Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis

Clinical Improvements in Myelopathy Result in Improved Patient-Reported Outcomes Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine if myelopathy severity predicted the magnitude of improvement in health-related quality of life metrics following anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Surgery for myelopathy is primarily performed to halt disease progression. However, it is still controversial if these patients can expect significant health-related quality-of life improvements following ACDF. We explore the relationship between modified Japanese Orthopaedic Association (mJOA) improvements and its effect on other health-related quality-of life metrics.

MATERIALS AND METHODS

Patients undergoing ACDF for myelopathy were grouped based on preoperative mJOA scores into mild (15-17), moderate (12-14), and severe (<12) groups. Patients were subsequently categorized based on if they attained the minimum clinically detectable improvement (MCID) threshold for mJOA. Multivariate linear regression was performed to determine the magnitude of improvement in ∆patient-reported outcome measures.

RESULTS

A total of 374 patients were identified for inclusion. Of those, 169 (45.2%) had mild myelopathy, 125 (33.4%) had moderate, and 80 (21.4%) had severe myelopathy. Only the moderate and severe groups had significant improvements in mJOA following surgery (mild: P =0.073, moderate: P <0.001, severe: P <0.001). There were no significant differences in the magnitude of improvement for any patient-reported outcome measure based on myelopathy severity, except for mJOA (mild: 0.27, moderate: 1.88, severe: 3.91; P <0.001). Patients meeting the MCID for mJOA had better ∆Short-Form 12 Mental Component Score (3.29 vs. -0.21, P =0.007), ∆Short-Form 12 Physical Component Score (6.82 vs. 1.96, P <0.001), ∆Visual Analog Scale Neck (-3.11 vs. -2.17, P =0.001), ∆Visual Analog Scale Arm (-2.92 vs. -1.48, P <0.001), ∆Neck Disability Index (-18.35 vs. -7.86, P <0.001), and ∆mJOA (3.38 vs. -0.56, P <0.001) compared with patients who did not.

CONCLUSIONS

Worse baseline myelopathy severity predicts worse postoperative outcomes. However, baseline myelopathy severity is not predictive of the magnitude of postoperative improvement with the exception of mJOA. Patients who attain MCID improvement in mJOA had greater postoperative improvement for other health-related quality of life metrics.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Cervical Versus Shoulder Surgery

STUDY DESIGN

Retrospective analysis of outcomes in cervical spine and shoulder arthroscopy patients.

OBJECTIVE

The objective of this study is to assess differential improvements in health-related quality of life for cervical spine surgery compared with shoulder surgery.

SUMMARY OF BACKGROUND DATA

An understanding of outcome differences between different types of orthopedic surgeries is helpful in counseling patients about expected postoperative recovery. This study compares outcomes in patients undergoing cervical spine surgery with arthroscopic shoulder surgery using computer-adaptive Patient-reported Outcome Information System scores.

MATERIALS AND METHODS

Patients undergoing cervical spine surgery (1-level or 2-level anterior cervical discectomy and fusion, cervical disc replacement) or arthroscopic shoulder surgery (rotator cuff repair±biceps tenodesis) were grouped. Patient-reported Outcome Information System scores of physical function, pain interference, and pain intensity at baseline and at 3, 6, and 12 months were compared using paired t tests.

RESULTS

Cervical spine (n=127) and shoulder (n=91) groups were similar in sex (25.8% vs. 41.8% female, P =0.731) but differed in age (51.6±11.6 vs. 58.60±11.2, P <0.05), operative time (148.3±68.6 vs. 75.9±26.9 min, P <0.05), American Society of Anesthesiologists (ASAs) (2.3±0.6 vs. 2.0±0.5, P =0.001), smoking status (15.7% vs. 4.4%, P =0.008), and length of stay (1.1±1.0 vs. 0.3±0.1, P =0.000). Spine patients had worse physical function (36.9 ±12.6 vs. 49.4±8.6, P <0.05) and greater pain interference (67.0±13.6 vs. 61.7±4.8, P =0.001) at baseline. Significant improvements were seen in all domains by 3 months for both groups, except for physical function after shoulder surgery. Spine patients had greater physical function improvements at all timepoints (3.33 vs. -0.43, P =0.003; 4.81 vs. 0.08, P =0.001; 6.5 vs. -5.24, P =<0.05). Conversely, shoulder surgery patients showed better 6-month improvement in pain intensity over spine patients (-8.86 vs. -4.46, P =0.001), but this difference resolved by 12 months.

CONCLUSIONS

Cervical spine patients had greater relative early improvement in physical function compared with shoulder patients, whereas pain interference and intensity did not significantly differ between the 2 groups after surgery. This will help in counseling patients about relative difference in recovery and improvement between the 2 surgery types.

LEVEL OF EVIDENCE

III.

Return to work after surgery for degenerative cervical myelopathy: a nationwide registry-based observational study

BACKGROUND

Few studies of high quality exist on return to work (RTW) rate after surgery for degenerative cervical myelopathy (DCM). This study aims to examine the RTW rate in patients undergoing surgery for DCM.

METHODS

Nationwide prospectively collected data were obtained from the Norwegian Registry for Spine Surgery and the Norwegian Labour and Welfare Administration. The primary outcome was return to work, defined as being at work at a given time postoperatively without any medical income-compensation benefits. Secondary endpoints included the neck disability index (NDI) and quality of life measured by EuroQol-5D (EQ-5D).

RESULTS

Among 439 patients operated for DCM between 2012 and 2018, 20% of the patients received a medical income-compensation benefit one year before surgery. This number increased steadily towards the operation at which timepoint 100% received benefits. By 12 months after surgery, 65% had returned to work. By 36 months, 75% had returned to work. Patients that returned to work were more likely to be non-smokers and to have a college education. They had less comorbidity, more were without benefit 1-year pre-surgery, and significantly more patients were employed at operation date. Average days of sick leave in the year before surgery were significantly less in the RTW group, and they had a significantly lower baseline NDI and EQ-5D All PROMs reached statistical significance at 12 months, in favor of the group that achieved RTW.

CONCLUSION

At 12 months following surgery, 65% had returned to work. At the end of the 36-month follow-up period, 75% had returned to work, 5% less than the working percentage in the beginning of the follow-up period. This study demonstrates that a large percentage of patients return to work after surgical treatment for DCM.

Development of new postoperative neck pain at 12 and 24 months after surgery for cervical spondylotic myelopathy: a Quality Outcomes Database study

OBJECTIVE

Patients who undergo surgery for cervical spondylotic myelopathy (CSM) will occasionally develop postoperative neck pain that was not present preoperatively, yet the incidence of this phenomenon is unclear. The authors aimed to elucidate patient and surgical factors associated with new-onset sustained pain after CSM surgery.

METHODS

The authors reviewed data from the Quality Outcomes Database (QOD) CSM module. The presence of neck pain was defined using the neck pain numeric rating scale (NRS). Patients with no neck pain at baseline (neck NRS score ≤ 1) were then stratified based on the presence of new postoperative pain development (neck NRS score ≥ 2) at 12 and 24 months postoperatively.

RESULTS

Of 1141 patients in the CSM QOD, 224 (19.6%) reported no neck pain at baseline. Among 170 patients with no baseline neck pain and available 12-month follow-up, 46 (27.1%) reported new postoperative pain. Among 184 patients with no baseline neck pain and available 24-month follow-up, 53 (28.8%) reported new postoperative pain. The mean differences in neck NRS scores were 4.3 for those with new postoperative pain compared with those without at 12 months (4.4 ± 2.2 vs 0.1 ± 0.3, p < 0.001) and 3.9 at 24 months (4.1 ± 2.4 vs 0.2 ± 0.4, p < 0.001). The majority of patients reporting new-onset neck pain reported being satisfied with surgery, but their satisfaction was significantly lower compared with patients without pain at the 12-month (66.7% vs 94.3%, p < 0.001) and 24-month (65.4% vs 90.8%, p < 0.001) follow-ups. The baseline Neck Disability Index (NDI) was an independent predictor of new postoperative neck pain at both the 12-month and 24-month time points (adjusted OR [aOR] 1.04, 95% CI 1.01-1.06; p = 0.002; and aOR 1.03, 95% CI 1.01-1.05; p = 0.026, respectively). The total number of levels treated was associated with new-onset neck pain at 12 months (aOR 1.34, 95% CI 1.09-1.64; p = 0.005), and duration of symptoms more than 3 months was a predictor of 24-month neck pain (aOR 3.22, 95% CI 1.01-10.22; p = 0.048).

CONCLUSIONS

Increased NDI at baseline, number of levels treated surgically, and duration of symptoms longer than 3 months preoperatively correlate positively with the risk of new-onset neck pain following CSM surgery. The majority of patients with new-onset neck pain still report satisfaction from surgery, suggesting that the risk of new-onset neck pain should not hinder indicated operations from being performed.

Prognostic and risk factors for the surgical efficacy of central spinal cord syndrome in patients with preexisting degenerative cervical spinal cord compression

OBJECTIVES

To analyze the prognostic and risk factors related to surgical treatment of central spinal cord syndrome (CSS) and to find out the optimal timing of operative management.

METHODS

From January 2011 to January 2019, a consecutive series of 128 patients with CSS confirmed by magnetic resonance imaging (MRI) were retrospectively analyzed including their clinical records and radiologic data from a prospectively maintained database in a single center.

RESULTS

According to the prognosis evaluated by the modified Japanese Orthopedic Association (mJOA), American Spinal Injury Association (ASIA) motor score (AMS), and ASIA impairment scale (AIS) grade, the overall postoperative outcome was good. Finally, it was found that surgical timing, presence of myelopathy or not at baseline, AMS at admission, and compression ratio were independent factors affecting the prognosis. Surgery as soon as possible after the occurrence of CSS is still advocated.

CONCLUSION

Cervical myelopathy at baseline, compression ratio, and AMS score on admission were independent prognostic factors for the surgical treatment of CSS. If surgical indications are clear, early surgical intervention should be actively considered.

