scholarly journals Route to diagnosis of degenerative cervical myelopathy in a UK healthcare system: a retrospective cohort study

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e027000 ◽  
Author(s):  
Bryn Hilton ◽  
Jennifer Tempest-Mitchell ◽  
Benjamin Davies ◽  
Mark Kotter
Keyword(s):  
Primary Care ◽  
Cohort Study ◽  
Symptom Onset ◽  
Cervical Myelopathy ◽  
Secondary Care ◽  
Primary Outcome ◽  
Cord Compression ◽  
Cervical Cord ◽  
Clinical Documentation ◽  
Degenerative Cervical Myelopathy

ObjectivesDegenerative cervical myelopathy (DCM) presents insidiously, making initial diagnosis challenging. Surgery has been shown to prevent further disability but existing spinal cord damage may be permanent. Delays in surgery lead to increased disability and reduced postoperative improvements. Therefore, rapid surgical assessment is key to improving patient outcomes. Unfortunately, diagnosis of DCM in primary care is often delayed. This study aimed to characterise patients with DCM route to diagnosis and surgical assessment as well as to plot disease progression over time.DesignRetrospective, observational cohort study.SettingSingle, tertiary centre using additional clinical records from primary and secondary care centres.ParticipantsOne year of cervical MRI scans conducted at a tertiary neurosciences centre (n=1123) were screened for cervical cord compression, a corresponding clinical diagnosis of myelopathy and sufficient clinical documentation to plot a route to diagnosis (n=43).Primary outcome measuresTime to diagnosis from symptom onset, route to diagnosis and disease progression were the primary outcome measures in this study. Disease severity was approximated using a prospectively validated method for inferring modified Japanese Orthopaedic Association (i-mJOA) functional scoring from clinical documentation.ResultsPatients received a referral to secondary care 6.4±7.7 months after symptom onset. Cervical MRI scanning and neurosurgical review occurred 12.5±13.0 and 15.8±13.5 months after symptom onset, respectively. i-mJOA was 16.0±1.7 at primary care assessment and 14.8±2.5 at surgical assessment. 61.0% of patients were offered operations. For those who received surgery, time between onset and surgery was 22.1±13.2 months.ConclusionsRoute to surgical assessment was heterogeneous and lengthy. Some patients deteriorated during this period. This study highlights the need for a streamlined pathway by which patients with cervical cord compression can receive timely assessment and treatment by a specialist. This would improve outcomes for patients using existing treatments.

scholarly journals 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

2017 ◽  
Vol 7 (3_suppl) ◽  
pp. 70S-83S ◽  
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.

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

Neurosurgery ◽  
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.

scholarly journals Tracking white and grey matter degeneration along the spinal cord axis in degenerative cervical myelopathy

2021 ◽  
Author(s):  
Kevin Vallotton ◽  
Gergely David ◽  
Markus Hupp ◽  
Nikolai Pfender ◽  
Julien Cohen-Adad ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Cervical Myelopathy ◽  
Grey Matter ◽  
Cord Compression ◽  
Cervical Cord ◽  
Tissue Specific ◽  
Microstructural Changes ◽  
Diffusion Weighted ◽  
Degenerative Cervical Myelopathy ◽  
Lumbar Cord

