Increased signal intensity on postoperative T2-weighted axial images in cervical spondylotic myelopathy: Patterns of changes and associated impact on outcomes

Spinal Cord Status Assessment and Early Interventional Personalized Rehabilitation after Endoscopic Surgery for Cervical Compressive Myelopathy: A Randomized Trial

BACKGROUND CONTEXT

Cervical compressive myelopathy (CCM), frequently arising from spinal degeneration, results in significant motor and sensory deficits. Currently, there is a lack of precise prognostic evaluation methods following decompression surgery for CCM, which hinders the optimization of personalized rehabilitation therapy. However, the combination of intraoperative endoscopic visualization of dural sac compression morphology and electrophysiological functional assessment holds promise in addressing this gap.

PURPOSE

To determine whether a personalized rehabilitation strategy, informed by intraoperative endoscopic and electrophysiological assessments, enhances postoperative functional outcomes in CCM patients compared to traditional rehabilitation after canal decompression surgery.

STUDY DESIGN/SETTING

PROSPECTIVE SINGLE-CENTER RANDOMIZED CONTROLLED STUDY, TRIAL REGISTRATION: ChiCTR2400081458.

PATIENT SAMPLE

78 patients underwent spinal decompression surgery at The Sixth Medical Center of Chinese PLA General Hospital. The inclusion criteria included a diagnosis of CCM due to spondylosis or ossification of the longitudinal ligament. Participants were excluded if they had prior spinal surgeries or comorbidities unrelated to CCM.

OUTCOME MEASURES

The primary outcome was the Japanese Orthopaedic Association (JOA) score, assessing spinal function. Secondary outcomes included the Neck Disability Index (NDI), Visual Analogue Scale (VAS) for pain, and three-dimensional gait analysis.

METHODS

This study was a double-blind randomized controlled trial comparing two postoperative rehabilitation strategies for patients with CCM following endoscopic spinal decompression surgery. After surgery, patients were randomly assigned to two groups. The experimental group received personalized rehabilitation based on real-time intraoperative spinal cord status assessments, using a combination of endoscopic visualization and electrophysiological grading. Interventions included lower limb exoskeleton-assisted walking and targeted motor function training. The control group received conventional standard rehabilitation treatment. Both groups were assessed using the JOA, NDI, and VAS scores before rehabilitation, 1 month, 3 months, and 12 months after the start of rehabilitation. Additionally, gait analysis (including stride frequency, gait velocity, and stride length) was performed before and 3 months after the start of rehabilitation to evaluate the clinical rehabilitation outcomes in both groups.

RESULTS

Both groups showed significant improvements in JOA, NDI, VAS scores, and gait tests during the postoperative rehabilitation process. The experimental group demonstrated a more substantial increase in the primary outcome measure, the JOA score (12MO: 4.79±0.74 vs 3.53±0.93, P < 0.05). Additionally, the experimental group exhibited notable improvements in both stride frequency and gait velocity (3MO: Stride frequency (3.76±0.23 vs 1.05±0.07) and Gait velocity (4.53±0.63 vs 4.21±0.43), P < 0.05).

CONCLUSIONS

The spinal cord status assessment methods based on spinal endoscopy and electrophysiological techniques can effectively evaluate the condition of the spinal cord. When combined with personalized rehabilitation strategies tailored to these assessments, they can significantly enhance the postoperative spinal cord function recovery in CCM patients, providing superior clinical rehabilitation outcomes compared to traditional rehabilitation methods.

Changes in Intramedullary Increased Signal Intensity on Axial T2-weighted MRI After Laminoplasty for Cervical Spondylotic Myelopathy: A 10-year Follow-up Study

STUDY DESIGN

A retrospective study.

OBJECTIVE

To investigate whether the preoperative classification and changes in the intramedullary increased signal intensity (ISI) on axial T2-weighted magnetic resonance imaging (MRI) reflect the postoperative functional outcome in patients after laminoplasty for cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

Although patients with CSM exhibit ISI on axial MRI, the association between ISI (preoperative classification and changes) and surgical outcomes has not been investigated.

PATIENTS AND METHODS

We retrospectively included patients with CSM who underwent MRI preoperatively and at least 10 years postoperatively after laminoplasty between January 2009 and December 2010. According to axial images for the cervical compressive myelopathy (Ax-CCM) system, the ISI on axial images was classified as follows: type 0, normal; type 1, diffuse; type 2, fuzzy focal; and type 3, discrete focal. Functional outcomes, as measured by the Japanese Orthopaedic Association (JOA) score and JOA recovery rate, were evaluated based on the Ax-CCM classification.

RESULTS

Forty-three patients were enrolled. The mean follow-up time was 11.0±1.0 years. At the final follow-up, postoperative changes in the type of ISI were observed in 62.8% of patients. The type of ISI improved in 5 patients (11.6%), remained unchanged in 16 patients (37.2%), and worsened in 22 patients (51.2%). Patients with preoperative type 2 ISI had worse postoperative JOA scores and JOA recovery rates than those with other types. A worse ISI type was related to a lower postoperative JOA score and a lower recovery rate at the final follow-up.

CONCLUSIONS

Type 2 ISI was associated with poor postoperative symptoms and low postoperative function improvement. ISI changed after laminoplasty in 27 patients (62.8%), and worsened ISI was related to poor surgical outcomes.

Pre-operative spinal cord perfusion quantified by DSC MRI as a predictor of post-operative prognosis in patients with cervical spondylotic myelopathy

OBJECTIVE

This study aims to investigate the potential of preoperative blood supply condition measured by dynamic susceptibility contract (DSC) MRI in prediction of postoperative outcomes for patients with cervical spondylotic myelopathy (CSM).

