Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis

Peripheral blood RNA biomarkers can predict lesion severity in degenerative cervical myelopathy

JOURNAL/nrgr/04.03/01300535-202506000-00027/figure1/v/2024-08-05T133530Z/r/image-tiff Degenerative cervical myelopathy is a common cause of spinal cord injury, with longer symptom duration and higher myelopathy severity indicating a worse prognosis. While numerous studies have investigated serological biomarkers for acute spinal cord injury, few studies have explored such biomarkers for diagnosing degenerative cervical myelopathy. This study involved 30 patients with degenerative cervical myelopathy (51.3 ± 7.3 years old, 12 women and 18 men), seven healthy controls (25.7 ± 1.7 years old, one woman and six men), and nine patients with cervical spondylotic radiculopathy (51.9 ± 8.6 years old, three women and six men). Analysis of blood samples from the three groups showed clear differences in transcriptomic characteristics. Enrichment analysis identified 128 differentially expressed genes that were enriched in patients with neurological disabilities. Using least absolute shrinkage and selection operator analysis, we constructed a five-gene model (TBCD, TPM2, PNKD, EIF4G2, and AP5Z1) to diagnose degenerative cervical myelopathy with an accuracy of 93.5%. One-gene models (TCAP and SDHA) identified mild and severe degenerative cervical myelopathy with accuracies of 83.3% and 76.7%, respectively. Signatures of two immune cell types (memory B cells and memory-activated CD4+ T cells) predicted levels of lesions in degenerative cervical myelopathy with 80% accuracy. Our results suggest that peripheral blood RNA biomarkers could be used to predict lesion severity in degenerative cervical myelopathy.

Comparison of anterior and posterior approaches for functional improvement in cervical myelopathy: A systematic review and meta-analysis of 33,025 patients

Background

Cervical myelopathy is caused by pressure on the spinal cord in the neck, leading to pain, numbness, and balance issues. Surgery aims to decompress the spinal cord, with different approaches; anterior, posterior, or both depending on specifies. This systematic review and meta-analysis aimed to compare the risks and benefits of anterior and posterior surgical techniques.

Methods

Adhering to the PRISMA guidelines, we conducted a systematic search across the databases including PubMed, Scopus, and Web of Science for studies comparing anterior and posterior surgical approaches for cervical myelopathy. Studies that met our predefined inclusion criteria were selected by 2 independent reviewers. The methodological quality of the selected studies was assessed using NOS and Rob-2 tools and analysis was done using the Review Manager tool. One RCT and 22 cohort studies including 33,025 patients were included in the analysis.

Results

The anterior approach was associated with better neurological recovery and a greater improvement in Cobb's angle with MD of 4.18 (95%CI: 0.38, 7.91, p=.03), and 6.91 (95%CI: 1.85, 11.97, p=.007), respectively. The anterior approach showed a statistically significant decrease in VAS, and NDI scales with MD of -0.44 (95%CI: -0.75, -0.12, p=.007), and -1.91 (95%CI: -3.74, -0.09, p=.04), respectively as compared to posterior approach.

Conclusions

Studies suggest that an anterior approach for cervical myelopathy may improve nerve function, correct spinal curvature more effectively, and lead to fewer complications, less pain, reduced blood loss, and a shorter hospital stay compared to a posterior approach.

Predictive Factors for Postoperative Outcomes of Cervical Spondylotic Myelopathy in Individuals With Cerebral Palsy

Study DesignRetrospective cohort study.ObjectivesThis study aimed to identify factors influencing postoperative outcomes of cervical spondylotic myelopathy (CSM) in individuals with cerebral palsy (CP).MethodsData from admitted individuals were retrospectively reviewed. Individuals whose modified Barthel index score, assessed at least 6 months after surgery, declined by 1 or more grades compared to their preoperative score were classified into the poor outcome (PO) group. Multivariate logistic regression analysis was performed to assess risk factors for poor postoperative outcomes.ResultsOf the 73 participants, 15 were in the PO group and 58 in the non-PO group. Duration (OR 1.99, 95% CI 1.25-3.65, P = .01), signal change grade 2 (OR 10.44, 95% CI 1.32-118.01, P = .034), and spinal cord compression ratio, M2 (OR 0.85, 95% CI, 0.73-0.96, P = .02) on preoperative MRI were identified as significant factors associated with the risk of poor postoperative outcomes. Based on the receiver operating characteristic curve analysis, the cutoff values for duration and cord compression metric were determined as 2 years (AUC = 0.689, 95% CI 0.532-0.845) and 76.2% (AUC = 0.841, 95% CI 0.696-0.987), respectively.ConclusionsThis study identified key predictors of poor postoperative outcomes in individuals with CP undergoing surgery for CSM. Symptom duration exceeding 2 years, signal change grade 2, and spinal cord compression ratio below 76.2% on preoperative MRI were found to be predictors of poor outcome. These results underscore the importance of early intervention and detailed preoperative radiological assessment to improve surgical outcomes in this population.

Outcomes for Degenerative Cervical Myelopathy Following Implementation of the AO Spine International Guidelines: A Single-Centre Service Evaluation

IntroductionDegenerative cervical myelopathy (DCM) is a syndrome of symptomatic cervical spinal cord compression due to degenerative spinal changes. Until recently there was no formal consensus on exactly which patients are suitable for surgical or conservative management. The AO Spine international guidelines were introduced to address this issue, based on the best available current evidence. However, their implementation into routine clinical practice has not yet been reported. The objective was to evaluate surgical outcomes following the implementation of the AO Spine guidelines at our spinal neurosurgical centre.MethodsA service evaluation was conducted using data collected from electronic healthcare records for 259 patients, with outcomes of interest including change in mJOA score and complications. Data from 193 patients were included in the final analysis.ResultsThere was a mean improvement of the mJOA score by 1.53 points, 1.44 point and 1.92 points at post-operative intervals of 3 months (P < .001), 6 months (P < .001) and 12 months (P < .001). The percentage (number) of patients whose increase in mJOA score was greater than or equal to the minimal clinically importance difference (MCID) was 41% (44/107), 34% (33/96) and 43% (49/114) at these respective time intervals. Intraoperative complications occurred in 28 patients (11.7%). No association was found between BMI and postoperative change in mJOA score.ConclusionOur results are comparable to those from best practice data and suggest adherence to international guidelines provides a service that promotes meaningful recovery for patients with DCM. Therefore, our results offer support for implementation of the AO Spine international guidelines in clinical practice.

Effects of Preoperative Cervical Range of Motion on Clinical Outcomes Following Posterior Decompression: A Multicenter Study of Patients With Cervical Ossification of the Posterior Longitudinal Ligament

Study DesignRetrospective multicenter study.ObjectivesTo investigate the impact of preoperative cervical range of motion (ROM) on clinical outcomes after posterior decompression for cervical ossification of the posterior longitudinal ligament (OPLL).MethodsWe analyzed data from 156 patients with cervical OPLL who underwent posterior decompression and were followed for at least 2 years. Patients were divided into two groups based on preoperative gap ROM, which was a novel indicator representing the difference between flexion and extension ROM: the gROM <0° and >0° groups, and their outcomes were compared.ResultsThere were no significant differences in patient demographics or surgical details between the gROM <0° and >0° groups. The gROM <0° group exhibited less lordosis in C2-7 angles before and after surgery compared to the gROM >0° group. Cervical ROM significantly decreased following posterior decompression regardless of whether preoperative gROM was <0° or >0°. Meanwhile, the incidence of perioperative complications was similar between the two groups. Furthermore, both groups showed significant improvement in Japanese Orthopaedic Association (JOA) scores postoperatively; however, there were no significant group differences in JOA scores, recovery rates, or visual analog scale for neck pain between the two groups at the preoperation and final follow-up.ConclusionsThe incidence of perioperative complications and postoperative clinical outcomes were comparable regardless of the magnitude of preoperative cervical gROM. Although cervical ROM decrease postoperatively, posterior decompression for cervical OPLL can offer favorable clinical outcomes irrespective of the preoperative cervical ROM magnitude, consequently.

Are Postoperative Neck Pain and Kyphotic Change After Laminoplasty Affected by Degree of Facet Joint Degeneration?

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To date, the association between postlaminoplasty neck pain or kyphosis and facet joint degeneration (FJD) remains unknown. Therefore, this study aimed to determine whether FJD affects postlaminoplasty neck pain or kyphosis.

SUMMARY OF BACKGROUND DATA

FJD can cause medial branch irritation leading to postlaminoplasty neck pain. Cervical lordosis is a prerequisite for laminoplasty as it achieves cord decompression through posterior shifting.

METHODS

This study included 126 consecutive patients who underwent laminoplasty and were followed up for a minimum of 2 years. The radiographic cervical sagittal parameters, neck pain visual analog scale (VAS), arm pain VAS, neck disability index (NDI), and Japanese Orthopedic Association score were evaluated. A comparison was made between patients with moderate-to-severe neck pain (neck pain VAS ≥4; severe neck pain group) and those with mild or no neck pain (neck pain VAS <4; mild neck pain group) at the 2-year follow-up. Furthermore, patients who experienced postlaminoplasty kyphosis of C2-C7 (kyphotic group) were compared with those who did not develop kyphosis (nonkyphotic group).

RESULTS

The mild and severe neck pain groups included 99 (78.6%) and 27 (21.4%) patients, respectively. The preoperative degree of FJD was significantly higher in the severe neck pain group ( P =0.040). The cervical sagittal parameters and demographics did not exhibit significant intergroup differences. Multivariate logistic regression analysis revealed that higher preoperative FJD grade was associated with postoperative severe neck pain ( P =0.046). In addition, lesser preoperative C2-C7 extension capacity was identified as a factor influencing postoperative kyphosis ( P =0.027).

CONCLUSIONS

This study demonstrates that patients with higher preoperative FJD are more likely to experience postoperative severe neck pain. However, it did not find an association between FJD and postlaminoplasty kyphosis, indicating that FJD does not influence cervical alignment aggravation.

LEVEL OF EVIDENCE

Level III.

A Systematic Review of Current Terminology for Conditions Preceding Degenerative Cervical Myelopathy: Evidence Synthesis to Inform an AO Spine Expert Opinion Statement

Study DesignSystematic review.ObjectivesThe pre-symptomatic state of Degenerative Cervical Myelopathy (DCM), wherein degenerative changes and spinal cord compression are seen without clinical findings, is poorly understood and inconsistently categorised. Clear identification may elucidate the temporality of DCM development. Therefore, a systematic assessment was undertaken of current terminology for pre-DCM states, with the objective of standardising definitions and informing an AO Spine expert position statement.MethodsMedline and Embase were searched for all studies on asymptomatic spinal compression or clinical findings preceding DCM, returning 3585 studies. After screening, 96 studies were included in the final analysis. The terminology used for pre-DCM states and their definitions were extracted, along with their frequencies or speciality/country of author in the literature.ResultsMultiple terms were used to represent pre-DCM stages, including "asymptomatic" (86 studies), "non-myelopathic" (26 studies), "without myelopathy" (15 studies), "pre-symptomatic" (9 studies) and "sub-clinical" (7 studies). "asymptomatic" was associated with the greatest inconsistency. Some defined this as patients with radiological signs of spinal degeneration with/without spinal cord compression but no clinical signs of myelopathy, whereas others used the term synonymously with healthy controls. This inconsistency is particularly challenging in clinical studies in which DCM patients are compared to those with pre-DCM states and/or healthy volunteers.ConclusionThere is substantial inconsistency in the terms used to describe pre-DCM states. There is no clear relationship between the terms used and the country or speciality of the main author. Standardised definitions for these disease states should be agreed and used in future studies.

