 months after surgery, 65% had returned to work. By 36 months, 75% had returned to work. Patients that returned to work were more likely to be non-smokers and to have a college education. They had less comorbidity, more were without benefit 1-year pre-surgery, and significantly more patients were employed at operation date. Average days of sick leave in the year before surgery were significantly less in the RTW group, and they had a significantly lower baseline NDI and EQ-5D All PROMs reached statistical significance at 12 months, in favor of the group that achieved RTW. CONCLUSION At 12 months following surgery, 65% had returned to work. At the end of the 36-month follow-up period, 75% had returned to work, 5% less than the working percentage in the beginning of the follow-up period. This study demonstrates that a large percentage of patients return to work after surgical treatment for DCM.
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Affiliation(s)
- Vetle Vangen Lønne
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway.
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, 7006, Trondheim, Norway.
| | - Sozaburo Hara
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, 7006, Trondheim, Norway
| | - Sasha Gulati
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, 7006, Trondheim, Norway
- National Advisory Board for Spinal Surgery, St. Olav's University Hospital, Trondheim, Norway
| | - Lene Aasdahl
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Unicare Helsefort Rehabilitation Centre, Rissa, Hasselvika, Norway
| | - Øyvind Salvesen
- Unit for Applied Clinical Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Øystein Petter Nygaard
- Department of Neurosurgery, St. Olav's University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, 7006, Trondheim, Norway
- National Advisory Board for Spinal Surgery, St. Olav's University Hospital, Trondheim, Norway
| | - Tore Solberg
- Department of Neurosurgery, University Hospital of Northern Norway, Tromsø, Norway
- Norwegian Registry for Spine Surgery (NORspine), Tromsø, Norway
| | - Karen Walseth Hara
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- NAV Advisory Service for Trøndelag, Trøndelag, Norway
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18
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Life expectancy in patients with degenerative cervical myelopathy is currently reduced but can be restored with timely treatment. Acta Neurochir (Wien) 2023; 165:1133-1140. [PMID: 36856831 PMCID: PMC10140127 DOI: 10.1007/s00701-023-05515-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/25/2022] [Indexed: 03/02/2023]
Abstract
PURPOSE Degenerative cervical myelopathy is a progressive slow-motion spinal cord injury. Surgery is the mainstay of treatment. Baseline disability predicts surgical recovery; therefore, timely treatment is critical to restoring function. However, current challenges mean most patients present with advanced disease and are instead left with life changing disabilities. While short-term mortality is rarely reported, the long-term effects of this on life expectancy are unknown, including whether function could be modifiable with timely treatment. This article investigates the effect of DCM on life expectancy. METHODS The survival of patients from an observational study of patients undergoing surgery from 1994 to 2007 was compared to their expected survival using a gender- and aged -matched cohort. Comparisons were made by one sample log-rank test and standardised mortality ratios. Factors associated with survival were explored using a Cox regression analysis, including disease severity. RESULTS A total of 357 patients were included in the analysis. After a median follow-up of 15.3 years, 135 of 349 patients had died; 114.7 deaths would have been expected. The DCM cohort had an increased risk of death compared to the non-DCM cohort (standardised mortality ratio 1.18 [95% CI: 1.02-1.34]. Age at operation 1.08 (95% CI: 1.07 to 1.1, p < 0.001) and severe DCM 1.6 (95% CI: 1.06 to 2.3, p = 0.02) were associated with worse survival (N = 287). In those surviving at least 2 years after surgery, only severe DCM was associated with conditional survival (HR 1.6, 95% CI 1.04 2.4, p = 0.03). CONCLUSION Life expectancy is reduced in those undergoing surgery for DCM. This is driven by premature mortality among those left with severe disability. As disability can be reduced with timely treatment, these findings reinforce the need for collective and global action to raise awareness of DCM and enable early diagnosis.
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Scalia G, Costanzo R, Brunasso L, Garufi G, Bonosi L, Ricciardo G, Graziano F, Nicoletti GF, Cardali SM, Iacopino DG, Maugeri R, Umana GE. Correlation between "Snake-Eyes" Sign and Role of Surgery with a Focus on Postoperative Outcome: A Systematic Review. Brain Sci 2023; 13:brainsci13020301. [PMID: 36831844 PMCID: PMC9954568 DOI: 10.3390/brainsci13020301] [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: 12/28/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/12/2023] Open
Abstract
(1) Background: The "snake-eyes" sign represents a unique finding characterized by bilateral hyperintense symmetric, circular, or ovoid foci on T2-weighted MRI sequences in the anterior horn cells of the spinal cord. There are conflicting opinions as some authors affirm that it does not affect the prognosis of cervical myelopathy while other papers emphasize the opposite, stating how the "snake-eyes" sign constitutes an irreversible lesion and a predictor of poor prognosis. This systematic review evaluates the correlation between the "snake-eyes" sign and the prognosis of cervical myelopathy after surgery including anterior and/or posterior approaches; (2) Methods: A systematic literature review was conducted following the PRISMA statement and a total of seven papers were included; (3) Results: A total of 419 patients were evaluated, with a mean age of 55.72 ± 14.38 years. After surgery, 26.01% of patients experienced a significant clinical improvement, while in 61.81%, there was no significant improvement. In particular, 144 of 196 patients (73.5%) treated through an anterior approach and 114 of 223 (51.1%) that underwent a posterior approach, did not present a significant improvement. Furthermore, in 12.17% of patients, the postoperative outcome was not reported, leading to a high risk of bias in the assessment of the prognostic significance of the "snake-eyes" appearance; (4) Conclusions: The "snake-eyes" sign is usually considered as an unfavorable predictive marker for myelopathic surgical patients, but the pathophysiology is still unclear, and the results have not yet reached unified levels of evidence.
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Affiliation(s)
- Gianluca Scalia
- Neurosurgery Unit, Head and Neck Surgery Department, Garibaldi Hospital, 95123 Catania, Italy
- Correspondence: ; Tel.: +39-3470589736
| | - Roberta Costanzo
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy
| | - Lara Brunasso
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy
| | - Giada Garufi
- Department of Neurosurgery, Mayo Clinic, Rochester, MN 55905, USA
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, 98158 Messina, Italy
| | - Lapo Bonosi
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy
| | - Giuseppe Ricciardo
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, 98158 Messina, Italy
| | - Francesca Graziano
- Neurosurgery Unit, Head and Neck Surgery Department, Garibaldi Hospital, 95123 Catania, Italy
| | | | - Salvatore Massimiliano Cardali
- Department of Neurosurgery, Azienda Ospedaliera Papardo, University of Messina, 98158 Messina, Italy
- Division of Neurosurgery, BIOMORF Department, University of Messina, 98125 Messina, Italy
| | - Domenico Gerardo Iacopino
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy
| | - Rosario Maugeri
- Neurosurgical Clinic, AOUP “Paolo Giaccone”, Post Graduate Residency Program in Neurologic Surgery, Department of Biomedicine Neurosciences and Advanced Diagnostics, School of Medicine, University of Palermo, 90127 Palermo, Italy
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Pons Carreto A, Ramírez Valencia M, de García Frutos A, Khoudeir Avila A, Montesinos Magraner L, Nuñez-Pereira S, Haddad S, Pellisé Urquiza F. Myelopathy disability index: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy. 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 2023; 32:584-589. [PMID: 36596911 DOI: 10.1007/s00586-022-07506-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE To find the cut-off values in the Myelopathy Disability Index (MDI) that will allow us to classify the severity of Degenerative Cervical Myelopathy (DCM) into mild, moderate and severe. METHODS Cross-sectional study with prospective data collection, with a total of 64 patients diagnosed with Degenerative Cervical Myelopathy (DCM). Anthropometric, diagnostic, neurological, functional and quality of life variables were collected. A Receiver Operating Curve (ROC) was performed. The cut-off points were validated by comparing the functional status of patients in the 3 groups and their Nurick scores. RESULTS Sixty-four patients (23 women) with a mean age of 61.97 (SD 11.57) participated in this study. The majority of patients were Nurick I (28.13%) and Nurick II (32.81%). The medium MDI was 7.36 (SD 6.66) and the mJOA was 14.08 (SD 2.57). The mild-moderate cut-off value was between 4 and 5, with an Area Under the Curve (AUC) of 0.805, sensitivity of 0.853 and specificity of 0.6. For moderate-severe, the cut-off value obtained was between 7 and 8, with an AUC of 0.862, sensitivity of 0.857 and specificity of 0.684. Patients with greater severity had significantly lower functionality, with a P-value of 0.004 in the 30 Metre Walking Test and 0.005 in the Nine-Hole Peg Test. Established severity groups were also significantly related to the different categories of the Nurick score (P-value = 0.000). CONCLUSION MDI values between 0 and 4 correspond to mild DCM, between 5 and 7 would be moderate DCM and from 8 to 30 indicate severe DCM.
