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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; 189:e1049-e1056. [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] [MESH Headings] [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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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 Frequency of Symptoms in Patients With a Diagnosis of Degenerative Cervical Myelopathy: Results of a Scoping Review. Global Spine J 2024; 14:1395-1421. [PMID: 37917661 PMCID: PMC11289544 DOI: 10.1177/21925682231210468] [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: 11/04/2023] Open
Abstract
STUDY DESIGN Delayed diagnosis of degenerative cervical myelopathy (DCM) is associated with reduced quality of life and greater disability. Developing diagnostic criteria for DCM has been identified as a top research priority. OBJECTIVES This scoping review aims to address the following questions: What is the diagnostic accuracy and frequency of clinical symptoms in patients with DCM? METHODS A scoping review was conducted using a database of all primary DCM studies published between 2005 and 2020. Studies were included if they (i) assessed the diagnostic accuracy of a symptom using an appropriate control group or (ii) reported the frequency of a symptom in a cohort of DCM patients. RESULTS This review identified three studies that discussed the diagnostic accuracy of various symptoms and included a control group. An additional 58 reported on the frequency of symptoms in a cohort of patients with DCM. The most frequent and sensitive symptoms in DCM include unspecified paresthesias (86%), hand numbness (82%) and hand paresthesias (79%). Neck and/or shoulder pain was present in 51% of patients with DCM, whereas a minority had back (19%) or lower extremity pain (10%). Bladder dysfunction was uncommon (38%) although more frequent than bowel (23%) and sexual impairment (4%). Gait impairment is also commonly seen in patients with DCM (72%). CONCLUSION Patients with DCM present with many different symptoms, most commonly sensorimotor impairment of the upper extremities, pain, bladder dysfunction and gait disturbance. If patients present with a combination of these symptoms, further neuroimaging is indicated to confirm the 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
| | - Konstantinos Margetis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Allan Martin
- Department of Neurosurgery, University of California Davis, Davis, CA, USA
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - 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
- Department of Neurology, New York UniversityLangone, New York, NY, USA
| | | | - Michael G. Fehlings
- Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, ON, Canada
| | - Jamie Wilson
- University of Nebraska Medical Center, Omaha, NE, USA
| | - Ratko Yurac
- Professor of Orthopedics and Traumatology, University del Desarrollo, Clinica Alemana de Santiago, Santiago, Chile
| | | | - Jamie Milligan
- Department of Family Medicine, McMaster University, Hamilton, ON, USA
| | - Julia Tabrah
- Hounslow and Richmond Community Healthcare, London, UK
| | | | - Lianne Wood
- Nottingham University Hospital, Nottingham, UK
| | | | | | - Lindsay Tetreault
- Department of Neurology, New York UniversityLangone, 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, USA
- Department of Neurosurgery, University of California Davis, Davis, CA, USA
- The Interface Group, Institute of Physiology, University of Zurich, Zurich, Switzerland
- Department of Neurology, New York UniversityLangone, New York, NY, USA
- Department of Surgery, Asaba Specialist Hospital, Asaba, Nigeria
- Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, ON, Canada
- University of Nebraska Medical Center, Omaha, NE, USA
- Professor of Orthopedics and Traumatology, University del Desarrollo, Clinica Alemana de Santiago, Santiago, Chile
- Duke University Medical Center, Durham, NC, USA
- Department of Family Medicine, McMaster University, Hamilton, ON, USA
- Hounslow and Richmond Community Healthcare, London, UK
- Myelopathy.org, Cambridge, UK
- Nottingham University Hospital, Nottingham, UK
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3
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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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4
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Sweetman H, Rahman M, Vedantam A, Satkunendrarajah K. Subclinical respiratory dysfunction and impaired ventilatory adaptation in degenerative cervical myelopathy. Exp Neurol 2024; 371:114600. [PMID: 37907124 DOI: 10.1016/j.expneurol.2023.114600] [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: 08/16/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/02/2023]
Abstract