Analysis of adverse sagittal alignment after anterior cervical discectomy and fusion (ACDF) for degenerative cervical myelopathy with local kyphosis

The aim of this study was to identify relevant factors associated with sagittal malalignment, which refers to the loss of lordosis or recurrence of kyphosis following an anterior cervical approach. Degenerative cervical kyphosis has increasingly attracted clinical attention, but there are few studies about the classification of local kyphosis and risk factors of adverse sagittal alignment (ASA) after anterior surgery. The study retrospectively reviewed 82 patients with degenerative cervical myelopathy and local kyphosis who underwent anterior cervical discectomy and fusion (ACDF) between January 2019 and December 2021. The patients' baseline characteristics and postoperative assessments were reviewed using electronic medical records from a single-institution database. Based on the postoperative ASA, the patients were divided into the maintaining and adverse groups. Bivariate and multivariate statistical analyses were performed to predict related factors of the ASA. Comparing the two groups, advanced age (p = 0.019), the classification of local kyphosis (p = 0.001), and preoperative thoracic 1 (T1) slope angle (p < 0.001), C2-7 sagittal vertical axis (SVA) (p < 0.001), C2-7 range of motion (ROM) (p = 0.001), and postoperative adjacent segment degeneration (ASD) (p = 0.009), neck disability index (NDI) (p < 0.001), visual analogue score (VAS) (p < 0.001) were significantly different. Multiple linear regression analysis results for relevant factors of the change of local and C2-7 kyphosis showed classification of kyphosis (p = 0.007 and p = 0.563, respectively), T1 slope angle (p = 0.018 and p = 0.004, respectively), C2-7 SVA (p = 0.109 and p = 0.017, respectively), C2-7 ROM (p = 0.028 and p = 0.007, respectively). Our data suggest that postoperative ASA affects recovery of neck pain, and is related to preoperative T1 slope, C2-7 SVA, C2-7 ROM, and the classification of kyphosis.

Mapping the Degenerative Cervical Myelopathy Research Landscape: Topic Modeling of the Literature

Study DesignTopic modeling of literature.ObjectivesOur study has 2 goals: (i) to clarify key themes in degenerative cervical myelopathy (DCM) research, and (ii) to evaluate the current trends in the popularity or decline of these topics. Additionally, we aim to highlight the potential of natural language processing (NLP) in facilitating research syntheses.MethodsDocuments were retrieved from Scopus, preprocessed, and modeled using BERTopic, an NLP-based topic modeling method. We specified a minimum topic size of 25 documents and 50 words per topic. After the models were trained, they generated a list of topics and corresponding representative documents. We utilized linear regression models to examine trends within the identified topics. In this context, topics exhibiting increasing linear slopes were categorized as "hot topics," while those with decreasing slopes were categorized as "cold topics".ResultsOur analysis retrieved 3510 documents that were classified into 21 different topics. The 3 most frequently occurring topics were "OPLL" (ossification of the posterior longitudinal ligament), "Anterior Fusion," and "Surgical Outcomes." Trend analysis revealed the hottest topics of the decade to be "Animal Models," "DCM in the Elderly," and "Posterior Decompression" while "Morphometric Analyses," "Questionnaires," and "MEP and SSEP" were identified as being the coldest topics.ConclusionsOur NLP methodology conducted a thorough and detailed analysis of DCM research, uncovering valuable insights into research trends that were otherwise difficult to discern using traditional techniques. The results provide valuable guidance for future research directions, policy considerations, and identification of emerging trends.

An in vivo 3-dimensional kinematics study of the cervical vertebrae under physiological loads in patients with cervical spondylosis

BACKGROUND CONTEXT

Studies of in vivo kinematic differences between healthy individuals and those with cervical spondylosis (CS) have been reported, but only movements under nonphysiological loads have been investigated. Differences in the in vivo, cervical kinematics between healthy individuals and those with CS are unknown.

PURPOSE

To investigate the in vivo, cervical kinematics of patients with CS under physiological loads.

STUDY DESIGN

This was a retrospective, case-controlled study that used three-dimensional (3D) to 3D registration techniques combined with conical beam computed tomography (CBCT) to investigate the cervical kinematics of patients with CS.

PATIENT SAMPLE

Twenty individuals diagnosed with CS were selected for study participation and matched with 20 participants who did not have CS and were in good health.

OUTCOME MEASURES

Pfirrmann grading, intervertebral range of motion (ROM), kinematics and cross-sectional area of posterior neck muscles (CAPNM).

METHODS

All study participants underwent seven CBCT scans of their cervical vertebrae. The 3D segmental motion features of the vertebra in vivo were calculated using 3D-to-3D volume registration to overlay images of the vertebra at each functional position. The 3D range of motion (ROM) of each cervical segment was expressed with six degrees of freedom using Euler angles and translated onto a coordinate system. A kinematic subgroup analysis was conducted based on the severity of symptoms within the CS group, and differences in muscle volume between the CS and control groups were also evaluated. Project supported by the National Natural Science Foundation of China (Grant No. 81960408,82260445), Key Project of Jiangxi Provincial Natural Science Foundation (Grant No. 20242BAB26125), Clinical Cultivation Project of The First Affiliated Hospital of Nanchang University (Grant No. YFYLCYJPY 20220203).The authors declare no conflict of interest in preparing this article.

RESULTS

The CS group exhibited noticeable reductions in the primary rotational ROMs of left-right rotation at C4-C5, C5-C6, C6-C7, C4-C7, and C1-C7 compared to the controls. During left-right bending, there were no significant differences in the primary ROMs, coupled translations, or rotations between the two groups. However, compared to controls, the CS group had significantly lower primary ROMs for C4-C7, C1-C7 and C5-C6 during flexion-extension. During left-right rotation, the primary rotations and coupled lateral bending at C6-C7 were significantly increased in the mild CS group compared to the moderate CS group. In the mild CS group, the primary ROM of the C4-C5 and C5-C6 during flexion-extension was significantly greater than that of the moderate CS group.

CONCLUSIONS

For the first time, the in vivo 3D kinematics of the cervical spine during head movement under physiological load in CS individuals have been adequately described and compared with healthy cervical vertebrae, which can be used as a reference point for future studies. The application of CBCT helps to obtain accurate and precise movement information of CS patients and effectively enhance the evaluation results obtained from imaging information.

Comprehensive review of the cervical ligamenta flava

PURPOSE

The current literature contains many data associated with the cervical ligamentum flavum (CLF). The present study is to overview knowledge of CLF.

METHODS

Comprehensive literature review was performed.

RESULTS

Topics include anatomy, embryology, histology, radiology, clinical relevance, and pathological manifestations of the CLF, including ossification, calcification, and hypertrophy. Spine procedures always require extreme precision; spine surgeons and neurosurgeons encounter challenges that put patients' lives at risk.

CONCLUSION

This study can assist clinicians in performing spinal interventions with the fewest possible complications. Because there have been few studies of the CLF, further investigation is suggested.

Meta-Analysis of Treatment for Adjacent Two-Segment Cervical Spondylotic Myelopathy: A Comparison Between Anterior Cervical Corpectomy and Fusion and Anterior Cervical Discectomy and Fusion

Study DesignA systematic review and meta-analysis comparing the outcomes of Anterior Cervical Discectomy and Fusion (ACDF) vs Anterior Cervical Corpectomy and Fusion (ACCF) in treating adjacent two-segment cervical spondylotic myelopathy.ObjectiveTo assess the clinical effectiveness and safety of ACDF compared to ACCF.MethodsA literature search was conducted in Cochrane Library, Web of Science, PubMed, and Embase up to December 2023. Studies included were prospective and observational involving ACDF or ACCF for adjacent two-segment cervical spondylotic myelopathy. Data were analyzed using RevMan 5.4 software.ResultsTen studies (nine case-control and one RCT) were included. ACDF showed a shorter hospital stay (SMD = -0.29, 95% CI: -0.53 to -0.04, P < 0.05), better Cobb angle (SMD = 0.52, 95% CI: 0.31 to 0.74, P < 0.01), and improved T1S (SMD = 0.54, 95% CI: 0.28 to 0.80, P < 0.01). No significant differences were found in upper limb VAS, neck VAS, JOA scores, NDI, fusion rates, C2-7 SVA, total complications, blood loss, and operation time.ConclusionsACDF and ACCF are both effective for adjacent two-segment cervical spondylotic myelopathy, with ACDF offering advantages in hospitalization duration and cervical curvature restoration, making it the preferred surgical approach. Further research is needed to validate these findings.

Increased Change in Cervical Lordosis Is Associated With Decreased Rate of Recovery in Patients With C5 Palsy

STUDY DESIGN

A retrospective chart review.

OBJECTIVE

The authors aim to investigate the role of clinical and radiographic parameters in patients who underwent posterior cervical surgery, and their association with C5 palsy severity and time to recovery.

BACKGROUND

Postoperative C5 palsy affects 1%-30% of patients undergoing posterior decompression, with or without fusion. Causation and avoidance of this complication remain widely debated.

MATERIALS AND METHODS

A single institution review of patients who underwent posterior cervical spine surgery was focused on using specific Common Procedural Technology codes associated with the patient population of interest. Patients were excluded if they had inadequate pre and postoperative imaging, as well as a history of prior cervical spine surgery, concurrent anterior surgery, intradural pathology, spinal tumor, or spinal trauma. Radiographic measurements of the pre and postoperative images were completed with subsequent intraclass correlation coefficient analysis to confirm the precision of measurements.

RESULTS

Out of 105 total patients, 35 (33%) patients developed a C5 palsy. Twenty-four (69%) of those palsies completely resolved, with a median time to recovery of 8 months. Preoperative demographics and radiographic parameters demonstrated heterogeneity among those patients who did and did not have a resolution of palsy. Patients with increased change in C2-C7 lordosis ( P = 0.011) after surgery were associated with decreased likelihood of recovery. Patients without a smoking history ( P = 0.009) had an increased likelihood of recovering from C5 palsy.

CONCLUSIONS

The degree of increased lordosis in the treatment of degenerative cervical disease plays a role in the rate of recovery from C5 palsy. This should be considered during preoperative planning in determining the amount of lordosis desired. In addition, patients without a smoking history were associated with a higher rate of recovery.

LEVEL OF EVIDENCE

Level IV.

Deep learning-based prediction of cervical canal stenosis from mid-sagittal T2-weighted MRI

OBJECTIVE

This study aims to establish a large degenerative cervical myelopathy cohort and develop deep learning models for predicting cervical canal stenosis from sagittal T2-weighted MRI.

