Risk factors for rapid progressive neurological deterioration in patients with cervical spondylotic myelopathy

[Analysis of imaging characteristics and effectiveness of cervical spondylotic myelopathy with cervical kyphosis]

Objective

To investigate the imaging characteristics of cervical kyphosis and spinal cord compression in cervical spondylotic myelopathy (CSM) with cervical kyphosis and the influence on effectiveness.

Methods

The clinical data of 36 patients with single-segment CSM with cervical kyphosis who were admitted between January 2020 and December 2022 and met the selection criteria were retrospectively analyzed. The patients were divided into 3 groups according to the positional relationship between the kyphosis focal on cervical spine X-ray film and the spinal cord compression point on MRI: the same group (group A, 20 cases, both points were in the same position), the adjacent group (group B, 10 cases, both points were located adjacent to each other), and the separated group (group C, 6 cases, both points were located >1 vertebra away from each other). There was no significant difference between groups ( P>0.05) in baseline data such as gender, age, body mass index, lesion segment, disease duration, and preoperative C 2-7 angle, C 2-7 sagittal vertical axis (C 2-7 SVA), C 7 slope (C 7S), kyphotic Cobb angle, fusion segment height, and Japanese Orthopedic Association (JOA) score. The patients underwent single-segment anterior cervical discectomy with fusion (ACDF). The occurrence of postoperative complications was recorded; preoperatively and at last follow-up, the patients' neurological function was evaluated using the JOA score, and the sagittal parameters (C 2-7 angle, C 2-7 SVA, C 7S, kyphotic Cobb angle, and height of the fused segments) were measured on cervical spine X-ray films and MRI and the correction rate of the cervical kyphosis was calculated; the correlation between changes in cervical sagittal parameters before and after operation and the JOA score improvement rate was analyzed using Pearson correlation analysis.

Results

In 36 patients, only 1 case of dysphagia occurred in group A, and the dysphagia symptoms disappeared at 3 days after operation, and the remaining patients had no surgery-related complications during the hospitalization. All patients were followed up 12-42 months, with a mean of 20.1 months; the difference in follow-up time between the groups was not significant ( P>0.05). At last follow-up, all the imaging indicators and JOA scores of patients in the 3 groups were significantly improved when compared with preoperative ones ( P<0.05). The correction rate of cervical kyphosis in group A was significantly better than that in group C, and the improvement rate of JOA score was significantly better than that in groups B and C, all showing significant differences ( P<0.05), and there was no significant difference between the other groups ( P>0.05). The correlation analysis showed that the improvement rate of JOA score was negatively correlated with C 2-7 angle and kyphotic Cobb angle at last follow-up ( r=-0.424, P=0.010; r=-0.573, P<0.001), and positively correlated with the C 7S and correction rate of cervical kyphosis at last follow-up ( r=0.336, P=0.045; r=0.587, P<0.001), and no correlation with the remaining indicators ( P>0.05).

Conclusion

There are three main positional relationships between the cervical kyphosis focal and the spinal cord compression point on imaging, and they have different impacts on the effectiveness and sagittal parameters after ACDF, and those with the same position cervical kyphosis focal and spinal cord compression point have the best improvement in effectiveness and sagittal parameters.

The role of comprehensive rehabilitation in the care of degenerative cervical myelopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To find out if comprehensive rehabilitation itself can improve daily performance in persons with DCM.

SETTING

The spinal department of a rehabilitation hospital.

METHODS

Data from 116 DCM inpatients who underwent comprehensive rehabilitation after spinal surgery were retrospectively analyzed. The definitions of the calculated outcome variables made possible analyses that distinguished the effect of rehabilitation from that of spinal surgery. Paired t-tests were used to compare admission with discharge outcomes and functional gains. Spearman's correlations were used to assess relationships between performance gain during rehabilitation and between time from surgery to rehabilitation.

RESULTS

The Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI) increased during rehabilitation from 57 (24) to 78 (19) (p < 0.001). The Spinal Cord Independence Measure 3rd version (SCIM III) gain attributed to neurological improvement (dSCIM-IIIn) was 6.3 (9.2), and that attributed to rehabilitation (dSCIM-IIIr) 16 (18.5) (p < 0.001). dSCIM-IIIr showed a rather weak negative correlation with time from spinal surgery to rehabilitation (r = -0.42, p < 0.001).

