Cord compression defined by MRI is the driving factor behind the decision to operate in Degenerative Cervical Myelopathy despite poor correlation with disease severity

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

Neurosurgical FOCUS ◽

10.3171/2016.3.focus1667 ◽

2016 ◽

Vol 40 (6) ◽

pp. E5 ◽

Cited By ~ 61

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.

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

Global Spine Journal ◽

10.1177/21925682211057484 ◽

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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Degenerative cervical myelopathy presenting as subjective lower limb weakness could be a trap towards misdiagnosis

Scientific Reports ◽

10.1038/s41598-020-78139-y ◽

2020 ◽

Vol 10 (1) ◽

Author(s):

Chi-An Luo ◽

Meng-Ling Lu ◽

Arun-Kumar Kaliya-Perumal ◽

Lih-Huei Chen ◽

Wen-Jer Chen ◽

...

Keyword(s):

Spinal Stenosis ◽

Functional Recovery ◽

Lower Limb ◽

Cervical Myelopathy ◽

Cord Compression ◽

Surgical Decompression ◽

Limb Weakness ◽

Lower Limb Weakness ◽

Tandem Spinal Stenosis ◽

Degenerative Cervical Myelopathy

AbstractWhen patients presenting with subjective lower limb weakness (SLLW) are encountered, it is natural to suspect a lumbar pathology and proceed with related clinical examination, investigations and management. However, SLLW could be a sign of degenerative cervical myelopathy (DCM) due to an evolving cord compression. In such circumstances, if symptoms are not correlated to myelopathy at the earliest, there could be potential complications over time. In this study, we intend to analyse the outcomes after surgical management of the cervical or thoracic cord compression in patients with SLLW. Retrospectively, patients who presented to our center during the years 2010–2016 with sole complaint of bilateral SLLW but radiologically diagnosed to have a solitary cervical or thoracic stenosis, or tandem spinal stenosis and underwent surgical decompression procedures were selected. Their clinical presentation was categorised into three types, myelopathy was graded using Nurick’s grading and JOA scoring; in addition, their lower limb functional status was assessed using the lower extremity functional scale (LEFS). Functional recovery following surgery was assessed at 6 weeks, 3 months, 6 months, one year, and two years. Selected patients (n = 24; Age, 56.4 ± 10.1 years; range 32–78 years) had SLLW for a period of 6.4 ± 3.2 months (range 2–13 months). Their preoperative JOA score was 11.3 ± 1.8 (range 7–15), and LEFS was 34.4 ± 7.7 (range 20–46). Radiological evidence of a solitary cervical lesion and tandem spinal stenosis was found in 6 and 18 patients respectively. Patients gradually recovered after surgical decompression with LEFS 59.8 ± 2.7 (range 56–65) at 1 year and JOA score 13.6 ± 2.7 (range − 17 to 100) at 2 years. The recovery rate at final follow up was 47.5%. Our results indicate the importance of clinically suspecting SLLW as an early non-specific sign of DCM to avoid misdiagnosis, especially in patients without conventional upper motor neuron signs. In such cases, surgical management of the cord compression resulted in significant functional recovery and halted the progression towards permanent disability.

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Study protocol for an observational study of cerebrospinal fluid pressure in patients with degenerative cervical myelopathy undergoing surgical deCOMPression of the spinal CORD: the COMP-CORD study

BMJ Open ◽

10.1136/bmjopen-2020-037332 ◽

2020 ◽

Vol 10 (9) ◽

pp. e037332

Author(s):

Carl Moritz Zipser ◽

Nikolai Pfender ◽

Jose Miguel Spirig ◽

Michael Betz ◽

Jose Aguirre ◽

...

Keyword(s):

Blood Pressure ◽

Spinal Cord ◽

Cerebrospinal Fluid ◽

Spinal Cord Compression ◽

Study Protocol ◽

Cervical Myelopathy ◽

Fluid Pressure ◽

Cord Compression ◽

Surgical Decompression ◽

Degenerative Cervical Myelopathy

IntroductionDegenerative cervical myelopathy (DCM) is a disabling spinal disorder characterised by sensorimotor deficits of upper and lower limbs, neurogenic bladder dysfunction and neuropathic pain. When suspected, cervical MRI helps to reveal spinal cord compression and rules out alternative diagnoses. However, the correlation between radiological findings and symptoms is weak. Cerebrospinal fluid pressure (CSFP) analysis may complement the appreciation of cord compression and be used for intraoperative and postoperative monitorings in patients undergoing surgical decompression.Methods and analysisTwenty patients diagnosed with DCM undergoing surgical decompression will receive standardised lumbar CSFP monitoring immediately before, during and 24 hours after operation. Rest (ie, opening pressure, CSF pulsation) and stimulated (ie, Valsalva, Queckenstedt’s) CSFP—findings in DCM will be compared with 20 controls and results from CSFP monitoring will be related to clinical and neurophysiological findings. Arterial blood pressure will be recorded perioperatively and postoperatively to calculate spinal cord perfusion pressure and spinal vascular reactivity index. Furthermore, measures of CSFP will be compared with markers of spinal cord compression by means of MR imaging.Ethics and disseminationThe study protocol conformed to the latest revision of the Declaration of Helsinki and was approved by the local Ethics Committee of the University Hospital of Zurich (KEK-ZH number PB-2016-00623). The main publications from this study will cover the CSFP fluid dynamics and pressure analysis preoperative, perioperative and postoperative correlated with imaging, clinical scores and neurophysiology. Other publications will deal with preoperative and postoperative spinal perfusion. Furthermore, we will disseminate an analysis on waveform morphology and the correlation with blood pressure and ECG. Parts of the data will be used for computational modelling of cervical stenosis.Trial registration numberClinicalTrials.gov Registry (NCT02170155).