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Affiliation(s)
- Alba Pons Carreto
- Spine Research Unit, Vall d'Hebron Research Institute, Barcelona, Spain
| | | | | | | | | | | | - Sleiman Haddad
- Spine Unit. Orthopaedic Department, Vall d'Hebron Hospital, Barcelona, Spain
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21
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Brannigan JFM, Davies BM, Stewart M, Smith S, Willison A, Ahmed S, Sadler I, Sarewitz E, Francis J, Stacpoole SRL, Kotter MRN, Mowforth OD. Degenerative cervical myelopathy education in UK medical schools: a national cross-sectional survey of medical students. Br J Neurosurg 2022; 36:728-736. [PMID: 35950690 DOI: 10.1080/02688697.2022.2106355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Degenerative cervical myelopathy (DCM) is a common and progressive neurological condition caused by injury of the cervical spinal cord by degenerative spinal pathology. Delayed diagnosis leading to avoidable and irreversible disability is a major current problem limiting patient outcomes. Lack of sufficient representation of DCM in undergraduate and postgraduate medical curricula may contribute to poor recognition of DCM by non-specialist doctors. The objective of this study was to assess the DCM teaching provision in UK medical schools and the DCM knowledge of UK medical students. METHODS UK medical students completed a web-based survey distributed nationally through university social media pages, university email bulletins and the national student network of Myelopathy.org. The survey comprised a 19-item questionnaire capturing data on student demographics, myelopathy teaching and myelopathy knowledge. Advertisements were repeated monthly over a 12-month recruitment period and participation was incentivised by entry into an Amazon voucher prize draw. Ethical approval for the study was granted by the Psychology Research Ethics Committee, University of Cambridge (PRE.2018.099). RESULTS A total of 751 medical students from 32 British medical schools completed the survey. Medical students from all year groups participated. Most students (520; 72%) had not received any medical school teaching about DCM. When students had received DCM teaching, the duration of teaching was minimal (75% < 1 h). A total of 350 students (47%) reported conducting private study on DCM. Modal student self-rating of their own knowledge of DCM was 'terrible' (356; 47%). There was no correlation between a student's subjective rating of their knowledge and their answers to objective questions. A total of 723 (96%) of students expressed interest in learning more about DCM, with lectures the preferred format. CONCLUSIONS DCM appears to be a neglected condition in medical education which has implications for clinical practice. However, student enthusiasm to undertake private study suggests future teaching interventions will be well-received. Future work is necessary to characterise the format of DCM teaching that is most effective and to subsequently measure how educational interventions translate into clinical benefits.
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Affiliation(s)
| | - Benjamin M Davies
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Max Stewart
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Sam Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Alice Willison
- Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Shahzaib Ahmed
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | | | - Jibin Francis
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Sybil R L Stacpoole
- Department of Clinical Neurosciences, Neurology Unit, University of Cambridge, Cambridge, UK
| | - Mark R N Kotter
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Oliver D Mowforth
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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22
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Tsitsopoulos PP, Mondello S, Holmström U, Marklund N. Cerebrospinal fluid biomarkers of white matter injury and astrogliosis are associated with the severity and surgical outcome of degenerative cervical spondylotic myelopathy. Spine J 2022; 22:1848-1856. [PMID: 35753639 DOI: 10.1016/j.spinee.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/09/2022] [Accepted: 06/16/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Degenerative cervical spondylotic myelopathy (DCM) is the commonest form of spinal cord injury in adults. However, a limited number of clinical reports have assessed the role of biomarkers in DCM. PURPOSE We evaluated cerebrospinal fluid (CSF) biomarkers in patients scheduled for DCM surgery and hypothesized that CSF biomarkers levels (1) would reflect the severity of preoperative neurological status; and (2) correlate with radiological appearance; and (3) correlate with clinical outcome. STUDY DESIGN/SETTING Prospective clinical and laboratory study. PATIENT SAMPLE Twenty-three DCM patients, aged 66.4±12.8 years and seven controls aged 45.4±5.3 years were included. OUTCOME MEASURES The American Spinal Injury Association Impairment Scale, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire and EuroQol 5-dimensions were assessed preoperatively and at 3 months post-surgery. METHODS We measured preoperative biomarkers (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], phosphorylated neurofilament-H [pNF-H] and Ubiquitin C-terminal hydrolase L1) in CSF samples collected from patients with progressive clinical DCM who underwent surgical treatment. Biomarker concentrations in DCM patients were compared with those of cervical radiculopathy controls. RESULTS The median symptom duration was 10 (interquartile range 6) months. The levels of GFAP, NFL, pNF-H, Ubiquitin C-terminal hydrolase L1 were significantly higher in the DCM group compared to controls (p=.044, p=.002, p=.016, and p=.006, respectively). Higher pNF-H levels were found in patients with low signal on T1 Magnetic Resonance Imaging sequence compared to those without (p=.022, area under the receiver operating characteristic curve [AUC] 0.780, 95% Confidence Interval: 0.59-0.98). Clinical improvement following surgery correlated mainly with NFL and GFAP levels (p<.05). CONCLUSIONS Our results suggest that CSF biomarkers of white matter injury and astrogliosis may be a useful tool to assess myelopathy severity and predict outcome after surgery, while providing valuable information on the underlying pathophysiology.
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Affiliation(s)
- Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokratio General Hospital, Constantinoupoleos 49, 54642, Aristotle University School of Medicine, Thessaloniki, Greece; Department of Neuroscience, Neurosurgery, Sjukhusvägen 3, 751 85, Uppsala University Hospital, Uppsala, Sweden.
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, A.O.U. "Policlinico G. Martino" Via Consolare Valeria, 98125, University of Messina, Messina, Italy
| | - Ulrika Holmström
- Department of Neuroscience, Neurosurgery, Sjukhusvägen 3, 751 85, Uppsala University Hospital, Uppsala, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hospital Klinikgatan 17A, 221 85 Lund, Sweden
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23
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Tetreault L, Kalsi-Ryan S, Benjamin Davies, Nanna-Lohkamp L, Garwood P, Martin AR, Wilson JR, Harrop JS, Guest JD, Kwon BK, Milligan J, Arizala AM, Kotter MR, Fehlings MG. Degenerative Cervical Myelopathy: A Practical Approach to Diagnosis. Global Spine J 2022; 12:1881-1893. [PMID: 35043715 PMCID: PMC9609530 DOI: 10.1177/21925682211072847] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Narrative Review. OBJECTIVES The objective of this review is to provide a stepwise approach to the assessment of patients with potential symptoms of degenerative cervical myelopathy (DCM). METHODS N/A. RESULTS DCM is an overarching term used to describe progressive compression of the cervical spinal cord by age-related changes to the spinal axis. These alterations to normal anatomy narrow the spinal canal, reduce the space available for the spinal cord, and may ultimately compress the ascending and descending neural tracts. Patients with DCM present with a wide range of symptoms that can significantly impact quality of life, including bilateral hand numbness and paresthesia, gait impairment, motor weakness of the upper and lower extremities, and bladder and bowel dysfunction. Unfortunately, DCM is often misdiagnosed, resulting in delayed assessment and management by the appropriate specialist. The proper evaluation of a patient with suspected DCM includes obtaining a detailed patient history, conducting a comprehensive neurological examination, and ordering appropriate tests to rule in or out other diagnoses. CONCLUSION This review summarizes a stepwise approach to the diagnosis of patients with DCM.
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Affiliation(s)
- Lindsay Tetreault
- Division of Neurology, Graduate
Medical Education, New York University
Langone, New York, NY, USA
| | | | - Benjamin Davies
- Department of Academic
Neurosurgery, University of Cambridge, Cambridge, UK
| | - Laura Nanna-Lohkamp
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada
| | - Philip Garwood
- Internal Medicine Resident,
Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Allan R. Martin
- Spine Neurosurgery, University of California
Davis, Davis, CA, USA
| | - Jefferson R. Wilson
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - James S. Harrop
- Departments of Neurological and
Orthopedic Surgery, Thomas Jefferson
University, Philadelphia, PA, USA
| | - James D. Guest
- The Miami Project to Cure
Paralysis, University of Miami, Miami, FL, USA
| | - Brian K. Kwon
- Department, of Orthopaedics, University of British
Columbia, Vancouver, BC, Canada
| | - James Milligan
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Mark R. Kotter
- Department of Academic
Neurosurgery, University of Cambridge, Cambridge, UK
| | - Michael G. Fehlings
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada,Michael G. Fehlings, MD, PhD, FRCSC, FACS,
Division of Neurosurgery and Spinal Program, Department of Surgery, University
of Toronto, Krembil Neuroscience Centre, Toronto Western Hospital, 399 Bathurst
Street, Suite 4WW-449, Toronto, ON M5T 2S8, Canada.
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Muacevic A, Adler JR. Identification of Degenerative Cervical Myelopathy in the Chiropractic Office: Case Report and a Review of the Literature. Cureus 2022; 14:e30508. [PMID: 36415361 PMCID: PMC9675290 DOI: 10.7759/cureus.30508] [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] [Accepted: 10/20/2022] [Indexed: 12/14/2022] Open
Abstract
Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction, yet it may be challenging to identify as it presents with variable symptoms. A 62-year-old woman presented to a chiropractor with a three-month exacerbation of neck pain, hand/finger numbness, and torso dysesthesia. She had previously seen primary care, physical therapy, rheumatology, and pain management. Previous cervical magnetic resonance imaging showed moderate cervical canal stenosis; however, previous providers had diagnosed her with radiculopathy and possible carpal tunnel syndrome yet had not requested neurosurgical consultation. On examination, the chiropractor identified sensorimotor deficits, hyperreflexia, and bilateral Hoffman reflexes, and referred the patient to a neurosurgeon for suspected DCM. The neurosurgeon performed an anterior cervical discectomy and fusion from C4-7. The patient's symptoms and disability level improved within two months of follow-up. We identified 11 previous cases in which a chiropractor suspected DCM which was then confirmed by a surgeon. Including the current case (i.e., 12 total), patients were older and mostly male; 50% had neck pain, 92% had hyperreflexia. Chiropractors referred each patient to a surgeon; 83% underwent cervical spine surgery. This case highlights the identification of DCM by a chiropractor and referral for neurosurgical evaluation with a positive outcome. Patients with previously undiagnosed DCM may present to chiropractors with varied symptoms and examination findings. DCM may contraindicate spinal manipulation and instead warrant surgery. Accordingly, chiropractors play a key role in the detection and referral of patients with misdiagnosed or overlooked DCM.