The Role of Magnetic Transcranial Stimulation in the Diagnosis and Post-Surgical Follow-Up of Cervical Spondylotic Myelopathy

Degenerative cervical myelopathy (DCM) consists of spinal cord damage due to its compression through the cervical spine. The leading cause is degenerative. The diagnosis is clinical, and the therapeutic approach is usually surgical. Confirmation of the diagnostic suspicion is done by magnetic resonance imaging (MRI); however, this test lacks functional information of the spinal cord, the abnormality of which may precede involvement in neuroimaging. Neurophysiological examination using somatosensory evoked potentials (SSEPs) and transcranial magnetic stimulation (TMS) allows for an evaluation of spinal cord function, and provides information in the diagnostic process. Its role in the post-surgical follow-up of patients undergoing decompressive surgery is being studied. We present a retrospective study of 24 patients with DCM and surgical decompression who underwent neurophysiological tests (TMS and SSEP) before, 6, and 12 months after surgery. The result of the TMS and the SSEP in the post-operative follow-up did not correlate with the clinical outcome, either subjective or measured by clinical scales at six months. We only found post-surgical improvement of central conduction times (CMCTs) in patients with severe pre-surgical motor impairment on TMS. In patients with normal pre-surgical CMCT, we found a transient worsening with return to baseline at the one-year follow-up. Most patients presented pre-surgical increased P40 latency at diagnosis. CMCT and SSEP were more related to clinical outcomes one year after the surgical procedure and were very useful in diagnosing.

Comparison of posterior muscle-preserving selective laminectomy and laminectomy with fusion for treating cervical spondylotic myelopathy: study protocol for a randomized controlled trial

BACKGROUND

Cervical spondylotic myelopathy (CSM) is the predominant cause of spinal cord dysfunction in the elderly. The patients are often frail and susceptible to complications. Posterior surgical techniques involving non-fusion are complicated by postlaminectomy kyphosis and instrumented fusion techniques by distal junction kyphosis, pseudarthrosis, or implant failure. The optimal surgical approach is still a matter of controversy. Since anterior and posterior fusion techniques have been compared without presenting any superiority, the objective of this study is to compare stand-alone laminectomy with laminectomy and fusion to determine which treatment has the lowest frequency of reoperations.

METHODS

This is a multicenter randomized, controlled, parallel-group non-inferiority trial. A total of 300 adult patients are allocated in a ratio of 1:1. The primary endpoint is reoperation for any reason at 5 years of follow-up. Sample size and power calculation were performed by estimating the reoperation rate after laminectomy to 3.5% and after laminectomy with fusion to 7.4% based on the data from the Swedish spine registry (Swespine) on patients with CSM. Secondary outcomes are the patient-derived Japanese Orthopaedic Association (P-mJOA) score, Neck Disability Index (NDI), European Quality of Life Five Dimensions (EQ-5D), Numeric Rating Scale (NRS) for neck and arm pain, Hospital Anxiety and Depression Scale (HADS), development of kyphosis measured as the cervical sagittal vertical axis (cSVA), and death. Clinical and radiological follow-up is performed at 3, 12, 24, and 60 months after surgery. The main inclusion criterium is 1-4 levels of CSM in the subaxial spine, C3-C7. The REDcap software will be used for safe data management. Data will be analyzed according to the modified intention to treat (mITT) population, defined as randomized patients who are still alive without having emigrated or left the study after 2 and 5 years.

DISCUSSION

This will be the first randomized controlled trial comparing two of the most common surgical treatments for CSM: the posterior muscle-preserving selective laminectomy and posterior laminectomy with instrumented fusion. The results of the myelopathy randomized controlled (MyRanC) study will provide surgical treatment recommendations for CSM. This may result in improvements in surgical treatment and clinical practice regarding CSM.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04936074 . Registered on 23 June 2021.

Correlation between "Snake-Eyes" Sign and Role of Surgery with a Focus on Postoperative Outcome: A Systematic Review

(1) Background: The "snake-eyes" sign represents a unique finding characterized by bilateral hyperintense symmetric, circular, or ovoid foci on T2-weighted MRI sequences in the anterior horn cells of the spinal cord. There are conflicting opinions as some authors affirm that it does not affect the prognosis of cervical myelopathy while other papers emphasize the opposite, stating how the "snake-eyes" sign constitutes an irreversible lesion and a predictor of poor prognosis. This systematic review evaluates the correlation between the "snake-eyes" sign and the prognosis of cervical myelopathy after surgery including anterior and/or posterior approaches; (2) Methods: A systematic literature review was conducted following the PRISMA statement and a total of seven papers were included; (3) Results: A total of 419 patients were evaluated, with a mean age of 55.72 ± 14.38 years. After surgery, 26.01% of patients experienced a significant clinical improvement, while in 61.81%, there was no significant improvement. In particular, 144 of 196 patients (73.5%) treated through an anterior approach and 114 of 223 (51.1%) that underwent a posterior approach, did not present a significant improvement. Furthermore, in 12.17% of patients, the postoperative outcome was not reported, leading to a high risk of bias in the assessment of the prognostic significance of the "snake-eyes" appearance; (4) Conclusions: The "snake-eyes" sign is usually considered as an unfavorable predictive marker for myelopathic surgical patients, but the pathophysiology is still unclear, and the results have not yet reached unified levels of evidence.

Determinants of quality of life in degenerative cervical myelopathy: a systematic review

BACKGROUND

Degenerative cervical myelopathy (DCM) is the most common cause of chronic, progressive spinal cord impairment worldwide. Patients experience substantial pain, functional neurological decline and disability. Health-related quality of life (HRQoL) appears to be particularly poor, even when compared to other chronic diseases. However, the determinants of HRQoL are poorly understood. The objective was to perform a systematic review of the determinants of quality of life of people with DCM.

METHODS

A systematic search was conducted in MEDLINE and Embase following PRISMA 2020 guidelines (PROSPERO CRD42018115675). Full-text papers in English, exclusively studying DCM, published before 26 March 2020 were eligible for inclusion and were assessed using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias 2 (RoB 2) tool. Study sample characteristics, patient demographics, cohort type, HRQoL instrument utilised, HRQoL score, and relationships of HRQoL with other variables were qualitatively synthesised.

RESULTS

A total of 1176 papers were identified; 77 papers and 13,572 patients were included in the final analysis. A total of 96% of papers studied surgical cohorts and 86% utilised the 36-Item Short Form Survey (SF-36) as a measure of HRQoL. HRQoL determinants were grouped into nine themes. The most common determinant to be assessed was surgical technique (38/77, 49%) and patient satisfaction and experience of pain (10/77, 13%). HRQoL appeared to improve after surgery. Pain was a negative predictor of HRQoL.

CONCLUSION

Current data on the determinants of HRQoL in DCM are limited, contradictory and heterogeneous. Limitations of this systematic review include lack of distinction between DCM subtypes and heterogenous findings amongst the papers in which HRQoL is measured postoperatively or post-diagnosis. This highlights the need for greater standardisation in DCM research to allow further synthesis. Studies of greater precision are necessary to account for HRQoL being complex, multi-factorial and both time and context dependent.

Myelopathy disability index: establishing criteria for mild, moderate and severe impairment in patients with degenerative cervical myelopathy

PURPOSE

To find the cut-off values in the Myelopathy Disability Index (MDI) that will allow us to classify the severity of Degenerative Cervical Myelopathy (DCM) into mild, moderate and severe.

METHODS

Cross-sectional study with prospective data collection, with a total of 64 patients diagnosed with Degenerative Cervical Myelopathy (DCM). Anthropometric, diagnostic, neurological, functional and quality of life variables were collected. A Receiver Operating Curve (ROC) was performed. The cut-off points were validated by comparing the functional status of patients in the 3 groups and their Nurick scores.

RESULTS

Sixty-four patients (23 women) with a mean age of 61.97 (SD 11.57) participated in this study. The majority of patients were Nurick I (28.13%) and Nurick II (32.81%). The medium MDI was 7.36 (SD 6.66) and the mJOA was 14.08 (SD 2.57). The mild-moderate cut-off value was between 4 and 5, with an Area Under the Curve (AUC) of 0.805, sensitivity of 0.853 and specificity of 0.6. For moderate-severe, the cut-off value obtained was between 7 and 8, with an AUC of 0.862, sensitivity of 0.857 and specificity of 0.684. Patients with greater severity had significantly lower functionality, with a P-value of 0.004 in the 30 Metre Walking Test and 0.005 in the Nine-Hole Peg Test. Established severity groups were also significantly related to the different categories of the Nurick score (P-value = 0.000).

CONCLUSION

MDI values between 0 and 4 correspond to mild DCM, between 5 and 7 would be moderate DCM and from 8 to 30 indicate severe DCM.

Technical Aspects of Intra-Operative Ultrasound for Spinal Cord Injury and Myelopathy: A Practical Review

OBJECTIVES

To compile intra-operative techniques, established imaging parameters, available equipment and software, and clinical applications of intraoperative ultrasound imaging (IOUSI) for spinal cord injury (SCI) and myelopathy.

METHODS

PubMed and Google Scholar were searched for relevant articles. The articles were reviewed and selected by 2 independent researchers. After article selection, data were extracted and summarized into research domains. PRISMA systematic review process was followed.

RESULTS

Of the 2477 articles screened, 16 articles met the inclusion criteria. In patients with SCI and myelopathy, common quantitative measurements obtained using IOUSI were noted: 1) ultrasound elastography, 2) midsagittal anteroposterior diameter, 3) transverse, 4) transverse diameter, 5) maximum spinal cord compression, and 6) compression ratioTo ensure adequate decompression and to look for residual compression, the lateral and the craniocaudal margins of the laminectomy site were inspected in both axial and sagittal planes. In instances where quantitative assessment was not possible, cord decompression and degree of residual compression were gauged by inspecting the interface between the ventral border of the spinal cord and any potentially compressive elements, and by searching for symmetric and rhythmic cerebrospinal fluid pulsations. Use of contrast-enhanced ultrasoundand molecular imaging are additional advances in objective assessments for SCI and myelopathy.

CONCLUSIONS

This review outlines the potential of IOUSI in patients presenting with SCI and myelopathy. Moreover, by identifying potential for inter-operator variability in certain subjective measurements, we illustrate the need for further research to quantify and standardize those assessments.

Timing of Recovery After Surgery for Patients With Degenerative Cervical Myelopathy: An Observational Study From the Canadian Spine Outcomes and Research Network

BACKGROUND

The time course over which postoperative neurological recovery occurs after surgery for degenerative cervical myelopathy occurs is poorly understood.

OBJECTIVE

To determine the time point at which patients experience significant neurological improvement.

METHODS

We reviewed data from an ongoing prospective multicenter cohort study. We measured neurological function at 3 months, 1 year, and 2 years after surgery using the modified Japanese Orthopedic Association (mJOA) scale. We implemented minimal clinical important differences (MCIDs) to guide interpretation of mJOA scores, and we used 1-way analysis of variance to compare changes between follow-up intervals.