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P90 A systematic review of spinal cord serum and cerebrospinal fluid biomarkers for use in degenerative cervical myelopathy

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2019-abn.147 ◽

2019 ◽

Vol 90 (3) ◽

pp. e45.3-e46 ◽

Cited By ~ 3

Author(s):

M Stewart ◽

S Smith ◽

B Davies ◽

P Hutchinson ◽

M Kotter

Keyword(s):

Spinal Cord ◽

High Throughput ◽

Cervical Myelopathy ◽

Evidence Base ◽

Cord Compression ◽

Response To Treatment ◽

Csf Biomarkers ◽

Spinal Cord Damage ◽

Cerebrospinal Fluid Biomarkers ◽

Degenerative Cervical Myelopathy

ObjectivesWhilst radiological evidence of compression is the hallmark of degenerative cervical myelopathy [DCM], it is unable to stage or prognosticate. Moreover, asymptomatic spinal cord compression is common and therefore new methods of assessing spinal cord function are required. We aimed to: 1) Evaluate the evidence-base for serum and CSF biomarkers of spinal cord damage in diagnosis, prognosis or predicting response to treatment in DCM 2) Identify serum and CSF biomarkers of spinal cord damage studied in other conditions, which may have relevance to DCM.DesignScoping review.SubjectsHuman only.MethodsA search of MEDLINE and EMBASE was performed. Studies involving DCM patients or biomarkers relevant to spinal cord pathobiology were included.Results852 results were screened, of which 83 were included. 9 studies explored 12 biomarkers in DCM. NFH (n=3), S100b and NSE (n=2) received most study. 74 studies explored a further 118 biomarkers in other conditions; S100b (n=13), NFH (n=11) and GFAP (n=10) received most study. Overall, 72 studies used targeted approaches, in which candidate biomarkers were chosen in advance. 11 used unbiased approaches, in which high throughput analyses identified candidate biomarkers during the study.ConclusionsThe evidence-base for use of biomarkers in DCM is limited. Whilst targeted approaches have identified a number of candidate spinal cord markers, few have shown clinical utility. There is a shift towards investigating panels of multiple markers and unbiased, high-throughput approaches.

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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)

Neurosurgery ◽

10.1093/neuros/nyz499 ◽

2019 ◽

Vol 86 (3) ◽

pp. E292-E299 ◽

Cited By ~ 1

Author(s):

Sukhvinder Kalsi-Ryan ◽

Lauren E Riehm ◽

Lindsay Tetreault ◽

Allan R Martin ◽

Florentina Teoderascu ◽

...

Keyword(s):

Upper Limb ◽

Functional Impairment ◽

Cervical Myelopathy ◽

Hand Function ◽

Intraclass Correlation ◽

Japanese Orthopaedic Association ◽

Neurological Impairment ◽

Cord Compression ◽

Manual Dexterity ◽

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

BMJ Open ◽

10.1136/bmjopen-2018-027000 ◽

2019 ◽

Vol 9 (5) ◽

pp. e027000 ◽

Cited By ~ 7

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.

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P.222 Subjective pattern of postoperative neurological recovery in degenerative cervical myelopathy varies by preoperative severity of disease

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2021.386 ◽

2021 ◽

Vol 48 (s3) ◽

pp. S84-S84

Author(s):

AC Friesen ◽

SA Detombe ◽

P Doyle-Pettypiece ◽

W Ng ◽

K Gurr ◽

...

Keyword(s):

Cervical Myelopathy ◽

Cord Compression ◽

Patient Expectations ◽

Postoperative Recovery ◽

Neurological Deficits ◽

Postoperative Patient ◽

Japanese Orthopedic Association ◽

Sphincter Function ◽

Moderate Disease ◽

Degenerative Cervical Myelopathy

Background: Degenerative cervical myelopathy is a spinal disorder resulting in progressive spinal cord compression and consequent neurological deficits that can be assessed and tracked using the modified Japanese Orthopedic Association (mJOA) questionnaire. However, it is difficult to predict which patients will recover neurological function after surgery, making it difficult for clinicians to set reliable postoperative patient expectations. Methods: Sixty-eight operative myelopathy patients (50 male, 14 female) consented to complete the mJOA questionnaire both preoperatively and 6-months postoperatively. Fifteen of these patients had mild, twenty-three had moderate, and thirty had severe preoperative disease. Results: We found that in mild myelopathy, sensation and strength recover in similar proportions. In moderate myelopathy, a greater proportion of patients recover in each domain except for sensation. Recovery in severe myelopathy was comparable to moderate disease, but showed more dramatic recovery in sensation and sphincter function. Conclusions: This study shows that the severity of myelopathic disease influences the pattern of postoperative recovery. Though limited in sample size, the recovery patterns identified above are an important first step in recognizing myelopathy as a disease that patients experience heterogeneously both pre- and post-operatively. Our results will aid clinicians in goals-of-surgery discussions and assist with managing postoperative patient expectations.

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