degenerative

Degenerative cervical myelopathy

Degenerative cervical myelopathy

J.Sales-Llopis

Neurosurgery Service, Alicante University General Hospital, Alicante, Spain.

The assessment, diagnosis, operative and nonoperative management of degenerative cervical myelopathy (DCM) have evolved rapidly over the last 20 years. A clearer understanding of the pathobiology of DCM has led to attempts to develop objective measurements of the severity of myelopathy, including technology such as multiparametric magnetic resonance imaging, biomarkers, and ancillary clinical testing. New pharmacological treatments have the potential to alter the course of surgical outcomes, and greater innovation in surgical techniques have made surgery safer, more effective and less invasive. Future developments for the treatment of DCM will seek to improve the diagnostic accuracy of imaging, improve the objectivity of clinical assessment, and increase the use of surgical techniques to ensure the best outcome is achieved for each individual patient 1).

Goel was troubled by the fact that his several PubMed and MEDLINE indexed articles on the subject published in leading journals dedicated to the study of the spine have not found any place in the huge reference list of 137 articles 2)

Definition

Degenerative cervical myelopathy definition.

Epidemiology

Degenerative cervical myelopathy epidemiology.

Etiology

Degenerative cervical myelopathy etiology.

Pathophysiology

A review of Tetreault et al. summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood-spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies 3).

Histological findings

MEDLINE and Embase were systematically searched (CRD42021281462) for primary research reporting on histological findings of DCM in the human cadaveric spinal cord tissue. Data were extracted using a piloted proforma. The risk of bias was assessed using Joanna Briggs Institute critical appraisal tools. Findings were compared to a systematic review of animal models (Ahkter et al. 2020 Front Neurosci 14).

The search yielded 4127 unique records. After the abstract and full-text screening, 19 were included in the final analysis, reporting on 150 autopsies (71% male) with an average age at death of 67.3 years. All findings were based on hematoxylin and eosin (H&E) staining. The most commonly reported grey matter findings included neuronal loss and cavity formation. The most commonly reported white matter finding was demyelination. Axon loss, gliosis, necrosis, and Schwann cell proliferation were also reported. Findings were consistent amongst cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. Cavitation was notably more prevalent in human autopsies compared to animal models.

Few human spinal cord tissue studies have been performed. Neuronal loss, demyelination and cavitation were common findings. Investigating the biological basis of DCM is a critical research priority. Human spinal cord specimen may be an underutilized but complementary approach 4).

Clinical features

Degenerative cervical myelopathy clinical features

Scales

European myelopathy score.

As a widespread used scale, the Modified Japanese Orthopaedic Association scale (mJOA) should be translated and culturally adapted 5).

see Cervical spine stenosis scales

Diagnosis

Degenerative cervical myelopathy diagnosis.

Differential diagnosis

Degenerative Cervical Myelopathy Differential Diagnosis.

Treatment

Degenerative cervical myelopathy treatment

Outcome

see Degenerative cervical myelopathy outcome.

Research

Degenerative cervical myelopathy research.

Randomized, controlled trials

A National Institutes of Health-funded (1R13AR065834-01) investigator meeting was held before the initiation of the trial to bring multiple stakeholders together to finalize the study protocol. Study investigators, coordinators, and major stakeholders were able to attend and discuss strengths of, limitations of, and concerns about the study. The final protocol was approved for funding by the Patient-Centered Outcomes Research Institute (CE-1304-6173). The trial began enrollment on April 1, 2014 6).

Case series

see Degenerative cervical myelopathy case series.

Case reports

Degenerative cervical myelopathy case reports

References

1)

Wilson JRF, Badhiwala JH, Moghaddamjou A, Martin AR, Fehlings MG. Degenerative Cervical Myelopathy; A Review of the Latest Advances and Future Directions in Management. Neurospine. 2019 Sep;16(3):494-505. doi: 10.14245/ns.1938314.157. Epub 2019 Aug 26. PubMed PMID: 31476852; PubMed Central PMCID: PMC6790745.
2)

Goel A. Degenerative Cervical Myelopathy. Neurospine. 2019 Dec;16(4):793-795. doi: 10.14245/ns.1938384.192. Epub 2019 Dec 31. PubMed PMID: 31905465.
3)

Tetreault L, Goldstein CL, Arnold P, Harrop J, Hilibrand A, Nouri A, Fehlings MG. Degenerative Cervical Myelopathy: A Spectrum of Related Disorders Affecting the Aging Spine. Neurosurgery. 2015 Oct;77 Suppl 4:S51-67. doi: 10.1227/NEU.0000000000000951. PubMed PMID: 26378358.
4)