AbstractObjectiveTo determine tissue-specific neurodegeneration across the spinal cord in patients with mild-moderate degenerative cervical myelopathy (DCM).MethodsTwenty-four mild-moderate DCM and 24 healthy subjects were recruited. In patients, a T2-weighted scan was acquired at the compression site, while in all participants a T2*-weighted and diffusion-weighted scan was acquired at the cervical level (C2-C3) and in the lumbar enlargement (i.e. rostral and caudal to the site of compression). We quantified intramedullary signal changes, maximal canal and cord compression, white (WM) and grey matter (GM) atrophy, and microstructural indices from diffusion-weighted scans. All patients underwent clinical (modified Japanese Orthopaedic Association (mJOA)) and electrophysiological assessments. Regression analysis assessed associations between MRI readouts and electrophysiological and clinical outcomes.ResultsTwenty patients were classified with mild and four with moderate DCM using the mJOA scale. The most frequent site of compression was at C5-C6 level with maximum cord compression of 4.68±0.83 mm. Ten patients showed imaging evidence of cervical myelopathy. In the cervical cord, WM and GM atrophy and WM microstructural changes were evident, while in the lumbar cord only WM showed atrophy and microstructural changes. Remote cervical cord WM microstructural changes were pronounced in patients with radiological myelopathy and associated with impaired electrophysiology. Lumbar cord WM atrophy was associated with lower limb sensory impairments.ConclusionTissue-specific neurodegeneration revealed by quantitative MRI, already apparent across the spinal cord in mild-moderate DCM prior to the onset of severe clinical impairments. WM microstructural changes are particularly sensitive to remote pathologically and clinically eloquent changes in DCM.

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

2021 ◽  
Vol 10 (5) ◽  
pp. 927
Author(s):  
Zdenek Kadanka ◽  
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.

scholarly journals Functional outcome of posterior laminectomy in case of cervical myelopathy with multilevel cervical cord compression

2018 ◽  
Vol 4 (4) ◽  
pp. 510-514
Author(s):  
Dr. Siddharth D Parekh ◽  
Dr. Arvind B Goregaonkar ◽  
Dr. Anoop Dhamangaokar ◽  
Dr. Apratim R Deekshit ◽  
Dr. Umesh P Kanade
Keyword(s):  
Functional Outcome ◽  
Cervical Myelopathy ◽  
Cord Compression ◽  
Cervical Cord ◽  
Cervical Cord Compression ◽  
Posterior Laminectomy

Cilostazol, a selective Type III phosphodiesterase inhibitor: prevention of cervical myelopathy in a rat chronic compression model

2014 ◽  
Vol 20 (1) ◽  
pp. 93-101 ◽  
Author(s):  
Shinji Yamamoto ◽  
Ryu Kurokawa ◽  
Phyo Kim
Keyword(s):  
Spinal Cord ◽  
Grip Strength ◽  
Motor Neurons ◽  
Cervical Myelopathy ◽  
Cervical Spondylotic Myelopathy ◽  
Phosphodiesterase Inhibitor ◽  
Cord Compression ◽  
Anterior Horn ◽  
Cervical Cord ◽  
Forced Running

Object Regional blood flow is decreased in experimental models of chronic spinal cord compression, and the alteration presumably contributes to the development of myelopathy. Cilostazol (Otsuka Pharmaceuticals Co.), a selective Type III phosphodiesterase inhibitor, has been shown to be neuroprotective in cerebral hypoperfusion animal models and clinically effective in preventing the recurrence of cerebral infarction. To investigate the neuroprotective effect of cilostazol on cervical spondylotic myelopathy, the preventive effect against progressive motor dysfunction and the loss of anterior horn motor neurons were assessed using a chronic cord compression model in rats. Methods To produce chronic cervical cord compression in male Wistar rats, thin polyurethane sheets (3 × 5 × 0.7 mm) that gradually expand over 48–72 hours by absorbing water were implanted under the C5–6 laminae. In sham operations, the sheets were momentarily placed and then immediately removed. This model has been shown to reproduce characteristic features of clinical cervical myelopathy, with progressive motor disturbances after a latency period and insidious neuronal loss preceding the onset of symptoms. In the treatment group, cilostazol (30 mg/kg/day) was orally administered to the rats once a day, starting the day after surgery and continuing through the entire observation period of 25 weeks. In the control group, vehicle solution was administered under the same protocol. Changes in motor function were monitored by measuring bilateral forepaw grip strength and the duration of forced running on a treadmill. Twenty-five weeks after surgery, cervical spinal cords were examined histopathologically. Results Cilostazol preserved both forepaw grip strength and forced running capability. The drug also preserved anterior horn motor neurons in the C5–6 spinal cord segment, which diminished in number in the untreated chronic compression group. The drug decreased the number of TUNEL-positive apoptotic cells. Conclusions These results indicate that cilostazol is neuroprotective in the chronically compressed cervical cord and is potentially useful in the treatment of cervical spondylotic myelopathy.