Degenerative cervical myelopathy (DCM) is a debilitating neurological condition characterized by chronic compression of the cervical spinal cord leading to impaired upper and lower limb function. Despite damage to areas of the cervical spinal cord that house the respiratory network, respiratory dysfunction is not a common symptom of DCM. However, DCM may be associated with respiratory dysfunction, and this can affect the ventilatory response to respiratory challenges during emergence from anesthesia, exercise, or pulmonary disease. Surgical spinal cord decompression, which is the primary treatment for DCM, leads to improved sensorimotor function in DCM; yet its impact on respiratory function is unknown. Here, using a clinically relevant model of DCM, we evaluate respiratory function during disease progression and assess adaptive ventilation to hypercapnic challenge before and after surgical intervention. We show that despite significant and progressive forelimb and locomotor deficits, there was no significant decline in eupneic ventilation from the early to late phases of spinal cord compression. Additionally, for the first time, we demonstrate that despite normal ventilation under resting conditions, DCM impairs acute adaptive ventilatory ability in response to hypercapnia. Remarkably, akin to DCM patients, surgical decompression treatment improved sensorimotor function in a subset of mice. In contrast, none of the mice that underwent surgical decompression recovered their ability to respond to hypercapnic ventilatory challenge. These findings underscore the impact of chronic spinal cord compression on respiratory function, highlighting the challenges associated with ventilatory response to respiratory challenges in individuals with DCM. This research highlights the impact of cervical spinal cord compression on respiratory dysfunction in DCM, as well as the persistence of adaptive ventilatory dysfunction after surgical spinal cord decompression. These results indicate the need for additional interventions to enhance recovery of respiratory function after surgery for DCM.
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Affiliation(s)
- Hannah Sweetman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
| | - Mahmudur Rahman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aditya Vedantam
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA
| | - Kajana Satkunendrarajah
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA; Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, USA; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Lenga P, Gülec G, Kiening K, Unterberg AW, Ishak B. Anterior cervical discectomy fusion versus posterior decompression and fusion in octogenarians with cervical myelopathy: Clinical outcomes and complications with a 3-year follow-up. BRAIN & SPINE 2023; 3:102683. [PMID: 38021012 PMCID: PMC10668093 DOI: 10.1016/j.bas.2023.102683] [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: 05/31/2023] [Revised: 08/20/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
Introduction Cervical stenosis and concurrent Cervical Spondylotic Myelopathy (CSM) are prevalent in the elderly. Treatment options include Anterior Cervical Discectomy Fusion (ACDF) and Posterior Decompression and Fusion (PDF). Research question This study aims to compare clinical outcomes and complications between ACDF and PDF in patients aged 80 and above. Material and methods Data from electronic medical records between 2005 and 2021 at a single institution were analyzed. Logistic and linear regression analyses were performed to explore risk factors and the relationship between comorbidities and neurological conditions. Results 21 patients with ACDF and 26 with PDF were studied over 16 years. PDF patients had more operated levels, higher blood loss, and longer hospital stays, but mortality rates and mJOA improvements were similar in both groups. The presence of comorbidities was a unique risk factor for postoperative complications. Discussion and conclusion ACDF and PDF led to neurological improvements in elderly CSM patients. However, the decision of surgical procedure should carefully consider the potential for postoperative complications, particularly in patients with comorbidities.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Gelo Gülec
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
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6
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Lenga P, Papakonstantinou V, Kiening K, Unterberg AW, Ishak B. Outcomes of cervical spinal stenosis surgery in patients aged ≥ 65 years based on insurance status: a single-center cohort study from a tertiary center in Germany. Acta Neurochir (Wien) 2023; 165:3089-3096. [PMID: 37410186 PMCID: PMC10541335 DOI: 10.1007/s00701-023-05700-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/25/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE The prevalence of degenerative disorders of the spine, such as cervical spinal stenosis with cervical spine myelopathy (CSM) in the geriatric population, has rapidly increased worldwide. To date, there has been no systematic analysis comparing outcomes in older patients suffering from progressive CSM and undergoing surgery depending on their health insurance status. We sought to compare the clinical outcomes and complications after anterior cervical discectomy and fusion (ACDF) or posterior decompression with