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Kobayashi H, Otani K, Nikaido T, Watanabe K, Kato K, Kobayashi Y, Yabuki S, Konno SI. Development of a Novel Diagnostic Support Tool for Degenerative Cervical Myelopathy Combining 10-s Grip and Release Test and Grip Strength: A Pilot Study. Diagnostics (Basel) 2022; 12:diagnostics12092108. [PMID: 36140509 PMCID: PMC9497574 DOI: 10.3390/diagnostics12092108] [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: 08/11/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/24/2022] Open
Abstract
Early diagnosis of degenerative cervical myelopathy (DCM) is desirable, as delayed treatment can cause irreversible spinal cord injury and subsequent activity of daily living (ADL) impairment. We attempted to develop a straightforward and accurate diagnostic tool for DCM by combining the grip and release test (GRT) and grip strength. As a pilot study, we measured the GRT and grip strength of patients with DCM (n = 247) and a control group (n = 721). Receiver operating characteristic analysis was performed using the lower left and right. The Youden index was used to set cutoff values by sex and age group. The diagnostic performance of each test varied by sex and age, and a diagnostic support tool was created to determine any abnormal results in a test. The calculated M/F cutoff values for GRT were as follows: 40–59 years, 21/18; 60–69 years, 17/17; 70–79 years, 15/15; and 80–89 years, 11/12. The calculated M/F cutoff values for grip strength 32/20, 29/13, 21/15, and 19/10. When either GRT or grip strength was judged as positive, the overall sensitivity was 88.2%, specificity was 78.1%, positive likelihood ratio was 4.03, and the negative likelihood ratio was 0.15. This novel diagnostic support tool was superior to using GRT and grip strength alone in the early DCM diagnosis. Future research to obtain age- and sex-specific data is necessary to validate and further improve the tool.
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26
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Guo S, Lin T, Wu R, Wang Z, Chen G, Liu W. The Pre-Operative Duration of Symptoms: The Most Important Predictor of Post-Operative Efficacy in Patients with Degenerative Cervical Myelopathy. Brain Sci 2022; 12:brainsci12081088. [PMID: 36009151 PMCID: PMC9405785 DOI: 10.3390/brainsci12081088] [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: 07/04/2022] [Revised: 07/20/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
Objective. To explore the most important predictors of post-operative efficacy in patients with degenerative cervical myelopathy (DCM). Methods. From January 2013 to January 2019, 284 patients with DCM were enrolled. They were categorized based on the different surgical methods used: single anterior cervical decompression and fusion (ACDF) (n = 80), double ACDF (n = 56), three ACDF (n = 13), anterior cervical corpectomy and fusion (ACCF) (n = 63), anterior cervical hybrid decompression and fusion (ACHDF) (n = 25), laminoplasty (n = 38) and laminectomy and fusion (n = 9). The follow-up time was 2 years. The patients were divided into two groups based on the mJOA recovery rate at the last follow-up: Group A (the excellent improvement group, mJOA recovery rate >50%, n = 213) and Group B (the poor improvement group, mJOA recovery rate ≤50%, n = 71). The evaluated data included age, gender, BMI, duration of symptoms (months), smoking, drinking, number of lesion segments, surgical methods, surgical time, blood loss, the Charlson Comorbidity Index (CCI), CCI classification, imaging parameters (CL, T1S, C2-7SVA, CL (F), T1S (F), C2-7SVA (F), CL (E), T1S (E), C2-7SVA (E), CL (ROM), T1S (ROM) and C2-7SVA (ROM)), maximum spinal cord compression (MSCC), maximum canal compromise (MCC), Transverse area (TA), Transverse area ratio (TAR), compression ratio (CR) and the Coefficient compression ratio (CCR). The visual analog score (VAS), neck disability index (NDI), modified Japanese Orthopedic Association (mJOA) and mJOA recovery rate were used to assess cervical spinal function and quality of life. Results. We found that there was no significant difference in the baseline data among the different surgical groups and that there were only significant differences in the number of lesion segments, C2−7SVA, T1S (F), T1S (ROM), TA, CR, surgical time and blood loss. Therefore, there was comparability of the post-operative recovery among the different surgical groups, and we found that there were significant differences in age, the duration of symptoms, CL and pre-mJOA between Group A and Group B. A binary logistic regression analysis showed that the duration of the symptoms was an independent risk factor for post-operative efficacy in patients with DCM. Meanwhile, when the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196). Conclusion. For patients with DCM (regardless of the number of lesion segments and the proposed surgical methods), the duration of symptoms was an independent risk factor for the post-operative efficacy. When the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196).
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Affiliation(s)
| | | | | | | | | | - Wenge Liu
- Correspondence: ; Tel.: +86-0591-833-578-96
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27
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Nouri A, Molliqaj G, Gondar R, Lavé A, Jannelli G, Davies B, Kotter M, Martin A, Virojanapa J, Cheng JS, Somma T, Cappabianca P, Vleggeert-Lankamp CLA, ter Wengel V, Meling T, Schaller K, Tessitore E. Can screening for degenerative cervical myelopathy (SCREEN-DCM) be effectively undertaken based on signs, symptoms and known risk factors? Rationale and research protocol for a prospective, multicentre, observational study. BMJ Open 2022. [PMCID: PMC9301786 DOI: 10.1136/bmjopen-2021-060689] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord impairment. Unfortunately, the condition remains poorly recognised and underdiagnosed. To better identify patients, screening tests that target individuals at high risk would be helpful. One group in particular known to have a high prevalence of DCM consists of patients with lumbar degenerative disease (LDD), with the combined presentation referred to as tandem stenosis. Given that LDD is one of the most common presentations in neurosurgical practice and primary care, it is the objective of the proposed study to administer a screening test to these patients as well as those with risk factors or symptoms which raise the suspicion of underlying DCM. Methods and analysis A screening test based on clinical signs/symptoms and known risk factors of DCM was designed. Screening will be performed in neurosurgical consultations for patients with LDD or those with any suspicion of myelopathy. Points are attributed based on the presence of signs/symptoms of DCM (eg, Hoffmann sign, hyper-reflexia) and for comorbidities that predispose or are frequently associated with cervical myelopathy (eg, rheumatoid arthritis, carpal tunnel syndrome). Patients with ≥3 points undergo cervical MRI examination. Patients with positive MRIs will be consulted and receive assessment via modified Japanese Orthopedic Association and Neck Disability Index scores, and subsequent clinical management will be based on practice guidelines. An exploratory multivariate analysis of the effectiveness and efficiency of this proposed screening test will be evaluated after positively screening 50 patients for DCM. Ethics and dissemination This study has received research ethics approval from the Swiss Association of Research Ethics Committees (ID: 2020-02785). The results of this study will be disseminated in a journal targeting physicians commonly encountering patients with LDD.
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Omi H, Yokoyama T, Naraoka T, Omi S, Takeuchi K. Prevalence of Cervical Canal Stenosis in Patients with Femoral Fracture: A Retrospective Single-Center Study. Spine Surg Relat Res 2022; 6:631-637. [PMID: 36561151 PMCID: PMC9747213 DOI: 10.22603/ssrr.2022-0014] [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: 01/17/2022] [Accepted: 04/17/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Cervical spine surgery reduces falls and subsequent femoral fractures. Nonetheless, current evidence on the prevalence of cervical cord compression (CCC) and increased signal intensity (ISI) in patients with femoral fractures is limited. We aimed to determine the prevalence of CCC and ISI and characterize the physical status and imaging findings using cervical spine magnetic resonance imaging (MRI) and brain computed tomography (CT) in patients with femoral fractures. Methods This study included 173 patients (140 women, 33 men) with femoral fractures caused by falling, who underwent both cervical spine MRI and brain CT. CCC cases classified as grade 2 (compression of less than one-third of the spinal cord) or higher were investigated. The ISI of the severely affected intervertebral disc level was evaluated using T2-weighted MRI. Hand grip strength and myelopathic signs were also evaluated. Data analysis was performed using the χ2 test, Fisher's exact test, and Student's t-test. Results Among the 173 patients, 83 (48.0%) had CCC, 29 (16.8%) had ISI, and 68 (39.3%) had abnormal brain CT findings. There was no ISI in patients in the non-CCC group. The patients' average age in the CCC group was significantly higher than that in the non-CCC group. There was no significant difference in the proportion of myelopathic sign and abnormal brain CT findings between the CCC and non-CCC groups or between the ISI and non-ISI groups. Bilateral hand grip strength was significantly negatively correlated with the stenosis rate (right, p=0.047; left, p=0.0018). Conclusions In conclusion, our study showed that patients with femoral fractures had a high frequency of cervical canal stenosis and intracranial lesions using cervical spine MRI and brain CT.