MATERIALS AND METHODS

Data was collected retrospectively from patients who underwent a cervical spine MRI from January 2007 to December 2022 at a single institution. Ground truth labels for cervical canal stenosis were obtained from sagittal T2-weighted MRI using Kang's grade, a four-level scoring system that classifies stenosis with the degree of subarachnoid space obliteration and cord indentation. ResNet50, VGG16, MobileNetV3, and EfficientNetV2 were trained using threefold cross-validation, and the models exhibiting the largest area under the receiver operating characteristic curve (AUC) were selected to produce the ensemble model. Gradient-weighted class activation mapping was adopted for qualitative assessment. Models that incorporate demographic features were trained, and their corresponding AUCs on the test set were evaluated.

RESULTS

Of 8676 patients, 7645 were eligible for developing deep learning models, where 6880 (mean age, 56.0 ± 14.3 years, 3480 men) were used for training while 765 (mean age, 56.5 ± 14.4 years, 386 men) were set aside for testing. The ensemble model exhibited the largest AUC of 0.95 (0.94-0.97). Accuracy was 0.875 (0.851-0.898), sensitivity was 0.885 (0.855-0.915), and specificity was 0.861 (0.824-0.898). Qualitative analyses demonstrated that the models accurately pinpoint radiologic findings suggestive of cervical canal stenosis and myelopathy. Incorporation of demographic features did not result in a gain of AUC.

CONCLUSION

We have developed deep learning models from a large degenerative cervical myelopathy cohort and thoroughly explored their robustness and explainability.

Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion in the Treatment of Degenerative Cervical Myelopathy: Patient Characteristics and Surgical Outcomes in a National Administrative Database

Study DesignA retrospective cohort utilizing the PearlDiver Patient Claims Database.ObjectiveCervical disc arthroplasty (CDA) is accepted treatment for cervical radiculopathy; however, it may also be safe and effective in myelopathy. Thus, we compared clinical characteristics and outcomes in patients undergoing CDA and anterior cervical discectomy and fusion (ACDF) for degenerative cervical myelopathy (DCM) specifically.MethodsPatients undergoing CDA or ACDF between 2015-2019 were identified with follow-up through 2021. Univariate and multivariable analyses were performed to identify factors associated with either procedure. Reoperation rates were compared using propensity-matched analysis.ResultsWe identified n = 2391 CDA and n = 50 845 ACDF procedures for DCM. Factors favoring CDA included: female sex, younger age, lower CCI, lower incidence of obesity, osteoporosis, diabetes, or smoking (P ≤ .001); remaining significant after multivariable logistic regression except for sex (P = .06). Single-level surgery was more predictive for undergoing CDA. CDA patients had lower 90-day readmissions, complications, and lower opioid utilization. The overall reoperation rate was 5%. Predictors of reoperation included: male sex, younger age, greater CCI, obesity, osteoporosis, diabetes, smoking, and multi-level surgery; all remaining significant after multivariable analysis except for diabetes (P = .23) and CCI (P = .05). After propensity-matching CDA and ACDF patients (n = 2391), there was no difference in re-operation rates (P = .47).ConclusionsCDA patients were healthier (less obesity, smoking, diabetes, better CCI) and represented 4.5% of anterior procedures for DCM. In univariate analysis, readmission rates, medical complications, and opioid use were lower in CDA patients, despite a similar reoperation rate. Considering these findings, CDA might be used very selectively for DCM.

Contemporary Practice Patterns in the Treatment of Cervical Stenosis and Central Cord Syndrome: A Survey of the Cervical Spine Research Society

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To evaluate for areas of consensus and divergence of opinion within the spine community regarding the management of cervical spondylotic conditions and acute traumatic central cord syndrome (ATCCS) and the influence of the patient's age, disease severity, and myelomalacia.

SUMMARY OF BACKGROUND DATA

There is ongoing disagreement regarding the indications for, and urgency of, operative intervention in patients with mild degenerative myelopathy, moderate to severe radiculopathy, isolated axial symptomatology with evidence of spinal cord compression, and ATCCS without myelomalacia.

METHODS

A survey request was sent to 330 attendees of the Cervical Spine Research Society (CSRS) 2021 Annual Meeting to assess practice patterns regarding the treatment of cervical stenosis, myelopathy, radiculopathy, and ATCCS in 16 unique clinical vignettes with associated MRIs. Operative versus nonoperative treatment consensus was defined by a management option selected by >80% of survey participants.

RESULTS

Overall, 116 meeting attendees completed the survey. Consensus supported nonoperative management for elderly patients with axial neck pain and adults with axial neck pain without myelomalacia. Operative management was indicated for adult patients with mild myelopathy and myelomalacia, adult patients with severe radiculopathy, elderly patients with severe radiculopathy and myelomalacia, and elderly ATCCS patients with pre-existing myelopathic symptoms. Treatment discrepancy in favor of nonoperative management was found for adult patients with isolated axial symptomatology and myelomalacia. Treatment discrepancy favored operative management for elderly patients with mild myelopathy, adult patients with mild myelopathy without myelomalacia, elderly patients with severe radiculopathy without myelomalacia, and elderly ATCCS patients without preceding symptoms.

CONCLUSIONS

Although there is uncertainty regarding the treatment of mild myelopathy, operative intervention was favored for nonelderly patients with evidence of myelomalacia or radiculopathy and for elderly patients with ATCCS, especially if pre-injury myelopathic symptoms were present.

LEVEL OF EVIDENCE

Level V.

Associated Factors of Cervical Spinal Cord Injury Without Radiographic Evidence of Trauma: A Retrospective Study

Background Spinal cord injury without radiographic evidence of trauma (SCIWORET) represents a significant portion of cervical spinal cord injuries (SCIs), particularly in elderly patients. Despite its clinical significance, the risk factors and their interactions remain poorly understood. This study aimed to identify key predictors of SCIWORET by analyzing anatomical and biomechanical factors in cervical SCI patients at a single tertiary emergency medical center. Methods We retrospectively analyzed consecutive patients with C3-C7 cervical SCI between April 2011 and November 2023. All patients underwent standardized neurological examination and comprehensive imaging studies, including whole-spine computed tomography (CT) and cervical magnetic resonance imaging (MRI). SCIWORET was defined as a neurological deficit without fracture, dislocation, or discoligamentous complex (DLC) injuries on imaging. We evaluated the presence of cervical canal stenosis (CCS), ossification of the posterior longitudinal ligament (OPLL), and diffuse idiopathic skeletal hyperostosis (DISH) using standardized criteria. Two experienced orthopedic surgeons independently assessed all imaging studies. Univariate logistic regression analysis was first examined to identify the associated factor of SCIWORET. We evaluated multicollinearity using variance inflation factors (VIFs) and correlation coefficients between CCS, OPLL, and DISH. Furthermore, multivariate logistic regression analysis was conducted to identify independent predictors of SCIWORET. Results Among the study population, 203 of 348 patients (58.3%) were diagnosed with SCIWORET. CCS was present in 174 of 348 patients (50.0%), with a significantly higher prevalence in the SCIWORET group (174 of 203 patients, or 85.7%) compared to the SCI with fracture group (78 of 145 patients, or 53.8%). OPLL was identified in 68 of 203 patients (33.5%), showing a higher prevalence in the SCIWORET group versus the SCI with fracture group (24 of 145 patients, or 16.6%). Regarding VIF, CCS, cervical OPLL, and DISH were 1.07, 1.12, and 1.19, respectively. Correlation analysis showed weak associations: CCS and DISH (r = 0.11), CCS and cervical OPLL (r = 0.25), and DISH to cervical OPLL (r = 0.33). Multivariate logistic regression analysis revealed that CCS (odds ratio (OR): 4.91, 95% CI: 2.78-8.70, p < 0.0001) and cervical OPLL (OR: 1.83, 95% CI: 1.01-3.29, p < 0.05) were independent predictors of SCIWORET, respectively. Conclusions CCS, with or without cervical OPLL, are independent predictors of SCIWORET. These findings emphasize the importance of comprehensive spinal evaluation in trauma patients, particularly in those presenting with neurological symptoms following low-energy trauma. Our results suggest that patients with pre-existing CCS or OPLL may be at increased risk for SCI, even in the absence of obvious radiographic abnormalities.

Clinical signs and symptoms for degenerative cervical myelopathy: a scoping review of case-control studies to facilitate early diagnosis among healthcare professionals with stakeholder engagement

STUDY DESIGN

Scoping Review.

OBJECTIVE

Degenerative cervical myelopathy (DCM) is a leading cause of chronic spinal cord dysfunction, with diverse clinical presentations that complicate diagnosis. Therefore, it is important to identify the signs and symptoms of DCM that demonstrate high diagnostic accuracy. This review aims to evaluate the sensitivity and specificity of signs and symptoms in diagnosing DCM.

METHODS

Articles up to June 2024 were retrieved from PubMed, EMBASE, and Cochrane databases using search terms like "degenerative cervical myelopathy", "cervical spondylotic myelopathy", "sensitivity", "specificity", and related signs and symptoms. Studies were screened based on selection criteria assessing the sensitivity and specificity of signs or symptoms using an appropriate control group.

RESULTS

Sixteen studies were included. The most sensitive signs were Tromner sign (93-97%) and hyperreflexia (15-85%). Specific signs included the Babinski sign (93-100%), Tromner sign (79-100%), clonus (96-99%), and inverted supinator sign (78-99%). Neck pain had a sensitivity of 76-94% and specificity of 11-73%. Hand incoordination showed 52% sensitivity and 92% specificity. Altered hand sensation had 76% sensitivity and 90% specificity. Upper extremity weakness had 51-75% sensitivity and 18-95% specificity. Gait imbalance exhibited 56-63% sensitivity and 52-95% specificity.

CONCLUSION

Sensitive signs like the Tromner sign and hyperreflexia are useful for screening, while specific signs such as Babinski, clonus, and the inverted supinator sign aid in confirmation of DCM. Symptoms like neck pain, hand incoordination, and altered hand sensation should heighten suspicion and guide differential diagnosis. Early and accurate diagnosis using these indicators can improve patient outcomes and reduce diagnostic delays.

Analysis of short- and delayed unplanned readmission rates after anterior discectomy and fusion for CSM

INTRODUCTION

Many patients with cervical spondylotic myelopathy (CSM) undergo anterior cervical discectomy and fusion (ACDF). Many of these patients are readmitted, but there is no clear understanding of drivers of readmission. The aim of this study was to assess the patient- and hospital-level factors that contribute to 7-, 30-, and 90-day readmissions after treatment of CSM.

METHODS

A retrospective cohort study was performed using the 2016-2019 Nationwide Readmissions Database (NRD). All adult patients undergoing ACDF for CSM were identified using ICD-10 coding. Patients were stratified by no readmission, readmission within 7 days, readmission within 8-30 days, or readmission within 31-90 days. Patient demographic information, comorbidities, and adverse events were collected.

RESULTS

Of the 19,621 patients included, 576 were readmitted within 7 days, 568 within 30, 794 within 90, and 17,683 who were not readmitted. The patients readmitted within 7 and 30 days were significantly older than the 90-day patients, who were older than the non-readmitted patients (p < 0.001) and had a higher frailty score by the modified frailty index (p < 0.001). The 30-day readmission cohort had the longest mean LOS (p < 0.001) and the greatest mean total admission costs (p < 0.001). Drivers of readmission included sepsis, infection, and acute kidney failure.

