Clinical value of 2-deoxy-[18F]fluoro-d-glucose positron emission tomography in patients with cervical spondylotic myelopathy

Cervical Spondylotic Myelopathy: From the World Federation of Neurosurgical Societies (WFNS) to the Italian Neurosurgical Society (SINch) Recommendations

Cervical spondylotic myelopathy (CSM) is a progressively growing pathology to afford by a spinal surgeon due to the aging of the population, associated with better treatment management and the best diagnosis and treatment solutions are greatly discussed. Nowadays that scientific literature is progressively increasing to identify the gold standard in diagnosis and treatment can be very challenging. This is particularly evident in spinal surgery with many different indications not only in different countries but also in the same local reality. In this scenario, many neurosurgical societies works to identify some guideline or recommendations to help spinal surgeons in daily practice. Furthermore, in an era in which legal issues are increasingly present in clinical practice to have some indications globally accepted can be very useful. World Federation of Neurosurgical Societies (WFNS) few years ago starts this process creating a list of recommendations originating from a worldwide steering committee to respect all the local reality. The spinal section of Italian Neurosurgical Society decides to adopt the WFNS recommendations with some revision basing on Italian scenario. The steering committee of the Spinal Section of Italian Neurosurgical Society identify 7 groups to review the literature of the last 10 years about different topics on CSM and to analyses the WFNS recommendations to adapt it to the Italian daily practice. The statements were discussed and voted in 2 sessions to obtain the final version. A list of recommendations on natural course and clinical presentation; diagnostic tests; conservative and surgical treatment; anterior, posterior and combined surgical treatment; role of neurophysiological monitoring and follow-up and outcome was created with only few new or revised statements respect the ones of WFNS. The Spine Section of Italian Neurosurgical Society create a list of recommendations that represent the more contemporary treatment concepts for CSM as presented in the highest quality clinical literature and best clinical practices available on this subject.

New Imaging Modalities for Degenerative Cervical Myelopathy

INTRODUCTION

Degenerative cervical myelopathy (DCM) is defined as dysfunction of the spinal cord as a result of compression from degenerative changes to surrounding joints, intervertebral disks, or ligaments. Symptoms can include upper extremity numbness and diminished dexterity, difficulty with fine manipulation of objects, gait imbalance, and incoordination, and compromised bowel and bladder function. Accurate diagnosis and evaluation of the degree of impairment due to degenerative cervical myelopathy remain a challenging clinical endeavor requiring a thorough and accurate history, physical examination, and assessment of imaging findings.

METHODS

A narrative review is presented summarizing the current landscape of imaging modalities utilized in DCM diagnostics and the future direction of research for spinal cord imaging.

RESULTS AND DISCUSSION

Current imaging modalities, particularly magnetic resonance imaging and, to a lesser extent, radiographs/CT, offer important information to aid in decision making but are not ideal as stand-alone tools. Newer imaging modalities currently being studied in the literature include diffusion tensor imaging, MR spectroscopy, functional magnetic resonance imaging, perfusion imaging, and positron emission tomography. These newer imaging modalities attempt to more accurately evaluate the physical structure, intrinsic connectivity, biochemical and metabolic function, and perfusion of the spinal cord in DCM. Although there are still substantial limitations to implementation, future clinical practice will likely be revolutionized by these new imaging modalities to diagnose, localize, surgically plan and manage, and follow patients with DCM.

Altered Coupling Between Resting-State Cerebral Blood Flow and Functional Connectivity Strength in Cervical Spondylotic Myelopathy Patients

Background: Changes in regional neural activity and functional connectivity in cervical spondylotic myelopathy (CSM) patients have been reported. However, resting-state cerebral blood flow (CBF) changes and coupling between CBF and functional connectivity in CSM patients are largely unknown.

Methods: Twenty-seven CSM patients and 24 sex/age-matched healthy participants underwent resting-state functional MRI and arterial spin labeling imaging to compare functional connectivity strength (FCS) and CBF between the two groups. The CBF–FCS coupling of the whole gray matter and specific regions of interest was also compared between the groups.

Results: Compared with healthy individuals, CBF–FCS coupling was significantly lower in CSM patients. The decrease in CBF–FCS coupling in CSM patients was observed in the superior frontal gyrus, bilateral thalamus, and right calcarine cortex, whereas the increase in CBF–FCS coupling was observed in the middle frontal gyrus. Moreover, low CBF and high FCS were observed in sensorimotor cortices and visual cortices, respectively.

Conclusion: In general, neurovascular decoupling at cortical level may be a potential neuropathological mechanism of CSM.

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick’s grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski’s sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

Intramedullary spinal cord metastases: an increasingly common diagnosis

OBJECT Intramedullary spinal cord metastases (ISCM) represent a small proportion of intramedullary tumors. However, with the lifespans of patients with malignant tumors increasing, incidents of ISCM are on the rise. Due to threateningly severe disabilities in patients, accompanied by limited life expectancy, every attempt should be made to treat these tumors the same way as metastases elsewhere in the CNS, with the goal of complete removal of the ISCM and preservation of neurological functions. The object of this study is to retrospectively analyze the experiences of 22 patients who were surgically treated for ISCM over a 22-year period. METHODS Hospital charts of 22 patients, who were surgically treated for ISCM between 1992 and 2014, were reviewed retrospectively. Demographic data, histopathological diagnoses of primary cancer, chronological sequence of the disease, and neurological status using the simplified McCormick functional classification were collected and reanalyzed. RESULTS The most frequent histology was metastasis of lung cancer, followed by brain and breast cancers. The time span from primary cancer diagnosis to the development of symptomatic spinal metastases ranged from 0 to 285 months, with a mean interval of 38 months. The leading presenting sign was dysesthesia (77% of the population), followed by paresis (68%). Only 5 patients (23%) showed urinary retention. Initial performance status represented by the McCormick Scale was on average 2.47. Total or near-total removal was achieved in 87% of cases. Compared with the clinical status 1-2 days after surgery, there was an improvement in the McCormick Scale grade at the last follow-up from 2.47 to 2.12 (p = 0.009). Likewise, an improvement was detected when comparing the preoperative status with the last follow-up (from 2.45 to 2.12; p = 0.029). The mean survival time after surgery was 11.6 months. CONCLUSIONS These results suggest that surgery for intramedullary metastases-with all of the challenges of a rare and potentially risky procedure-can be beneficial to patients with advanced stages of cancer. Surgery can be performed with minimal new morbidity and results in maintaining neurological performance status.