Dohle E, Beardall S, Chang A, Mena KPC, Jovanović L, Nath U, Lee KS, Smith AH, Thirunavukarasu AJ, Touzet AY, Norton EJ, Mowforth OD, Kotter MRN, Davies BM. Human spinal cord tissue is an underutilised resource in degenerative cervical myelopathy: findings from a systematic review of human autopsies. Acta Neurochir (Wien). 2023 Feb 23. doi: 10.1007/s00701-023-05526-5. Epub ahead of print. PMID: 36820887.
5)

Augusto MT, Diniz JM, Rolemberg Dantas FL, Fernandes de Oliveira M, Rotta JM, Botelho RV. Development of the Portuguese version of the modified Japanese Orthopaedic Association Score: cross-cultural adaptation, reliability, validity and responsiveness. World Neurosurg. 2018 Jun 1. pii: S1878-8750(18)31127-6. doi: 10.1016/j.wneu.2018.05.173. [Epub ahead of print] PubMed PMID: 29864576.
6)

Ghogawala Z, Benzel EC, Heary RF, Riew KD, Albert TJ, Butler WE, Barker FG 2nd, Heller JG, McCormick PC, Whitmore RG, Freund KM, Schwartz JS. Cervical Spondylotic Myelopathy Surgical Trial: Randomized, Controlled Trial Design and Rationale. Neurosurgery. 2014 Oct;75(4):334-346. PubMed PMID: 24991714.

Diffusion tensor imaging for degenerative cervical myelopathy

Diffusion tensor imaging for degenerative cervical myelopathy

Despite its invasiveness, computed tomography myelography (CTM) is still considered an important supplement to conventional magnetic resonance imaging (MRI) for preoperative evaluation of multilevel degenerative cervical myelopathy. Schöller et al., analyzed if diffusion tensor imaging (DTI) could be a less invasive alternative for this purpose.

In 20 patients with degenerative cervical myelopathy and an indication for decompression of at least one level, CTM was performed preoperatively to determine the extent of spinal canal/cerebrospinal fluid (CSF) space and cord compression (Naganawa score) for a decision on the number of levels to be decompressed. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were correlated with these parameters and with MRI-based increased signal intensity (ISI). Receiver operating characteristic analysis was performed to determine the sensitivity to discriminate levels requiring decompression surgery. European Myelopathy Score(EMS) and neck/radicular visual analog scale (VAS-N/R) were used for clinical evaluation.

According to preoperative CTM, 20 levels of maximum and 16 levels of relevant additional stenosis were defined and decompressed. Preoperative FA and particularly ADC showed a significant correlation with the CTM Naganawa score but also with the ISI grade. Furthermore, both FA and ADC facilitated a good discrimination between stenotic and nonstenotic levels with cutoff values < 0.49 for FA and > 1.15 × 10-9 m2/s for ADC. FA and especially ADC revealed a considerably higher sensitivity (79% and 82%, respectively) in discriminating levels requiring decompression surgery compared with ISI (55%). EMS and VAS-N/R were significantly improved at 14 months compared with preoperative values.

DTI parameters are highly sensitive at distinguishing surgical from nonsurgical levels in CSM patients and might therefore represent a less invasive alternative to CTM for surgical planning 1).

A study population included 50 patients with symptoms of cervical myelopathy. The patients were evaluated based on symptoms using the European myelopathy scoring system and were divided into: Grade 1, including patients with mild symptoms; Grade 2, referring to patients with moderate symptoms and Grade 3, which included patients revealing severe symptoms. All the patients were investigated with a 1.5 T MRI unit acquiring DWI and DTI sequences. FA and ADC values from each spinal segment were analyzed in terms of Frequency, Percentage, Mean, Standard Deviation and Confidence Intervals. The comparison of values was done by ANOVA and post hoc analysis by bonferroni test. Comparison of accuracy of FA, ADC and T2WI in recognizing myelopathic changes was done by t-test. Receiver Operating Characteristics (ROC) analysis was performed to obtain a cut off value of FA and ADC for each spinal level to identify myelopathic change in the spinal cord.