scholarly journals Magnetic resonance imaging assessment of degenerative cervical myelopathy: a review of structural changes and measurement techniques

2016 ◽  
Vol 40 (6) ◽  
pp. E5 ◽  
Author(s):  
Aria Nouri ◽  
Allan R. Martin ◽  
David Mikulis ◽  
Michael G. Fehlings
Keyword(s):  
Spinal Cord ◽  
Cervical Spine ◽  
Cervical Myelopathy ◽  
Structural Changes ◽  
Sagittal Alignment ◽  
Measurement Techniques ◽  
Cord Compression ◽  
Age Related ◽  
Magnetic Resonance Imaging Assessment ◽  
Degenerative Cervical Myelopathy

Degenerative cervical myelopathy encompasses a spectrum of age-related structural changes of the cervical spine that result in static and dynamic injury to the spinal cord and collectively represent the most common cause of myelopathy in adults. Although cervical myelopathy is determined clinically, the diagnosis requires confirmation via imaging, and MRI is the preferred modality. Because of the heterogeneity of the condition and evolution of MRI technology, multiple techniques have been developed over the years in an attempt to quantify the degree of baseline severity and potential for neurological recovery. In this review, these techniques are categorized anatomically into those that focus on bone, ligaments, discs, and the spinal cord. In addition, measurements for the cervical spine canal size and sagittal alignment are also described briefly. These tools have resulted collectively in the identification of numerous useful parameters. However, the development of multiple techniques for assessing the same feature, such as cord compression, has also resulted in a number of challenges, including introducing ambiguity in terms of which methods to use and hindering effective comparisons of analysis in the literature. In addition, newer techniques that use advanced MRI are emerging and providing exciting new tools for assessing the spinal cord in patients with degenerative cervical myelopathy.

scholarly journals Imaging and Electrophysiology for Degenerative Cervical Myelopathy [AO Spine RECODE DCM Research Priority Number 9]

2021 ◽  
pp. 219256822110574
Author(s):  
Allan R. Martin ◽  
Lindsay Tetreault ◽  
Benjamin M. Davies ◽  
Armin Curt ◽  
Patrick Freund ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Cervical Myelopathy ◽  
Tissue Injury ◽  
Quantitative Imaging ◽  
Cord Compression ◽  
Narrative Review ◽  
Imaging Tool ◽  
Spinal Cord Dysfunction ◽  
Degenerative Cervical Myelopathy ◽  
And Function

Study Design Narrative review. Objective The current review aimed to describe the role of existing techniques and emerging methods of imaging and electrophysiology for the management of degenerative cervical myelopathy (DCM), a common and often progressive condition that causes spinal cord dysfunction and significant morbidity globally. Methods A narrative review was conducted to summarize the existing literature and highlight future directions. Results Anatomical magnetic resonance imaging (MRI) is well established in the literature as the key imaging tool to identify spinal cord compression, disc herniation/bulging, and inbuckling of the ligamentum flavum, thus facilitating surgical planning, while radiographs and computed tomography (CT) provide complimentary information. Electrophysiology techniques are primarily used to rule out competing diagnoses. However, signal change and measures of cord compression on conventional MRI have limited utility to characterize the degree of tissue injury, which may be helpful for diagnosis, prognostication, and repeated assessments to identify deterioration. Early translational studies of quantitative imaging and electrophysiology techniques show potential of these methods to more accurately reflect changes in spinal cord microstructure and function. Conclusion Currently, clinical management of DCM relies heavily on anatomical MRI, with additional contributions from radiographs, CT, and electrophysiology. Novel quantitative assessments of microstructure, perfusion, and function have the potential to transform clinical practice, but require robust validation, automation, and standardization prior to uptake.

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