Degenerative cervical myelopathy outcome

Degenerative cervical myelopathy outcome

Preoperative duration of symptoms may significantly impact outcomes in patients treated surgically for degenerative cervical myelopathy (DCM).

Tetreault et al. analyzed whether duration of symptoms is associated with preoperative functional impairment, disability, and quality of life and (ii) determine the optimal timing for decompressive surgery.

Patients with DCM were prospectively enrolled in either the AOSpine North American or International study at 26 global sites (n = 757). Postoperative functional impairment was evaluated at 1-yr using the modified Japanese Orthopaedic Association (mJOA) score. Change scores between baseline and 1-yr were computed for the mJOA. Duration of symptoms was dichotomized into a “short” and “long” group at several cut-offs. Analysis of covariance was used to evaluate differences in change scores on the mJOA between the duration of symptoms groups in 4-mo increments.

The cohort consisted of 424 men and 255 women, with a mean duration of symptoms of 26.1 ± 36.4 mo (0.25-252 mo). Duration of symptoms was not correlated with preoperative mJOA, Nurick, Neck Disability Index, or Short-Form (SF)-36 Physical and Mental Component Scores. Patients with a duration of symptoms shorter than 4 mo had significantly better functional outcomes on the mJOA than patients with a longer duration of symptoms (>4 mo). Thirty-two months was also a significant cut-off.

Patients who are operated on within 4 mo of symptom presentation have better mJOA outcomes than those treated after 4 mo. It is recommended that patients with DCM are diagnosed in a timely fashion and managed appropriately 1).


Zileli et al. conducted a study to review the literature systematically to determine the most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures they recommended to use modified Japanese Orthopaedic Association scaleNurick scale, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticityclonus, and Babinski sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future 2).


Left untreated degenerative cervical myelopathy can lead to spastic tetraparesis 3).

A study investigating quality of life in DCM patients indicated they suffer among the worst SF36 health scores of all chronic diseases 4).

Cervical spondylotic myelopathy surgery outcome

References

1)

Tetreault L, Wilson JR, Kotter MRN, Côté P, Nouri A, Kopjar B, Arnold PM, Fehlings MG. Is Preoperative Duration of Symptoms a Significant Predictor of Functional Outcomes in Patients Undergoing Surgery for the Treatment of Degenerative Cervical Myelopathy? Neurosurgery. 2019 Nov 1;85(5):642-647. doi: 10.1093/neuros/nyy474. PubMed PMID: 30445506.
2)

Zileli M, Maheshwari S, Kale SS, Garg K, Menon SK, Parthiban J. Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations. Neurospine. 2019 Sep;16(3):435-447. doi: 10.14245/ns.1938196.098. Epub 2019 Sep 30. PubMed PMID: 31607075.
3)

Chen LF, Tu TH, Chen YC, Wu JC, Chang PY, Liu L, Huang WC, Lo SS, Cheng H. Risk of spinal cord injury in patients with cervical spondylotic myelopathy and ossification of posterior longitudinal ligament: a national cohort study. Neurosurg Focus. 2016 Jun;40(6):E4. doi: 10.3171/2016.3.FOCUS1663. PubMed PMID: 27246487.
4)

Oh T, Lafage R, Lafage V, Protopsaltis T, Challier V, Shaffrey C, Kim HJ, Arnold P, Chapman J, Schwab F, Massicotte E, Yoon T, Bess S, Fehlings M, Smith J, Ames C. Comparing Quality of Life in Cervical Spondylotic Myelopathy with Other Chronic Debilitating Diseases Using the Short Form Survey 36-Health Survey. World Neurosurg. 2017 Oct;106:699-706. doi: 10.1016/j.wneu.2016.12.124. Epub 2017 Jan 5. PubMed PMID: 28065875.