The study revealed a significant difference in the mean FA and ADC value of stenotic and Non-stenotic segments. T2WI was highly significant (p = 0.000) in recognizing myelopathy changes in patients falling under Grade 2(moderate) and Grade 3(severe) according to European Myelopathy scoring system. Regarding patients under Grade 1 (mild) FA and ADC values showed significant difference compared to T2WI. The collective sensitivity in the identification of myelopathic changes was highest with FA (79%) as compared to ADC (71%) and T2WI (50%). ROC analysis was done to determine the cut off values of FA and ADC at each cervical spine segments. The proposed cut off, for FA and ADC at the level of C1-C2 is 0.68 and 0.92, C2-C3 is 0.65 and 1.03, C3-C4 is 0.63 and 1.01, C4-C5 0.61 and 0.98, At C5-C6 0.57 and 1.04, At C6-C7 0.56 and 0.96 respectively.

FA and ADC values enhance the efficacy and accuracy of MRI in the diagnosis of cervical spondylotic myelopathy. Hence diffusion tensor imaging can be used as a non-invasive modality to recognize spondylotic myelopathy changes even in the early stages, which can be helpful in deciding on appropriate timing of decompression surgery before the irreversible chronic changes set in 2).

A meta-analysis was conducted to assess alterations in measures of diffusion tensor imaging (DTI) in the patients of cervical spondylotic myelopathy (CSM), exploring the potential role of DTI as a diagnosis biomarker. A systematic search of all related studies written in English was conducted using PubMed, Web of Science, EMBASE, CINAHL, and Cochrane comparing CSM patients with healthy controls. Key details for each study regarding participants, imaging techniques, and results were extracted. DTI measurements, such as fractional anisotropy (FA), apparent diffusion coefficient (ADC), and mean diffusivity (MD) were pooled to calculate the effect size (ES) by fixed or random effects meta-analysis. 14 studies involving 479 CSM patients and 278 controls were identified. Meta-analysis of the most compressed levels (MCL) of CSM patients demonstrated that FA was significantly reduced (ES -1.52, 95% CI -1.87 to -1.16, P < 0.001) and ADC was significantly increased (ES 1.09, 95% CI 0.89 to 1.28, P < 0.001). In addition, a notable ES was found for lowered FA at C2-C3 for CSM vs. controls (ES -0.83, 95% CI -1.09 to -0.570, P < 0.001). Meta-regression analysis revealed that male ratio of CSM patients had a significant effect on reduction of FA at MCL (P = 0.03). The meta-analysis of DTI studies of CSM patients clearly demonstrated a significant FA reduction and ADC increase compared with healthy subjects. This result supports the use of DTI parameters in differentiating CSM patients from health subjects. Future researches are required to investigate the diagnosis performance of DTI in cervical spondylotic myelopathy 3).

The measurement of DTI indexes within the spinal cord provides a quantitative assessment of neural damage in various spinal cord pathologies. DTI studies in animal models of spinal cord injury indicate that DTI is a reliable imaging technique with important histological and functional correlates.

DTI is a noninvasive marker of microstructural change within the spinal cord. In human studies, spinal cord DTI shows definite changes in subjects with acute and chronic spinal cord injury, as well as cervical spondylotic myelopathy. Interestingly, changes in DTI indexes are visualized in regions of the cord, which appear normal on conventional magnetic resonance imaging and are remote from the site of cord compression. Spinal cord DTI provides data that can help us understand underlying microstructural changes within the cord and assist in prognostication and planning of therapies 4).

References

1)

Schöller K, Siller S, Brem C, Lutz J, Zausinger S. Diffusion Tensor Imaging for Surgical Planning in Patients with Cervical Spondylotic Myelopathy. J Neurol Surg A Cent Eur Neurosurg. 2019 Jun 10. doi: 10.1055/s-0039-1691822. [Epub ahead of print] PubMed PMID: 31181580.
2)

Nukala M, Abraham J, Khandige G, Shetty BK, Rao APA. Efficacy of diffusion tensor imaging in identification of degenerative cervical spondylotic myelopathy. Eur J Radiol Open. 2018 Dec 12;6:16-23. doi: 10.1016/j.ejro.2018.08.006. eCollection 2019. PubMed PMID: 30581892; PubMed Central PMCID: PMC6293016.
3)

Guan X, Fan G, Wu X, Gu G, Gu X, Zhang H, He S. Diffusion tensor imaging studies of cervical spondylotic myelopathy: a systemic review and meta-analysis. PLoS One. 2015 Feb 11;10(2):e0117707. doi: 10.1371/journal.pone.0117707. eCollection 2015. Review. PubMed PMID: 25671624; PubMed Central PMCID: PMC4363894.
4)

Vedantam A, Jirjis MB, Schmit BD, Wang MC, Ulmer JL, Kurpad SN. Diffusion tensor imaging of the spinal cord: insights from animal and human studies. Neurosurgery. 2014 Jan;74(1):1-8. doi: 10.1227/NEU.0000000000000171. PubMed PMID: 24064483.