RESULTS

Among 330 patients, the mean overall mJOA improved from 12.9 (SD 2.6) to 14.6 (SD 2.4) at 3 months, 14.7 (SD 2.4) at 1 year, and 14.8 (SD 2.5) at 2 years. The difference in means was statistically significant (P < .01) at the interval from baseline to 3 months postoperatively, but not from 3 months to 1 year or 1 year to 2 years. The MCID was reached by 161 patients at 3 months, 32 more at 1 year, and 15 more at 2 years, with a statistically significant difference only at 3 months. Patients with moderate or severe disease reached the MCID more frequently than those with mild disease.

CONCLUSION

Among patients who underwent surgery for degenerative cervical myelopathy, most significant neurological improvement occurred by 3 months after surgery. These findings will facilitate valid discussions about postoperative expectations during shared clinical decision making between patients and their surgeons.

Successful treatment of thoracic myelopathy caused by spontaneous spinal epidural hematoma (SSEH) combined with calcification of the ligamentum flavum (CLF) by posterior percutaneous endoscopic surgery (PPES): A case report

Study Design

A retrospective case report.

Objective

To report a case who developed deteriorated paraplegia by spontaneous spinal epidural hematoma (SSEH) based on calcification of the ligamentum flavum (CLF) at the T10-11 level, achieved full neurological recovery following posterior percutaneous endoscopic surgery (PPES).

Summary of Background Data

CLF rarely occurs at the thoracic spine, and the symptom usually progress slowly. SSEH is another rare spinal lesion that might progress rapidly and cause emergent severe spinal cord compression syndrome. Coexistence of SSEH and CLF at the same thoracic level was rarely reported in English literature.

Methods

A 65-year-old man presented to our hospital with the complaint of sensorimotor loss on the lower limbs and dysfunction of bladder for 1 day after a progressive weakness and numbness of the lower limbs for 3 months. MR examination found a dorsal protruding mass at the T10-11 level, while computed tomography (CT) found the protruding mass contained scattered calcified deposits. The patient was diagnosed with thoracic CLF. Decompression via PPES was carried out to realize bilateral decompression through a unilateral approach.

Results

During the operation, the protruding mass was found to be composed of SSEH and CLF together. After the operation, the patient's neurological function recovered quickly. One week later, the patient could walk by himself. After 3 months, complete neurological function had recovered.

Conclusion

SSEH could develop based on CLF at thoracic level and cause serious neurological dysfunction. PPES might be an advisable method to remove CLF and evacuate SSEH with good clinical results.

Comparing Combined Anterior and Posterior to Posterior-Only Decompression and Fusion Crossing the Cervico-Thoracic Junction in Octogenarians

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purpose of the study was to compare early complication, morbidity and mortality risks associated with fusion surgery crossing the cervico-thoracic junction in patients aged over 80 years undergoing combined anterior and posterior approach versus a posterior-only approach.

METHODS

We retrospectively identified octogenarian patients with myelopathy who underwent fusion crossing the cervico-thoracic junction. Patient demographics, Nurick score, surgical characteristics, complications, hospital course, early outcome and 90-day mortality were collected. Comorbidities were classified using the age-adjusted Charlson Comorbidity Index (AACCI). Radiographic measurements for deformity correction included the C2-C7 sagittal Cobb angle, C2-7 sagittal vertical axis and T1 slope pre- and postoperatively.

RESULTS

Out of 8,521 surgically treated patients, 12 octogenarian patients had a combined anterior and posterior approach (AP group) and 14 were treated from posterior-only (P group). Mean age was 81.4 ± 1.2 and 82.5 ± 2.7 years, respectively. There was no significant difference in Nurick scores between the groups (P > 0.05). The major complication risk in the AP group was significantly higher, requiring PEG tube placement due to severe dysphagia in 4 patients (33%) compared to none in the P group. A greater improvement in cervical lordosis could be achieved through a combined approach. The 90-day mortality risk was 8% for the AP group and 0% for the P group.

CONCLUSIONS

A combined anterior and posterior approach is associated with a significantly higher major complication rate and can result in severe dysphagia requiring PEG tube placement in one-third of patients over 80 years of age.

Cervical spondylotic myelopathy with severe axial neck pain: is anterior or posterior approach better?

OBJECTIVE

The aim of this study was to determine whether multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical laminectomy and fusion (PCLF) is superior for patients with cervical spondylotic myelopathy (CSM) and high preoperative neck pain.

METHODS

This was a retrospective study of prospectively collected data using the Quality Outcomes Database (QOD) CSM module. Patients who received a subaxial fusion of 3 or 4 segments and had a visual analog scale (VAS) neck pain score of 7 or greater at baseline were included. The 3-, 12-, and 24-month outcomes were compared for patients undergoing ACDF with those undergoing PCLF.

RESULTS

Overall, 1141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score > 6). After applying inclusion and exclusion criteria, we compared 65 patients (54.6%) undergoing 3- and 4-level ACDF and 54 patients (45.4%) undergoing 3- and 4-level PCLF. Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs 45.9 ± 16.8, p = 0.03) but similar neck pain (p > 0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively). At the 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p < 0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p > 0.05). However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (β = 1.5 [95% CI 0.5-2.6], adjusted p = 0.01), higher EQ-5D score (β = 0.1 [95% CI 0.01-0.2], adjusted p = 0.04), and higher likelihood for return to baseline activities (OR 1.2 [95% CI 1.1-1.4], adjusted p = 0.002).

CONCLUSIONS

Severe neck pain is prevalent among patients undergoing surgery for CSM, affecting more than 40% of patients. Both ACDF and PCLF achieved comparable postoperative neck pain improvement 3, 12, and 24 months following 3- or 4-segment surgery for patients with CSM and severe neck pain. However, multilevel ACDF was associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.

Influence of clinical and radiological parameters on the likelihood of neurological improvement after surgery for degenerative cervical myelopathy

OBJECTIVE

Degenerative cervical myelopathy (DCM) is routinely treated with surgical decompression, but disparate postoperative outcomes are frequently observed, ranging from complete neurological recovery to persistent decline. Although numerous clinical and radiological factors have been independently associated with failure to improve, the relative impact of these proposed risk factors remains obscure. In this study, the authors assess the combined role of clinical and radiographic parameters in contributing to failure to attain neurological improvement after surgery.

METHODS

A consecutive series of patients who underwent surgery for DCM between July 2013 and August 2018 at a single institution was identified from a prospectively maintained database. Retrospective chart review was undertaken to record perioperative clinical and radiographic parameters. Failure to improve on the last follow-up evaluation after surgery, defined as a change in modified Japanese Orthopaedic Association (mJOA) score less than 2, was the primary outcome in univariate and multivariate analyses.

RESULTS

The authors included 183 patients in the final cohort. In total, 109 (59.6%) patients improved (i.e., responders with ΔmJOA score ≥ 2) after surgery and 74 (40.4%) were nonresponders with ΔmJOA score < 2. Baseline demographic variables and comorbidity rates were similar, whereas baseline Nurick score was the only clinical variable that differed between responders and nonresponders (2.7 vs 3.0, p = 0.02). In contrast, several preoperative radiographic variables differed between the groups, including presence and degree of cervical kyphosis, number of levels with bidirectional cord compression, presence and number of levels with T2-weighted signal change, intramedullary lesion (IML) length, Torg ratio, and both narrowest spinal canal and cord diameter. On multivariate analysis, preoperative degree of kyphosis at C2-7 (OR 1.19, p = 0.004), number of levels with bidirectional compression (OR 1.83, p = 0.003), and IML length (OR 1.14, p < 0.001) demonstrated the highest predictive power for nonresponse (area under the receiver operating characteristic curve 0.818). A risk factor point system that predicted failure of improvement was derived by incorporating these 3 variables.

CONCLUSIONS

When a large spectrum of both clinical and radiographic variables is considered, the degree of cervical kyphosis, number of levels with bidirectional compression, and IML length are the most predictive of nonresponse after surgery for DCM. Assessment of these radiographic factors can help guide surgical decision-making and more appropriately stratify patients in clinical trials.

Screening for degenerative cervical myelopathy with the 10-second grip-and-release test using a smartphone and machine learning: A pilot study

Objective

Early detection and intervention are essential for the mitigation of degenerative cervical myelopathy (DCM). However, although several screening methods exist, they are difficult to understand for community-dwelling people, and the equipment required to set up the test environment is expensive. This study investigated the viability of a DCM-screening method based on the 10-second grip-and-release test using a machine learning algorithm and a smartphone equipped with a camera to facilitate a simple screening system.

Methods

Twenty-two participants comprising a group of DCM patients and 17 comprising a control group participated in this study. A spine surgeon diagnosed the presence of DCM. Patients performing the 10-second grip-and-release test were filmed, and the videos were analyzed. The probability of the presence of DCM was estimated using a support vector machine algorithm, and sensitivity, specificity, and area under the curve (AUC) were calculated. Two assessments of the correlation between estimated scores were conducted. The first used a random forest regression model and the Japanese Orthopaedic Association scores for cervical myelopathy (C-JOA). The second assessment used a different model, random forest regression, and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

The final classification model had a sensitivity of 90.9%, specificity of 88.2%, and AUC of 0.93. The correlations between each estimated score and the C-JOA and DASH scores were 0.79 and 0.67, respectively.

Conclusions

The proposed model could be a helpful screening tool for DCM as it showed excellent performance and high usability for community-dwelling people and non-spine surgeons.

Magnetic resonance image segmentation of the compressed spinal cord in patients with degenerative cervical myelopathy using convolutional neural networks

PURPOSE

Spinal cord segmentation is the first step in atlas-based spinal cord image analysis, but segmentation of compressed spinal cords from patients with degenerative cervical myelopathy is challenging. We applied convolutional neural network models to segment the spinal cord from T2-weighted axial magnetic resonance images of DCM patients. Furthermore, we assessed the correlation between the cross-sectional area segmented by this network and the neurological symptoms of the patients.

METHODS

The CNN architecture was built using U-Net and DeepLabv3 + and PyTorch. The CNN was trained on 2762 axial slices from 174 patients, and an additional 517 axial slices from 33 patients were held out for validation and 777 axial slices from 46 patients for testing. The performance of the CNN was evaluated on a test dataset with Dice coefficients as the outcome measure. The ratio of CSA at the maximum compression level to CSA at the C2 level, as segmented by the CNN, was calculated. The correlation between the spinal cord CSA ratio and the Japanese Orthopaedic Association score in DCM patients from the test dataset was investigated using Spearman's rank correlation coefficient.