fusion in patients aged ≥ 65 years with multilevel cervical spinal canal stenosis and concomitant CSM with special focus on their insurance status. METHODS Clinical and imaging data were retrieved from patients' electronic medical records at a single institution between September 2005 and December 2021. Patients were allocated into two groups with respect to their health insurance status: statutory health insurance (SHI) vs. private insurance (PI). RESULTS A total of 236 patients were included in the SHI group and 100 patients in the privately insured group (PI) group. The overall mean age was 71.7 ± 5.2 years. Regarding comorbidities, as defined with the age-adjusted CCI, SHI patients presented with higher rates of comorbidities as defined by a CCI of 6.7 ± 2.3 and higher prevalence of previous malignancies (9.3%) when compared to the PI group (CCI 5.4 ± 2.5, p = 0.051; 7.0%, p = 0.048). Both groups underwent ACDF (SHI: 58.5% vs. PI: 61.4%; p = 0.618), and the surgical duration was similar between both groups. Concerning the intraoperative blood transfusion rates, no significant differences were observed. The hospital stay (12.5 ± 1.1 days vs. 8.6 ± 6.3 days; p = 0.042) and intenisve care unit stay (1.5 ± 0.2 days vs. 0.4 ± 0.1 days; p = 0.049) were significantly longer in the PI group than in the SHI group. Similar in-hospital and 90-day mortality rates were noted across the groups. The presence of comorbidities, as defined with the age-adjusted CCI, poor neurological status at baseline, and SHI status, was significant predictor for the presence of adverse events, while the type of surgical technique, operated levels, duration of surgery, or blood loss was not. CONCLUSIONS Herein, we found that surgeons make decisions independent of health insurance status and aim to provide the most optimal therapeutic option for each individual; hence, outcomes were similar between the groups. However, longer hospitalization stays were present in privately insured patients, while SHI patients presented on admission with poorer baseline status.
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Affiliation(s)
- Pavlina Lenga
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Vassilios Papakonstantinou
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Karl Kiening
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Vázquez-Sánchez F, Lloria-Gil MDC, Gómez-Menéndez AI, Isidro-Mesas F, Echavarría-Íñiguez A, Martín-Alonso J, González-Bernal J, González-Santos J, Berardi A, Tofani M, Galeoto G, García-López B. The Role of Magnetic Transcranial Stimulation in the Diagnosis and Post-Surgical Follow-Up of Cervical Spondylotic Myelopathy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3690. [PMID: 36834385 PMCID: PMC9959727 DOI: 10.3390/ijerph20043690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 06/18/2023]
Abstract
Degenerative cervical myelopathy (DCM) consists of spinal cord damage due to its compression through the cervical spine. The leading cause is degenerative. The diagnosis is clinical, and the therapeutic approach is usually surgical. Confirmation of the diagnostic suspicion is done by magnetic resonance imaging (MRI); however, this test lacks functional information of the spinal cord, the abnormality of which may precede involvement in neuroimaging. Neurophysiological examination using somatosensory evoked potentials (SSEPs) and transcranial magnetic stimulation (TMS) allows for an evaluation of spinal cord function, and provides information in the diagnostic process. Its role in the post-surgical follow-up of patients undergoing decompressive surgery is being studied. We present a retrospective study of 24 patients with DCM and surgical decompression who underwent neurophysiological tests (TMS and SSEP) before, 6, and 12 months after surgery. The result of the TMS and the SSEP in the post-operative follow-up did not correlate with the clinical outcome, either subjective or measured by clinical scales at six months. We only found post-surgical improvement of central conduction times (CMCTs) in patients with severe pre-surgical motor impairment on TMS. In patients with normal pre-surgical CMCT, we found a transient worsening with return to baseline at the one-year follow-up. Most patients presented pre-surgical increased P40 latency at diagnosis. CMCT and SSEP were more related to clinical outcomes one year after the surgical procedure and were very useful in diagnosing.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Anna Berardi
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Marco Tofani
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Giovanni Galeoto
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