AOSpine Principles Course— Degenerative Spine and Tumors

It is going to be the third AOSpine course in Bulgaria and the second in Varna.

The course is targeted for residents and specialist in neurosurgery and orthopedics with limited experience in surgery of degenerative spine and spinal tumors. It focuses on the surgical approaches to the cervical, thoracic and lumbar spine for degenerative and neoplastic pathologies as well as on the spinal decompression and instrumentation for an accompanying instability.

Program

Degenerative Spinal Deformity: Creating Lordosis in the Lumbar Spine, An Issue of Neurosurgery Clinics of North America (The Clinics: Surgery)

Degenerative Spinal Deformity: Creating Lordosis in the Lumbar Spine, An Issue of Neurosurgery Clinics of North America (The Clinics: Surgery)

This issue of Neurosurgery Clinics, edited by Drs. Sigurd Berven and Praveen V. Mummaneni, will cover Degenerative Spinal Deformity: Creating Lordosis in the Lumbar Spine. Topics will include, but are not limited to, Spinopelvic Parameters; Location of lordosis (priority for L4-S1) and Age Adjustments; Approach Selection; Nuances of Pedicle Subtraction Osteotomy; Preventing Pseudarthrosis and PJK; The Challenge of Creating Lordosis in High Grade Dysplastic Spondylolisthesis; Sacropelvic Fixation; Evolution of the MISDEF Algorithm; Transpsoas Approach Nuances; Lateral Prepsoas Approach Nuances; Anterior Column Release; Navigation assisted MIS deformity correction; MIS TLIF; MIS PSO; and The challenge of L4-S1- fractional curves.

 

Book: Degenerative Diseases of the Cervical Spine: Therapeutic Management in the Subaxial Section

Degenerative Diseases of the Cervical Spine: Therapeutic Management in the Subaxial Section
By Alexander König, Uwe Spetzger

Degenerative Diseases of the Cervical Spine: Therapeutic Management in the Subaxial Section

List Price:$159.00
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The authors present anatomical, biomechanical, and clinical basic knowledge relevant to degenerative diseases of the surgical spine and describe how to choose the approach, implant, and surgical technique in detail. Numerous figures illustrate the decision-making process and surgical techniques step-by-step. The book also contains key points about implant safety and possible complications as well as an outlook to the future of cervical spine surgery.
Degenerative Diseases of the Cervical Spine is aimed at spinal surgeons (neurosurgeons and orthopaedic surgeons), physical therapists, general practitioners, and rehabilitation physicians, worldwide.

Product Details

  • Original language: German
  • Number of items: 1
  • Dimensions: 9.30″ h x .0″ w x 6.10″ l, .0 pounds
  • Binding: Hardcover
  • 132 pages

About the Author

S. Alexander König and Uwe Spetzger
Klinikum Karlsruhe, Karlsruhe, Germany

New Book: MRI of Degenerative Disease of the Spine: A Case-Based Atlas

MRI of Degenerative Disease of the Spine: A Case-Based Atlas
By Paola D’Aprile

MRI of Degenerative Disease of the Spine: A Case-Based Atlas

This richly illustrated case-based atlas thoroughly depicts the role of MR imaging in the assessment of patients presenting with pain due to degenerative disease of the spine and will serve as an excellent guide to differential diagnosis. Importantly, generic radicular compression is the main reason for the painful symptomatology in only a limited number of cases, and this book illustrates and emphasizes how various anatomic elements of the spine can be responsible. The imaging features of a range of disorders involving both the anterior and posterior elements of the spine are described, including active inflammatory osteochondrosis, atypical herniated discs, facet joint disorders, spondylolysis, and degenerative-inflammatory changes of the spinal ligaments and posterior perispinal muscles. Each example is supported by clinical data, and a series of unusual cases are also presented. MR study protocols include T2-weighted sequences with fat saturation and contrast-enhanced T1-weighted sequences with fat saturation to allow better visualization or highlighting of various inflammatory changes in the spine. Radiologists, neuroradiologists, neurosurgeons, orthopedists, and rehabilitation physicians will all find this atlas a valuable asset in their practice.