CONCLUSION

Our study found that the most common diagnoses during readmission included sepsis and other infection for 7-, 30-, and 90-day readmission for CSM patients who underwent ACDF. Further studies are needed to understand how to decrease likelihood for readmission.

Progression from outpatient referral to spinal surgery in an Australian cohort with degenerative spinal disease

BACKGROUND

Degenerative spine disease (DSD) encompasses a range of conditions with increasing prevalence and a significant burden of disease. Patients with DSD are often referred to a neurosurgery clinic with lengthy waiting times from referral to consultation. The reported proportion of referred patients who undergo spinal surgery varies from 20.05% to 54% in heterogenous study populations from predominantly North American and European study populations. These rates do not correlate with institutional data in the Australian public hospital system and there is limited Australian data in the literature. This retrospective study aimed to quantify the proportion of patients referred to a neurosurgery clinic who progressed to elective spinal surgery and explore predictors for surgery based on referral contents.

METHODS

All patients referred for DSD to a single tertiary centre between 1/1/16 and 31/12/22 were included. Referrals for spinal pathology due to trauma, infection or tumour were excluded. Patient demographics, clinical presentation and imaging findings contained in the outpatient referral were recorded. Outcomes, including progression to surgery, were also recorded. Univariate and multivariate analysis was performed to determine predictive factors for surgery.

RESULTS

Of 5189 referrals, only 471 (9.1%) underwent surgery. Only 4.7% had surgery at our institution with the remaining 4.4% undergoing surgery elsewhere. Referrals from neurologists, rheumatologists and referrals specifying limb weakness or sensory change, were more likely to progress to surgery, although these predictors were only present in 0.7 - 3.9% of referrals. Axial pain negatively predicted surgery.

CONCLUSION

To our knowledge, this is the only study in an Australian population to analyse the outcome of DSD referrals to neurosurgery clinic, based on referral contents alone. The vast majority of patients do not require surgery. Though there are a few predictive factors, progression to surgery cannot reliably be predicted from the referral, highlighting the opportunity to improve patient outcomes and healthcare utilisation for patients with DSD.

Presenting Symptoms Define Time to Diagnosis in Degenerative Cervical Myelopathy: Process Mapping From a Musculoskeletal Triage Unit in the UK

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Tackling delayed diagnosis in degenerative cervical myelopathy (DCM) is a global research priority. On average, it takes 2-5 years, leading to worse outcomes from surgery and greater disability. Many countries in the UK use interface triage units run by specialist physiotherapists that sit between primary and secondary care termed musculoskeletal services. Their role in the efficient diagnosis of DCM is unknown. The aim of this study was to map the journey of the patient in the musculoskeletal service and to establish the presenting signs and symptoms.

METHODS

A retrospective review of 2.5 years of clinical notes was performed in a musculoskeletal service. Process mapping was utilised to visualise the patient's journey and identify delays to diagnosis and presenting signs and symptoms.

RESULTS

Twenty-seven cases were reviewed. Patients spent an average of three months in the service. There was a wide variety of presenting symptoms. DCM was more often suspected if patients had both upper limb symptoms and gait disturbance or pathological reflexes. Delays occurred when patients had no gait disturbance or a normal or incomplete neurological assessment. Longest delays occurred when patients received electrophysiology tests for differential diagnosis of peripheral neuropathies. Delays were also seen with incorrect triaging of MRI results.

CONCLUSIONS

Where DCM is the principal differential diagnosis, diagnosis was faster. Incomplete examination, misinterpretation of MRI findings or delays in other investigations contributed to delays. Improved awareness and protocols of care within musculoskeletal services represent an opportunity to accelerate diagnosis in DCM.

Ischemia-reperfusion injury after spinal cord decompressive surgery-An in vivo rat model

BACKGROUND

Although decompression surgery is the optimal treatment for patients with severe degenerative cervical myelopathy (DCM), some individuals experience no improvement or even a decline in neurological function after surgery, with spinal cord ischemia-reperfusion injury (SCII) identified as the primary cause. Spinal cord compression results in local ischemia and blood perfusion following decompression is fundamental to SCII. However, owing to inadequate perioperative blood flow monitoring, direct evidence regarding the occurrence of SCII after decompression is lacking. The objective of this study was to establish a suitable animal model for investigating the underlying mechanism of spinal cord ischemia-reperfusion injury following decompression surgery for degenerative cervical myelopathy (DCM) and to elucidate alterations in neurological function and local blood flow within the spinal cord before and after decompression.

METHODS

Twenty-four Sprague-Dawley rats were allocated to three groups: the DCM group (cervical compression group, with implanted compression material in the spinal canal, n = 8), the DCM-D group (cervical decompression group, with removal of compression material from the spinal canal 4 weeks after implantation, n = 8), and the SHAM group (sham operation, n = 8). Von Frey test, forepaw grip strength, and gait were assessed within 4 weeks post-implantation. Spinal cord compression was evaluated using magnetic resonance imaging. Local blood flow in the spinal cord was monitored during the perioperative decompression. The rats were sacrificed 1 week after decompression to observe morphological changes in the compressed or decompressed segments of the spinal cord. Additionally, NeuN expression and the oxidative damage marker 8-oxoG DNA were analyzed.

RESULTS

Following spinal cord compression, abnormal mechanical pain worsened, and a decrease in forepaw grip strength was observed within 1-4 weeks. Upon decompression, the abnormal mechanical pain subsided, and forepaw grip strength was restored; however, neither reached the level of the sham operation group. Decompression leads to an increase in the local blood flow, indicating improved perfusion of the spinal cord. The number of NeuN-positive cells in the spinal cord of rats in the DCM-D group exceeded that in the DCM group but remained lower than that in the SHAM group. Notably, a higher level of 8-oxoG DNA expression was observed, suggesting oxidative stress following spinal cord decompression.

CONCLUSION

This model is deemed suitable for analyzing the underlying mechanism of SCII following decompressive cervical laminectomy, as we posit that the obtained results are comparable to the clinical progression of degenerative cervical myelopathy (DCM) post-decompression and exhibit analogous neurological alterations. Notably, this model revealed ischemic reperfusion in the spinal cord after decompression, concomitant with oxidative damage, which plausibly underlies the neurological deterioration observed after decompression.

Evaluation of Financial Support Workshops for Patients Under State Pension Age With Degenerative Cervical Myelopathy: Survey Study

Background

Degenerative cervical myelopathy (DCM), a form of slow-motion and progressive spinal cord injury caused by spinal cord compression secondary to degenerative pathology, leads to high levels of disability and dependence, and may reduce quality of life. Myelopathy.org is the first global scientific and clinical charity for DCM, providing an accessible platform freely disseminating information relevant to the DCM diagnosis and its treatment. Significant transient and long-term change to earnings do occur and can thrust individuals into poverty. People with DCM face many challenges accessing state financial assistance. This can have a cumulative negative financial effect due to the association between DCM and low socioeconomic index. Financial support available to patients under pension age include Universal Credit (UC), a payment that helps with living costs, and Personal Independence Payment (PIP), which helps with extra living costs if someone has both a long-term health condition or disability and difficulty doing certain everyday tasks.

Objective

This study aimed to assess if delivering workshops centered around access to financial support could assist people with DCM living in the United Kingdom.

Methods

A series of 2 internet-based workshops was targeted at accessing financial support for English patients under the state pension age, with an anonymized survey delivered to participants after each session. The first session was on UC and the second on PIP. The survey consisted of a mixture of Likert scales, free text and yes or no answers. Survey responses were analyzed using descriptive statistics and free text answers underwent inductive thematic analysis.

Results

The average rating on the use of UC was 9.00/10. Presession self-rated confidence levels were 5.11/10 rising to 8.00/10. The mean score of wanting further similar sessions was 8.67/10 with 56% (5/9) of participants wanting one-to-one sessions. For PIP, the average session use rating was 10/10. Presession self-rated confidence levels were 4.43/10 rising to 9.57/10. The mean score of wanting further similar sessions was 8.71/10, with 43% (3/7) of participants wanting one-to-one sessions . Following inductive thematic analysis, themes regarding the usefulness of such sessions and the challenges to accessing financial support emerged. One participant gave negative feedback, which included the length of the session and perceived problems around confidentiality and data protection.

Conclusions

The pilot series was largely perceived as a success, with participants finding them useful and increasing their self-rated confidence in navigating the UK financial support system. Given the small sample size, it is hard to predict the success of future sessions. Finally, given that the hurdles in accessing financial support extend beyond DCM, such workshops may be relevant to other organizations.

Fluid biomarkers for cervical spondylotic myelopathy

INTRODUCTION

There is a scarcity of literature exploring fluid-based biomarkers that have the potential to provide deeper insights into the cellular mechanisms underlying cervical spondylotic myelopathy (CSM) symptom presentation and postoperative recovery. This systematic review synthesized the literature on invasive, fluid-based biomarkers and their clinical significance with CSM.

MATERIALS AND METHODS

A comprehensive search strategy was developed for concepts of biomarkers and CSM. Retrieved results underwent title, abstract, and full-text screening with inclusion criteria being original research including animal or human subjects affected by CSM/compression myelopathy that investigated the relationship between a fluid-based biomarker and CSM. Risk-of-bias was reported using the OHAT Risk of Bias Rating Tool.

RESULTS

The search strategy resulted in 191 unique manuscripts, with 20 meeting the predetermined inclusion/exclusion criteria, included in final analysis. Of these, 15 (75.0%) were human studies, two (10.0%) were animal studies, and three studies (15.0%) included both human and animal subjects. Across human studies, the fluid utilized for biomarker assessment was blood, (N = 8, 44.4%), cerebrospinal fluid (CSF) (N = 9, 50.0%), and both blood and CSF (N = 1, 5.6%). The three most common biomarkers assessed across human studies were NSE (N = 4, 22.2%), S100b (N = 4, 22.2%), and pNF-H (N = 4, 22.2%). Risk of bias due to inadequate comparison groups was present in three human studies (16.7%) and two animal studies (40%).

CONCLUSIONS

This comprehensive systematic review identified several associations between blood and CSF-based neural, glial, and inflammatory biomarkers and CSM. However, the vast heterogeneity across studies renders it difficult to draw definitive conclusions. Future research within larger, prospective patient cohorts is needed to fully elucidate the utility these biomarkers may hold in the clinical evaluation of patients with CSM.

Who gets better after surgery for degenerative cervical myelopathy? A responder analysis from the multicenter Canadian Spine Outcomes and Research Network

BACKGROUND CONTEXT

Degenerative cervical myelopathy (DCM) is the most common cause of acquired nontraumatic spinal cord injury worldwide. Surgery is a common treatment for DCM; however, outcomes often vary across patients.

PURPOSE

To inform preoperative education and counseling, we performed a responder analysis to identify factors associated with treatment response.

STUDY DESIGN/SETTING

An observational cohort study was conducted utilizing prospectively collected data from the Canadian Spine Outcomes Research Network (CSORN) registry collected between 2015-2022.

PATIENT SAMPLE

We included all surgically treated DCM patients with complete 12-month follow-up and patient-reported outcomes (PROs) available at 1-year.