RESULTS

The best Dice coefficient was achieved when U-Net was used as the architecture and EfficientNet-b7 as the model for transfer learning. Spearman's r_s between the spinal cord CSA ratio and the JOA score of DCM patients was 0.38 (p = 0.007), showing a weak correlation.

CONCLUSION

Using deep learning with magnetic resonance images of deformed spinal cords as training data, we were able to segment compressed spinal cords of DCM patients with a high concordance with expert manual segmentation. In addition, the spinal cord CSA ratio was weakly, but significantly, correlated with neurological symptoms. Our study demonstrated the first steps needed to implement automated atlas-based analysis of DCM patients.

Utility of Diffusion Basis Spectrum Imaging in Quantifying Baseline Disease Severity and Prognosis of Cervical Spondylotic Myelopathy

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim was to assess the association between diffusion tensor imaging (DTI) and diffusion basis spectrum imaging (DBSI) measures and cervical spondylotic myelopathy (CSM) clinical assessments at baseline and two-year follow-up.

SUMMARY OF BACKGROUND DATA

Despite advancements in diffusion-weighted imaging, few studies have examined associations between diffusion magnetic resonance imaging (MRI) markers and CSM-specific clinical domains at baseline and long-term follow-up.

MATERIALS AND METHODS

A single-center prospective cohort study enrolled 50 CSM patients who underwent surgical decompression and 20 controls from 2018 to 2020. At initial evaluation, all patients underwent diffusion-weighted MRI acquisition, followed by DTI and DBSI analyses. Diffusion-weighted MRI metrics assessed white matter integrity by fractional anisotropy, axial diffusivity, radial diffusivity, and fiber fraction. To improve estimations of intra-axonal anisotropic diffusion, DBSI measures intra-/extra-axonal fraction and intra-axonal axial diffusivity. DBSI also evaluates extra-axonal isotropic diffusion by restricted and nonrestricted fraction. Clinical assessments were performed at baseline and two-year follow-up and included the modified Japanese Orthopedic Association (mJOA); 36-Item Short Form Survey physical component summary (SF-36 PCS); SF-36 mental component summary; neck disability index; myelopathy disability index; and disability of the arm, shoulder, and hand. Pearson correlation coefficients were computed to compare associations between DTI/DBSI and clinical measures. A False Discovery Rate correction was applied for multiple comparisons testing.

RESULTS

At baseline presentation, of 36 correlations analyzed between DTI metrics and CSM clinical measures, only DTI fractional anisotropy showed a positive correlation with SF-36 PCS ( r =0.36, P =0.02). In comparison, there were 30/81 (37%) significant correlations among DBSI and clinical measures. Increased DBSI axial diffusivity, intra-axonal axial diffusivity, intra-axonal fraction, restricted fraction, and extra-axonal anisotropic fraction were associated with worse clinical presentation (decreased mJOA; SF-36 PCS/mental component summary; and increased neck disability index; myelopathy disability index; disability of the arm, shoulder, and hand). At latest follow-up, increased preoperative DBSI intra-axonal axial diffusivity and extra-axonal anisotropic fraction were significantly correlated with improved mJOA.

CONCLUSIONS

This findings demonstrate that DBSI measures may reflect baseline disease burden and long-term prognosis of CSM as compared with DTI. With further validation, DBSI may serve as a noninvasive biomarker following decompressive surgery.

LEVEL OF EVIDENCE

3.

New Imaging Modalities for Degenerative Cervical Myelopathy

INTRODUCTION

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

METHODS

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

RESULTS AND DISCUSSION

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

The Natural History of Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is the most frequent cause of spinal cord dysfunction and injury in the adult population and leads to significant loss of quality of life and economic impact from its associated medical care expenditures and loss of work. Surgical intervention is recommended for patients manifesting progressing neurological signs and symptoms of myelopathy, but the optimal management in individuals who have mild and clinically stable disease manifestations is controversial. Understanding the natural history of DCM is, thus, important in assessing patients and identifying those most appropriately indicated for surgical management. Despite the attempts to rigorously perform studies of the natural history of these patients, most published investigations suffer from methodological weaknesses or are underpowered to provide definitive answers. Investigations of particular patient subsets, however, provide some clinical guidance as to which patients stand most to benefit from surgery, and these may include those with lower baseline mJOA scores, evidence of segmental hypermobility, cord signal changes on MRI, abnormal somatosensory or motor-evoked potentials, or the presence of certain inflammatory markers. Clinicians should assess patients with mild myelopathy and those harboring asymptomatic cervical spinal cord compression individually when making treatment decisions and an understanding of the various factors that may influence natural history may aid in identifying those best indicated for surgery. Further investigations will likely identify how variables that affect natural history can be used in devising more precise treatment algorithms.

Review of Prospective Trials for Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults. DCM refers to a collection of degenerative conditions that cause the narrowing of the cervical canal resulting in neurological dysfunction. A lack of high-quality studies and a recent increase in public health awareness has led to numerous prospective studies evaluating DCM. Studies evaluating the efficacy of surgical intervention for DCM can be characterized by the presence (comparative) or absence (noncomparative) of a nonoperative control group. Noncomparative studies predominate due to concerns regarding treatment equipoise. Comparative studies have been limited by methodological issues and have not produced consistent findings. More recent noncomparative studies have established the safety and efficacy of surgical intervention for DCM, including mild myelopathy. The optimal surgical intervention for DCM remains controversial. A recent randomized clinical trial comparing dorsal and ventral techniques found similar improvements in patient-reported physical function at early follow-up. Recent prospective studies have enriched our understanding of DCM and helped guide current treatment recommendations.

Degenerative cervical myelopathy education in UK medical schools: a national cross-sectional survey of medical students

INTRODUCTION

Degenerative cervical myelopathy (DCM) is a common and progressive neurological condition caused by injury of the cervical spinal cord by degenerative spinal pathology. Delayed diagnosis leading to avoidable and irreversible disability is a major current problem limiting patient outcomes. Lack of sufficient representation of DCM in undergraduate and postgraduate medical curricula may contribute to poor recognition of DCM by non-specialist doctors. The objective of this study was to assess the DCM teaching provision in UK medical schools and the DCM knowledge of UK medical students.

METHODS

UK medical students completed a web-based survey distributed nationally through university social media pages, university email bulletins and the national student network of Myelopathy.org. The survey comprised a 19-item questionnaire capturing data on student demographics, myelopathy teaching and myelopathy knowledge. Advertisements were repeated monthly over a 12-month recruitment period and participation was incentivised by entry into an Amazon voucher prize draw. Ethical approval for the study was granted by the Psychology Research Ethics Committee, University of Cambridge (PRE.2018.099).

RESULTS

A total of 751 medical students from 32 British medical schools completed the survey. Medical students from all year groups participated. Most students (520; 72%) had not received any medical school teaching about DCM. When students had received DCM teaching, the duration of teaching was minimal (75% < 1 h). A total of 350 students (47%) reported conducting private study on DCM. Modal student self-rating of their own knowledge of DCM was 'terrible' (356; 47%). There was no correlation between a student's subjective rating of their knowledge and their answers to objective questions. A total of 723 (96%) of students expressed interest in learning more about DCM, with lectures the preferred format.

CONCLUSIONS

DCM appears to be a neglected condition in medical education which has implications for clinical practice. However, student enthusiasm to undertake private study suggests future teaching interventions will be well-received. Future work is necessary to characterise the format of DCM teaching that is most effective and to subsequently measure how educational interventions translate into clinical benefits.

Zero-profile implant versus conventional cage-plate construct in anterior cervical discectomy and fusion for the treatment of single-level degenerative cervical spondylosis: a systematic review and meta-analysis

BACKGROUND

The clinical outcomes of single-level anterior cervical discectomy and fusion (ACDF) with the Zero-profile (Zero-p) were evaluated in comparison with the anterior cervical cage-plate construct (CPC).

METHODS

We performed a systematic search covering PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Medline, China National Knowledge Infrastructure (NCKI), Wan Fang Database, and Wei Pu Database. Articles focused on single-level ACDF or data of the single - level that can be extracted were included, and articles that did not directly compare Zero-p and CPC were excluded. Twenty-seven studies were included with a total of 1866 patients, 931 in the Zero-p group and 935 in the CPC group. All outcomes were analyzed using Review Manager 5.4.

RESULTS

The meta-analysis outcomes indicated that operative time (WMD = - 12.47, 95% CI (- 16.89, - 8.05), P < 0.00001), intraoperative blood loss (WMD = - 13.30, 95% CI (- 18.83, - 7.78), P < 0.00001), risk of adjacent segment degeneration (ASD) (OR 0.31, 95% CI (0.20, 0.48), P < 0.0001), risk of dysphagia of short-term (OR 0.40, 95% CI (0.30, 0.54), P < 0.0001), medium-term (OR 0.31, 95% CI (0.20, 0.49), P < 0.0001), and long-term (OR 0.29, 95% CI (0.17, 0.51), P < 0.0001) of Zero-p group were significantly lower. The JOA score of Zero-p group at the final follow-up was significantly higher (WMD = - 0.17, 95% CI (- 0.32, - 0.03), P = 0.02). There were no significant differences in length of stay (LOS), Neck Disability Index (NDI), Visual Analogue Score (VAS), fusion rate, segmental Cobb angle, cervical Cobb angle, prevertebral soft tissue thickness (PSTT), SF-36, subsidence, implant failure, and hoarseness between the two groups. This study was registered with PROSPERO, CRD42022347146.

CONCLUSION

Zero-p group reduced operative time, intraoperative blood loss, JOA score at follow-up and reduced the incidence of dysphagia and postoperative ASD, but the two devices had the same efficacy in restoring the cervical curvature, preventing the cage subsidence, and in postoperative VAS, NDI, LOS, PSTT, SF-36, fusion rate, implant failure, and hoarseness in single-level ACDF. The use of Zero-p in single-level ACDF was recommended.

Should cervicothoracic junctions be avoided in long cervical posterior fusion surgery? Analysis of clinical and radiologic outcomes over two years

PURPOSE

This study aimed to confirm the usefulness of surgery that avoids the cervicothoracic junction (CTJ) by comparing the clinical and radiographic outcomes after posterior cervical fusion at C5/6 with those at C7/T1.