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Takizawa T, Ikegami S, Uehara M, Kuraishi S, Oba H, Munakata R, Hatakenaka T, Kamanaka T, Miyaoka Y, Mimura T, Koseki M, Takahashi J. Surgical results for cervical spondylotic myelopathy with inconsistent between deep tendon reflex findings and magnetic resonance imaging findings. J Clin Neurosci 2023; 107:157-161. [PMID: 36376150 DOI: 10.1016/j.jocn.2022.11.001] [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: 07/25/2022] [Revised: 10/23/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND To evaluate the surgical results of patients with cervical spondylotic myelopathy (CSM) with inconsistency between deep tendon reflex findings and cervical magnetic resonance imaging (MRI) findings and to analyze the differences between patients with good and poor surgical outcomes. METHODS We evaluated 50 subjects with CSM (30 males, 20 females; mean age: 70.4 years) who underwent posterior surgery and were followed for at least 1 year postoperatively. Matched CSM was defined as a consistent preoperative neurological pattern determined by deep tendon reflex and cervical MRI T2-weighted high-signal intramedullary area or stenosis in the most cranial compression levels. A lack of consistency was classified as unmatched CSM. Recovery rate (RR) according to Japanese Orthopaedic Association (JOA) scoring preoperatively and at 1 year postoperatively were compared between the groups. RESULTS The matched and unmatched CSM group included 27 subjects (13 males, 14 females; mean age: 68.2 years) and 23 subjects (17 males, 6 females; mean age: 72.8 years), respectively. RR was significantly higher in the matched CSM group (56.1 ± 3.7 % vs 36.8 ± 2.7 %; p = 0.002). Unmatched CSM was significantly associated with a lower RR independently of sex, patient age, surgical procedure, preoperative JOA score, diagnosis levels, and complication of diabetes. CONCLUSIONS Postoperative JOA score RR was significantly diminished among unmatched CSM patients comprising of 46% of cases. Some patients with unmatched CSM had multiple levels of spinal canal stenosis, foraminal stenosis, and peripheral neuropathy, suggesting that surgical results were poorer than those of matched CSM.
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Affiliation(s)
- Takashi Takizawa
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Shota Ikegami
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Masashi Uehara
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan.
| | - Shugo Kuraishi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Hiroki Oba
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Ryo Munakata
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Terue Hatakenaka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Takayuki Kamanaka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Yoshinari Miyaoka
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Tetsuhiko Mimura
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
| | - Michihiko Koseki
- Faculty of Textile Science and Technology, Shinshu University, 3-15-1 Tokida, Ueda, Nagano 386-8567, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano 390-8621, Japan
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9
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Ganau L, Ligarotti GKI, Ganau M. Neurological recovery rate and minimal clinically important difference as metrics for assessing outcomes of decompressive surgery in patients with degenerative cervical myelopathy. Acta Neurochir (Wien) 2022; 164:3181-3183. [PMID: 36136168 DOI: 10.1007/s00701-022-05364-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Laura Ganau
- School of Medicine, University of Cagliari, Cagliari, Italy
| | | | - Mario Ganau
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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10
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Andreyeva TO, Stoyanov OM, Chebotaryova GM, Vastyanov RS, Kalashnikov VI, Stoyanov AO. Comparative clinical and morphometric investigations of cervical stenosis of the spinal canal in humans and dogs. REGULATORY MECHANISMS IN BIOSYSTEMS 2022. [DOI: 10.15421/022239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Acquired stenosis of the spinal canal is a common problem in human and animal pathology. It is defined as a pathological condition that mainly develops as degeneration of the spine with cervical myelopathy development, which is a characteristic manifestation of this pathology. Pain both in the neck and upper back is the leading syndrome of this pathology. 65 human patients aged 20–65 years and 19 dogs weighing more than 20 kg were examined with the aim of comparative clinical and morphometric analysis of stenosis of the spinal canal. The age of the dogs was maximally converted to the age of a person. Computed tomography using the Pavlov-Torg index and the reserve space evaluation supplemented diagnosis of stenosis of the spinal canal. The mass proportion of stenotic changes of the spinal canal against the background of the degenerative-dystrophic process was 21 in males (n = 25) 84.0%, females – 28 persons (n = 40) 70.0%. Pain syndrome was the main complaint in all patients. Cervicalgia prevailed in 60 (92.3%), pain in the upper back was registered in 32 (49.2%) patients. The intensity of pain syndrome was equal to 3.1 ± 0.4 points. Motor deficiency in the form of paresis, mainly of the distal parts of the hands, was registered in 48 patients (73.8%), pyramidal symptoms were noted in the legs in 32 (49.2%) patients, pelvic reservoir