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Affiliation(s)
- Hirotsugu Omi
- Department of Orthopaedic Surgery, Omi Orthopaedic Clinic, Hirosaki, Aomori, Japan
| | - Toru Yokoyama
- Department of Orthopaedic Surgery, Odate Municipal General Hospital, Odate, Akita, Japan
| | - Takuya Naraoka
- Department of Orthopaedic Surgery, Fujinomiya City General Hospital, Fujinomiya, Shizuoka, Japan
| | - Sanae Omi
- Department of Radiology, Kin-ikyo Chuo Hospital, Sapporo, Hokkaido, Japan
| | - Kazunari Takeuchi
- Department of Orthopaedic Surgery, Odate Municipal General Hospital, Odate, Akita, Japan
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El Khoury M, Mowforth OD, El Khoury A, Partha-Sarathi C, Hirayama Y, Davies BM, Kotter MR. Tremor as a symptom of degenerative cervical myelopathy: a systematic review. Br J Neurosurg 2022; 36:340-345. [PMID: 35132923 DOI: 10.1080/02688697.2022.2033701] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AO Spine RECODE-DCM (Research objectives and common data elements for degenerative cervical myelopathy) has highlighted that the subjective disability reported by people living with DCM is much broader than routinely considered today by most professionals. This includes a description of tremor. The objective of this review was to study the incidence and possible aetiology of tremor in degenerative cervical myelopathy (DCM). METHODS A systematic review registered in PROSPERO (CRD42020176905) was conducted in Embase and MEDLINE for papers studying tremor and DCM published on or before the 20th of July 2020. All manuscripts describing an association between tremor and DCM in humans were included. Articles relating to non-human animals, and those not available in English were excluded. An analysis was conducted in accordance with PRISMA and SWiM guidelines for systematic reviews. RESULTS Out of a total of 4402 screened abstracts, we identified 7 case reports and series describing tremor in 9 DCM patients. Papers were divided into three groups for the discussion. The first group includes DCM correctly identified on presentation, with tremor as a described symptom. The second group includes cases where DCM was misdiagnosed, often as Parkinson's disease. The third group includes a single case with a previous history of DCM, presenting with an otherwise unexplained tremor. This grouping allows for the clustering of cases supporting various arguments for the association between tremor and DCM. CONCLUSION DCM can be associated with tremor. The current evidence is restricted to case series. Further study is warranted to establish tremor prevalence, and its significance to assessment and management.
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Affiliation(s)
- Marc El Khoury
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Oliver D Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Anthony El Khoury
- Southwest Indiana Internal Medicine Residency, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Yuri Hirayama
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mark R Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Anne McLaren Laboratory for Regenerative Medicine, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
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Davies BM, Munro C, Khan DZ, Fitzpatrick SM, Hilton B, Mowforth OD, McNair AGK, Sadler I, Kotter MRN. Outcomes of Degenerative Cervical Myelopathy From The Perspective of Persons Living With the Condition: Findings of a Semistructured Interview Process With Partnered Internet Survey. Global Spine J 2022; 12:432-440. [PMID: 33203262 PMCID: PMC9121154 DOI: 10.1177/2192568220953811] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
STUDY DESIGN Mixed-methods cross-sectional study. OBJECTIVES Degenerative cervical myelopathy (DCM) is a common and disabling condition. While classically, assessment and diagnosis has focused on neuromuscular symptoms, many other disabilities have been linked. The aim of this study was to explore the consequences of DCM for those with lived experience, producing a long list to inform the development of a core outcome set for DCM research. METHODS A 2-stage process was used: a focus group session of people with DCM (PwCM) and their supporters (n = 8) discussed the impact of DCM. This was used to develop a preliminary list of consequences, which were then placed into a survey of an online community of DCM sufferers (n = 224). Survey participants were asked to tick the consequences that they had experienced and given the opportunity to submit additional. Additional consequences were reviewed by a group of healthcare professionals and PwCM and included if not already represented. Demographic information including disease severity, age, and sex were captured for sampling comparison. RESULTS A total of 52 outcomes were identified from the focus group and nominally divided into 2 categories; symptoms (36 outcomes) and handicaps (18 outcomes), and further evaluated using a survey. All outcomes were recognized by at least 5% of respondents. A further 16 outcomes were added following the survey. CONCLUSIONS A list of DCM consequences has been defined from the perspective of PwCM. This will now be evaluated as part of AO Spine RECODE-DCM, an international multistakeholder collaboration to establish a core outcome set for research.
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Affiliation(s)
- Benjamin M. Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Colin Munro
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Danyal Z. Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,Danyal Z. Khan, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | | | - Bryn Hilton
- Colchester Hospital University, East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
| | - Oliver D. Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Angus G. K. McNair
- Bristol Medical School: Population Health Sciences, University of Bristol, Bristol, UK
| | - Iwan Sadler
- Myelopathy Support, Myelopathy.org, Cambridge, UK
| | - Mark R. N. Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK,WT MRC Cambridge Stem Cell Institute, Anne McLaren Laboratory, Cambridge, UK
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Davies BM, Phillips R, Clarke D, Furlan JC, Demetriades AK, Milligan J, Witiw CD, Harrop JS, Aarabi B, Kurpad SN, Guest JD, Wilson JR, Kwon BK, Vaccaro AR, Fehlings MG, Rahimi-Movaghar V, Kotter MRN. Establishing the Socio-Economic Impact of Degenerative Cervical Myelopathy Is Fundamental to Improving Outcomes [AO Spine RECODE-DCM Research Priority Number 8]. Global Spine J 2022; 12:122S-129S. [PMID: 35174730 PMCID: PMC8859704 DOI: 10.1177/21925682211039835] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Literature Review (Narrative). OBJECTIVE To contextualize AO Spine RECODE-DCM research priority number 5: What is the socio-economic impact of DCM? (The financial impact of living with DCM to the individual, their supporters, and society as a whole). METHODS In this review, we introduce the methodology of health-economic investigation, including potential techniques and approaches. We summarize the current health-economic evidence within DCM, so far focused on surgical treatment. We also cover the first national estimate, in partnership with Myelopathy.org from the United Kingdom, of the cost of DCM to society. We then demonstrate the significance of this question to advancing care and outcomes in the field. RESULTS DCM is a common and often disabling condition, with a significant lack of recognition. While evidence demonstrates the cost-effectives of surgery, even among higher income countries, health inequalities exist. Further the prevalent residual disability in myelopathy, despite treatment affects both the individual and society as a whole. A report from the United Kingdom provides the first cost-estimate to their society; an annual cost of ∼£681.6 million per year, but this is likely a significant underestimate. CONCLUSION A clear quantification of the impact of DCM is needed to raise the profile of a common and disabling condition. Current evidence suggests this is likely to be globally substantial.
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Affiliation(s)
- Benjamin M. Davies
- Department of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- , International Charity for Degenerative Cervical Myelopathy, United Kingdom
| | | | - David Clarke
- Department of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Julio C. Furlan
- KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Jamie Milligan
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christopher D. Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - 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
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Brian K. Kwon
- Department of Orthopedics, Vancouver Spine Surgery Institute, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mark R. N. Kotter
- Department of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
- , International Charity for Degenerative Cervical Myelopathy, United Kingdom
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Mowforth OD, Khan DZ, Wong MY, Pickering GAE, Dean L, Magee J, Mullarkey L, Hirayama Y, Rihova M, Butler M, Stewart M, Goulson B, Ahmed S, Fricke K, Popa-Nimigean V, Millar Z, Venkatesh A, Willison A, Senthil K, Hazenbiller O, Sarewitz E, Sadler I, Gronlund T, Tetreault L, Harrop JS, Aarabi B, Rahimi-Movaghar V, Kurpad SN, Guest JD, Wilson JR, Kwon BK, Fehlings MG, McNair AG, Davies BM, Kotter MR. Gathering Global Perspectives to Establish the Research Priorities and Minimum Data Sets for Degenerative Cervical Myelopathy: Sampling Strategy of the First Round Consensus Surveys of AO Spine RECODE-DCM. Global Spine J 2022; 12:8S-18S. [PMID: 34879754 PMCID: PMC8859701 DOI: 10.1177/21925682211047546] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Survey. INTRODUCTION AO Spine Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy (AO Spine RECODE-DCM) is an international initiative that aims to accelerate knowledge discovery and improve outcomes by developing a consensus framework for research. This includes defining the top research priorities, an index term and a minimum data set (core outcome set and core data elements set - core outcome set (COS)/core data elements (CDE)). OBJECTIVE To describe how perspectives were gathered and report the detailed sampling characteristics. METHODS A two-stage, electronic survey was used to gather and seek initial consensus. Perspectives were sought from spinal surgeons, other healthcare professionals and people with degenerative cervical myelopathy (DCM). Participants were allocated to one of two parallel streams: (1) priority setting or (2) minimum dataset. An email campaign was developed to advertise the survey to relevant global stakeholder individuals and organisations. People with DCM were recruited using the international DCM charity Myelopathy.org and its social media channels. A network of global partners was recruited to act as project ambassadors. Data from Google Analytics, MailChimp and Calibrum helped optimise survey dissemination. RESULTS Survey engagement was high amongst the three stakeholder groups: 208 people with DCM, 389 spinal surgeons and 157 other healthcare professionals. Individuals from 76 different countries participated; the United States, United Kingdom and Canada were the most common countries of participants. CONCLUSION AO Spine RECODE-DCM recruited a diverse and sufficient number of participants for an international PSP and COS/CDE process. Whilst PSP and COS/CDE have been undertaken in other fields, to our knowledge, this is the first time they have been combined in one process.