METHODS

Patients who underwent laminectomy and posterior cervical instrument fusion for cervical spondylotic myelopathy (CSM) from 2012 to 2019 were retrospectively reviewed and divided according to whether the end level was at C5/6 (group 1) or C7/T1 (group 2). Demographic variables and incidence of distal junctional kyphosis (DJK) were compared between the groups. Clinical outcomes (visual analog scale [VAS] score for arm and neck pain and the Neck Disability Index value) and radiologic outcomes (T1 slope, cervical lordosis, segmental lordosis, C2-7 sagittal vertical axis, T1 slope-cervical lordosis mismatch) were compared over time.

RESULTS

Sixty-seven patients were included. There were 32 patients in group 1 and 35 in group 2. The VAS score for neck pain was significantly lower in group 1 than in group 2 at 2 years after surgery (p = 0.03). The C2-7 sagittal vertical axis was significantly larger in group 2 than in group 1 at 1 year and 2 years postoperatively (p = 0.04). The incidence of DJK was higher in group 2 than in group 1 (28.57% vs 9.37%, p = 0.04).

CONCLUSION

This study found that when CTJs are included in the posterior cervical long fusion surgery, although it would be better than preoperation, postoperative kyphosis and consequent neck pain may progress. The results of this study advocate the concept of avoiding CTJ fusion if possible.

Determining the time frame of maximum clinical improvement in surgical decompression for cervical spondylotic myelopathy when stratified by preoperative myelopathy severity: a cervical Quality Outcomes Database study

OBJECTIVE

While surgical decompression is an important treatment modality for cervical spondylotic myelopathy (CSM), it remains unclear if the severity of preoperative myelopathy status affects potential benefit from surgical intervention and when maximum postoperative improvement is expected. This investigation sought to determine if retrospective analysis of prospectively collected patient-reported outcomes (PROs) following surgery for CSM differed when stratified by preoperative myelopathy status. Secondary objectives included assessment of the minimal clinically important difference (MCID).

METHODS

A total of 1151 patients with CSM were prospectively enrolled from the Quality Outcomes Database at 14 US hospitals. Baseline demographics and PROs at baseline and 3 and 12 months were measured. These included the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), quality-adjusted life-years (QALYs) from the EQ-5D, and visual analog scale from the EQ-5D (EQ-VAS). Patients were stratified by preoperative myelopathy severity using criteria established by the AO Spine study group: mild (mJOA score 15-17), moderate (mJOA score 12-14), or severe (mJOA score < 12). Univariate analysis was used to identify demographic variables that significantly varied between myelopathy groups. Then, multivariate linear regression and linear mixed regression were used to model the effect of severity and time on PROs, respectively.

RESULTS

For NDI, EQ-VAS, and QALY, patients in all myelopathy cohorts achieved significant, maximal improvement at 3 months without further improvement at 12 months. For mJOA, moderate and severe myelopathy groups demonstrated significant, maximal improvement at 3 months, without further improvement at 12 months. The mild myelopathy group did not demonstrate significant change in mJOA score but did maintain and achieve higher PRO scores overall when compared with more advanced myelopathy cohorts. The MCID threshold was reached in all myelopathy cohorts at 3 months for mJOA, NDI, EQ-VAS, and QALY, with the only exception being mild myelopathy QALY at 3 months.

CONCLUSIONS

As assessed by statistical regression and MCID analysis, patients with cervical myelopathy experience maximal improvement in their quality of life, neck disability, myelopathy score, and overall health by 3 months after surgical decompression, regardless of their baseline myelopathy severity. An exception was seen for the mJOA score in the mild myelopathy cohort, improvement of which may have been limited by ceiling effect. The data presented here will aid surgeons in patient selection, preoperative counseling, and expected postoperative time courses.

Cerebrospinal fluid biomarkers of white matter injury and astrogliosis are associated with the severity and surgical outcome of degenerative cervical spondylotic myelopathy

BACKGROUND CONTEXT

Degenerative cervical spondylotic myelopathy (DCM) is the commonest form of spinal cord injury in adults. However, a limited number of clinical reports have assessed the role of biomarkers in DCM.

PURPOSE

We evaluated cerebrospinal fluid (CSF) biomarkers in patients scheduled for DCM surgery and hypothesized that CSF biomarkers levels (1) would reflect the severity of preoperative neurological status; and (2) correlate with radiological appearance; and (3) correlate with clinical outcome.

STUDY DESIGN/SETTING

Prospective clinical and laboratory study.

PATIENT SAMPLE

Twenty-three DCM patients, aged 66.4±12.8 years and seven controls aged 45.4±5.3 years were included.

OUTCOME MEASURES

The American Spinal Injury Association Impairment Scale, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire and EuroQol 5-dimensions were assessed preoperatively and at 3 months post-surgery.

METHODS

We measured preoperative biomarkers (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], phosphorylated neurofilament-H [pNF-H] and Ubiquitin C-terminal hydrolase L1) in CSF samples collected from patients with progressive clinical DCM who underwent surgical treatment. Biomarker concentrations in DCM patients were compared with those of cervical radiculopathy controls.

RESULTS

The median symptom duration was 10 (interquartile range 6) months. The levels of GFAP, NFL, pNF-H, Ubiquitin C-terminal hydrolase L1 were significantly higher in the DCM group compared to controls (p=.044, p=.002, p=.016, and p=.006, respectively). Higher pNF-H levels were found in patients with low signal on T1 Magnetic Resonance Imaging sequence compared to those without (p=.022, area under the receiver operating characteristic curve [AUC] 0.780, 95% Confidence Interval: 0.59-0.98). Clinical improvement following surgery correlated mainly with NFL and GFAP levels (p<.05).

CONCLUSIONS

Our results suggest that CSF biomarkers of white matter injury and astrogliosis may be a useful tool to assess myelopathy severity and predict outcome after surgery, while providing valuable information on the underlying pathophysiology.

Clinical and Research MRI Techniques for Assessing Spinal Cord Integrity in Degenerative Cervical Myelopathy-A Scoping Review

BACKGROUND

Degenerative cervical myelopathy (DCM) manifests as the primary cause of spinal cord dysfunction and is non-traumatic, chronic and progressive in nature. Decompressive surgery is typically utilised to halt further disability and neurological dysfunction. The limitations of current diagnostic options surrounding assessment and prognostic potential render DCM still largely a clinical diagnosis.

AIMS

To outline the limitations of current diagnostic techniques, present evidence behind novel quantitative MRI (qMRI) techniques for assessing spinal cord integrity in DCM and suggest future directions.

METHOD

Articles published up to November 2021 were retrieved from Medline, EMBASE and EBM using key search terms: spinal cord, spine, neck, MRI, magnetic resonance imaging, qMRI, T1, T2, T2*, R2*, DTI, diffusion tensor imaging, MT, magnetisation transfer, SWI, susceptibility weighted imaging, BOLD, blood oxygen level dependent, fMRI, functional magnetic resonance imaging, functional MRI, MRS, magnetic resonance spectroscopy.

RESULTS

A total of 2057 articles were retrieved with 68 articles included for analysis. The search yielded 2 articles on Quantitative T1 mapping which suggested higher T1 values in spinal cord of moderate-severe DCM; 43 articles on DTI which indicated a strong correlation of fractional anisotropy and modified Japanese Orthopaedic Association scores; 15 articles on fMRI (BOLD) which demonstrated positive correlation of functional connectivity and volume of activation of various connections in the brain with post-surgical recovery; 6 articles on MRS which suggested that Choline/N-acetylaspartate (Cho/NAA) ratio presents the best correlation with DCM severity; and 4 articles on MT which revealed a preliminary negative correlation of magnetisation transfer ratio with DCM severity. Notably, most studies were of low sample size with short timeframes within 6 months.

CONCLUSIONS

Further longitudinal studies with higher sample sizes and longer time horizons are necessary to determine the full prognostic capacity of qMRI in DCM.

Evidence for a genetic contribution to the ossification of spinal ligaments in Ossification of Posterior Longitudinal Ligament and Diffuse idiopathic skeletal hyperostosis: A narrative review

Diffuse Idiopathic Skeletal Hyperostosis (DISH) and Ossification of the Posterior Longitudinal Ligament (OPLL) are common disorders characterized by the ossification of spinal ligaments. The cause for this ossification is currently unknown but a genetic contribution has been hypothesized. Over the last decade, many studies on the genetics of ectopic calcification disorders have been performed, mainly on OPLL. Most of these studies were based on linkage analysis and case control association studies. Animal models have provided some clues but so far, the involvement of the identified genes has not been confirmed in human cases. In the last few years, many common variants in several genes have been associated with OPLL. However, these associations have not been at definitive levels of significance and evidence of functional significance is generally modest. The current evidence suggests a multifactorial aetiopathogenesis for DISH and OPLL with a subset of cases showing a stronger genetic component.

Where Is the Way Forward for New Media Empowering Public Health? Development Strategy Options Based on SWOT-AHP Model

(1) Background: In recent years, new media and the integration of sport and medicine have promoted the rapid integration and development of the two fields of health and, to a certain extent, the pursuit of public health knowledge and the promotion of health concepts. However, the overall development process is at an early stage and the aim of this paper is to make an empirical analysis of its development through a SWOT-AHP model and give corresponding recommendations. (2) Methods: The SWOT-AHP model was constructed to quantitatively and qualitatively analyse the four dimensions of strengths, weaknesses, opportunities and threats obtained through the Delphi method, with regard to development and to determine the strategic direction of its development. (3) Results: The strategic azimuth θ is -13.243° and the strategic coefficient p is 0.53699, in the diversification zone. (4) Conclusions: New media, as a fast track to empowering the integration of sport and medicine for health, is a field with a bright future, but its own strengths and external threats coexist and should be maximised to overcome the disruptions caused by external threats through a variety of measures.

High-Dimensional Analysis of Finger Motion and Screening of Cervical Myelopathy With a Noncontact Sensor: Diagnostic Case-Control Study

BACKGROUND

Cervical myelopathy (CM) causes several symptoms such as clumsiness of the hands and often requires surgery. Screening and early diagnosis of CM are important because some patients are unaware of their early symptoms and consult a surgeon only after their condition has become severe. The 10-second hand grip and release test is commonly used to check for the presence of CM. The test is simple but would be more useful for screening if it could objectively evaluate the changes in movement specific to CM. A previous study analyzed finger movements in the 10-second hand grip and release test using the Leap Motion, a noncontact sensor, and a system was developed that can diagnose CM with high sensitivity and specificity using machine learning. However, the previous study had limitations in that the system recorded few parameters and did not differentiate CM from other hand disorders.