dysfunction (7.0–10.8%), and sensory disorders were also found (24.0–36.9%). Such manifestations of cervical myelopathy progressed slowly. Pyramidal symptoms were more frequent and more pronounced in men. According to the computed tomography scan, degenerative changes of the spine were maximal at the level of the C6 vertebra with the maximum clinical correlation (neurological deficit, pain syndrome, etc.). In the course of the research, probable stenosis of the spinal canal was found in people on computed tomography images. In the 19 dogs observed weighing 20 kg or more the presence of pain syndrome was evaluated in all the animals (100.0%) as well as behaviour change (100.0%). During the examination, gait disorder was detected (18.0–94.7%); reaction to palpation of the neck area (15.0–78.9%); the habitus of animals experiencing pain, especially during neck movements (14.0–73.7%), body tension (12.0–63.1%), etc. Bony outgrowths of the edges of the vertebrae and intervertebral joints were found in almost all dogs of 18 (94.7%) large breeds compared to others. Narrowing of the intervertebral openings, deformation and sclerotic changes of the locking plates, thickening of the yellow and elongated ligaments occurred three to four times more in large breeds compared to dogs weighing less than 20 kg, and were absent in cats. Stenosis of the spinal canal was detected in 15 (78.9%) dogs. Therefore, acquired stenosis of the spinal canal probably develops after degenerative-dystrophic changes in the neck in 87.7% of people and in 78.9% of dogs with clinical manifestations of cervical myelopathy and with persistent pain syndrome (equal to 3.1 ± 0.3 points in humans and 2.6 ± 0.4 points in animals according to visual analog scale). This kind of pathological process in the investigated groups developed mainly at the level of the C6 vertebra. Similar clinical and morphometric indexes were obtained in humans (87.7%). It was found that the maximum similarity of pathological processes with stenosis of the spinal canal formation was characteristic in dogs of exclusively large breeds. Therefore, we consider it promising to study the development mechanisms of stenosis of the spinal canal and peculiarities primarily in young generations of humans and animals, to implement modern non-invasive neuroimaging methods, in particular for animals with investigation of morphometric indexes. This will prevent the occurrence of most comorbid syndromes, including chronic pain, neurological deficits as well as help find new opportunities for correction of stenosis of the spinal canal, to suppress the aging processes not only of the muscle-skeletal system but also of the body as a whole. The importance of this work, we suppose, lies in the further identification of adequate models in animals of different breeds and weight categories with stenosis of the spinal canal pathology in which it develops significantly faster, for extrapolation to humans to predict the development of pathological events.
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Davies BM, Mowforth O, Gharooni AA, Tetreault L, Nouri A, Dhillon RS, Bednarik J, Martin AR, Young A, Takahashi H, Boerger TF, Newcombe VF, Zipser CM, Freund P, Koljonen PA, Rodrigues-Pinto R, Rahimi-Movaghar V, Wilson JR, Kurpad SN, Fehlings MG, Kwon BK, Harrop JS, Guest JD, Curt A, Kotter MRN. A New Framework for Investigating the Biological Basis of Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 5]: Mechanical Stress, Vulnerability and Time. Global Spine J 2022; 12:78S-96S. [PMID: 35174728 PMCID: PMC8859710 DOI: 10.1177/21925682211057546] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Literature Review (Narrative). OBJECTIVE To propose a new framework, to support the investigation and understanding of the pathobiology of DCM, AO Spine RECODE-DCM research priority number 5. METHODS Degenerative cervical myelopathy is a common and disabling spinal cord disorder. In this perspective, we review key knowledge gaps between the clinical phenotype and our biological models. We then propose a reappraisal of the key driving forces behind DCM and an individual's susceptibility, including the proposal of a new framework. RESULTS Present pathobiological and mechanistic knowledge does not adequately explain the disease phenotype; why only a subset of patients with visualized cord compression show clinical myelopathy, and the amount of cord compression only weakly correlates with disability. We propose that DCM is better represented as a function of several interacting mechanical forces, such as shear, tension and compression, alongside an individual's vulnerability to spinal cord injury, influenced by factors such as age, genetics, their cardiovascular, gastrointestinal and nervous system status, and time. CONCLUSION Understanding the disease pathobiology is a fundamental research priority. We believe a framework of mechanical stress, vulnerability, and time may better represent the disease as a whole. Whilst this remains theoretical, we hope that at the very least it will inspire new avenues of research that better encapsulate the full spectrum of disease.