MATERIALS AND METHOD

Thirty-nine patients (Age: 61 ± 7, male: 23, female: 16) with CSM who underwent laminoplasty were enrolled. All patients received DSC MRI before the operation. Five parameters include Enhance, rEnhance, full width at half maxima (FWHM), Slope1 and Slope2 in DSC MRI, were calculated at all the compressed spinal cord segments. Clinical outcomes were evaluated by modified Japanese Orthopaedic Association (mJOA) scores. Patients were divided into two groups based on mJOA recovery rate of 5 years: good recovery (> 50%) or poor recovery (≤ 50%). The difference between two groups were compared. The value of DSC MRI to CSM was evaluated by logistic and receiver operating characteristic (ROC) curve analysis.

RESULTS

There were 26 patients in good recovery group and 13 patients in poor recovery group. The baseline characteristics, including age, gender, preoperative mJOA score, and smoking status showed no significant difference between the two groups (all p > 0.05). The FWHM was significantly higher in the poor recovery group (9.77 ± 2.78) compared to the good recovery group (6.64 ± 1.65) (p = 0.002). Logistic regression analysis indicated that an increased FWHM was a significant risk factor for poor prognosis recovery (p = 0.013, OR = 0.392, 95%CI: 0.187-0.822). The AUC of FWHM for ROC was 0.843 (95% CI: 0.710-0.975) with a p value of 0.001. In addition, an FWHM greater than 5.87, with a sensitivity of 92.3% and specificity of 69.2%, was found to be an independent risk factor for poor postoperative recovery in patients with CSM.

CONCLUSION

In this study, we successfully quantified the spinal cord blood supply condition by DSC MRI technique. We found that an increase in FWHM was an independent risk factor for poor postoperative recovery in CSM patients. Specifically, patients with FWHM > 5.87 have a poor postoperative recovery.

Application of Short T1 Inversion Recovery Sequence in Increased Signal Intensity Following Cervical Spondylotic Myelopathy

OBJECTIVES

To compare magnetic resonance (MR) short T1 inversion recovery (STIR) sequence with MR T2-weighted (T2W) sequence for detecting increased signal intensity (ISI) and assessing outcomes of ISI in cervical spondylotic myelopathy (CSM).

METHODS

Data of patients with CSM who showed ISI on MR imaging and had undergone cervical spine surgery were retrospectively reviewed. STIR and T2W images were examined to assess signal intensity ratio (SIR), length and grading of the ISI, maximal spinal cord compression, canal narrowing ratio, and ligamentum flavum hypertrophy. The patients were divided into good and poor groups based on their outcomes. χ2 tests and variance analysis were used to assess intergroup differences. Univariate and multivariate logistic regression analyses were performed to identify risk factors for poor outcomes, and receiver operating characteristic curves were plotted to detect prognostic effects.

RESULTS

SIR and ISI lengths were significantly different between the STIR and T2 images. In the univariate logistic regression analysis, age, diabetes, SIRT2, SIRSTIR, and ISISTIR grading were significant factors. Accordingly, in the multivariate logistic regression analysis, age, diabetes, SIRT2, and SIRSTIR were included in the model. Among patients with diabetes, we observed a significant difference between SIRT2 and SIRSTIR.

CONCLUSIONS

The STIR sequence demonstrated superior capability to the T2W sequence in detecting ISI; however, there was no obvious difference in predicted outcomes. STIR sequence has a better prognostic value than T2W sequence in patients with diabetes who have CSM. ISI grading based on the STIR sequence may be a clinically valuable indicator.

Predictive Nomogram for Clinical Prognosis in Cervical Spondylotic Myelopathy With Intramedullary T2-Weighted Increased Signal Intensity: A Novel Digital Tool for Patient Prognosis Education

AIMS

To establish a predictive nomogram for clinical prognosis in cervical spondylotic myelopathy (CSM) with intramedullary T2-weighted increased signal intensity (ISI).

METHODS

The clinical data of 680 patients with CSM with intramedullary T2-weighted ISI were retrospectively analyzed. The patients were divided into the modeling group (476) and the validation group (204) by using a random number table at a ratio of 7:3. The independent prognostic factors were screened using multivariate logistic regression analysis. The factors were subsequently incorporated into the establishment of the predictive nomogram. The area under the receiver operating characteristic (ROC) curve (AUC) was undertaken to estimate the discrimination of the predictive nomogram. The calibration curve and the Hosmer-Lemeshow test were used to assess the calibration of the predictive nomogram. The clinical usefulness of the predictive nomogram was evaluated by decision curve analysis (DCA).

RESULTS

Based on the pre-operative Japanese Orthopedic Association (JOA) score, maximal canal compromise (MCC), and maximal spinal cord compression (MSCC), we established a predictive nomogram. The AUCs in the modeling group and validation group were 0.892 (95% CI: 0.861~0.924) and 0.885 (95% CI: 0.835~0.936), respectively, suggesting good discrimination of the nomogram. Calibration curves showed a favorable consistency between the predicted probability and the actual probability. In addition, the values of P of the Hosmer-Lemeshow were 0.253 and 0.184, respectively, suggesting good calibration of the nomogram. DCA demonstrated that the nomogram had good clinical usefulness.

CONCLUSION

We established and validated a predictive nomogram for the clinical prognosis in CSM with intramedullary T2-weighted ISI. This predictive nomogram could help clinicians and patients identify high-risk patients and educate them about prognosis, thereby improving the prognosis of high-risk patients.