CONCLUSIONS

The study showed, for the first time, that comprehensive rehabilitation can achieve considerable functional improvement for persons with DCM of any degree, beyond that of spinal surgery. Combined with previously published evidence, this indicates that comprehensive rehabilitation can be considered for persons with DCM of any functional degree, before surgery.

Voxel- and tensor-based morphometry with machine learning techniques identifying characteristic brain impairment in patients with cervical spondylotic myelopathy

Aim

The diagnosis of cervical spondylotic myelopathy (CSM) relies on several methods, including x-rays, computed tomography, and magnetic resonance imaging (MRI). Although MRI is the most useful diagnostic tool, strategies to improve the precise and independent diagnosis of CSM using novel MRI imaging techniques are urgently needed. This study aimed to explore potential brain biomarkers to improve the precise diagnosis of CSM through the combination of voxel-based morphometry (VBM) and tensor-based morphometry (TBM) with machine learning techniques.

Methods

In this retrospective study, 57 patients with CSM and 57 healthy controls (HCs) were enrolled. The structural changes in the gray matter volume and white matter volume were determined by VBM. Gray and white matter deformations were measured by TBM. The support vector machine (SVM) was used for the classification of CSM patients from HCs based on the structural features of VBM and TBM.

Results

CSM patients exhibited characteristic structural abnormalities in the sensorimotor, visual, cognitive, and subcortical regions, as well as in the anterior corona radiata and the corpus callosum [P < 0.05, false discovery rate (FDR) corrected]. A multivariate pattern classification analysis revealed that VBM and TBM could successfully identify CSM patients and HCs [classification accuracy: 81.58%, area under the curve (AUC): 0.85; P < 0.005, Bonferroni corrected] through characteristic gray matter and white matter impairments.

Conclusion

CSM may cause widespread and remote impairments in brain structures. This study provided a valuable reference for developing novel diagnostic strategies to identify CSM.

The significance of metabolic disease in degenerative cervical myelopathy: a systematic review

Introduction

Degenerative cervical myelopathy (DCM) is a form of chronic spinal cord injury, with a natural history of potential for progression over time. Whilst driven by mechanical stress on the spinal cord from degenerative and congenital pathology, the neurological phenotype of DCM is likely to be modified by multiple systemic factors. The role of metabolic factors is therefore of interest, particularly given that ischaemia is considered a key pathological mechanism of spinal cord injury. The objective was therefore to synthesise current evidence on the effect of metabolism on DCM susceptibility, severity, and surgical outcomes.

Methods

A systematic review in MEDLINE and Embase was conducted following PRISMA guidelines. Full-text papers in English, with a focus on DCM and metabolism, including diabetes, cardiovascular disease, anaemia, and lipid profile, were eligible for inclusion. Risk of methodological bias was assessed using the Joanna Briggs Institute (JBI) critical assessment tools. Quality assessments were performed using the GRADE assessment tool. Patient demographics, metabolic factors and the relationships between metabolism and spinal cord disease, spinal column disease and post-operative outcomes were assessed.

Results

In total, 8,523 papers were identified, of which 57 met criteria for inclusion in the final analysis. A total of 91% (52/57) of included papers assessed the effects of diabetes in relation to DCM, of which 85% (44/52) reported an association with poor surgical outcomes; 42% of papers (24/57) discussed the association between cardiovascular health and DCM, of which 88% (21/24) reported a significant association. Overall, DCM patients with diabetes or cardiovascular disease experienced greater perioperative morbidity and poorer neurological recovery. They were also more likely to have comorbidities such as obesity and hyperlipidaemia.

Conclusion

Metabolic factors appear to be associated with surgical outcomes in DCM. However, evidence for a more specific role in DCM susceptibility and severity is uncertain. The pathophysiology and natural history of DCM are critical research priorities; the role of metabolism is therefore a key area for future research focus.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021268814.

Cervical alignment and clinical outcome of anterior cervical discectomy and fusion vs. anterior cervical corpectomy and fusion in local kyphotic cervical spondylotic myelopathy

Background

Cervical local kyphosis (CLK) is a common degenerative disorder with a potentially debilitating and intractable condition. Currently, there is still debate on the optimal treatment of local kyphotic cervical spondylotic myelopathy (LKCSM) via different anterior approaches.