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Affiliation(s)
- Benjamin M Davies
- Department of Neurosurgery, 2152University of Cambridge, Cambridge, UK
| | - Oliver Mowforth
- Department of Neurosurgery, 2152University of Cambridge, Cambridge, UK
| | - Aref-Ali Gharooni
- Department of Neurosurgery, 2152University of Cambridge, Cambridge, UK
| | - Lindsay Tetreault
- New York University, Langone Health, Graduate Medical Education, 5894Department of Neurology, New York, NY, USA
| | - Aria Nouri
- Division of Neurosurgery, Geneva University Hospitals, 27230University of Geneva, Genève, Switzerland
| | - Rana S Dhillon
- Department of Neurosurgery, 60078St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Josef Bednarik
- Department of Neurology, University Hospital Brno and Faculty of Medicine, 37748Masaryk University, Brno, Czech Republic
| | - Allan R Martin
- Department of Neurosurgery, 8789University of California Davis, Sacramento, CA, USA
| | - Adam Young
- Department of Neurosurgery, 2152University of Cambridge, Cambridge, UK
| | - Hitoshi Takahashi
- Department of Pathology, Brain Research Institute, 12978Niigata University, Niigata, Japan
| | - Timothy F Boerger
- Department of Neurosurgery, 5506Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Virginia Fj Newcombe
- Division of Anaesthesia, Department of Medicine, 2152University of Cambridge, Cambridge, UK
| | - Carl Moritz Zipser
- University Spine Center, 31031Balgrist University Hospital, Zurich, Switzerland
| | - Patrick Freund
- University Spine Center, 31031Balgrist University Hospital, Zurich, Switzerland
| | - Paul Aarne Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, 25809The University of Hong Kong, Hong Kong, China
| | - Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, 112085Centro Hospitalar Universitário do Porto - Hospital de Santo António, Porto, Portugal
- 89239Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, 48439Tehran University of Medical Sciences, Tehran, Iran
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, 7938University of Toronto, Toronto, ON, Canada
| | - Shekar N Kurpad
- Department of Neurosurgery, 5506Medical College of Wisconsin, Wauwatosa, WI, USA
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, 7938University of Toronto, Toronto, ON, Canada
| | - Brian K Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - James S Harrop
- Department of Neurological Surgery, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - James D Guest
- Department of Neurosurgery and the Miami Project to Cure Paralysis, The Miller School of Medicine, 12235University of Miami, Miami, FL, USA
| | - Armin Curt
- University Spine Center, 31031Balgrist University Hospital, Zurich, Switzerland
| | - Mark R N Kotter
- Department of Neurosurgery, 2152University of Cambridge, Cambridge, UK
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12
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First neurological symptoms in degenerative cervical myelopathy: does it predict the outcome? 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 2021; 31:327-333. [PMID: 34822020 DOI: 10.1007/s00586-021-07060-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/27/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Degenerative cervical myelopathy (DCM) is the most common non-traumatic cause of spinal cord dysfunction. Prediction of the neurological outcome after surgery is important. The aim of this study was to analyze the relationship between first symptoms of DCM and the neurological outcome after surgery. METHODS A retrospective analysis over a period of 10 years was performed. First symptoms such as cervicobrachial neuralgia, sensory and motor deficits and gait disturbances were evaluated regarding the postoperative neurological outcome. The modified Japanese Orthopedic Association Score (mJOA Score) was used to evaluate neurological outcome. RESULTS In total, 411 patients (263 males, 64%) with a median age of 62.6 ± 12.1 years were included. Cervicobrachial neuralgia was described in 40.2%, gait disturbance in 31.6%, sensory deficits in 19% and motor deficits in 9.2% as first symptom. Patients with cervicobrachial neuralgia were significantly younger (median age of 58 years, p = 0.0005) than patients with gait disturbances (median age of 68 years, p = 0.0005). Patients with gait disturbances and motor deficits as first symptom showed significantly lower mJOA Scores than other patients (p = 0.0005). Additionally, motor deficits and gait disturbance were negative predictors for postoperative outcome according to the mJOA Score. CONCLUSION Motor deficits and gait disturbances as the first symptom of DCM are negative predictors for postoperative neurological outcome. Nevertheless, patients with motor deficits and gait disturbance significantly profit from the surgical treatment despite poor preoperative mJOA Score.