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Affiliation(s)
- Oliver D. Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge; Addenbrooke's Hospital, UK
| | - Danyal Z Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge; Addenbrooke's Hospital, UK
| | - Mei Yin Wong
- School of Clinical Medicine, University of Cambridge, UK
| | | | - Lydia Dean
- School of Clinical Medicine, University of Cambridge, UK
| | - Joe Magee
- School of Clinical Medicine, University of Cambridge, UK
| | | | - Yuri Hirayama
- School of Clinical Medicine, University of Cambridge, UK
| | - Martina Rihova
- School of Clinical Medicine, University of Cambridge, UK
| | | | - Max Stewart
- School of Clinical Medicine, University of Cambridge, UK
| | - Beth Goulson
- School of Clinical Medicine, University of Cambridge, UK
| | - Shahzaib Ahmed
- School of Clinical Medicine, University of Cambridge, UK
| | - Kai Fricke
- School of Clinical Medicine, University of Cambridge, UK
| | | | - Zack Millar
- School of Clinical Medicine, University of Cambridge, UK
| | | | | | | | | | | | | | - Toto Gronlund
- National Institute for Health Research, University of Southampton, UK
| | - Lindsay Tetreault
- Langone Health, Graduate Medical Education, Department of Neurology, New York University, New York, NY, USA
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, United States
| | - James D. Guest
- Department of Neurosurgery, University of Miami, Miami, FL, United States
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Canada
| | - 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, Canada
| | | | - Benjamin M. Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge; Addenbrooke's Hospital, UK
| | - Mark R.N. Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge; Addenbrooke's Hospital, UK
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Donnally CJ, Patel PD, Canseco JA, Vaccaro AR, Kepler CK. Current Management of Cervical Spondylotic Myelopathy. Clin Spine Surg 2022; 35:E68-E76. [PMID: 34379614 DOI: 10.1097/bsd.0000000000001113] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
Cervical spondylotic myelopathy (CSM) develops insidiously as degenerative changes of the cervical spine impact the spinal cord. Unfortunately, CSM is a form of spinal cord injury in older patients that often experiences delayed treatment. This summary evaluates the pathophysiology, natural history, diagnosis, and current management of CSM. Frequently, patients do not appreciate or correlate their symptomatology with cervical spine disease, and those with radiographic findings may be clinically asymptomatic. Providers should remember the classic symptoms of CSM-poor hand dexterity, new unsteady gait patterns, new onset and progressive difficulty with motor skills. An magnetic resonance imaging is required in patients with suspected CSM, but computerized tomography myelography is an alternative in patients with implants as contraindications to magnetic resonance imaging. The management of those with CSM has continued to be a controversial topic. In general, patients with incidental findings of cervical cord compression that are asymptomatic can be managed conservatively. Those with daily moderate-severe disease that significantly affects activities of daily living should be treated operatively.
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Affiliation(s)
| | - Parthik D Patel
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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Davies BM, Mowforth O, Wood H, Karimi Z, Sadler I, Tetreault L, Milligan J, Wilson JRF, Kalsi-Ryan S, Furlan JC, Kawaguchi Y, Ito M, Zipser CM, Boerger TF, Vaccaro AR, Murphy RKJ, Hutton M, Rodrigues-Pinto R, Koljonen PA, Harrop JS, Aarabi B, Rahimi-Movaghar V, Kurpad SN, Guest JD, Wilson JR, Kwon BK, Kotter MRN, Fehlings MG. Improving Awareness Could Transform Outcomes in Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 1]. Global Spine J 2022; 12:28S-38S. [PMID: 35174734 PMCID: PMC8859708 DOI: 10.1177/21925682211050927] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
STUDY DESIGN Literature Review (Narrative). OBJECTIVE To introduce the number one research priority for Degenerative Cervical Myelopathy (DCM): Raising Awareness. METHODS Raising awareness has been recognized by AO Spine RECODE-DCM as the number one research priority. This article reviews the evidence that awareness is low, the potential drivers, and why this must be addressed. Case studies of success from other diseases are also reviewed, drawing potential parallels and opportunities for DCM. RESULTS DCM may affect as many as 1 in 50 adults, yet few will receive a diagnosis and those that do will wait many years for it. This leads to poorer outcomes from surgery and greater disability. DCM is rarely featured in healthcare professional training programs and has received relatively little research funding (<2% of Amyotrophic Lateral Sclerosis or Multiple Sclerosis over the last 25 years). The transformation of stroke and acute coronary syndrome services, from a position of best supportive care with occasional surgery over 50 years ago, to avoidable disability today, represents transferable examples of success and potential opportunities for DCM. Central to this is raising awareness. CONCLUSION Despite the devastating burden on the patient, recognition across research, clinical practice, and healthcare policy are limited. DCM represents a significant unmet need that must become an international public health priority.
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Affiliation(s)
- Benjamin M. Davies
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, Cambridge, UK
- Department of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Oliver Mowforth
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, Cambridge, UK
- Department of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Helen Wood
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, Cambridge, UK
| | - Zahabiya Karimi
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, Cambridge, UK
| | - Iwan Sadler
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, Cambridge, UK
| | - Lindsay Tetreault
- Department of Neurology, Langone Health, Graduate Medical Education, New York University, New York, NY, USA
| | - Jamie Milligan
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Jamie R. F. Wilson
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sukhvinder Kalsi-Ryan
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
| | - Julio C. Furlan
- KITE Research Institute, University Health Network, Toronto, ON, Canada
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada
| | | | - Manabu Ito
- Department of Orthopaedic Surgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Carl Moritz Zipser
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Timothy F Boerger
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rory K. J. Murphy
- Department of Neurosurgery, St. Joseph’s Hospital and Medical Center, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Mike Hutton
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Ricardo Rodrigues-Pinto
- Department of Orthopaedics, Spinal Unit (UVM), Centro Hospitalar Universitário Do Porto - Hospital de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Paul A. Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, 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, Tehran, Iran
| | - 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
| | - Jefferson R. Wilson
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Brian K. Kwon
- Department of Orthopedics, Vancouver Spine Surgery Institute, The University of British Columbia, Vancouver, BC, Canada
| | - Mark R. N. Kotter
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, Cambridge, UK
- Department of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Michael G. Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
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Hilton B, Gardner EL, Jiang Z, Tetreault L, Wilson JRF, Zipser CM, Riew KD, Guest JD, Harrop JS, Fehlings MG, Rodrigues-Pinto R, Rahimi-Movaghar V, Aarabi B, Koljonen PA, Kotter MRN, Davies BM, Kwon BK. Establishing Diagnostic Criteria for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 3]. Global Spine J 2022; 12:55S-63S. [PMID: 35174729 PMCID: PMC8859706 DOI: 10.1177/21925682211030871] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVES To discuss the importance of establishing diagnostic criteria in Degenerative Cervical Myelopathy (DCM), including factors that must be taken into account and challenges that must be overcome in this process. METHODS Literature review summarising current evidence of establishing diagnostic criteria for DCM. RESULTS Degenerative Cervical Myelopathy (DCM) is characterised by a degenerative process of the cervical spine resulting in chronic spinal cord dysfunction and subsequent neurological disability. Diagnostic delays lead to progressive neurological decline with associated reduction in quality of life for patients. Surgical decompression may halt neurologic worsening and, in many cases, improves function. Therefore, making a prompt diagnosis of DCM in order to facilitate early surgical intervention is a clinical priority in DCM. CONCLUSION There are often extensive delays in the diagnosis of DCM. Presently, no single set of diagnostic criteria exists for DCM, making it challenging for clinicians to make the diagnosis. Earlier diagnosis and subsequent specialist referral could lead to improved patient outcomes using existing treatment modalities.
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Affiliation(s)
- Bryn Hilton
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Emma L. Gardner
- Colchester Hospital, East Suffolk and North Essex NHS Foundation Trust, Colchester, United Kingdom
| | - Zhilin Jiang
- Kings College Hospital, Kings College Hospital NHS Foundation Trust, London, United Kingdom
| | - Lindsay Tetreault
- Langone Health, Graduate Medical Education, Department of Neurology, New York University, NY, USA
| | - Jamie R. F. Wilson
- University of Nebraska Medical Center, Department of Neurosurgery, Omaha, Nebraska, USA
| | - Carl Moritz Zipser
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - K. Daniel Riew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, NY, 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
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ricardo Rodrigues-Pinto
- Department of Orthopaedics, Spinal Unit (UVM), Centro Hospitalar Universitário do Porto - Hospital de Santo António, Porto, Portugal
- Department of Orthopaedics, Instituto de CiM), Centro Hospital, Portugal
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul A. Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Mark R. N. Kotter
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, United Kingdom
- Department of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin M. Davies
- Myelopathy.org, International Charity for Degenerative Cervical Myelopathy, United Kingdom
- Department of Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Brian K. Kwon
- Department of Orthopaedics, University of British Columbia, Blusson Spinal Cord Center, Vancouver, British Columbia, Canada
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Johansen TO, Vangen-Lønne V, Holmberg ST, Salvesen ØO, Solberg TK, Gulati AM, Nygaard ØP, Gulati S. Surgery for degenerative cervical myelopathy in the elderly: a nationwide registry-based observational study with patient-reported outcomes. Acta Neurochir (Wien) 2022; 164:2317-2326. [PMID: 35852626 PMCID: PMC9427907 DOI: 10.1007/s00701-022-05282-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/06/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to investigate whether clinical outcomes in patients aged ≥ 70 undergoing decompressive surgery for degenerative cervical myelopathy (DCM) differ from those of younger patients (50-70 years) at 1 year. METHODS Data were obtained from the Norwegian Registry for Spine Surgery (NORspine). Among 651 patients included, 177 (27.2%) were ≥ 70 years old. The primary outcome was change in the Neck Disability Index (NDI). Secondary outcomes were changes in the European Myelopathy Score (EMS), quality of life (EuroQoL EQ-5D), numeric rating scales (NRS) for headache, neck pain, and arm pain, and complications. RESULTS Significant improvements in all patient-reported outcomes (PROMs) were detected for both age cohorts at 1 year. For the two age cohorts combined, there was a statistically significant improvement in the NDI score (mean 9.2, 95% CI 7.7 to 10.6, P < 0.001). There were no differences between age cohorts in mean change of NDI (- 8.9 vs. - 10.1, P = 0.48), EQ-5D (0.13 vs. 0.17, P = 0.37), or NRS pain scores, but elderly patients experienced a larger improvement in EMS (0.7 vs. 1.3, P = 0.02). A total of 74 patients (15.6%) in the younger cohort and 43 patients (24.3%) in the older cohort experienced complications or adverse effects within 3 months of surgery, mainly urinary and respiratory tract infections. CONCLUSION Surgery for DCM was associated with significant improvement across a wide range of PROMs for both younger and elderly patients. Surgery for DCM should not be denied based on age alone.