OBJECTIVE

This study aims to develop a system that can diagnose CM with higher sensitivity and specificity, and distinguish CM from carpal tunnel syndrome (CTS), a common hand disorder. We then validated the system with a modified Leap Motion that can record the joints of each finger.

METHODS

In total, 31, 27, and 29 participants were recruited into the CM, CTS, and control groups, respectively. We developed a system using Leap Motion that recorded 229 parameters of finger movements while participants gripped and released their fingers as rapidly as possible. A support vector machine was used for machine learning to develop the binary classification model and calculated the sensitivity, specificity, and area under the curve (AUC). We developed two models, one to diagnose CM among the CM and control groups (CM/control model), and the other to diagnose CM among the CM and non-CM groups (CM/non-CM model).

RESULTS

The CM/control model indexes were as follows: sensitivity 74.2%, specificity 89.7%, and AUC 0.82. The CM/non-CM model indexes were as follows: sensitivity 71%, specificity 72.87%, and AUC 0.74.

CONCLUSIONS

We developed a screening system capable of diagnosing CM with higher sensitivity and specificity. This system can differentiate patients with CM from patients with CTS as well as healthy patients and has the potential to screen for CM in a variety of patients.

Analysis of combined clinical and diffusion basis spectrum imaging metrics to predict the outcome of chronic cervical spondylotic myelopathy following cervical decompression surgery

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is the most common cause of chronic spinal cord injury, a significant public health problem. Diffusion tensor imaging (DTI) is a neuroimaging technique widely used to assess CNS tissue pathology and is increasingly used in CSM. However, DTI lacks the needed accuracy, precision, and recall to image pathologies of spinal cord injury as the disease progresses. Thus, the authors used diffusion basis spectrum imaging (DBSI) to delineate white matter injury more accurately in the setting of spinal cord compression. It was hypothesized that the profiles of multiple DBSI metrics can serve as imaging outcome predictors to accurately predict a patient's response to therapy and his or her long-term prognosis. This hypothesis was tested by using DBSI metrics as input features in a support vector machine (SVM) algorithm.

METHODS

Fifty patients with CSM and 20 healthy controls were recruited to receive diffusion-weighted MRI examinations. All spinal cord white matter was identified as the region of interest (ROI). DBSI and DTI metrics were extracted from all voxels in the ROI and the median value of each patient was used in analyses. An SVM with optimized hyperparameters was trained using clinical and imaging metrics separately and collectively to predict patient outcomes. Patient outcomes were determined by calculating changes between pre- and postoperative modified Japanese Orthopaedic Association (mJOA) scale scores.

RESULTS

Accuracy, precision, recall, and F1 score were reported for each SVM iteration. The highest performance was observed when a combination of clinical and DBSI metrics was used to train an SVM. When assessing patient outcomes using mJOA scale scores, the SVM trained with clinical and DBSI metrics achieved accuracy and an area under the curve of 88.1% and 0.95, compared with 66.7% and 0.65, respectively, when clinical and DTI metrics were used together.

CONCLUSIONS

The accuracy and efficacy of the SVM incorporating clinical and DBSI metrics show promise for clinical applications in predicting patient outcomes. These results suggest that DBSI metrics, along with the clinical presentation, could serve as a surrogate in prognosticating outcomes of patients with CSM.

Degenerative Cervical Myelopathy: A Practical Approach to Diagnosis

STUDY DESIGN

Narrative Review.

OBJECTIVES

The objective of this review is to provide a stepwise approach to the assessment of patients with potential symptoms of degenerative cervical myelopathy (DCM).

METHODS

N/A.

RESULTS

DCM is an overarching term used to describe progressive compression of the cervical spinal cord by age-related changes to the spinal axis. These alterations to normal anatomy narrow the spinal canal, reduce the space available for the spinal cord, and may ultimately compress the ascending and descending neural tracts. Patients with DCM present with a wide range of symptoms that can significantly impact quality of life, including bilateral hand numbness and paresthesia, gait impairment, motor weakness of the upper and lower extremities, and bladder and bowel dysfunction. Unfortunately, DCM is often misdiagnosed, resulting in delayed assessment and management by the appropriate specialist. The proper evaluation of a patient with suspected DCM includes obtaining a detailed patient history, conducting a comprehensive neurological examination, and ordering appropriate tests to rule in or out other diagnoses.

CONCLUSION

This review summarizes a stepwise approach to the diagnosis of patients with DCM.

Identification of Degenerative Cervical Myelopathy in the Chiropractic Office: Case Report and a Review of the Literature

Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction, yet it may be challenging to identify as it presents with variable symptoms. A 62-year-old woman presented to a chiropractor with a three-month exacerbation of neck pain, hand/finger numbness, and torso dysesthesia. She had previously seen primary care, physical therapy, rheumatology, and pain management. Previous cervical magnetic resonance imaging showed moderate cervical canal stenosis; however, previous providers had diagnosed her with radiculopathy and possible carpal tunnel syndrome yet had not requested neurosurgical consultation. On examination, the chiropractor identified sensorimotor deficits, hyperreflexia, and bilateral Hoffman reflexes, and referred the patient to a neurosurgeon for suspected DCM. The neurosurgeon performed an anterior cervical discectomy and fusion from C4-7. The patient's symptoms and disability level improved within two months of follow-up. We identified 11 previous cases in which a chiropractor suspected DCM which was then confirmed by a surgeon. Including the current case (i.e., 12 total), patients were older and mostly male; 50% had neck pain, 92% had hyperreflexia. Chiropractors referred each patient to a surgeon; 83% underwent cervical spine surgery. This case highlights the identification of DCM by a chiropractor and referral for neurosurgical evaluation with a positive outcome. Patients with previously undiagnosed DCM may present to chiropractors with varied symptoms and examination findings. DCM may contraindicate spinal manipulation and instead warrant surgery. Accordingly, chiropractors play a key role in the detection and referral of patients with misdiagnosed or overlooked DCM.

Predictors of home discharge after scheduled surgery for degenerative cervical myelopathy

OBJECTIVE

Degenerative cervical myelopathy (DCM) is an important public health issue. Surgery is the mainstay of treatment for moderate and severe DCM. Delayed discharge of patients after DCM surgery is associated with increased healthcare costs. There is a paucity of data regarding predictive factors for discharge destination after scheduled surgery for patients with DCM. The purpose of this study was to identify factors predictive of home versus nonhome discharge after DCM surgery.

METHODS

Patients undergoing scheduled DCM surgery who had been enrolled in a prospective DCM substudy of the Canadian Spine Outcomes and Research Network registry between January 2015 and October 2020 were included in this retrospective analysis. Patient data were evaluated to identify potential factors predictive of home discharge after surgery. Logistic regression was used to identify independent factors predictive of home discharge. A multivariable model was then used as a final model.

RESULTS

Overall, 639 patients were included in the initial analysis, 543 (85%) of whom were discharged home. The mean age of the entire cohort was 60 years (SD 11.8 years), with a BMI of 28.9 (SD 5.7). Overall, 61.7% of the patients were female. The mean length of stay was 2.72 days (SD 1.7 days). The final internally validated bootstrapped multivariable model revealed that younger age, higher 9-Item Patient Health Questionnaire score, lower Neck Disability Index scores, fewer operated levels, mJOA scores indicating mild disease, anterior cervical discectomy and fusion procedure, and no perioperative adverse effects were predictive of home discharge.

CONCLUSIONS

Younger age, less neck-related disability, fewer operated levels, more significant depression, less severe myelopathy, anterior cervical discectomy and fusion procedure, and no perioperative adverse effects are predictive of home discharge after surgery for DCM. These factors can help to guide clinical decision-making and optimize postoperative care pathways.

Adverse Events Relating to Prolonged Hard Collar Immobilisation: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To evaluate systematically the complications of prolonged cervical immobilisation in a hard collar.

METHODS

Following registration with PROSPERO, a systematic search of electronic databases (MEDLINE, EMBASE) was conducted. Two reviewers independently screened the search results according to pre-determined search criteria. Data was extracted and tabulated. Joanna Briggs Institute checklists were used for assessing the quality of included studies.

RESULTS

The search identified 773 articles. A total of 25 studies were selected for final inclusion. The results largely comprised a mixture of case reports/series, cohort studies and reviews. The most commonly reported complications were pressure ulcers, dysphagia and increased intracranial pressure. A pressure ulcer pooled prevalence of 7% was calculated. There was insufficient data for quantitative analysis of any other complication.

CONCLUSIONS

There is significant morbidity from prolonged hard collar immobilisation, even amongst younger patients. Whilst based upon limited and low-quality evidence, these findings, combined with the low-quality evidence for the efficacy of hard collars, highlights a knowledge gap for future research.

Acute Systemic White Blood Cell Changes following Degenerative Cervical Myelopathy (DCM) in a Mouse Model

Degenerative cervical myelopathy (DCM) is caused by age-related degeneration of the cervical spine, causing chronic spinal cord compression and inflammation. The aim of this study was to assess whether the natural progression of DCM is accompanied by hematological changes in the white blood cell composition. If so, these changes can be used for diagnosis complementing established imaging approaches and for the development of treatment strategies, since peripheral immunity affects the progression of DCM. Gradual compression of the spinal cord was induced in C57B/L mice at the C5-6 level. The composition of circulating white blood cells was analyzed longitudinally at four time points after induction of DCM using flow cytometry. At 12 weeks, serum cytokine levels were measured using a Luminex x-MAP assay. Neurological impairment in the mouse model was also assessed using the ladder walk test and CatWalk. Stepping function (* p < 0.05) and overground locomotion (*** p < 0.001) were impaired in the DCM group. Importantly, circulating monocytes and T cells were affected primarily at 3 weeks following DCM. T cells were two-fold lower in the DCM group (*** p < 0.0006), whereas monocytes were four-fold increased (*** p < 0.0006) in the DCM compared with the sham group. Our data suggest that changes in white blood cell populations are modest, which is unique to other spinal cord pathologies, and precede the development of neurobehavioral symptoms.

Coexistence of flavum ligament ossification with diffuse idiopathic skeletal hyperostosis in the cervical spine: Review of literature and technical note starting from a rare case

BACKGROUND

Cervical flavum ligament ossification (C-OLF) is very rare source of myeloradiculopathy. Less than 100 cases have been reported in modern English literature up to 2020. Association between C-OLF and Diffuse Idiopathic Skeletal Hyperostosis (DISH) at cervical level has never been described.