Objective

The objective of this study was to evaluate the surgical efficacy of anterior cervical discectomy and fusion (ACDF) vs. anterior cervical corpectomy and fusion (ACCF) for the treatment of LKCSM. In addition, the cervical sagittal alignment parameters and axial symptoms (AS) severity after CLK correction were analyzed.

Materials and methods

From January 2016 and December 2020, 104 patients who suffered LKCSM were retrospectively reviewed. These patients underwent ACDF (n = 53) and ACCF (n = 51). Pre- and postoperatively, cervical sagittal alignment parameters were measured on the lateral X-rays, including local kyphotic angles (LKA), C2-7 Cobb angle, T1 slope, and C2-7 sagittal vertical axis (C2-7 SVA). The neurological recovery rate was calculated according to the Japanese Orthopedic Association (JOA) score. The AS severity was evaluated using Neck Disability Index (NDI).

Results

Significant differences (P < 0.05) were demonstrated between ACDF and ACCF groups regarding LKA, LKA correction, C2-7 Cobb angle, T1 slope, C2-7 SVA, NDI, NDI recovery and NDI ranking system. However, no significant differences (P > 0.05) existed in JOA score, recovery rate, and neurological recovery rate grade. In both groups, significant differences (P < 0.05) were demonstrated between pre- and postoperative LKA, T1 slope, C2-7 Cobb angle, C2-7 SVA, JOA score, and NDI. LKA correction showed the positive correlations with the recovery rate (r = 0.48, P < 0.001), and with the NDI recovery in ACDF group (r = 0.49, P < 0.001) and in ACCF group (r = 0.55, P < 0.001).

Conclusions

LKCSM with ≤3 segments of spinal cord compression can be improved with either ACDF or ACCF, resulting in satisfactory neurological outcomes. CLK correction can significantly improve the neurological function and AS, and increase the T1 slope and C2-7 SVA. However, ACDF was more favorable than ACCF in the CLK correction.

Magnetic Resonance Imaging-CCCFLS Scoring System: Toward Predicting Clinical Symptoms and C5 Paralysis

STUDY DESIGN

A retrospective study.

OBJECTIVE

To develop a new MRI scoring system to assess patients' clinical characteristics, outcomes and complications.

METHODS

A retrospective 1-year follow-up study of 366 patients with cervical spondylosis from 2017 to 2021. The CCCFLS scores (cervical curvature and balance (CC), spinal cord curvature (SC), spinal cord compression ratio (CR), cerebrospinal fluid space (CFS). Spinal cord and lesion location (SL). Increased Signal Intensity (ISI) were divided into Mild group (0-6), Moderate group (6-12), and Severe group (12-18) for comparison, and the Japanese Orthopaedic Association (JOA) scores, visual analog scale (VAS), numerical rating scale (NRS), Neck Disability Index (NDI) and Nurick scores were evaluated. Correlation and regression analyses were performed between each variable and the total model in relation to clinical symptoms and C5 palsy.

RESULTS

The CCCFLS scoring system was linearly correlated with JOA, NRS, Nurick and NDI scores, with significant differences in JOA scores among patients with different CC, CR, CFS, ISI scores, with a predictive model (R2 = 69.3%), and significant differences in preoperative and final follow-up clinical scores among the 3 groups, with a higher rate of improvement in JOA in the severe group (P < .05), while patients with and without C5 paralysis had significant differences in preoperative SC and SL (P < .05).

CONCLUSIONS

CCCFLS scoring system can be divided into mild (0-6). moderate (6-12), severe (12-18) groups. It can effectively reflect the severity of clinical symptoms, and the improvement rate of JOA is better in the severe group, while the preoperative SC and SL scores are closely related to C5 palsy.

LEVEL OF EVIDENCE

III.

Patient-reported Data as Predictors of Surgical Outcome in Patients With Degenerative Cervical Myelopathy: Analysis of a National Multicenter Dataset

STUDY DESIGN

Retrospective study design on prospectively collected registry data.

OBJECTIVE

To investigate whether improvement after surgery for degenerative cervical myelopathy is associated with preoperative disease severity and to identify predictors of outcome.

