Characteristics of Upper Limb Impairment Related to Degenerative Cervical Myelopathy: Development of a Sensitive Hand Assessment (Graded Redefined Assessment of Strength, Sensibility, and Prehension Version Myelopathy)

Abstract BACKGROUND Degenerative cervical myelopathy (DCM) involves spinal cord compression, which causes neurological decline. Neurological impairment in DCM is variable and can involve complex upper limb dysfunction including loss of manual dexterity, hyperreflexia, focal weakness, and sensory impairment. The modified Japanese Orthopaedic Association (mJOA) score relies on the patients’ subjective perceptions, whereas existing objective measures such as strength and sensory testing do not capture subtle changes in dexterity and function. OBJECTIVE 1) To characterize arm and hand function in DCM; and 2) To develop and validate Graded Redefined Assessment of Strength, Sensibility, and Prehension Version-Myelopathy (GRASSP-M), a clinical assessment that quantifies upper limb impairment. METHODS A total of 148 DCM patients (categorized into mild, moderate, and severe based on mJOA grade) and 21 healthy subjects were enrolled. A complete neurological exam, the mJOA, the QuickDASH, grip dynamometry, and the GRASSP-M were administered. RESULTS Strength, sensation, and manual dexterity significantly declined with increasing DCM severity (P ≤ .05). Impairment in hand dexterity showed better discrimination between mild, moderate, and severe DCM categories than strength or sensation. The GRASSP-M was found to be both a reliable (intraclass correlation coefficient >0.75 for intra- and inter-rater reliability) and valid (with both concurrent and construct validity) tool. CONCLUSION These results demonstrate that patients’ subjective reporting of functional status, especially in the mild DCM category, may underrepresent the extent of functional impairment. The GRASSP-M is an objective tool designed to characterize patients’ functional impairment related to the upper limb, which proves useful to diagnose and quantify mild dysfunction, monitor patients for deterioration, and help determine when patients should be treated surgically.

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Change in Functional Impairment, Disability, and Quality of Life Following Operative Treatment for Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis

Global Spine Journal ◽

10.1177/2192568217710137 ◽

2017 ◽

Vol 7 (3_suppl) ◽

pp. 53S-69S ◽

Cited By ~ 21

Author(s):

Michael G. Fehlings ◽

Lindsay A. Tetreault ◽

Shekar Kurpad ◽

Darrel S. Brodke ◽

Jefferson R. Wilson ◽

...

Keyword(s):

Systematic Review ◽

Operative Treatment ◽

Functional Impairment ◽

Cervical Myelopathy ◽

Surgical Intervention ◽

Japanese Orthopaedic Association ◽

Duration Of Symptoms ◽

Degenerative Cervical Myelopathy ◽

The Impact

Study Design: Systematic review. Objectives: The primary objective of this systematic review was to define the change in impairment, disability, and pain following surgical intervention in patients with degenerative cervical myelopathy (DCM). Secondary objectives included to assess the impact of preoperative disease severity and duration of symptoms on outcomes and to summarize complications associated with surgery. Methods: A systematic literature search was conducted to identify prospective studies evaluating the effectiveness and safety of operative treatment in patients with DCM. Outcomes of interest were functional status, disability, pain, and complications. The quality of each study was evaluated using the Newcastle-Ottawa Scale, and the strength of the overall body of evidence was rated using guidelines outlined by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. Results: Of the 385 retrieved citations, 32 met inclusion criteria and are summarized in this review. Based on our results, pooled standard mean differences showed a large effect for improvement in Japanese Orthopaedic Association or modified Japanese Orthopaedic Association score from baseline at short-, medium-, and long-term follow-up: 6 to 12 months (1.92; 95% confidence interval [CI] = 1.41 to 2.43), 13 to 36 months (1.40; 95% CI = 1.12 to 1.67), and ≥36 months (1.92; 95% CI = 1.14 to 2.69) (moderate evidence). Surgery also resulted in significant improvements in Nurick, Neck Disability Index, and Visual Analogue Scale scores (low to very low evidence). The cumulative incidence of complications was low (14.1%; 95% CI = 10.1% to 18.2%). Conclusion: Surgical intervention for DCM results in significant improvements in functional impairment, disability, and pain and is associated with an acceptably low rate of complications.