Miyazaki syndrome

Miyazaki syndrome

Miyazaki syndrome is a cervical myelopathy or cervical radiculopathy caused by cervical epidural venous congestion, due to shunt overdrainage. The complex pathophysiology includes CSF pressure-changes consistent with the Monro-Kellie hypothesis and a non-functional Starling resistor, leading to spinal epidural venous plexus enlargement and dilation. This venous congestion may be significant enough to exert compression on the spinal cord or nerve roots. The typical clinical and imaging findings together with a history of ventricular CSF shunting may establish the diagnosis, proven by a successful treatment. The aim of treatment is the abrogation of CSF over-drainage. The eligible interventions may be the followings: the increase of the opening-pressure of the valve system by the insertion of a new programmable valve if necessary, closing or removing the shunt.


In 1997 Miyazaki et al. described a case of intracranial hypotension syndrome due to overdrainage of cerebrospinal fluid presented with hearing loss afterventriculoperitoneal shunting procedure. A 69-year-old man suffering from subarachnoid hemorrhage presented with an angiogram showing two aneurysms, one of the right internal carotid artery and one of the middle cerebral artery. Neck clipping was performed. One month later, he developed normal pressure hydrocephalus (NPH), which was treated by ventriculoperitoneal shunting procedure using low pressure Pudenz valve system. Trias of NPH were improved by insertion of shunt system. However, he complained of hearing loss which was worsened by upright position and improved by lying down. Such kinds of phenomenon were demonstrated by audiogram showing that the transitory decrease of hearing and electrocochleography showing the elongation of N1 latency at upright position. These data suggested that his hearing loss was caused by inner ear or auditory nerve lesion. After the shunt system was replaced into the antisiphon device, his hearing disturbance improved. Axial computed tomography of bone window at the level of orbitomeatal line demonstrated widely perilymphatic duct on both sides. This finding suggested that the fluctuation of intracranial pressure was easily transmitted into the cochlear through the widened perilymphatic duct, resulting in hearing disturbance 1).


Várallyay et al. want to call attention to this rare iatrogenic condition with potentially severe consequences.

They performed a systematic literature-review and presented ther five cases.

Once recognized in time, Miyazaki syndrome can be well taken care of.

Patients with chronic ventricular shunt need monitoring for CSF over-drainage to recognise potential complications such as cervical myelopathy or radiculopathy 2).


In 2018 a 33-year-old patient had undergone placement of a ventriculoperitoneal shunt with a pressure-adjustable valve for communicating hydrocephalus years before presenting to our department with the complaints of constant headache and unsteady gait. On the basis of the clinical picture and her history, plain and contrast-enhanced cranial and whole spine magnetic resonance imaging and magnetic resonance angiography examinations were performed, with the scans revealing signs indicative of cerebrospinal fluid hypotension typical of Miyazaki syndrome 3).


In 2015 Caruso et al. reported one case 4).

References

1)

Miyazaki Y, Tomii M, Sawauchi S, Ikeuchi S, Yuki K, Abe T. [A case of hearing loss caused by overdrainage of cerebrospinal fluid after ventriculo-peritoneal shunting procedure]. No Shinkei Geka. 1997 Apr;25(4):367-71. Japanese. PubMed PMID: 9125722.
2)

Várallyay P, Nagy Z, Szűcs A, Czigléczki G, Markia B, Nagy G, Osztie É, Vajda J, Vitanovics D. Miyazaki syndrome: Cervical myelo/radiculopathy caused by overshunting. A systematic review. Clin Neurol Neurosurg. 2019 Sep 24;186:105531. doi: 10.1016/j.clineuro.2019.105531. [Epub ahead of print] PubMed PMID: 31622897.
3)

Kovács A, Németh T, Csomor A, Novák T, Kövér F, Vörös E. Miyazaki Syndrome due to Ventriculoperitoneal Shunt Treatment. World Neurosurg. 2018 Aug;116:29-34. doi: 10.1016/j.wneu.2018.05.032. Epub 2018 May 31. PubMed PMID: 29775766.
4)

Caruso R, Wierzbicki V, Marrocco L, Pesce A, Piccione E. A Poorly Known Cerebrospinal Fluid Shunt Complication: Miyazaki Syndrome. World Neurosurg. 2015 Sep;84(3):834-8. doi: 10.1016/j.wneu.2015.04.030. Epub 2015 Apr 23. PubMed PMID: 25913430.
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