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TO THE EDITOR. Spine (Phila Pa 1976) 2021; 46:E1066-E1067. [PMID: 34269763 DOI: 10.1097/brs.0000000000004168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
STUDY DESIGN Retrospective study (data analysis). OBJECTIVE The purpose of this study was to assess the role of different factors on postoperative outcome of patients with degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA Ongoing degenerative changes of DCM lead to progressive neurological deficits. The optimal timing of surgical treatment is still unclear, especially in patients with mild DCM. METHODS Patients with DCM treated in our clinic between 2007 and 2016 were retrospectively analyzed. Pre- and postoperative neurological function was assessed by the modified Japanese Orthopaedic Association Score (mJOA Score) at different stages. The minimum clinically important difference (MCID) was used to evaluate the improvement after surgery. The comorbidities were recorded using the Charlson Comorbidity Index (CCI). Possible associations between age, sex, CCI, preoperative symptoms duration, high signal intensity (SI) on T2-weighted magnetic resonance imaging (MRI) with mJOA Score and MCID were analyzed using univariate analysis and multivariate regression models. Additionally, subgroup analysis was performed according to the severity of DCM (mild: mJOA Score ≥15 points; moderate: mJOA Score of 12-14 points; and severe: mJOA Score <12 points). RESULTS The mean age of the final cohort (n = 411) was 62.6 years (range: 31-96 years), 36.0% were females. High SI on T2-weighted MRI was detected in 60.3% of the cases. In the multivariate analysis, patients' age (P = 0.005), higher CCI (P = 0.001), and presence of high SI on T2-weighted MRI (P = 0.0005) were associated independently with lower pre- and postoperative mJOA Score and postoperative MCID. Subgroup analysis revealed age and high SI on T2-weighted MRI as predictors of pre- and postoperative mJOA. However, symptom duration did not influence neurological outcome according to the severity of DCM. CONCLUSION Surgery for DCM leads to significant functional improvement. However, better outcome was observed in younger individuals with lower CCI and absence of radiographic myelopathy signs. Therefore, DCM surgery, particularly before occurrence of high SI on MRI, seems to be essential for postoperative functional improvement regardless the above-mentioned confounders.Level of Evidence: 3.
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Nouri A, Gondar R, Cheng JS, Kotter MR, Tessitore E. Degenerative Cervical Myelopathy and the Aging Spine: Introduction to the Special Issue. J Clin Med 2020; 9:jcm9082535. [PMID: 32781513 PMCID: PMC7465261 DOI: 10.3390/jcm9082535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 11/16/2022] Open
Abstract
Degenerative Cervical Myelopathy (DCM) is the most common cause of spinal cord injury in the world, but despite this, there remains many areas of uncertainty regarding the management of the condition. This special issue was dedicated to presenting current research topics in DCM. Within this issue, 12 publications are presented, including an introductory narrative overview of DCM and 11 articles comprising 9 research papers and 2 systematic reviews focusing on different aspects, ranging from genetic factors to clinical assessments, imaging, sagittal balance, surgical treatment, and outcome prediction. These articles represented contributions from a diverse group of researchers coming from multiple countries, including Switzerland, Germany, Italy, United Kingdom, United States, South Korea, and Canada.
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Affiliation(s)
- Aria Nouri
- Department of Neurosurgery, Geneva University Hospitals, 1205 Geneva, Switzerland; (R.G.); (E.T.)
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
- Correspondence:
| | - Renato Gondar
- Department of Neurosurgery, Geneva University Hospitals, 1205 Geneva, Switzerland; (R.G.); (E.T.)
| | - Joseph S. Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA;
| | - Mark R.N. Kotter
- Division of Neurosurgery, University of Cambridge, Cambridge CB2 1TN, UK;
| | - Enrico Tessitore
- Department of Neurosurgery, Geneva University Hospitals, 1205 Geneva, Switzerland; (R.G.); (E.T.)
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