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Affiliation(s)
- Tonje Okkenhaug Johansen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway ,Department of Neurosurgery, St. Olavs Hospital, NO-7006 Trondheim, Norway
| | - Vetle Vangen-Lønne
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway ,Department of Neurosurgery, St. Olavs Hospital, NO-7006 Trondheim, Norway
| | - Siril T. Holmberg
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway ,Department of Neurosurgery, St. Olavs Hospital, NO-7006 Trondheim, Norway
| | - Øyvind O. Salvesen
- Department of Public Health and General Practice, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway
| | - Tore K. Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery, University Hospital of North Norway, Tromsø, Norway ,Institute for Clinical Medicine, UNN The Arctic University of Norway, Tromsø, Norway
| | - Agnete M. Gulati
- Department of Rheumatology, St. Olavs Hospital, NO-7006 Trondheim, Norway
| | - Øystein P. Nygaard
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway ,Department of Neurosurgery, St. Olavs Hospital, NO-7006 Trondheim, Norway ,National Advisory Unit On Spinal Surgery, St. Olavs Hospital, NO-7006 Trondheim, Norway
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, NO-7491 Trondheim, Norway ,Department of Neurosurgery, St. Olavs Hospital, NO-7006 Trondheim, Norway
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Wathieu N, Hussein M, Omar M, Wathieu D, Skinner KA, Toraih E, Borchardt J, Kandil E. Intraoperative neurophysiologic monitoring prevented iatrogenic spinal cord injury during robotic-assisted transabdominal adrenalectomy: a case report. Gland Surg 2021; 10:3155-3162. [PMID: 34926231 DOI: 10.21037/gs-21-235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 10/04/2021] [Indexed: 11/06/2022]
Abstract
Cervical spondylotic myelopathy (CSM) is the most common disease of the cervical spinal cord in patients older than 55 and is characterized by an initial asymptomatic period followed by progressive neurological deficit from degenerative changes of the cervical vertebrae. These changes cause compression and vascular compromise to the cervical spinal cord. Because there are no pathognomonic symptoms, its diagnosis is commonly delayed. Herein we report the first case of the use of IONM during a transabdominal adrenalectomy in a patient with CSM, which prevented an iatrogenic spinal cord injury (SCI). The patient is a 74-year-old male with what was proven later as cervical spinal stenosis who presented for robotic-assisted transabdominal adrenalectomy. When positioned supine on the operating table, he exhibited upper and lower extremity neurological symptoms, prompting awake fiberoptic intubation and the use of IONM secondary to suspicion for CSM. After being positioned into lateral decubitus, IONM showed a loss of transcranial motor evoked potentials (TcMEP) and attenuated somatosensory evoked potentials (SSEP) from the right lower extremities and the procedure was aborted and the patient returned supine. TcMEPs returned to baseline, but SSEPs remained attenuated. The patient exhibited normal movement and sensation in post-anesthesia care. A high index of suspicion for CSM is required for older patients, as early diagnosis allows for spinal surgery treatment before acute worsening during anesthesia or non-spinal surgery. Furthermore, a low threshold for the use of IONM in patients with a high likelihood of CSM who require a non-spinal surgery can successfully prevent iatrogenic SCI.
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Affiliation(s)
| | - Mohammad Hussein
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Mahmoud Omar
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Donald Wathieu
- Tulane University School of Medicine, New Orleans, LA, USA
| | - Kristin A Skinner
- Department of Anesthesiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Eman Toraih
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jeffrey Borchardt
- Department of Anesthesiology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, 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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Degenerative Cervical Myelopathy: Clinical Presentation, Assessment, and Natural History. J Clin Med 2021; 10:jcm10163626. [PMID: 34441921 PMCID: PMC8396963 DOI: 10.3390/jcm10163626] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/05/2021] [Accepted: 08/14/2021] [Indexed: 11/17/2022] Open
Abstract
Degenerative cervical myelopathy (DCM) is a leading cause of spinal cord injury and a major contributor to morbidity resulting from narrowing of the spinal canal due to osteoarthritic changes. This narrowing produces chronic spinal cord compression and neurologic disability with a variety of symptoms ranging from mild numbness in the upper extremities to quadriparesis and incontinence. Clinicians from all specialties should be familiar with the early signs and symptoms of this prevalent condition to prevent gradual neurologic compromise through surgical consultation, where appropriate. The purpose of this review is to familiarize medical practitioners with the pathophysiology, common presentations, diagnosis, and management (conservative and surgical) for DCM to develop informed discussions with patients and recognize those in need of early surgical referral to prevent severe neurologic deterioration.
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Gulati S, Vangen-Lønne V, Nygaard ØP, Gulati AM, Hammer TA, Johansen TO, Peul WC, Salvesen ØO, Solberg TK. Surgery for Degenerative Cervical Myelopathy: A Nationwide Registry-Based Observational Study With Patient-Reported Outcomes. Neurosurgery 2021; 89:704-711. [PMID: 34325471 PMCID: PMC8453385 DOI: 10.1093/neuros/nyab259] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/16/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Indications and optimal timing for surgical treatment of degenerative cervical myelopathy (DCM) remain unclear, and data from daily clinical practice are warranted. OBJECTIVE To investigate clinical outcomes following decompressive surgery for DCM. METHODS Data were obtained from the Norwegian Registry for Spine Surgery. The primary outcome was change in the neck disability index (NDI) 1 yr after surgery. Secondary endpoints were the European myelopathy score (EMS), quality of life (EuroQoL 5D [EQ-5D]), numeric rating scales (NRS) for headache, neck pain, and arm pain, complications, and perceived benefit of surgery assessed by the Global Perceived Effect (GPE) scale. RESULTS We included 905 patients operated between January 2012 and June 2018. There were significant improvements in all patient-reported outcome measures (PROMs) including NDI (mean -10.0, 95% CI -11.5 to -8.4, P < .001), EMS (mean 1.0, 95% CI 0.8-1.1, P < .001), EQ-5D index score (mean 0.16, 95% CI 0.13-0.19, P < .001), EQ-5D visual analogue scale (mean 13.8, 95% CI 11.7-15.9, P < .001), headache NRS (mean -1.1, 95% CI -1.4 to -0.8, P < .001), neck pain NRS (mean -1.8, 95% CI -2.0 to -1.5, P < .001), and arm pain NRS (mean -1.7, 95% CI -1.9 to -1.4, P < .001). According to GPE scale assessments, 229/513 patients (44.6%) experienced "complete recovery" or felt "much better" at 1 yr. There were significant improvements in all PROMs for both mild and moderate-to-severe DCM. A total of 251 patients (27.7%) experienced adverse effects within 3 mo. CONCLUSION Surgery for DCM is associated with significant and clinically meaningful improvement across a wide range of PROMs.
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Affiliation(s)
- Sasha Gulati
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway.,National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim, Norway
| | - Vetle Vangen-Lønne
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Øystein P Nygaard
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway.,National Advisory Unit on Spinal Surgery, St. Olavs Hospital, Trondheim, Norway
| | - Agnete M Gulati
- Department of Rheumatology, St. Olavs Hospital, Trondheim, Norway
| | - Tommy A Hammer
- Department of Radiology, St. Olavs Hospital, Trondheim, Norway
| | - Tonje O Johansen
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, Netherlands.,Department of Neurosurgery, Haaglanden Medical Centre, The Hague, Netherlands
| | - Øyvind O Salvesen
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway
| | - Tore K Solberg
- Department of Neurosurgery, University Hospital of North Norway, Norwegian Registry for Spine Surgery, Tromsø, Norway.,Institute for Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
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Grodzinski B, Durham R, Mowforth O, Stubbs D, Kotter MRN, Davies BM. The effect of ageing on presentation, management and outcomes in degenerative cervical myelopathy: a systematic review. Age Ageing 2021; 50:705-715. [PMID: 33219816 DOI: 10.1093/ageing/afaa236] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Degenerative cervical myelopathy (DCM) is a disabling neurological condition. The underlying degenerative changes are known to be more common with age, but the impact of age on clinical aspects of DCM has never been synthesised. The objective of this study is to determine whether age is a significant predictor in three domains-clinical presentation, surgical management and post-operative outcomes of DCM. METHODS a systematic review of the Medline and Embase databases (inception to 12 December 2019), registered with PROSPERO (CRD42019162077) and reported in accordance with preferred reporting items of systematic reviews and meta-analysis (PRISMA) guidelines, was conducted. The inclusion criteria were full text articles in English, evaluating the impact of age on clinical aspects of DCM. RESULTS the initial search yielded 2,420 citations, of which 206 articles were eventually included. Age was found to be a significant predictor in a variety of measures. Within the presentation domain, older patients have a worse pre-operative functional status. Within the management domain, older patients are more likely to undergo posterior surgery, with more levels decompressed. Within the outcomes domain, older patients have a worse post-operative functional status, but a similar amount of improvement in functional status. Because of heterogenous data reporting, meta-analysis was not possible. CONCLUSION the current evidence demonstrates that age significantly influences the presentation, management and outcomes of DCM. Although older patients have worse health at all individual timepoints, they experience the same absolute benefit from surgery as younger patients. This finding is of particular relevance when considering the eligibility of older patients for surgery.