SUMMARY OF BACKGROUND DATA

Degenerative cervical myelopathy is the most common cause of spinal cord compromise in adults and surgery is often the treatment of choice. Identifying predictors may help to improve patient selection.

MATERIALS AND METHODS

This nationwide study from the Swedish spine registry included 901 patients treated surgically for degenerative cervical myelopathy. To investigate improvement in different disease severity groups, the individuals were divided into quartiles based on their preoperative European Myelopathy Scale (EMS) and EuroQol-5 Dimension (EQ-5D) index. Statistical analyses were made with analysis of variance, χ 2 , McNemar, and t tests. Multivariable linear or logistic regression was used to identify predictors for one-year improvement in EMS and EQ-5D index, and satisfaction at one year. In the regressions, the patient-reported outcome measures were dichotomized at their median, except improvement in EMS.

RESULTS

All patient-reported outcome measures improved from baseline to the one-year follow-up ( P <0.001). Statistically significant outcome improvements were seen in all disease severity groups. Preoperative low EMS (β=-1.37, P <0.001), long walking distance (<500 vs. >500 m; β=0.44, P =0.030), and low NDI (β=-0.43, P =0.048) were independent predictors of improvement in EMS. R2 was 0.11 for the multivariable model. Preoperative low EQ-5D index (odds ratio=0.11; 95% confidence interval: 0.07-0.16) and low NDI (0.56; 0.36-0.88) were independent predictors of improvement in EQ-5D index. Preoperative high EMS (1.86; 1.20-2.90) and shorter arm pain duration [<12 vs. >12 months (0.54; 0.33-0.88)] were independent predictors of satisfaction.

CONCLUSIONS

Postoperative improvement was seen over the whole range of disease severity. Disease severity, symptom duration, and walking distance were predictors of outcome in patients treated surgically for degenerative cervical myelopathy.

LEVEL OF EVIDENCE

III.

Influence of fixed titanium plate position on the effectiveness of open-door laminoplasty for cervical spondylotic myelopathy

BACKGROUND

During open-door laminoplasty, the position of the bone gutter is not fixed, and when the gutter migrates inward, the outer end of the titanium plate must be fixed on the lamina edge. It is unclear whether this will affect the clinical efficacy. This study aimed to observe the influence of the titanium plate fixation position on the effectiveness of open-door laminoplasty for cervical spondylotic myelopathy (CSM).

METHODS

A total of 98 patients with CSM who underwent open-door laminoplasty from August 2016 to October 2019 were included in this retrospective study. Fifty-five patients had the titanium plate fixed on the lateral mass (lateral mass group), and 43 patients had the titanium plate fixed on the lamina edge (lamina group). The opening angle, opening width, occurrence of hinge fracture, spinal cord drift distance, cervical curvature index (CCI), neurological function recovery (JOA score), neck function (NDI), C5 palsy and severity of axial symptoms were observed and compared between the two groups.

RESULTS

The opening angle in the lamina group was significantly larger than that in the lateral mass group, while the opening width and the spinal cord drift distance were significantly smaller than those in the lateral mass group (P < 0.05). The occurrence of hinge fracture in the lamina group was significantly higher than that in the lateral group (25.6% and 9.1%, respectively) (P < 0.05). The CCI was maintained well in both groups (P > 0.05), and there was no significant difference between the groups (P > 0.05). After surgery, the JOA score significantly increased in both groups (P < 0.05), and the neurological recovery rates were similar between the two groups (62.6% vs. 64.5%). The NDI score significantly decreased in both groups (P < 0.05), but the lateral mass group recovered to a greater degree than the lamina group (P < 0.05). The occurrence of C5 palsy was 2.3% in the lamina group and 14.5% in the lateral mass group, and there was a significant difference between the groups (P < 0.05). Postoperative axial symptom severity was significantly worse in the lamina group than in the lateral mass group (P < 0.05).

CONCLUSIONS

In open-door laminoplasty, it is feasible to fix the titanium plate on the lateral mass or to the lamina due to the same neurological function recovery. However, fixing it to the lamina will increase the opening angle and decrease the opening width, making the hinge prone to fracture and increasing the severity of postoperative axial symptoms.