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Recovery priorities in degenerative cervical myelopathy: a cross-sectional survey of an international, online community of patients

BMJ Open ◽

10.1136/bmjopen-2019-031486 ◽

2019 ◽

Vol 9 (10) ◽

pp. e031486 ◽

Cited By ~ 5

Author(s):

Benjamin Davies ◽

Oliver Mowforth ◽

Iwan Sadler ◽

Bizhan Aarabi ◽

Brian Kwon ◽

...

Keyword(s):

Sexual Function ◽

Cervical Myelopathy ◽

Online Survey ◽

Functional Disability ◽

Hand Function ◽

Japanese Orthopaedic Association ◽

Future Research ◽

Cross Sectional ◽

Disease Characteristics ◽

Degenerative Cervical Myelopathy

ObjectivesTo establish the recovery priorities of individuals suffering with degenerative cervical myelopathy (DCM).DesignA cross-sectional, observational study.SettingPatients from across the world with a diagnosis of DCM accessed the survey over an 18-month period on Myelopathy.org, an international myelopathy charity.Participants481 individuals suffering from DCM completed the online survey fully.Main outcome measuresFunctional recovery domains were established through qualitative interviews and a consensus process. Individuals were asked about their disease characteristics, including limb pain (Visual Analogue Scale) and functional disability (patient-derived version of the modified Japanese Orthopaedic Association score). Individuals ranked recovery domains (arm and hand function, walking, upper body/trunk function, sexual function, elimination of pain, sensation and bladder/bowel function) in order of priority. Priorities were analysed as the modal first priority and mean ranking. The influence of demographics on selection was analysed, with significancep<0.05.ResultsOf 659 survey responses obtained, 481 were complete. Overall, pain was the most popular recovery priority (39.9%) of respondents, followed by walking (20.2%), sensation (11.9%) and arm and hand function (11.5%). Sexual function (5.7%), bladder and bowel (3.7%) and trunk function (3.5%) were chosen less frequently. When considering the average ranking of symptoms, while pain remained the priority (2.6±2.0), this was closely followed by walking (2.9±1.7) and arm/hand function (3.0±1.4). Sensation ranked lower (4.3±2.1). With respect to disease characteristics, overall pain remained the recovery priority, with the exception of patients with greater walking impairment (p<0.005) who prioritised walking, even among patients with lower pain scores.ConclusionsThis is the first study investigating patient priorities in DCM. The patient priorities reported provide an important framework for future research and will help to ensure that it is aligned with patient needs.

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Short-term predictive potential of quantitative assessment of spinal cord impairment in patients undergoing French-door Laminoplasty for degenerative cervical myelopathy: preliminary results of an exploratory study exploiting intraoperative ultrasound data

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03319-w ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Guoliang Chen ◽

Jiachun Li ◽

Fuxin Wei ◽

Qiao Ji ◽

Wenyuan Sui ◽

...

Keyword(s):