METHODS

In this article we performed a systematic review about epidemiology, physiopathology, clinical and surgical management of C-OLF. Moreover, we research its possible association with other cervical spine ligament ossification and in particular with anterior longitudinal ligament ossification. We report a case of 73 years-old woman experiencing mild cervical myeloradiculopathy caused by C6-C7 C-OLF compression and coexistence of DISH at cervico-thoracic level. A brief technical note about intraoperative management of C-OLF has also been described.

RESULT

Our research found 81 previous reported case of C-OLF. The coexistence of Posterior longitudinal ligament ossification has been reported in 21.3% of C-OLF case. Conversely, we reported the first case describing the association between DISH and C-OLF. Posterior surgical decompression is the only useful treatment providing good long-term functional outcome. Instrumentation should be tailored according to pre-operative findings.

CONCLUSIONS

C-OLF is a rare source of myeloradiculopathy and it may coexists with DISH probably due to alteration in the cervical mechanical stress and tendency of bone formation in patients harboring coexistent ligament ossifications. According to our result, skip en-bloc microsurgical laminectomy is safe and less invasive method to avoid complication and to provide optimal cervical spinal cord and nerve decompression avoiding CSF-leak.

Top 100 most cited articles on anterior cervical discectomy and fusion

Study Design

Bibliometric analysis.

Objective

Anterior cervical discectomy and fusion (ACDF) is a typical surgical method in spine surgery and has progressed significantly in the last several decades. The purpose of this study is to determine how the 100 most-cited original articles on ACDF have been the most influential in this field by identifying and analyzing them.

Methods

The articles on ACDF were identified by searching the Thomson ISI Web of Science database on 30 May 2022. The 100 most-cited articles were selected according to specific criteria. The data extracted from the articles included title, publication date, total citations, journal name, first author, institutions, and keywords.

Results

The total number of citations was 13,181, with a mean number of 131.81 ± 100.18. The publication dates ranged from 1994 to 2018. Most of these articles originated in the United States (68%) and were published in the 2000s (32%) and 2010s (48%). Spine published most of the articles (30%), followed by the Journal of Neurosurgery-Spine (16%), Spine Journal (14%), and European Spine Journal (13%). The most prolific author was Dr. Todd J Albert (n = 7), with 1,312 citations. The Texas Back Institute was the most productive institution (n = 10). The keywords ACDF, cervical spine, cervical spine, and fusion showed the highest degree of centrality.

Conclusion

One hundred top-cited articles on ACDF were identified and analyzed in this study. We demonstrate that ACDF is a growing and popular area of research, with the focus of research varying through timeline trends. This will provide a comprehensive and detailed basis for spine surgeons to make clinical decisions and assimilate the research focus of cervical spine surgery.

Change in Physical and Mental Quality-of-Life between the Short- and Mid-Term Periods after Cervical Laminoplasty for Cervical Spondylotic Myelopathy: A Retrospective Cohort Study with Minimum 5 Years Follow-up

The mid-term surgical outcomes of cervical spondylotic myelopathy (CSM), evaluated using the cervical Japanese Orthopedic Association (cJOA) score, are reported to be satisfactory. However, there remains room for improvement in quality-of-life (QOL), especially after short-term follow-up. We aimed to demonstrate changes in mental and physical QOL between short- and mid-term follow-ups and determine the predictive factors for deterioration of QOL. In this retrospective cohort study, 80 consecutive patients underwent laminoplasty for CSM. The outcome measures were Short Form-36 Physical Component Summary (PCS), Mental Component Summary (MCS), and cJOA scores. PCS and MCS scores were compared at the 2- and 5-year postoperative time points. Additionally, a multivariate logistic regression model was used to identify the predictive factors for deterioration. Significant factors in the logistic regression analysis were analyzed using receiver-operating characteristic curves. The results showed that MCS scores did not deteriorate after 2 years postoperatively (p = 0.912). Meanwhile, PCS significantly declined between 2 and 5 years postoperatively (p = 0.008). cJOA scores at 2 years postoperatively were significantly associated with PCS deterioration at 2-year follow-up. In conclusion, only physical QOL might show deterioration after short-term follow-up. Such deterioration is likely in patients with a cJOA score <13.0 at 2 years postoperatively.

Prevalence of pre-existing factors causing spinal cord compression: Is there a difference between patients suffering from cervical spinal cord injury with and without bone injury?

BACKGROUND

Recently, the prevalence of elderly patients suffering from cervical spinal cord injury (CSCI) without bone injury has been increasing in various countries. Pre-existing factors causing spinal cord compression, such as ossification of the posterior longitudinal ligament (OPLL), can increase the risk of CSCI without bone injury. However, no study has compared the prevalence of pre-existing factors between CSCI with and without bone injury. This study aimed to compare the prevalence of pre-existing factors between CSCI with and without bone injury.

METHODS

In 168 consecutive patients with CSCI, pre-existing factors including OPLL, posterior spur of the vertebral body, developmental stenosis, disc bulge and calcification of yellow ligament (CYL) were evaluated on imaging studies. The prevalence of each type of pre-existing factors was compared between patients with and without bone injury.

RESULTS

The prevalence of pre-existing factors in patients without bone injury (86%) was significantly higher than in those with bone injury (20%) (P < 0.001; odds ratio, 23.9). The most common pre-existing factor was OPLL followed by developmental stenosis, posterior spur, disc bulge and CYL in both groups. OPLL, development stenosis and posterior spur were significantly more common in patients without bone injury compared to those with bone injury (P < 0.01).

CONCLUSIONS

Prevalence of pre-existing factors, such as OPLL, development stenosis and posterior spur was significantly higher in patients without bone injury than in those with bone injury. Thus, these pre-existing factors might be a potential risk of CSCI without bone injury.

Use of Telemedicine in the Diagnosis of Cervical Spondylotic Myelopathy in a US Veteran During the COVID-19 Pandemic: A Case Report

Objective

The purpose of this case study was to describe the diagnosis of cervical spondylotic myelopathy through telemedicine during the COVID-19 pandemic.

Clinical Features

A 57-year-old male patient was evaluated at a Veterans Affairs chiropractic clinic via video telemedicine for evaluation regarding neck pain and bilateral arm paresthesia.

Intervention and Outcome

During the initial evaluation performed by video telemedicine, the doctor of chiropractic was concerned about the possibility of cervical spondylotic myelopathy. This prompted a face-to-face consultation with the patient for further evaluation. The face-to-face evaluation revealed correlating objective findings, including brisk reflexes and transient clonus. Noncontrast magnetic resonance imaging of the cervical spine was performed, which showed evidence of cord compression with associated myelomalacia in the cervical spine at the C4-C5 level. After a neurosurgical consultation, the patient underwent successful anterior cervical decompression and fusion at the C4-C5 level.

Conclusion

Chiropractic services through live video telemedicine in conjunction with face-to-face evaluation resulted in a timely neurosurgical consultation and successful decompression of the affected region. In this case, telemedicine facilitated a positive outcome for a patient with cervical spondylotic myelopathy.

Level-specific Perioperative and Clinical Outcome Comparison: Cervical Disk Replacement Versus Anterior Cervical Diskectomy and Fusion at C5-C6 in Patients With Myeloradiculopathy

INTRODUCTION

This study compares perioperative and postoperative clinical outcomes in patients undergoing anterior cervical diskectomy and fusion (ACDF) or cervical disk replacement (CDR) at C5-C6 in patients with myeloradiculopathy.

METHODS

Primary, elective, single-level CDR or ACDF procedures at C5-C6 for patients with myeloradiculopathy were included. Patient-reported outcome measures (PROMs) included visual analog scale (VAS) neck, VAS arm, Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), and Short-Form 12-Item Physical Composite Score (SF-12 PCS) collected at preoperative/6-week/12-week/6-month/1-year time points. Surgical cohorts were assessed for differences in demographics/perioperative characteristics using the chi square test and unpaired Student t-test for categorical and continuous variables, respectively. Achievement of minimum clinically important difference (MCID) was determined by comparing ΔPROMs with established thresholds. Outcome measures were compared at postoperative time points with the Student t-test, and improvement from preoperative baseline was assessed with a paired sample t-test.

RESULTS

One hundred thirty-seven patients were included, 43 CDR and 94 ACDF. CDR patients demonstrated significantly reduced surgical times (46.3 versus 55.1 minutes), estimated blood loss (24.4 versus 43.6 mL), revision surgery rates (0.0% versus 5.3%), postoperative length of stay (8.9 versus 23.0 hours), and postoperative narcotic consumption (P < 0.017, all). Complication rates and mean PROMs did not differ between cohorts. The CDR cohort markedly improved from baseline for all PROMs postoperatively except SF-12 PCS/PROMIS-PF at 6 weeks. The ACDF cohort markedly improved at each time point except VAS arm at 1 year, NDI at 6 weeks/1 year, and SF-12 PCS/PROMIS-PF at 6 weeks. A majority of both cohorts achieved overall MCID for VAS neck/NDI/PROMIS-PF. MCID achievement rates did not differ except NDI at 12 weeks/1 year and SF-12 PCS at 6 months, both favoring CDR.

DISCUSSION

Both procedural cohorts demonstrated similar long-term clinical outcomes for arm/neck pain and physical function; however, patients undergoing CDR at C5-C6 demonstrated an improved ability to maintain 1-year postoperative progress for neck disability with improved 1-year NDI MCID achievement. The CDR cohort, in addition, demonstrated an improved perioperative profile and reduced rate of revision surgery.

A Systematic Review of Definitions for Dysphagia and Dysphonia in Patients Treated Surgically for Degenerative Cervical Myelopathy

STUDY DESIGN

Systematic review. Surgical decompression for degenerative cervical myelopathy (DCM) is associated with perioperative complications, including difficulty or discomfort with swallowing (dysphagia) as well as changes in sound production (dysphonia). This systematic review aims to (1) outline how dysphagia and dysphonia are defined in the literature and (2) assess the quality of definitions using a novel 4-point rating system.

METHODS

An electronic database search was conducted for studies that reported on dysphagia, dysphonia or other related complications of DCM surgery. Data extracted included study design, surgical details, as well as definitions and rates of surgical complications. A 4-point rating scale was developed to assess the quality of definitions for each complication.