This is an excerpt from the content

  • A 48-year-old woman

  • Chronic low back pain

  • Improvement with rest

Fig. 1

(a–c) Sagittal SE T1-weighted image (a), sagittal TSE T2-weighted image with fat saturation (b), sagittal SE T1-weighted image with fat saturation following administration of contrast medium (c). The opposing L4 and L5 vertebral bodies present a hypointense band in T1 (a, arrows), with hyperintense signal in T2 (b, arrows) and contrast enhancement (c, arrows). The L4/L5 intervertebral disc is collapsed. The same disc shows hyperintense signal in T2 (b) and marginal contrast enhancement (c), due to sterile inflammation. Diagnosis: osteochondrosis in active-inflammatory phase (i.e. osteochondritis)

New Book: Degenerative Erkrankungen der Halswirbelsäule: Therapeutisches Management im subaxialen Abschnitt

Degenerative Erkrankungen der Halswirbelsäule: Therapeutisches Management im subaxialen Abschnitt (German Edition)

By Stefan Alexander König, Uwe SpetzgerDegenerative Erkrankungen der Halswirbelsäule: Therapeutisches Management im subaxialen Abschnitt (German Edition)

List Price $79.99
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Der Weg zur richtigen Therapieentscheidung in der HWS-Chirurgie. Zur Behandlung degenerativer Erkrankungen der Halswirbelsäule hat sich eine Vielzahl unterschiedlicher Verfahren mit spezifischen Indikationen, Vor- und Nachteilen entwickelt. Neben der konservativen Therapie steht die operative Stabilisierung der Halswirbelsäule mit Diskusprothesen, Cages und Wirbelkörperersatz im Vordergrund.
Basierend auf ihrer Erfahrung sowie biomechanischen und klinischen Studien stellen die Autoren eine klare Strategie bei der Auswahl des operativen Zugangswegs und des Implantats vor.
Neben den anatomischen, biomechanischen und klinischen Grundlagen beschreiben sie im einzelnen
– die Auswahl des operativen Zugangswegs
– die Auswahl des Implantats
– die Operationstechnik bei den einzelnen Verfahren.
Zahlreiche Abbildungen illustrieren die Befunde, die zur Therapieentscheidung führen, und Schritt für Schritt die operativen Verfahren. Empfehlungen zur Aufklärung und Beratung des Patienten, zum wichtigen Aspekt der Implantatsicherheit und zu den möglichen Komplikationen sowie ein Ausblick auf zukünftige Entwicklungen runden die Darstellung ab.
Umfassend, fundiert und reich illustriert – alle Aspekte der operativen Behandlung degenerativer Erkrankungen der Halswirbelsäule

Product Details

  • Original language: German
  • Number of items: 1
  • Dimensions: 9.80″ h x .59″ w x 6.77″ l,
  • Binding: Hardcover
  • 143 pages

Editorial Reviews

From the Back Cover
Der Weg zur richtigen Therapieentscheidung in der HWS-Chirurgie. Zur Behandlung degenerativer Erkrankungen der Halswirbelsäule hat sich eine Vielzahl unterschiedlicher Verfahren mit spezifischen Indikationen, Vor- und Nachteilen entwickelt. Neben der konservativen Therapie steht die operative Stabilisierung der Halswirbelsäule mit Diskusprothesen, Cages und Wirbelkörperersatz im Vordergrund.
Basierend auf ihrer Erfahrung sowie biomechanischen und klinischen Studien stellen die Autoren eine klare Strategie bei der Auswahl des operativen Zugangswegs und des Implantats vor.
Neben den anatomischen, biomechanischen und klinischen Grundlagen beschreiben sie im einzelnen
–        die Auswahl des operativen Zugangswegs
–        die Auswahl des Implantats
–        die Operationstechnik bei den einzelnen Verfahren.
Zahlreiche Abbildungen illustrieren die Befunde, die zur Therapieentscheidung führen, und Schritt für Schritt die operativen Verfahren. Empfehlungen zur Aufklärung und Beratung des Patienten,  zum wichtigen Aspekt der Implantatsicherheit und zu den möglichen Komplikationen sowie ein Ausblick auf zukünftige Entwicklungen runden die Darstellung ab.
Umfassend, fundiert und reich illustriert – alle Aspekte der operativen Behandlung degenerativer Erkrankungen der Halswirbelsäule
About the Author
Herr Dr. Alexander König, Facharzt für Neurochirurgie, Oberarzt an der Neurochirurgischen Klinik des Klinikums Karlsruhe; Herr Prof. Dr.Dr.h.c. Uwe Spetzger, Klinikdirektor dieser Klinik.