Spinal Cord ◽

Spinal Cord Compression ◽

Cervical Myelopathy ◽

Quantitative Assessment ◽

Japanese Orthopaedic Association ◽

Intraoperative Ultrasound ◽

Cord Compression ◽

Postoperative Mri ◽

Degenerative Cervical Myelopathy ◽

Gray Values

Abstract Background To study the correlation of neurological function in degenerative cervical myelopathy (DCM) patients with quantitative assessment of spinal cord compression and impairment by intraoperative ultrasound imaging (IOUSI). Methods Twenty-three patients who underwent French-Door laminoplasty for multilevel DCM were followed for 6 months. Modified Japanese Orthopaedic Association (mJOA) score and cervical MRI were assessed before surgery and at postoperative 6 months. IOUS, used to guide decompression, were recorded. The anteroposterior diameter (APD) and the gray values of the IOUSI hyperechogenicity of the midsagittal IOUSI at the narrowest level and at the lesion-free level, and the APD and traverse diameter at the traverse maximum compression level of IOUSI were measured. Maximum spinal cord compression (MSCC), compression rate (CR), and IOUSI gray value ratio (Rgray) were calculated. The appearance of preoperative T2W MRI increased signal intensity (ISI), and the signal change rate (SCR) on postoperative T2W MRI of 9 patients were also measured and calculated, and compared with that of IOUSI hyperechogenicity. Results Average mJOA score increased significantly from 11.57 ± 2.67 before surgery to 15.39 ± 1.50 at 6 months after surgery, with an average recovery rate (RR) of 71.11 ± 22.81%. The difference between the appearance of preoperative T2W MRI ISI and IOUSI hyperechogenicity was not significant. Spearman correlation analysis found that the IOUSI Rgray were negatively correlated with the RR of mJOA score with a coefficient of − 0.77, and the IOUSI Rgray was not correlated with the postoperative MRI SCR. Conclusions In DCM patients, the gray values of IOUSI can be measured accurately. The IOUSI Rgray correlated with postoperative neurological recovery significantly.

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Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy

Neurosurgery ◽

10.1093/neuros/nyz325 ◽

2019 ◽

Vol 86 (6) ◽

pp. 763-768

Author(s):

Inamullah Khan ◽

Kristin R Archer ◽

John Paul Wanner ◽

Mohamad Bydon ◽

Jacquelyn S Pennings ◽

...

Keyword(s):

Cervical Myelopathy ◽

Elective Surgery ◽

Japanese Orthopaedic Association ◽

Cord Compression ◽

Cervical Cord ◽

Multivariable Logistic Regression Model ◽

Quality Outcomes ◽

Degenerative Cervical Myelopathy ◽

Postoperative Improvement

Abstract BACKGROUND Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored. OBJECTIVE To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM. METHODS This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest. RESULTS A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in their myelopathic symptoms, compared to patients with mild mJOA score in. CONCLUSION Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.

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Is Preoperative Duration of Symptoms a Significant Predictor of Functional Outcomes in Patients Undergoing Surgery for the Treatment of Degenerative Cervical Myelopathy?

Neurosurgery ◽

10.1093/neuros/nyy474 ◽

2018 ◽

Vol 85 (5) ◽

pp. 642-647 ◽

Cited By ~ 2

Author(s):

Lindsay Tetreault ◽

Jefferson R Wilson ◽

Mark R N Kotter ◽

Pierre Côté ◽

Aria Nouri ◽

...

Keyword(s):

Functional Impairment ◽

Cervical Myelopathy ◽

Functional Outcomes ◽

Short Form ◽

Japanese Orthopaedic Association ◽

Neck Disability Index ◽

Analysis Of Covariance ◽

Duration Of Symptoms ◽

Change Scores ◽

Degenerative Cervical Myelopathy

Abstract BACKGROUND Preoperative duration of symptoms may significantly impact outcomes in patients treated surgically for degenerative cervical myelopathy (DCM). OBJECTIVE To (i) analyze whether duration of symptoms is associated with preoperative functional impairment, disability, and quality of life and (ii) determine the optimal timing for decompressive surgery. METHODS 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 duration of symptoms groups in 4-mo increments. RESULTS Our 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. CONCLUSION 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.

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Walk and Run Test in Patients with Degenerative Compression of the Cervical Spinal Cord

Journal of Clinical Medicine ◽

10.3390/jcm10050927 ◽

2021 ◽

Vol 10 (5) ◽

pp. 927

Author(s):

Zdenek Kadanka ◽

Tomas Skutil ◽

Eva Vlckova ◽

Josef Bednarik

Keyword(s):