OUTCOME MEASURES

Treatment response was measured using the minimal clinically important difference (MCID) in PROs including the Neck Disability Index (NDI) and EuroQol-5D (EQ-5D) at 12 months postsurgery.

METHODS

A Least Absolute Shrinkage and Selection Operator (LASSO) machine learning model was used to identify significant associations between 14 preoperative patient factors and likelihood of treatment response measured by achievement of the MCID in NDI, and EQ-5D. Variable importance was measured using standardized coefficients. To test robustness of findings we trained a separate XGBOOST model, with variable importance measured using SHAP values.

RESULTS

Among the 554 DCM patients included, 229 (41.3%) and 330 (59.6%) patients responded to treatment by meeting or surpassing MCID thresholds for NDI and EQ-5D at 1-year, respectively. LASSO regression for likelihood of treatment response measured through NDI found the variable importance rank order to be baseline NDI (OR 1.06 per 1 point increase; 95% CI 1.04-1.07), then symptom duration (OR 0.65; 95% CI 0.44-0.97). For EQ-5D, the variable importance rank order was baseline EQ-5D (OR 0.16 per 0.1-point increase; 95% CI 0.03-0.78), living independently (OR 2.17; 95% CI 1.22-3.85), symptom duration (OR 0.62; 95% CI 0.40-0.97), then number of levels affected (OR 0.80 per additional level; 95% CI 0.67-0.96). A separate XGBoost model of treatment response measured through NDI, corroborated findings that patients with higher baseline NDI, and shorter symptom duration were more likely to respond to treatment, and additionally found older patients, and those with kyphosis on baseline upright X-ray were less likely to respond. Similarly, an XGBoost model for treatment response measured through EQ-5D corroborated findings that patients with higher baseline EQ-5D, shorter symptom duration, living independently, with fewer affected levels were more likely to respond to treatment, and additionally found older patients were less likely to respond.

CONCLUSIONS

Our findings suggest patients with shorter symptom duration, higher baseline patient NDI, lower EQ-5D, younger age, living independently, without kyphosis on preoperative X-ray, and fewer affected levels are more likely to respond to treatment. Timing of surgery with respect to patient symptoms is underscored as a crucial and modifiable patient factor associated with improved surgical outcomes in DCM.

Acute pleurisy mimicking neck pain in a young volleyball player: a case report

INTRODUCTION

Patients presenting to direct access physiotherapists may present with a serious pathology that mimics a musculoskeletal condition. Recognition of atypical clinical patterns allows for referral to an appropriate provider when a serious pathology is present. This case report details a patient with a pulmonary pathology who presented to a physiotherapist with a complaint of neck and chest pain following medical consultations.

CASE PRESENTATION

A 29-year-old amateur volleyball player arrived at the physiotherapist's clinic five days after experiencing the onset of neck pain. She complained of pain on the right side, which extended to the trapezius, as well as occasional discomfort in the lower lateral and anterior chest. The patient noted that the pain worsened when lying supine or on her left side, and during coughing. After developing symptoms resembling a cold, she sought care at two different emergency clinics where physicians diagnosed seasonal flu and an unrelated muscle strain. Despite treatment, the pain persisted, accompanied by fever and general weakness, disrupting her sleep. Following a review of a medical history and a physical examination, musculoskeletal causes of pain appeared unlikely, prompting consideration of a pulmonary pathology. Referral to a specialist was deemed necessary.

CONCLUSION

This case report highlights the importance of screening for serious pathology in direct access physiotherapy, irrespective of a prior physician consultation.

Presence of Cerebrospinal Fluid on Preoperative Imaging and the Associated Cervical Myelopathy Diagnosis and Outcome

STUDY DESIGN

Retrospective chart review.

OBJECTIVE

The objective of this study is to determine whether the presence of cerebrospinal fluid is associated with the severity of degenerative cervical myelopathy or postoperative outcomes.

SUMMARY OF BACKGROUND DATA

Degenerative cervical myelopathy (DCM) is a clinical diagnosis characterized as neurologic dysfunction. Preoperative imaging is used to determine the source of cord compression. In clinical practice, cerebrospinal fluid (CSF) around the cord is often used as an indicator to determine whether stenosis is relevant. It is unclear if the presence of CSF around the cord can serve as a metric for clinically relevant cord compression.

METHODS

Patients undergoing single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy were identified from our institution's surgical database. Pre- and postoperative patient-reported health outcomes visual analog scale for neck pain (VAS-NP) and modified Japanese Orthopaedic Association (mJOA) were collected. The level of ACDF plus one level above and below were assessed for the presence of cerebrospinal fluid, as well as measuring the area of the spinal canal and spinal cord on preoperative magnetic resonance imaging.

RESULTS

Two hundred forty-nine patients were included. Spearman correlation test comparing cord/canal ratios at the level of compression and preoperative mJOA shows a significant negative correlation (Rho = -0.206, P = 0.043). There was no significant correlation with postoperative change in mJOA scores (Rho = -0.002, P = 0.986).

CONCLUSION

The presence of CSF around the cord was weakly correlated with the severity of myelopathy; however, it had no correlation with postoperative outcomes. The presence of CSF around the cord should not in isolation be used to rule in or rule out operative levels in cervical myelopathy.

What is the best strategy for C3 in open-door laminoplasty: laminectomy versus laminoplasty-a systematic review and meta-analysis

BACKGROUND

Conventional open-door laminoplasty is commonly used to treat multilevel cervical disorders but often leads to complications such as loss of cervical lordosis, limited neck motion, and axial symptoms. These issues stem from the extensive disruption of musculature and structural alterations involved in conventional methods. To address these shortcomings, the modified open-door laminoplasty with C3 laminectomy technique has been developed as a modification of conventional open-door laminoplasty, with the aims to preserve the semispinalis cervicis muscle attached to the C2 spinous process, potentially improving postoperative outcomes by maintaining muscle integrity and stability of the cervical spine.

PURPOSE

This study seeks to evaluate the clinical benefits of modified open-door laminoplasty with C3 laminectomy in comparison to conventional open-door laminoplasty approaches.

STUDY DESIGN/SETTING

Patient Sample: patients undergoing open-door laminoplasty OUTCOME MEASURES: The outcome measures assessed were categoried into self-report Measure including pain indices, physiologic measures including complications, and functional measures including operative time, Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) scores, length of hospital stay, and cervical range of motion (ROM).

METHODS

We conducted a comprehensive search across multiple databases, including PubMed, Scopus, EMBASE, Web of Science, and the Cochrane Library, to identify randomized controlled trials (RCTs), cohort studies, and case-control studies that compare the clinical outcomes of conventional open-door laminoplasty and modified open-door laminoplasty with C3 laminectomy. Statistical analyses were performed using RevMan software to evaluate the differences between the 2 surgical techniques.

RESULTS

Our analysis included 11 studies encompassing 873 participants. The meta-analysis revealed no significant differences between patients undergoing conventional open-door laminoplasty and modified open-door laminoplasty with C3 laminectomy regarding operation time (mean difference, MD: 5.08, 95% confidence interval, CI: -3.04 to 13.21), length of hospital stay (MD: -0.33, 95% CI: -1.43 to 0.77), JOA scores (MD: 0.18, 95% CI: -0.03 to 0.40), NDI scores (MD: -0.14, 95% CI: -4.00 to 3.72), and complication rates (risk difference, RD: 0.01, 95% CI: -0.03 to 0.04). However, participants in the group that underwent modified open-door laminoplasty with C3 laminectomy exhibited a significantly greater range of motion (MD: 4.13, 95% CI: 0.07 to 7.20) and lower postoperative pain scores (standard mean difference, SMD: -0.57, 95% CI: -1.05 to -0.10).

CONCLUSION

Our study suggests that modified open-door laminoplasty with C3 laminectomy improves range of motion and reduces pain compared to conventional open-door laminoplasty, with no differences in other clinical outcomes. Further studies are needed to confirm these results.

Spinal cord demyelination predicts neurological deterioration in patients with mild degenerative cervical myelopathy

Background

Degenerative cervical myelopathy (DCM) is the most common form of atraumatic spinal cord injury globally. Clinical guidelines regarding surgery for patients with mild DCM and minimal symptoms remain uncertain. This study aims to identify imaging and clinical predictors of neurological deterioration in mild DCM and explore pathophysiological correlates to guide clinical decision-making.

Methods

Patients with mild DCM underwent advanced MRI scans that included T2-weighted, diffusion tensor imaging and magnetisation transfer (MT) sequences, along with clinical outcome measures at baseline and 6-month intervals after enrolment. Quantitative MRI (qMRI) metrics were derived above and below maximally compressed cervical levels (MCCLs). Various machine learning (ML) models were trained to predict 6 month neurological deterioration, followed by global and local model interpretation to assess feature importance.

Results

A total of 49 patients were followed for a maximum of 2 years, contributing 110 6-month data entries. Neurological deterioration occurred in 38% of cases. The best-performing ML model, combining clinical and qMRI metrics, achieved a balanced accuracy of 83%, and an area under curve-receiver operating characteristic of 0.87. Key predictors included MT ratio (demyelination) above the MCCL in the dorsal and ventral funiculi and moderate tingling in the arm, shoulder or hand. qMRI metrics significantly improved predictive performance compared to models using only clinical (bal. acc=68.1%) or imaging data (bal. acc=57.4%).

Conclusions

Reduced myelin content in the dorsal and ventral funiculi above the site of compression, combined with sensory deficits in the hands and gait/balance disturbances, predicts 6-month neurological deterioration in mild DCM and may warrant early surgical intervention.

Racial/Ethnic Disparities in Perception of Health Literacy and Barriers to Care Among Cervical Stenosis Patients

Study DesignCross-Sectional Survey.ObjectiveThis study aimed to assess racial disparities in self-reported barriers to care, health literacy, and health status within a large cohort of cervical stenosis patients.MethodsThis cross-sectional study used ICD-9 and ICD-10 codes to identify cervical stenosis patients recorded in the NIH All of Us Research Program between 2017 and 2022. Demographic information and self-reported measures of health status, health literacy, and perceived barriers to care were compared among White, Black, and Hispanic patients using Chi square tests.ResultsOf 5480 patients identified, 658 (12.0) were Black, 379 (6.9) Hispanic, and 4443 (81.1) White. White patients were more likely to possess college education (P < .001), income >$50k per year (P < .001), and non-disabled employment status (P < .001). Black and Hispanic patients reported higher levels of 7-10 pain (P < .001), "severe" 7-day fatigue (P < .001), and poor general health (P < .001). Black and Hispanic patients also reported greater difficulties understanding medical information (P < .001) and navigating medical forms alone (P < .001). Black and Hispanic patients were likelier to report delaying care due to unaffordable copays (P < .001), transportation difficulties (P < .001), or dissimilar provider background. Provider background was more likely to be described as "very important" by Black and Hispanic patients (P < .001).ConclusionThis study identified significant disparities in health status, health literacy, and access to care among patients with cervical stenosis, highlighting diverse patient perspectives on barriers to care which may warrant further study.