RESULTS

Our search yielded 2,673 unique citations, 11 of which met eligibility criteria and were summarized in this review. Defined complications included odynophagia (n = 1), dysphagia (n = 11), dysphonia (n = 2), perioperative swelling complications (n = 2), and soft tissue swelling (n = 3). Rates of dysphagia varied substantially (0.0%-50.0%) depending on whether this complication was patient-reported (4.4%); patient-reported using a modified Swallowing Quality of Life questionnaire (43.1%) or the Bazaz criteria (8.8%-50.0%); or diagnosed using an extensive protocol consisting of clinical assessment, a bedside swallowing test, evaluation by a speech and language pathologist and a modified barium swallowing test/fiberoptic endoscopy (42.9%). The reported incidences of dysphonia also ranged significantly from 0.6% to 38.0%.

CONCLUSION

There is substantial variability in reported rates of dysphagia and dysphonia due to differences in data collection methods, diagnostic strategies, and definitions. Consolidation of nomenclature will improve evaluation of the overall safety of surgery.

Differences in postoperative quality of life in young, early elderly, and late elderly patients undergoing surgical treatment for degenerative cervical myelopathy

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is a common progressive spine disorder affecting predominantly middle-aged and elderly populations. With increasing life expectancy, the incidence of CSM is expected to rise further. The outcomes of elderly patients undergoing CSM surgery and especially their quality of life (QOL) postoperatively remain undetermined. This study retrospectively reviewed patients to identify baseline differences and validated postoperative patient-reported outcome (PRO) measures in elderly patients undergoing CSM surgery.

METHODS

The multi-institutional, neurosurgery-specific NeuroPoint Quality Outcomes Database was queried to identify CSM patients treated surgically at the 14 highest-volume sites from January 2016 to December 2018. Patients were divided into three groups: young (< 65 years), early elderly (65-74 years), and late elderly (≥ 75 years). Demographic and PRO measures (Neck Disability Index [NDI] score, modified Japanese Orthopaedic Association [mJOA] score, EQ-5D score, EQ-5D visual analog scale [VAS] score, arm pain VAS, and neck pain VAS) were compared among the groups at baseline and 3 and 12 months postoperatively.

RESULTS

A total of 1151 patients were identified: 691 patients (60%) in the young, 331 patients (28.7%) in the early elderly, and 129 patients (11.2%) in the late elderly groups. At baseline, younger patients presented with worse NDI scores (p < 0.001) and lower EQ-5D VAS (p = 0.004) and EQ-5D (p < 0.001) scores compared with early and late elderly patients. No differences among age groups were found in the mJOA score. An improvement of all QOL scores was noted in all age groups. On unadjusted analysis at 3 months, younger patients had greater improvement in arm pain VAS, NDI, and EQ-5D VAS compared with early and late elderly patients. At 12 months, the same changes were seen, but on adjusted analysis, there were no differences in PROs between the age groups.

CONCLUSIONS

The authors' results indicate that elderly patients undergoing CSM surgery achieved QOL outcomes that were equivalent to those of younger patients at the 12-month follow-up.

Outcome of Anterior and Posterior Endoscopic Procedures for Cervical Radiculopathy Due to Degenerative Disk Disease: A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVES

Cervical spine endoscopic discectomy and decompression have gained popularity in the last decade. This review aimed to shed light on the current outcomes of cervical spine endoscopic procedures for degenerative disc disease (DDD) and to calculate a pooled estimate of various outcome measures.

METHODS

We retrieved articles published in English related to endoscopic cervical spine procedures from 3 central databases from inception until September 2020. A subgroup analysis based on the anterior versus the posterior approach was performed.

RESULTS

Thirty-one articles fulfilled the eligibility criteria and included 1,410 patients. A successful outcome was observed in 91.3% (88.6-93.4%, P = 0.000). This percentage was lower for the anterior approach (89.6% [85.8-92.5%], P = 0.000) than for the posterior approach (94.2% [90.4-96.5%], P = 0.000). A higher percentage of poor outcomes was reported for the anterior approach (5.7% [3.2-10.1%], P = 0.000 vs. 2.3% [1-5.5%], P = 0.000 for the posterior approach). The overall complication rate was 7.2% (5.2-9.8%, P = 0.000). There was a slightly higher complication rate for the anterior approach (7.9% [4.5-13.3%], P = 0.000) than for the posterior approach (6.7% [4.4-10%], P = 0.000). The revision rate was 4.2% (2.6-6.8%, P = 0.000); and 4.2% (1.8-9.7%, P = 0.000) for the anterior approach and 4.00% (2.2-7.4%, P = 0.000) for the posterior approach.

CONCLUSIONS

There is a higher success rate and lower complication rate with the posterior approach than with the anterior approach. However, high-quality randomized controlled trials are vital to evaluate the efficacy of these procedures.

Surgery for degenerative cervical myelopathy in the elderly: a nationwide registry-based observational study with patient-reported outcomes

BACKGROUND

The aim of this study was to investigate whether clinical outcomes in patients aged ≥ 70 undergoing decompressive surgery for degenerative cervical myelopathy (DCM) differ from those of younger patients (50-70 years) at 1 year.

METHODS

Data were obtained from the Norwegian Registry for Spine Surgery (NORspine). Among 651 patients included, 177 (27.2%) were ≥ 70 years old. The primary outcome was change in the Neck Disability Index (NDI). Secondary outcomes were changes in the European Myelopathy Score (EMS), quality of life (EuroQoL EQ-5D), numeric rating scales (NRS) for headache, neck pain, and arm pain, and complications.

RESULTS

Significant improvements in all patient-reported outcomes (PROMs) were detected for both age cohorts at 1 year. For the two age cohorts combined, there was a statistically significant improvement in the NDI score (mean 9.2, 95% CI 7.7 to 10.6, P < 0.001). There were no differences between age cohorts in mean change of NDI (- 8.9 vs. - 10.1, P = 0.48), EQ-5D (0.13 vs. 0.17, P = 0.37), or NRS pain scores, but elderly patients experienced a larger improvement in EMS (0.7 vs. 1.3, P = 0.02). A total of 74 patients (15.6%) in the younger cohort and 43 patients (24.3%) in the older cohort experienced complications or adverse effects within 3 months of surgery, mainly urinary and respiratory tract infections.

CONCLUSION

Surgery for DCM was associated with significant improvement across a wide range of PROMs for both younger and elderly patients. Surgery for DCM should not be denied based on age alone.

Comparison of surgical outcomes of posterior surgeries between cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

To compare the surgical outcomes and complications of posterior decompression between individuals with cervical spondylotic myelopathy (CSM) and those with ossification of the posterior longitudinal ligament (OPLL).

SETTING

Seventeen medical institutions in Japan.

METHODS

This study included 814 individuals with CSM (n = 636) and OPLL (n = 178) who underwent posterior decompression. Propensity score matching of the baseline characteristics was performed to compare surgical outcomes and perioperative complications between the CSM and OPLL groups.

RESULTS

Before propensity score matching, the OPLL group had higher percentage of male individuals, body mass index, and number of stenosis levels and longer duration of symptoms (P < 0.01, P < 0.01, P < 0.01, and P < 0.01, respectively). After matching, the baseline characteristics were comparable between the CSM (n = 98) and OPLL (n = 98) groups. The postoperative Japanese Orthopaedic Association (JOA) scores, preoperative-to-postoperative changes in the JOA scores, and JOA score recovery rates were not significantly different between the groups (P = 0.42, P = 0.47, and P = 0.09, respectively). The postoperative visual analog scale (VAS) score for neck pain and preoperative-to-postoperative changes in the VAS score for neck pain were not significantly different between the groups (P = 0.25 and P = 0.50, respectively). The incidence of perioperative complications was comparable between groups.

CONCLUSION

Neurological improvement and complication rates after surgery were comparable between individuals with CSM and those with OPLL, suggesting similar effectiveness and safety of posterior decompression for both conditions.

The Pre-Operative Duration of Symptoms: The Most Important Predictor of Post-Operative Efficacy in Patients with Degenerative Cervical Myelopathy

Objective. To explore the most important predictors of post-operative efficacy in patients with degenerative cervical myelopathy (DCM). Methods. From January 2013 to January 2019, 284 patients with DCM were enrolled. They were categorized based on the different surgical methods used: single anterior cervical decompression and fusion (ACDF) (n = 80), double ACDF (n = 56), three ACDF (n = 13), anterior cervical corpectomy and fusion (ACCF) (n = 63), anterior cervical hybrid decompression and fusion (ACHDF) (n = 25), laminoplasty (n = 38) and laminectomy and fusion (n = 9). The follow-up time was 2 years. The patients were divided into two groups based on the mJOA recovery rate at the last follow-up: Group A (the excellent improvement group, mJOA recovery rate >50%, n = 213) and Group B (the poor improvement group, mJOA recovery rate ≤50%, n = 71). The evaluated data included age, gender, BMI, duration of symptoms (months), smoking, drinking, number of lesion segments, surgical methods, surgical time, blood loss, the Charlson Comorbidity Index (CCI), CCI classification, imaging parameters (CL, T1S, C2-7SVA, CL (F), T1S (F), C2-7SVA (F), CL (E), T1S (E), C2-7SVA (E), CL (ROM), T1S (ROM) and C2-7SVA (ROM)), maximum spinal cord compression (MSCC), maximum canal compromise (MCC), Transverse area (TA), Transverse area ratio (TAR), compression ratio (CR) and the Coefficient compression ratio (CCR). The visual analog score (VAS), neck disability index (NDI), modified Japanese Orthopedic Association (mJOA) and mJOA recovery rate were used to assess cervical spinal function and quality of life. Results. We found that there was no significant difference in the baseline data among the different surgical groups and that there were only significant differences in the number of lesion segments, C2−7SVA, T1S (F), T1S (ROM), TA, CR, surgical time and blood loss. Therefore, there was comparability of the post-operative recovery among the different surgical groups, and we found that there were significant differences in age, the duration of symptoms, CL and pre-mJOA between Group A and Group B. A binary logistic regression analysis showed that the duration of the symptoms was an independent risk factor for post-operative efficacy in patients with DCM. Meanwhile, when the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196). Conclusion. For patients with DCM (regardless of the number of lesion segments and the proposed surgical methods), the duration of symptoms was an independent risk factor for the post-operative efficacy. When the duration of symptoms was ≥6.5 months, the prognosis of patients was more likely to be poor, and the probability of a poor prognosis increased by 0.196 times for each additional month of symptom duration (p < 0.001, OR = 1.196).