Cervical Spinal Cord ◽

Japanese Orthopaedic Association ◽

Cord Compression ◽

Cervical Cord ◽

Cross Sectional ◽

Severity Of Disability ◽

Degree Of Disability ◽

Degenerative Cervical Myelopathy ◽

Cardinal Symptoms ◽

Run Test

Impaired gait is one of the cardinal symptoms of degenerative cervical myelopathy (DCM) and frequently its initial presentation. Quantitative gait analysis is therefore a promising objective tool in the disclosure of early cervical cord impairment in patients with degenerative cervical compression. The aim of this cross-sectional observational cohort study was to verify whether an objective and easily-used walk and run test is capable of detecting early gait impairment in a practical proportion of non-myelopathic degenerative cervical cord compression (NMDCC) patients and of revealing any correlation with severity of disability in DCM. The study group consisted of 45 DCM patients (median age 58 years), 126 NMDCC subjects (59 years), and 100 healthy controls (HC) (55.5 years), all of whom performed a standardized 10-m walk and run test. Walking/running time/velocity, number of steps and cadence of walking/running were recorded; analysis disclosed abnormalities in 66.7% of NMDCC subjects. The DCM group exhibited significantly more pronounced abnormalities in all walk/run parameters when compared with the NMDCC group. These were apparent in 84.4% of the DCM group and correlated closely with disability as quantified by the modified Japanese Orthopaedic Association scale. A standardized 10-m walk/run test has the capacity to disclose locomotion abnormalities in NMDCC subjects who lack other clear myelopathic signs and may provide a means of classifying DCM patients according to their degree of disability.

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Predictors of Return to Normal Neurological Function After Surgery for Moderate and Severe Degenerative Cervical Myelopathy: An Analysis of A Global AOSpine Cohort of Patients

Neurosurgery ◽

10.1093/neuros/nyz178 ◽

2019 ◽

Vol 85 (5) ◽

pp. E917-E923 ◽

Cited By ~ 1

Author(s):

Rafael De la Garza Ramos ◽

Aria Nouri ◽

Jonathan Nakhla ◽

Murray Echt ◽

Yaroslav Gelfand ◽

...

Keyword(s):

Cervical Myelopathy ◽

Multiple Logistic Regression Analysis ◽

Japanese Orthopaedic Association ◽

Area Under The Curve ◽

Neurological Function ◽

International Studies ◽

Patient Counseling ◽

Multicenter Studies ◽

Degenerative Cervical Myelopathy ◽

Walking Time

Abstract BACKGROUND Multiple studies have established the safety and efficacy of surgical intervention for degenerative cervical myelopathy (DCM). Although the main goal of surgery is symptom stabilization, a subset of patients achieves remarkable improvements. OBJECTIVE To identify predictors of return to normal neurological function after surgery for moderate or severe DCM. METHODS This is an analysis of 2 prospective multicenter studies (the AOSpine CSM-North America and CSM-International studies) conducted between 2005 and 2011. For patients with complete preoperative magnetic resonance imaging (MRI) and 2-yr follow-up, characteristics were compared between those who achieved a modified Japanese Orthopaedic Association (mJOA) score of 18 at 2 yr (no signs of myelopathy) vs controls. Only patients with baseline mJOA ≤ 14 (moderate and severe myelopathy) were included to minimize ceiling effects. RESULTS A total of 51 patients (20.3%) out of 251 with moderate or severe baseline myelopathy achieved an mJOA score of 18 at 2 yr. On stepwise multiple logistic regression analysis, T1-weighted (T1W1)-hypointensity (odds ratio [OR] 0.10; 95% confidence interval [CI], 0.01-0.79; P = .03) and longer walking time on the 30-m walking test (OR 0.95; 95% CI, 0.92-0.99; P = .03) were independent predictors of outcome, with an area under the curve of 0.71 for the model. CONCLUSION In this study, T1W-hypointensity on MRI and longer walking time were found to predict a less likelihood of achieving return to normal neurological function after surgery for moderate or severe DCM. These findings may provide useful information for patient counseling and perioperative expectations.

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Duration of symptoms in the quantification of upper limb disability and impairment for individuals with mild degenerative cervical myelopathy (DCM)

PLoS ONE ◽

10.1371/journal.pone.0222134 ◽

2019 ◽

Vol 14 (9) ◽

pp. e0222134 ◽

Cited By ~ 2

Author(s):

Sukhvinder Kalsi-Ryan ◽

Jerri Clout ◽

Pouya Rostami ◽

Eric M. Massicotte ◽

Michael G. Fehlings

Keyword(s):

Upper Limb ◽

Cervical Myelopathy ◽

Duration Of Symptoms ◽

Degenerative Cervical Myelopathy

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A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression

Global Spine Journal ◽

10.1177/2192568217701914 ◽

2017 ◽

Vol 7 (3_suppl) ◽

pp. 70S-83S ◽

Cited By ~ 75

Author(s):

Michael G. Fehlings ◽

Lindsay A. Tetreault ◽

K. Daniel Riew ◽

James W. Middleton ◽

Bizhan Aarabi ◽

...