Open-Door Cervical Laminoplasty Using Instrumentation of Every Level Versus Alternate Levels: A Multicenter, Randomized Controlled Trial

BACKGROUND

In the setting of cervical open-door laminoplasty, the question of whether or not every opened laminar level should be instrumented has not been sufficiently investigated. We postulated that the surgical outcomes of open-door laminoplasty with instrumentation of every second opened level (skip-fixation) might not be inferior to those of laminoplasty with instrumentation of every opened level (all-fixation). The purpose of the present study was to test the noninferiority of laminoplasty with skip-fixation in improving myelopathy at 2 years postoperatively compared with all-fixation. Additionally, we compared radiographic and surgical outcomes between the 2 types of procedures.

METHODS

This prospective, multicenter, unblinded randomized controlled trial included patients ≥60 years of age who underwent C3 to C6 open-door cervical laminoplasty for the treatment of degenerative cervical myelopathy. Patients were allocated to the skip-fixation group (n = 80) or the all-fixation group (n = 75) using a permuted block method. The primary outcome was the between-group difference in the Japanese Orthopaedic Association (JOA) score at 2 years postoperatively. Secondary outcomes included surgical data, complications, 2-year change in the JOA score, Neck Disability Index (NDI), EQ-5D-5L (EuroQol 5-dimension 5-level instrument) score, visual analog scale (VAS) score for neck pain, and radiographic outcomes.

RESULTS

One hundred and thirty patients (including 66 in the skip-fixation group and 64 in the all-fixation group) completed the trial at 2 years (follow-up rate, 83.9%). The difference in the JOA score at 2 years was 0.0298 (95% confidence interval [CI], -0.706 to 0.766), which was within the noninferiority margin (p < 0.0001; noninferiority test). In the secondary analyses, laminoplasty with skip-fixation demonstrated a significantly shorter surgical time (p = 0.010; Mann-Whitney U test) and greater improvement in the VAS score for neck pain, NDI, and EQ-5D-5L score (p = 0.006, p = 0.047, p = 0.037, respectively; mixed-effect model) compared with all-fixation. There were no significant between-group differences in radiographic outcomes, including the hinge union rate.

CONCLUSIONS

Skip-fixation may be sufficient to achieve noninferior 2-year postoperative improvement in myelopathy. Additionally, laminoplasty with skip-fixation potentially can lead to improvements in terms of neck pain, neck disability, and quality of life compared with all-fixation.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Optimising early detection of degenerative cervical myelopathy: a systematic review of quantitative screening tools for primary care

Background

Early diagnosis of degenerative cervical myelopathy (DCM) is often challenging due to subtle, non-specific symptoms, limited disease awareness and a lack of definitive diagnostic criteria. As primary care physicians are typically the first to encounter patients with early DCM, equipping them with effective screening tools is crucial for reducing diagnostic delays and improving patient outcomes. This systematic review evaluates the efficacy of quantitative screening methods for DCM that can be implemented in primary care settings.

Methods

A systematic search following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted across PubMed, Embase and Cochrane Library up to July 2024 using keywords relevant to DCM screening. Studies were included if they evaluated the sensitivity and specificity of DCM screening tools applicable to primary care settings. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

Results

The search identified 14 studies evaluating 18 screening methods for DCM. Questionnaires consistently showed high diagnostic accuracy, with Youden indices exceeding 0.60, while only three out of nine conventional physical performance tests met the same threshold. Sensor-assisted tests, particularly those using advanced technology like finger-wearable gyro sensors, exhibited the highest diagnostic accuracy but present challenges related to accessibility and learning curves.

Conclusion

This review highlights the potential of quantitative screening methods for early DCM detection in primary care. While questionnaires and conventional tests are effective and accessible, sensor-assisted tests offer greater accuracy but face implementation challenges. A tailored, multifaceted approach is crucial for improving outcomes. Future research should focus on validating these tools in diverse populations and standardising diagnostic criteria.

Anterior Cervical Discectomy and Fusion Versus Cervical Corpectomy With Iliac Crest Graft and Fusion in Multilevel Degenerative Myelopathy: A Single Center Experience

STUDY DESIGN

Cohort retrospective study.

OBJECTIVE

We evaluated and compared the outcomes of anterior cervical discectomy with fusion (CDF) and anterior cervical corpectomy with iliac crest graft and fusion (CCF) in patients with ≥3 level degenerative cervical myelopathy (DCM).

BACKGROUND

Anterior and posterior approaches are widely employed in DCM when compressive elements predominate in the anterior or posterior spinal cord, respectively. Indications for each approach remain controversial in some contexts.

METHODS

Following the STROBE statement, a retrospective enrollment from records of patients who underwent anterior CDF and/or CCF between June 2015 and June 2022. Linear mixed models were applied to establish the effects of the type of surgery according to the follow-up time (mo).

RESULTS

In this study, 73 patients met the inclusion criteria, of which 21 (28.8%) were included in the CDF group and 52 (71.2%) in the CCF group. Twenty surgeries were performed at 3 cervical levels and 53 at 4 levels. There was an improvement in the NDI and VAS score, with an Odom mean of 1.63±0.67 at 12 months of follow-up, with no differences between CDF and CCF. In the CDF group, it was reported a greater C2-7 Cobb angle at the third month of follow-up. In the CCF group, the C2-7 Cobb angle had a negative correlation with the NDI and VAS scales, and a positive correlation with the mJOA scale. Intraoperative estimated blood loss (EBL), surgical time, and postoperative hospital stay were shorter in CDF. There were no differences between the 2 groups in medical complications and other radiologic findings.

CONCLUSION

Surgery for multilevel DCM using an anterior approach with CDF or CCF showed good clinical outcomes without significant differences between the 2 groups, and equivalent results in medical complications and radiologic parameters. The CDF group had better perioperative results and shorter postoperative hospitalization time.

The Relationship Between Craniocervical Morphology and the Presence and Level of Cervical Facet Joint Degeneration

OBJECTIVE

To investigate the relationship between craniocervical morphology and the presence and level of cervical facet joint degeneration (FJD).

METHODS

A total of 108 consecutive female patients aged 45-55 years who had undergone neck + brain CT angiography were included in this retrospective sectional study. Only patients of a certain age and of the same gender were included in order to eliminate the differences that create a disposition to the development of spinal degeneration. The presence of facet joint (FJ) arthritis (grade ≥2 degeneration in at least one affected facet joint) and the grade of the facet joint degeneration for each patient were recorded. A total of 20 lengths and 3 angles of craniocervical morphology were measured. The differences between the individuals with and without FJ arthritis were investigated with the independent-sample t test, and the relationship between the FJD grade and craniocervical morphology was investigated using the Spearman correlation test.

RESULTS

Individuals with FJ arthritis were found to have longer Grabb-Oakes measurement, shorter FM AP length, lower ADI, lower EOP thickness, higher clivus length, higher crista gall-ATS distance, lower CCA angle, lower distance between the C1 vertebra lateral masses, and higher BAI than those without FJ arthritis ( P ˂ 0.05). Besides, we found that the FJD grade increased as the Grabb-Oakes measurement increased, ADI distance decreased, FM AP length decreased, EOP thickness decreased, clivus length increased, basal angle increased, distance between the C1 vertebra lateral masses decreased, and BAI increased ( P ˂ 0.05).

CONCLUSIONS

Differences in craniocervical morphology are statistically associated with degenerative processes that result in degenerative changes in the facet joint. Therefore, some morphological changes in craniocervical anatomy cause changes in the momentum and distribution of the load on the facet joints, predisposing the patient to facet arthropathy and osteoarthritis.

Contact heat evoked potentials reveal distinct patterns of spinal cord impairment in degenerative cervical myelopathy beyond MRI lesions

BACKGROUND

Magnetic resonance imaging may suggest spinal cord compression and structural lesions in degenerative cervical myelopathy (DCM) but cannot reveal functional impairments in spinal pathways. We aimed to assess the value of contact heat evoked potentials (CHEPs) in addition to MRI and hypothesized that abnormal CHEPs may be evident in DCM independent of MR-lesions and are related to dynamic mechanical cord stress.

METHODS

Individuals with DCM underwent neurologic examination including segmental sensory (pinprick, light touch) and motor testing. The presence or absence of hyperintense signal on T2-weighted MRI (T2-positive/negative) was assessed. Phase-contrast MRI was used to assess spinal cord motion as an indicator of dynamic mechanical stress. Dermatomal somatosensory evoked potentials and CHEPs were recorded after stimulation of dermatomes C6, C8, and T4 (CHEPs only) to assess spinal cord integrity.

RESULTS

Of 138 individuals included in this study (age 56 ± 13 years), 35% (N = 48) presented with T2-positive and 65% (N = 90) presented with T2-negative DCM. Abnormal CHEPs were present in T2-positive DCM (C6:41%; C8:32%; T4:24%) and T2-negative DCM (C6:35%; C8:54%; T4:26%). Multisegmental CHEP abnormalities at C6 and C8 were related to increased spinal cord motion (p = 0.030; ϵ2 = 0.072), and reduced upper extremity pinprick (p = 0.046; ϵ2 = 0.063) and motor scores (p = 0.005; ϵ2 = 0.108).

CONCLUSIONS

CHEPs revealed distinct patterns of spinal cord impairment independent of structural T2-positive lesions, which were associated with measures of cord motion. CHEPs thus provide valuable complementary diagnostic insights into spinal cord integrity beyond MRI. This is especially important in incipient myelopathy to inform early diagnosis and timely interventions before the development of definite cord lesions.

Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial

BACKGROUND AND OBJECTIVES

Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW.

METHODS

In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model.

RESULTS

A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively.

CONCLUSION

Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

Does Intra-Operative Methylprednisolone Improve Outcomes of Surgery for Degenerative Cervical Myelopathy? - A Prospective Randomized Study

STUDY DESIGN

Randomized controlled trial.

OBJECTIVES

In this study, we hypothesize administering fixed-dose intravenous steroid (Methylprednisolone) intraoperatively would reduce neuroinflammation and enhance functional and radiological outcomes in decompressive surgeries for DCM. Primary objectives were to assess effect of intraoperative MP on modified Japanese Orthopedic Association (mJOA) score, Nurick grade, and MRI signal changes.

METHODS

This prospective triple-blinded randomized controlled trial included 65 patients allocated into MP (n = 33) and control (n = 32) groups. MP (dose-1g) was administered intraoperatively at the beginning of decompression. Clinical outcome measures included mJOA score, Nurick grading, mJOA recovery rate (mJOA RR), Nurick recovery rate (NRR), and complication rates in both groups at 1-, 3-and 24-month follow-up. Radiological outcome was assessed by analyzing regression of T2W and T1W SI changes on MRI scans as per Chen's grading at 24-months follow-up.

RESULTS

MP group exhibited greater improvement in mJOA scores at 24-months (mean improvement: +6.69 vs +6.42; difference: +0.27, 95% CI: -0.37 to +0.91) but was statistically insignificant (P = .107). Similarly, mJOA-RR showed a moderate effect size of 0.42 (95% CI: 0.04 to 0.80) and 0.37 (95% CI: -0.01 to 0.75) at 1-and 3-months follow-up respectively. NRR improvements were observed, with effect sizes of 0.40 (95% CI: 0.02 to 0.78) and 0.49 (95% CI: 0.11 to 0.87) at 1- and 3-months respectively, but not statistically significant (P = .28). At 24-months, MP group had significantly better MRI outcome (Chen grading: mean change +1.15 vs +0.83; effect size: -0.71, 95% CI: -1.09 to -0.33; P = .038).Complication rates were comparable between both groups, emphasizing safety of MP administration.