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Affiliation(s)
- Ben Grodzinski
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Rory Durham
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Oliver Mowforth
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
| | - Daniel Stubbs
- University Department of Anesthesia, Department of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Mark R N Kotter
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
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Shea GKH, Koljonen PA, Chan YS, Cheung KMC. Prospects of cell replacement therapy for the treatment of degenerative cervical myelopathy. Rev Neurosci 2020; 32:275-287. [PMID: 33661584 DOI: 10.1515/revneuro-2020-0075] [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: 07/16/2020] [Accepted: 10/03/2020] [Indexed: 11/15/2022]
Abstract
Degenerative cervical myelopathy (DCM) presents insidiously during middle-age with deterioration in neurological function. It accounts for the most common cause of non-traumatic spinal cord injury in developed countries and disease prevalence is expected to rise with the aging population. Whilst surgery can prevent further deterioration, biological therapies may be required to restore neurological function in advanced disease. Cell replacement therapy has been inordinately focused on treatment of traumatic spinal cord injury yet holds immense promise in DCM. We build upon this thesis by reviewing the pathophysiology of DCM as revealed by cadaveric and molecular studies. Loss of oligodendrocytes and neurons occurs via apoptosis. The tissue microenvironment in DCM prior to end-stage disease is distinct from that following acute trauma, and in many ways more favourable to receiving exogenous cells. We highlight clinical considerations for cell replacement in DCM such as selection of cell type, timing and method of delivery, as well as biological treatment adjuncts. Critically, disease models often fail to mimic features of human pathology. We discuss directions for translational research towards clinical application.
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Affiliation(s)
- Graham Ka Hon Shea
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Hong Kong, China
| | - Paul Aarne Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Hong Kong, China
| | - Ying Shing Chan
- School of Biomedical Sciences, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kenneth Man Chee Cheung
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Road, Hong Kong, China
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The Frequency of Various "Myelopathic Symptoms" in Cervical Myelopathy: Evaluation in a Large Surgical Cohort. Clin Spine Surg 2020; 33:E448-E453. [PMID: 32205520 DOI: 10.1097/bsd.0000000000000968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
STUDY DESIGN A retrospective cohort of prospective data. OBJECTIVE Determine the frequency of various symptoms in a surgical cohort of cervical myelopathy (CM). SUMMARY OF BACKGROUND DATA CM can be difficult to diagnose as there is no sine qua non "myelopathic symptom." Despite extensive literature, the likelihood or frequency of symptoms at presentation remains unclear. MATERIALS AND METHODS A total of 484 patients treated at a single academic center were reviewed. Preoperative symptoms included: axial neck pain; upper extremity (UE) pain; UE sensory or motor deficit; lower extremity (LE) sensory or motor deficit; and sphincter dysfunction. It was noted whether a symptom was the chief complaint (CC) and/or one of a list of overall symptoms (OS) reported by the patient. Magnetic resonance imaging was assessed for the maximal cord compression level and T2 hyperintensity. RESULTS The most common CC was UE sensory deficit (46.5%), whereas the most common OS were UE and LE motor deficits (82.6% and 81.2%). Neck pain was significantly less common (32.6% CC, 55.4% OS), and sphincter dysfunction was rare (0.6% CC, 16.5% OS). UE pain as a CC was significantly higher when the maximal compression involved a more distal level. The presence of T2 hyperintensity was negatively associated with neck pain but positively associated with sensory and motor deficits of LE. CONCLUSIONS The most common CC in CM related to UE sensation, whereas the most common OS related to upper and lower motor function. UE pain was more common with more distal cord compression. Those with T2 hyperintensity had worse myelopathy and were less likely to have neck pain, but more likely to have LE symptoms. To our knowledge, this study is the largest to quantify the frequency of myelopathic symptom presentation in a surgical population. These findings provide valuable insight into the symptomatic presentation of CM in clinical practice and can be used to better inform diagnosis and treatment in this complex patient population. LEVEL OF EVIDENCE Level II-retrospective study.
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Zipser CM, Pfender N, Spirig JM, Betz M, Aguirre J, Hupp M, Farshad M, Curt A, Schubert M. Study protocol for an observational study of cerebrospinal fluid pressure in patients with degenerative cervical myelopathy undergoing surgical deCOMPression of the spinal CORD: the COMP-CORD study. BMJ Open 2020; 10:e037332. [PMID: 32958488 PMCID: PMC7507854 DOI: 10.1136/bmjopen-2020-037332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Degenerative cervical myelopathy (DCM) is a disabling spinal disorder characterised by sensorimotor deficits of upper and lower limbs, neurogenic bladder dysfunction and neuropathic pain. When suspected, cervical MRI helps to reveal spinal cord compression and rules out alternative diagnoses. However, the correlation between radiological findings and symptoms is weak. Cerebrospinal fluid pressure (CSFP) analysis may complement the appreciation of cord compression and be used for intraoperative and postoperative monitorings in patients undergoing surgical decompression. METHODS AND ANALYSIS Twenty patients diagnosed with DCM undergoing surgical decompression will receive standardised lumbar CSFP monitoring immediately before, during and 24 hours after operation. Rest (ie, opening pressure, CSF pulsation) and stimulated (ie, Valsalva, Queckenstedt's) CSFP-findings in DCM will be compared with 20 controls and results from CSFP monitoring will be related to clinical and neurophysiological findings. Arterial blood pressure will be recorded perioperatively and postoperatively to calculate spinal cord perfusion pressure and spinal vascular reactivity index. Furthermore, measures of CSFP will be compared with markers of spinal cord compression by means of MR imaging. ETHICS AND DISSEMINATION The study protocol conformed to the latest revision of the Declaration of Helsinki and was approved by the local Ethics Committee of the University Hospital of Zurich (KEK-ZH number PB-2016-00623). The main publications from this study will cover the CSFP fluid dynamics and pressure analysis preoperative, perioperative and postoperative correlated with imaging, clinical scores and neurophysiology. Other publications will deal with preoperative and postoperative spinal perfusion. Furthermore, we will disseminate an analysis on waveform morphology and the correlation with blood pressure and ECG. Parts of the data will be used for computational modelling of cervical stenosis. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT02170155).
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Affiliation(s)
- Carl Moritz Zipser
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Nikolai Pfender
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Jose Miguel Spirig
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Michael Betz
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Jose Aguirre
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Markus Hupp
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Department of Neurology and Neurophysiology, Balgrist University Hospital, Zurich, Switzerland
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
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Mowforth O, Davies B, Stewart M, Smith S, Willison A, Ahmed S, Starkey M, Sadler I, Sarewitz E, Stacpoole S, Kotter M. Current provision of myelopathy education in medical schools in the UK: protocol for a national medical student survey. BMJ Open 2020; 10:e035563. [PMID: 32847904 PMCID: PMC7451530 DOI: 10.1136/bmjopen-2019-035563] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Degenerative cervical myelopathy (DCM) is a common, disabling and progressive neurological condition triggered by chronic compression of the cervical spinal cord by surrounding degenerative changes. Early diagnosis and specialist management are essential to reduce disability, yet time to diagnosis is typically prolonged. Lack of sufficient representation of DCM in undergraduate and postgraduate medical curricula may contribute to the poor recognition of DCM by non-specialist doctors in clinical practice.In this study, our objective, therefore, is to assess DCM teaching provision in medical schools throughout the UK and to assess the impact of teaching on the DCM knowledge of UK medical students. METHODS AND ANALYSIS A 19-item questionnaire capturing data on medical student demographics, myelopathy teaching and myelopathy knowledge was designed. Ethical approval was granted by the Psychology Research Ethics Committee, University of Cambridge. An online survey was hosted on Myelopathy.org, an international myelopathy charity. Students studying at a UK medical school are eligible for inclusion. The survey is advertised nationally through university social media pages, university email bulletins and the national student network of Myelopathy.org. Advertisements are scheduled monthly over a 12-month recruitment period. Participation is incentivised by entering consenting participants of completed surveys to an Amazon voucher prize draw. Responses are anonymised using participant-chosen unique identifier codes. A participant information sheet followed by an explicit survey question captures participant informed consent. Regular updates on the progress of the study will be published on Myelopathy.org. ETHICS AND DISSEMINATION Ethical approval for the study was granted by the Psychology Research Ethics Committee, University of Cambridge (PRE.2018.099). The findings of the study described in this protocol, and all other related work, will be submitted for publication in a peer-reviewed journal and will be presented at scientific conferences.