Keyword(s):

Cervical Myelopathy ◽

Surgical Intervention ◽

Guideline Development ◽

Cord Compression ◽

Operative Intervention ◽

Prophylactic Surgery ◽

Cervical Cord ◽

Duration Of Symptoms ◽

Degenerative Cervical Myelopathy ◽

The Impact

Study Design: Guideline development. Objectives: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM). Results: Our recommendations were as follows: (1) “We recommend surgical intervention for patients with moderate and severe DCM.” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve.” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.” Conclusions: These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

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Predicting the minimum clinically important difference in patients undergoing surgery for the treatment of degenerative cervical myelopathy

Neurosurgical FOCUS ◽

10.3171/2016.3.focus1665 ◽

2016 ◽

Vol 40 (6) ◽

pp. E14 ◽

Cited By ~ 23

Author(s):

Lindsay Tetreault ◽

Jefferson R. Wilson ◽

Mark R. N. Kotter ◽

Aria Nouri ◽

Pierre Côté ◽

...

Keyword(s):

Relative Risk ◽

Cervical Myelopathy ◽

Univariate Analysis ◽

Japanese Orthopaedic Association ◽

Minimum Clinically Important Difference ◽

Duration Of Symptoms ◽

Clinically Important Difference ◽

Younger Age ◽

Degenerative Cervical Myelopathy ◽

Unstable Gait

OBJECTIVE The minimum clinically important difference (MCID) is defined as the minimum change in a measurement that a patient would identify as beneficial. Before undergoing surgery, patients are likely to inquire about the ultimate goals of the operation and of their chances of experiencing meaningful improvements. The objective of this study was to define significant predictors of achieving an MCID on the modified Japanese Orthopaedic Association (mJOA) scale at 2 years following surgery for the treatment of degenerative cervical myelopathy (DCM). METHODS Seven hundred fifty-seven patients were prospectively enrolled in either the AOSpine North America or International study at 26 global sites. Fourteen patients had a perfect preoperative mJOA score of 18 and were excluded from this analysis (n = 743). Data were collected for each participating subject, including demographic information, symptomatology, medical history, causative pathology, and functional impairment. Univariate log-binominal regression analyses were conducted to evaluate the association between preoperative clinical factors and achieving an MCID on the mJOA scale. Modified Poisson regression using robust error variances was used to create the final multivariate model and compute the relative risk for each predictor. RESULTS The sample consisted of 463 men (62.31%) and 280 women (37.69%), with an average age of 56.48 ± 11.85 years. At 2 years following surgery, patients exhibited a mean change in functional status of 2.71 ± 2.89 points on the mJOA scale. Of the 687 patients with available follow-up data, 481 (70.01%) exhibited meaningful gains on the mJOA scale, whereas 206 (29.98%) failed to achieve an MCID. Based on univariate analysis, significant predictors of achieving the MCID on the mJOA scale were younger age; female sex; shorter duration of symptoms; nonsmoking status; a lower comorbidity score and absence of cardiovascular disease; and absence of upgoing plantar responses, lower-limb spasticity, and broad-based unstable gait. The final model included age (relative risk [RR] 0.924, p < 0.0001), smoking status (RR 0.837, p = 0.0043), broad-based unstable gait (RR 0.869, p = 0.0036), and duration of symptoms (RR 0.943, p = 0.0003). CONCLUSIONS In this large multinational prospective cohort, 70% of patients treated surgically for DCM exhibited a meaningful functional gain on the mJOA scale. The key predictors of achieving an MCID on the mJOA scale were younger age, shorter duration of symptoms, nonsmoking status, and lack of significant gait impairment.

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