CONCLUSION

Although null hypothesis was not proven, intraoperative MP administration in DCM surgery demonstrated safety and suggested potential neuroprotective benefits to enhance clinical recovery and reduce spinal cord signal changes. However, further large-scale, multicentric studies are needed to validate these findings and optimize its dose.

Enhancing fluid signal in driven-equilibrium short-TI inversion-recovery imaging with short TR times: A feasibility study

PURPOSE

Fluid-sensitive turbo spin echo (TSE) MRI with short-TI inversion-recovery preparation for fat suppression (STIR) plays a critical role in the diagnostics of the musculoskeletal system (e.g., close to metal implants). Potential advantages of 3D acquisitions, however, are difficult to exploit due to long acquisition times. Shortening the TR incurs a signal loss, and a driven-equilibrium (DE) extension reduces fluid signal even further.

METHODS

The phase of the flip-back pulse was changed by 180° relative to the conventional implementation (i.e., 90° along the positive x-axis (90°x) instead of -90°x). After signal modeling and numerical simulations, the modification was implemented in STIR-TSE sequences and tested on a clinical 3T system. Imaging was performed in the lumbar spine, and long-TR images without DE were acquired as reference. CSF SNR and fluid-muscle contrast were measured and compared between the sequences. Imaging was repeated in a metal implant phantom.

RESULTS

A shortening of TR by 43%-57% reduced the CSF SNR by 39%-59%. A conventional DE module further reduced SNR to 26%-40%, whereas the modified DE recovered SNR to 59%-108% compared with the long-TR acquisitions. Fluid-tissue contrast was increased by about 340% with the modified DE module compared with the conventional extension. Similar results were obtained in implant measurements.

CONCLUSIONS

The proposed DE element for TSE-STIR sequences has the potential to accelerate the acquisition of fluid-sensitive images. DE-STIR may work most efficiently for 3D acquisitions, in which no temporo-spatial interleaving of inversion and imaging pulses is possible.

A Study on Interobserver and Intraobserver Reliability of the Huashan Radiologic Classification System for Cervical Spinal Cord Injury Without Fracture and Dislocation

STUDY DESIGN

Observational study.

OBJECTIVE

To assess the reproducibility and reliability of the system.

BACKGROUND

The Huashan radiologic classification system for cervical spinal cord injury without fracture and dislocation (CSCIWFD) was recently proposed and found useful for clinical practice.

PATIENTS AND METHODS

Patients diagnosed with CSCIWFD between 2015 and 2021 were recruited. Six spine surgeons from different institutions, three experienced and other inexperienced respectively, were trained as observers of the system, and these surgeons classified the recruited patients using the system. Then, 8 weeks later, they repeated the classification on the same patients in a different order. The interobserver and intraobserver agreement between the results was analyzed using percentage agreement, weighted kappa, and Cohen kappa ( κ ) statistics.

RESULTS

A total of 60 patients were included in the analysis. Type I was the most frequent type (29 cases, 48.3%), followed by type II (13 cases, 21.7%), type III (12 cases, 20%), and type IV (6 cases, 10%). For all the observers, experienced observers, and inexperienced observers, the overall agreement percentages were 77.6% ( κ = 0.78), 84.4% ( κ = 0.84), and 72.8% ( κ = 0.74), respectively, indicating substantial to nearly perfect interobserver reproducibility. A higher level of agreement was found for differentiating type I from other types, with the percentage agreement ranging from 87.8% to 94.4% ( κ = 0.74-0.88). For distinguishing compression on the spinal cord (types I and II vs types III and IV) among the different groups of observers, the percentage agreement was 97.8% ( κ = 0.94), indicating nearly perfect reproducibility. As for intraobserver agreement, the percentage agreement ranged from 86.7% to 96.7% ( κ = 0.78-0.95), indicating at least substantial reliability.

CONCLUSIONS

The Huashan radiologic classification system for CSCIWFD was easy to learn and apply in a clinical environment, showing excellent reproducibility and reliability. Therefore, it would be promising to apply and promote this system for the precise evaluation and personalized treatment strategy.

Delayed Infection After Cervical Disc Arthroplasty: A Case Report and Review of the Literature

STUDY DESIGN

Case report and literature review.

OBJECTIVE

To report the relatively rare complication of delayed infection after cervical disc arthroplasty (CDA).

BACKGROUND

Delayed infection of the M6 device has been a rarely reported complication, with all cases described outside of the United States. The reliability of positive intraoperative cultures remains an ongoing debate.

METHODS

Cases were reviewed, and findings were summarized. A literature review was performed and discussed, with special consideration to current reports of delayed M6 infection, etiology, and utility of intraoperative cultures.

RESULTS

We present a case of delayed infection 6 years after primary 1-level CDA with the M6 device. At revision surgery, gross purulence was encountered. Intraoperative cultures finalized with Staphylococcus epidermidis and Cutibacterium acnes. The patient was revised with removal of the M6 and conversion to anterior cervical discectomy and fusion. A prolonged course of intravenous antibiotics was followed by an oral course for suppression. At the final follow-up, the patient's preoperative symptoms had resolved.

CONCLUSION

Delayed infection after CDA is a rare complication, with ongoing debate regarding the reliability of positive cultures. We describe an infected M6 and demonstrate the utility of implant removal, conversion to anterior cervical discectomy and fusion, and long-term antibiotics as definitive treatment.

LEVEL OF EVIDENCE

Level V-case report and literature review.

Feasibility of Using Intraoperative Neurophysiological Monitoring for Detecting Bone Layer of Cervical Spine Surgery

STUDY DESIGN

Intraoperative neurophysiological monitoring (IONM) as a guide to bone layer estimation was examined during posterior cervical spine lamina grinding.

OBJECTIVE

To explore the feasibility of IONM to estimate bone layer thickness.

SUMMARY OF BACKGROUND DATA

Cervical laminoplasty is a classic operation for cervical spondylosis. To increase safety and accuracy, surgery-assistant robots are currently being studied. It combines the advantages of various program awareness methods to form a feasible security strategy. In the field of spinal surgery, robots have been successfully used to help place pedicle screws. IONM is used to monitor intraoperative nerve conditions in spinal surgery. This study was designed to explore the feasibility of adding IONM to robot safety strategies.

METHODS

Chinese miniature pig model was used. Electrodes were placed on the lamina, and the minimum stimulation threshold of DNEP for each lamina was measured (Intact lamina, IL). The laminae were ground to measure the DNEP threshold after incomplete grinding (Inner cortical bone preserved, ICP) and complete grinding (Inner cortical bone grinded, ICG). Subsequently, the lateral cervical mass screw canal drilling was performed, and the t-EMG threshold of the intact and perforated screw canals was measured and compared.

RESULT

The threshold was significantly lower than that of the recommended threshold of DENP via percutaneous cervical laminae measurement. The DNEP threshold decreases with the process of laminae grinding. The DNEP threshold of the IL group was significantly higher than ICP and ICG group, while there was no significant difference between the ICP group and the ICG group. There was no significant relationship between the integrity of the cervical spine lateral mass screw path and t-EMG threshold.

CONCLUSIONS

It is feasible to use DENP threshold to estimate lamina thickness. Cervical lateral mass screw canals by t-EMG showed no help to evaluate the integrity.

Comparison of Cervical Pedicle Screw Placement Accuracy With Robotic Guidance System Versus Image Guidance System Using Propensity Score Matching

STUDY DESIGN

A retrospective study.

OBJECTIVE

To compare the accuracy of cervical pedicle screw (CPS) placement using a robotic guidance system (RGS) with that of using an image guidance system (IGS; navigation system) through propensity score matching.

BACKGROUND

The RGS may provide accurate CPS placement, which may outperform IGS. However, no study has directly compared the accuracy of CPS placement with the RGS to that with the IGS.

PATIENTS AND METHODS

We retrospectively reviewed the data of patients who had undergone cervical fusion surgery using CPS with the RGS or IGS. To adjust for potential confounders (patient demographic characteristics, disease etiology, and registration material), propensity score matching was performed, creating robotic guidance (RG) and matched image guidance (IG) groups. The accuracy of CPS placement from C2 to C6, where the vertebral artery runs, was evaluated on postoperative computed tomography images according to the Neo classification (grade 0 to grade 3). Furthermore, the intraoperative CPS revisions and related complications were examined.

RESULTS

Using propensity score matching, 22 patients were included in the RG and matched groups each, and a total of 95 and 105 CPSs, respectively, were included in the analysis. In both the axial and sagittal planes, the clinically acceptable rate (grades 0 + 1) of CPS placement did not differ between the RG and matched IG groups (97.9% vs 94.3% and 95.8% vs 96.2%, respectively). The incidence of CPS revision was similar between the groups (2.1% vs 2.9%), and no CPS-related complications were documented. Meanwhile, the incidence of lateral breach (grades 1 + 2 + 3) was significantly lower in the RG group than in the matched IG group (1.1% vs 7.7%, P = 0.037).

CONCLUSION

The RGS and IGS can equally aid in accurate and safe CPS placement in clinical settings. Nonetheless, RGS can further reduce the lateral breach, compared with IGS.

Cervical Degenerative Myelopathy is an Unexpected Risk Factor for Hip Fractures

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To assess the potential role of degenerative myelopathy as a risk factor for major fragility fractures in older patients.

BACKGROUND

Degenerative cervical myelopathy (DCM) stands as the foremost spinal disorder affecting adults, significantly impacting patients' quality of life. However, it is often underdiagnosed, with its prevalence traditionally considered low (0.06%-0.112%). Despite the rising prevalence of hip fractures with an aging population and the identification of numerous risk factors, DCM is not typically regarded as a primary risk factor for such fractures. In 2015, an American study revealed an unexpectedly high rate of 18% of undiagnosed DCM in patients with hip fractures within a small cohort. We sought to replicate this study in a larger cohort of a European population.

MATERIALS AND METHODS

Our cross-sectional study targeted patients older than 65 years with hip fractures and aimed to identify cases of DCM at the time of fracture. Exclusions were made for patients with preexisting DCM diagnoses, neurological disorders, prior cervical surgeries, and instances of high-energy trauma. Comprehensive demographic, clinical, and radiologic data were collected, followed by descriptive and statistical analysis.

RESULTS

In our study, 147 patients (mean age: 82.9 y) were included. Through a combination of clinical assessment and physical examination, 23 patients (15.6%) were identified as indicative of myelopathy. Confirmation through magnetic resonance imaging led to an estimated overall prevalence of DCM at 10.5%. Logistic regression analysis revealed that the presence of hypertonic reflexes, cervical pain, or cervicobrachialgia were specific and valuable indicators for diagnosing myelopathy.

CONCLUSION

This study marks the first investigation of its kind in a European population, highlighting the notably high prevalence of undiagnosed DCM among older patients who have experienced hip fractures. This underscores DCM as a potential risk factor for hip fractures in the elderly, despite its underdiagnosis and undertreatment.