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Affiliation(s)
- Oliver Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Max Stewart
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Sam Smith
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Alice Willison
- Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Shahzaib Ahmed
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | | | | | - Sybil Stacpoole
- Neurology Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mark Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Anne McLaren Laboratory for Regenerative Medicine, Wellcome Trust-Medical Research Council Cambridge Stem Cell Institute, University of Cambridge, Cambridge, UK
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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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Diagnostic Delays Lead to Greater Disability in Degenerative Cervical Myelopathy and Represent a Health Inequality. Spine (Phila Pa 1976) 2020; 45:368-377. [PMID: 31658234 DOI: 10.1097/brs.0000000000003305] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Online survey. OBJECTIVE This study seeks to quantify delays faced, determine demographics of patients most likely to face delay, and determine whether delays affect surgical management and outcomes. SUMMARY OF BACKGROUND DATA Patients report significant delays in diagnosis of degenerative cervical myelopathy (DCM). METHODS Seven hundred seventy-eighty patients with self-reported DCM recruited via online survey hosted on myelopathy.org. A cumulative odds ordinal logistic regression was run to determine the effects of demographic (sex, country of residence, ethnicity, household income, and educational status) on the delay in diagnosis of DCM. Chi-square tests of homogeneity were run to determine the effects of delayed diagnosis on functional outcomes (patient-derived modified Japanese Orthopaedic Association disability score, support dependence, and employment status) and surgical management (anterior/posterior approach, single-/multilevel surgery). A Kruskal-Wallis H test was used to determine whether delayed diagnosis affected the number of operations undergone. RESULTS The average delay in diagnosis faced was "1-2 years.' Greater delays in diagnosis were faced by Black or African American patients (P = 0.010). Delayed diagnosis was predictive of greater disability as assessed by patient-derived modified Japanese Orthopaedic Association score (P = 0.001), support dependence (P = 0.040), and employment status (P < 0.0005). Delayed diagnosis did not affect the likelihood of surgery, the number of operations undergone or perioperative characteristics. CONCLUSION Patients continue to face significant delays in diagnosis of DCM. Ethnicity significantly influences length of delay experienced. Longer delays do not appear to affect surgical management but are associated with greater disability. LEVEL OF EVIDENCE 3.
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Waqar M, Wilcock J, Garner J, Davies B, Kotter M. Quantitative analysis of medical students' and physicians' knowledge of degenerative cervical myelopathy. BMJ Open 2020; 10:e028455. [PMID: 31932384 PMCID: PMC7044983 DOI: 10.1136/bmjopen-2018-028455] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We have previously identified a delay in general practitioner (GP) referrals for patients with degenerative cervical myelopathy (DCM). The aim of this study was to evaluate whether an education gap existed for DCM along the GP training pathway by quantitatively assessing training in, and knowledge of, this condition. DESIGN Gap analysis: comparison of DCM to other conditions. Comparators selected on the basis of similar presentation/epidemiology (multiple sclerosis), an important spinal emergency (cauda equina syndrome) and a common disease (diabetes mellitus). SUBJECTS Medical students, foundation doctors and GP trainees. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Assessment of training: quantitative comparison of references to DCM in curricula (undergraduate/postgraduate) and commonly used textbooks (Oxford Handbook Series), to other conditions using modal ranks. (2) Assessment of knowledge: using standardised questions placed in an online question-bank (Passmedicine). Results were presented relative to the question-bank mean (+/-). RESULTS DCM had the lowest modal rank of references to the condition in curricula analysis and second lowest modal rank in textbook analysis. In knowledge analysis questions were attempted 127 457 times. Performance for DCM questions in themes of presentation (+6.1%), workup (+0.1%) and management (+1.8%) were all greater than the question-bank mean and within one SD. For students and junior trainees, there was a serial decrease in performance from presentation and workup (-0.7% to +10.4% relative to question-bank mean) and management (-0.6% to -3.9% relative to question-bank mean). CONCLUSIONS Although infrequently cited in curricula and learning resources, knowledge relating to DCM was above average. However, knowledge relating to its management was relatively poor.
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Affiliation(s)
- Mueez Waqar
- Academic Neurosurgery, University of Manchester, Manchester, UK
| | - Jane Wilcock
- Department of Undergraduate Medical Education, University of Liverpool, Liverpool, UK
| | - Jayne Garner
- Department of Undergraduate Medical Education, University of Liverpool, Liverpool, UK
| | - Benjamin Davies
- Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
| | - Mark Kotter
- Department of Clinical Neurosurgery, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, Ann McLaren Laboratory of Regenerative Medicine, Cambridge, UK
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Barkoh K, Ohiorhenuan IE, Lee L, Lucas J, Arakelyan A, Ornelas C, Buser Z, Hsieh P, Acosta F, Liu J, Wang JC, Hah R. The DOWN Questionnaire: A Novel Screening Tool for Cervical Spondylotic Myelopathy. Global Spine J 2019; 9:607-612. [PMID: 31448193 PMCID: PMC6693067 DOI: 10.1177/2192568218815863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Case-control study. OBJECTIVES Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord injury in adults aged over 55 years. However, since the onset is typically insidious, accurately diagnosing CSM can be challenging, often requiring referral to a subspecialist and advanced imaging. To help identify patients at risk for CSM, this case-control study compared responses to a series of 4 questions (DOWN questionnaire) in myelopathic and non-myelopathic patients. METHODS Ninety-two patients, 46 with and 46 without myelopathy, were recruited for the study. Each patient answered 4 questions encompassing common symptoms associated with CSM. Responses between patient groups were compared, and Cohen's κ was used to assess for agreement between responses and the diagnosis of myelopathy. RESULTS We found a sensitivity of 91% and a κ of 0.54 to 3 positive responses and a sensitivity of 72% and a κ of 0.61 to 4 positive responses. CONCLUSIONS Positive responses to 3 or more DOWN questions has high sensitivity and moderate agreement with the diagnosis of myelopathy based on history, physical exam, and review of advanced imaging by an orthopedic or neurological surgeon. The DOWN questionnaire is a potentially useful screening tool to identify patients at risk for CSM.
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Affiliation(s)
- Kaku Barkoh
- University of Southern California, Los Angeles, CA, USA
| | - Ifije E. Ohiorhenuan
- University of Southern California, Los Angeles, CA, USA,Ifije E. Ohiorhenuan, University of Southern
California, 1200 N State Street, Suite 3300, Los Angeles, CA 90042, USA.
| | - Larry Lee
- University of Southern California, Los Angeles, CA, USA
| | - Joshua Lucas
- University of Southern California, Los Angeles, CA, USA
| | | | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
| | - Patrick Hsieh
- University of Southern California, Los Angeles, CA, USA
| | - Frank Acosta
- University of Southern California, Los Angeles, CA, USA
| | - John Liu
- University of Southern California, Los Angeles, CA, USA
| | | | - Raymond Hah
- University of Southern California, Los Angeles, CA, USA
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Tempest-Mitchell J, Hilton B, Davies BM, Nouri A, Hutchinson PJ, Scoffings DJ, Mannion RJ, Trivedi R, Timofeev I, Crawford JR, Hay D, Laing RJ, Kotter MRN. A comparison of radiological descriptions of spinal cord compression with quantitative measures, and their role in non-specialist clinical management. PLoS One 2019; 14:e0219380. [PMID: 31329621 PMCID: PMC6645712 DOI: 10.1371/journal.pone.0219380] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 06/23/2019] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) is gold-standard for investigating Degenerative Cervical Myelopathy (DCM), a disabling disease triggered by compression of the spinal cord following degenerative changes of adjacent structures. Quantifiable compression correlates poorly with disease and language describing compression in radiological reports is un-standardised. STUDY DESIGN Retrospective chart review. OBJECTIVES 1) Identify terminology in radiological reporting of cord compression and elucidate relationships between language and quantitative measures 2) Evaluate language's ability to distinguish myelopathic from asymptomatic compression 3) Explore correlations between quantitative or qualitative features and symptom severity 4) Investigate the influence of quantitative and qualitative measures on surgical referrals. METHODS From all cervical spine MRIs conducted during one year at a tertiary centre (N = 1123), 166 patients had reported cord compression. For each spinal level deemed compressed by radiologists (N = 218), four quantitative measurements were calculated: 'Maximum Canal Compromise (MCC); 'Maximum Spinal Cord Compression' (MSCC); 'Spinal Canal Occupation Ratio' (SCOR) and 'Compression Ratio' (CR). These were compared to associated radiological reporting terminology. RESULTS 1) Terminology in radiological reports was varied. Objective measures of compromise correlated poorly with language. "Compressed" was used for more severe cord compromise as measured by MCC (p<0.001), MSCC (p<0.001), and CR (p = 0.002). 2) Greater compromise was seen in cords with a myelopathy diagnosis across MCC (p<0.001); MSCC (p = 0.002) and CR (p<0.001). "Compress" (p<0.001) and "Flatten" (p<0.001) were used more commonly for myelopathy-diagnosis levels. 3) Measurements of cord compromise (MCC: p = 0.304; MSCC: p = 0.217; SCOR: p = 0.503; CR: p = 0.256) and descriptive terms (p = 0.591) did not correlate with i-mJOA score. 4) The only variables affecting spinal surgery referral were increased MSCC (p = 0.001) and use of 'Compressed' (p = 0.045). CONCLUSIONS Radiological reporting in DCM is variable and language is not fully predictive of the degree of quantitative cord compression. Additionally, terminology may influence surgical referrals.
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Affiliation(s)
| | - Bryn Hilton
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin M. Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Aria Nouri
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Daniel J. Scoffings
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Richard J. Mannion
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Rikin Trivedi
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - John R. Crawford
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Douglas Hay
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Rodney J. Laing
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Mark R. N. Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Anne McLaren Laboratory for Regenerative Medicine, Welcome Trust MRC Cambridge Stem Cell Institute, University of Cambridge, Cambridge, United Kingdom
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