LEVEL OF EVIDENCE

Level III.

Degenerative Cervical Myelopathy: History, Physical Examination, and Diagnosis

Background: Degenerative cervical myelopathy is a progressive neurological disorder that is commonly encountered in clinical practice and its incidence is expected to increase alongside the aging population. Given the importance of early and accurate diagnosis in this patient population, this narrative review aims to provide a repository of up-to-date information regarding pertinent patient history, physical exam findings, and potential alternate diagnoses. Methods: The PubMed database was queried for publications from 1 January 2019 to 19 March 2024. The search terms utilized are as follows: cervical myelopathy", "cervical spondylotic myelopathy", "degenerative cervical myelopathy", "epidemiology", "prevalence", "incidence", "etiology", "diagnosis", "differential", "symptoms", "clinical presentation", and "atypical symptoms". The resultant articles were reviewed for relevance and redundancy and are presented within the following categories: Natural History, Epidemiology, Clinical Presentation, Diagnosis, and Management. Results: Myelopathy patients often present with subtle and non-specific symptoms such as sleep disturbances, increased falls, and difficulty driving, which can lead to underdiagnosis and misdiagnosis. Failing to diagnose degenerative cervical myelopathy in a timely manner can result in progressive and irreparable neurological damage. Although many nonoperative treatment modalities are available, surgical decompression is ultimately recommended in most cases to limit further deterioration in neurological function and optimize long-term patient outcomes. Conclusions: A thorough clinical history and physical examination remain the most important diagnostic tools to avoid misdiagnosis and implement early treatment in this patient population.

Previous Surgical Exposure and the Onset of Degenerative Cervical Myelopathy: A Propensity-Matched Case-Control Analysis Nested Within the UK Biobank Cohort

STUDY DESIGN

Case-control study.

OBJECTIVES

Degenerative Cervical Myelopathy (DCM) is a progressive neurological condition caused by mechanical stress on the cervical spine. Surgical exposure in the preceding months to a DCM diagnosis is a common theme of Patient and Public Involvement (PPI) discussions. Such a relationship has biological plausibility (e.g. neck positioning, cord perfusion) but evidence to support this association is lacking.

METHODS

We analysed UK Hospital Episode Statistics (HES) data for participants in the UK BioBank cohort. We defined cases as those episodes with a primary diagnosis of DCM and generated controls using non-DCM HES episodes. Cases and controls were propensity score-matched by age, sex and date of episode, and a directed acyclic graph was used to robustly control for confounders. We defined the exposure as any surgical procedure under general or regional anaesthetic occurring within the 6-24 months prior to the episode.

RESULTS

We analysed 806 DCM and 2287432 non-DCM hospital episodes. On multivariable logistic regression analysis, the odds ratio (95% CI) for the effect of a binarised (0 vs ≥ 1) exposure on risk of developing DCM was 1.20 (1.02-1.41), and for categorised (0 vs 1 and 0 vs ≥ 2) exposure was 1.11 (0.882-1.39) & 1.33 (1.075-1.65).

CONCLUSIONS

This study supports the patient narrative of surgery as a risk factor for the development of DCM. The association displays temporality, dose-response relationship, and biological plausibility. Further work is needed to confirm this in other cohorts, explore mediating mechanisms, and identify those at greatest risk.

PLGA/BK microspheres targeting the bradykinin signaling pathway as a therapeutic strategy to delay intervertebral disc degeneration

Intervertebral disc degeneration(IVDD) is a common spinal condition with limited effective treatments available. This study aims to investigate the impact of poly(lactic-co-glycolic acid)/Bradykinin (PLGA/BK) microspheres on IVDD and its underlying mechanisms. We collected nucleus pulposus samples from both healthy and degenerated human intervertebral disks and conducted immunohistochemical analyses, revealing reduced BK expression in degenerated tissues. Subsequently, we used BK to treat nucleus pulposus cells and conducted Bulk RNA sequencing (RNA-seq), identifying BK's involvement in cellular senescence, extracellular matrix metabolism, and the PI3K signaling pathway. Further experiments using tert-butyl hydroperoxide (TBHP)-induced cell senescence showed that BK treatment reduced senescence, enhanced extracellular matrix synthesis, and inhibited degradation, along with activation of the PI3K pathway. These effects were mediated through B2R (BK receptor 2) and the downstream PI3K pathway. Following this, we developed sustained-release BK microspheres with an optimized manufacturing process. In vitro co-culture experiments showed no observable toxicity. We established an IVDD model in rat tail vertebrae through fine needle puncture, administering local injections of BK sustained-release microspheres. Using various experimental methods, including X-ray, MRI, histopathology, and immunohistochemistry, we found that these microspheres could slow the progression of IVDD. This study highlights the potential of injectable PLGA/BK microspheres to regulate cellular senescence and extracellular matrix metabolism via the B2R and PI3K pathways, ultimately delaying IVDD.

Treatment decision-making factors among patients with cervical myelopathy: a discrete-choice experiment

BACKGROUND

Degenerative Cervical Myelopathy is a debilitating condition and current recommendations encourage shared decision-making between surgeons and patients. However, there is limited data on patients' values and preferences for surgical decision making. This study aimed to quantify and compare the relative importance of neurologic function, risk of future surgery, and complications to patients with cervical stenosis.

METHODS

Patients with cervical stenosis presenting for surgical evaluation, or post-operative cervical decompression patients, were recruited to participate. Demographic information including modified Japanese Orthopedic Association (mJOA) score, type of surgery, and complications were recorded and anonymized to study ID. Patients then completed an online discrete-choice experiment survey. In a series of 10 questions, respondents chose between two hypothetical health states defined in terms of five attributes, or "decision factors": (i) upper extremity neurologic function, (ii) lower extremity neurologic function, (iii) risk of cervical spine surgery, (iv) dysphagia, and (v) C5 palsy. Participants were asked to choose which 'life' they preferred, and a regression model was used to quantify the importance of each decision factor.

RESULTS

We report three key findings that can aid clinicians in shared decision-making conversations: (i) all patients regard lower extremity neurologic function as the most important decision factor, (ii) dysphagia, a complication, and upper extremity neurologic function are equally important, and (iii) patients who have undergone surgery weigh neurologic function as less important, and complications as more important than patients who have not undergone surgery.

CONCLUSIONS

Patient preferences for management of degenerative cervical myelopathy are influenced by several considerations including the experience of surgery itself. Communication of benefits and harms associated with surgical and conservative care can optimize shared decision making. Further research should be conducted to evaluate for decisional regret and the impact of complications to inform treatment conversations.

Intra-epidermal electrically evoked potentials are sensitive to detect degenerative cervical myelopathy suggesting their spinothalamic propagation

OBJECTIVE

Degenerative cervical myelopathy (DCM) is a centromedullary spinal cord disorder mainly affecting crossing fibers. While contact heat evoked potentials (CHEPs) are sensitive in detecting DCM by testing spinothalamic integrity, somatosensory evoked potentials (dSSEPs) show unaffected dorsal column conduction. Intra-epidermal electrically evoked potentials (IEEPs) have unknown spinal propagation after noxious stimulation. We investigated (1) the spinothalamic tract propagation and (2) the discriminative power in detecting spinal pathology of IEEPs compared to CHEPs and dSSEPs in DCM.

METHODS

DCM was diagnosed by neurological examination regarding stenosis (MRI). Stimulation of C6, C8, and T4 dermatomes yielded dSSEPs, CHEPs, and IEEPs. (1) Spinal propagation was assessed through concordant or discordant responses, and (2) discriminative power was determined using receiver operating characteristic curves (ROC).

RESULTS

Twenty-seven patients (8F, 56 ± 12yrs) with DCM were analyzed and compared to age-matched healthy controls. IEEPs were abnormal in 43-54%, CHEPs in 37-69%, and dSSEPs in 4-12%. IEEPs showed high concordance with abnormalities of CHEPs (62-69%). ROC analyses showed good discriminative power of CHEPs and IEEPs contrary to dSSEPs.

CONCLUSIONS

The concordance of abnormal responses of CHEPs and IEEPs contrary to dSSEPs suggests spinothalamic propagation of IEEPs.

SIGNIFICANCE

Minimal differences between CHEPs and IEEPs suggest complementary potential by the combined testing of spinothalamic tract integrity.

Fusion Free Median Corpectomy - Long-Term Consequence of Foregoing Fusion and Fixation: A Serendipitous Observation

BACKGROUND

Anterior cervical corpectomy and fusion (ACCF) involves placement of a graft/implant to ensure fusion and stabilization along with neural decompression. We share our experience with a subset of ACCF patients in whom graft/implant could not be placed post decompression for varying reasons but had a favorable long-term outcome. The necessity for routine fusion after corpectomy is critically analyzed, and the feasibility of an alternative surgical option without graft/implant is discussed.

MATERIAL AND METHODS

A retrospective observational study of long-term outcomes of five patients with cervical compressive myelopathy who underwent neural decompression alone without an in situ graft/implant was done. All the patients underwent the modified cervical corpectomy technique, involving a smaller wedge size (12 × 15 mm) corpectomy. Pre- and postoperative clinical, radiological, electrophysiological, and operative findings were meticulously evaluated and analyzed.

RESULTS

This retrospective observational study reviewed records of 124 patients who underwent ACCF between 1998 and 2012. The surgical procedure involved a wedge median cervical corpectomy. In seven patients, graft/implant could not be placed or had to be removed for various reasons. Long-term follow-up was available for five of these patients who were included in the study. In two patients, the graft could not be placed intraoperatively due to hemodynamic complications. In one patient, the graft had to be removed due to postoperative infection, and in two patients, the graft had to be removed due to graft extrusion. Four patients showed marked improvement, and one patient showed minimal improvement on long-term follow-up in clinical, radiological, and electrophysiological parameters.

CONCLUSION

This small case series suggests that a modified cervical corpectomy technique, involving a smaller wedge size (12 × 15 mm), may be considered in selected cases without radicular symptoms. This approach helps to provide neural decompression without compromising stability and avoids graft-related complications. While promising, further research, including prospective randomized-controlled trials, is essential to validate the biomechanical properties and clinical outcomes of this modified technique compared to traditional ACCF.

Current Status and Trends of Research on Cervical Spondylotic Myelopathy from the Perspective of Bibliometrics

This review was performed to analyze the research on cervical spondylotic myelopathy published during the past 25 years, summarize the developments in existing research, and predict future hotspots in the field. The goal is to provide a comprehensive overview and exploration of developments in this research area. A bibliometric analysis was performed using CiteSpace and VOSviewer to quantitatively and visually analyze relevant literature from Web of Science between 1998 and 2023. Co-occurrence analysis and co-citation analysis were conducted to evaluate papers, authors, journals, countries, and keywords. In total, 1886 papers were included. The overall publication output in this field increased throughout the review period. Stable author collaboration groups were formed, with the most influential author being Fehlings M.G. Japan and the United States contributed the highest number of publications. The predicted future research hotspots include risk factor analysis, outcome prediction, and machine learning. This study provides both an overview of the research trajectory in the field of cervical spondylotic myelopathy for scholars interested in this area, as well as offering insights and references for future research directions in the field.