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

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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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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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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Cervical cord compression due to ossification of the ligamentum flavum – A case report and literature review

Surgical Neurology International ◽

10.25259/sni_605_2019 ◽

2020 ◽

Vol 11 ◽

pp. 37

Author(s):

Noama Iftekhar ◽

Abdullah Rasool ◽

Irfan Khan

Keyword(s):

Older Patients ◽

Ligamentum Flavum ◽

Cervical Spinal Cord ◽

The Elderly ◽

Cord Compression ◽

Cervical Cord ◽

Case Description ◽

Male Population ◽

Decompressive Laminectomy ◽

Asian Male

Background: Symptomatic compression of the cervical spinal cord by ossification of the ligamentum flavum (OLF) is rare. It typically involves the elderly and is particularly prominent in the Asian male population. Here, we present a 70-year-old Pakistani female who became quadriparetic due to OLF. Case Description: A 70-year-old female became increasingly quadriparetic over 3 months duration, but exhibited preservation of vibration and proprioception. The cervical magnetic resonance/computed tomography revealed dorsal OLF measuring 7 mm × 25 mm × 14 mm. Two months following a decompressive laminectomy, her symptoms fully resolved. Conclusion: Although rare in older patients, cervical OLF may contribute to significant cervical myelopathy characterized by a progressive quadriparesis that can be readily resolved with a decompressive laminectomy.

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Provision and Perception of Physiotherapy in the Nonoperative Management of Degenerative Cervical Myelopathy (DCM): A Cross-Sectional Questionnaire of People Living With DCM

Global Spine Journal ◽

10.1177/2192568220961357 ◽

2020 ◽

pp. 219256822096135

Author(s):

Max B. Butler ◽

Oliver D. Mowforth ◽

Abdul Badran ◽

Michelle Starkey ◽

Timothy Boerger ◽

...

Keyword(s):

Cervical Myelopathy ◽

Nonoperative Management ◽

Japanese Orthopaedic Association ◽

Multivariate Logistic Regression Analysis ◽

Demographic Characteristics ◽

Symptom Duration ◽

Cross Sectional Survey ◽

Cross Sectional ◽

International Guidelines ◽

Degenerative Cervical Myelopathy

Study Design: Cross-sectional survey. Objectives: Degenerative cervical myelopathy (DCM) is a common syndrome of acquired spinal cord impairment caused by canal stenosis secondary to arthritic changes of the spine. International guidelines consider physiotherapy an option for mild, stable DCM; however, few studies have been conducted on nonoperative management. The objective was to determine current usage and perceptions of nonoperative physiotherapy for DCM. Methods: Persons with DCM were recruited to a web-based survey. Participants with complete responses that had not received surgery were included (n = 167). Variables included symptom duration, treatment history, current disability, and demographic characteristics. Results: Disease and demographic characteristics were equivalent between those who did and did not receive physiotherapy. In all, 19.5% of physiotherapy recipients reported subjective benefit from physiotherapy. Those perceiving benefit had significantly higher mJOA (modified Japanese Orthopaedic Association) scores, lower neck pain scores, and shorter symptom duration. In multivariate logistic regression analysis, those with mild DCM were more likely to perceive benefit than those with severe DCM, as were those with moderate DCM (to a lesser extent). Individuals whose diagnosis was delayed 1 to 2 years were less likely to perceive benefit than those that waited 0 to 6 months. Conclusions: The provision of nonoperative physiotherapy in the management of DCM is inconsistent and appears to differ from international guidelines. Few patients perceived benefit from physiotherapy; however, this was more likely in those with mild DCM and in those with shorter symptom durations. Further work is needed to establish the appropriate role of physiotherapy for this population.

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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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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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Comparison of proton density MRI and T2-Weighted Fast Echo for The Detection of Cervical Spinal Cord Multiple Sclerosis Lesions

Journal of the Faculty of Medicine Baghdad ◽

10.32007/jfacmedbagdad.604159 ◽

2019 ◽

Vol 60 (4) ◽

pp. 195-201

Author(s):

Iman Emad Ahmed ◽

Hayder Kareem Al-Jaberi ◽

Mohammed M. Jawad Alkahlissi

Keyword(s):

Multiple Sclerosis ◽

Spinal Cord ◽

Cervical Spinal Cord ◽

Spin Echo ◽

Fast Spin Echo ◽

Cervical Cord ◽

Proton Density ◽

P Value ◽

Cross Sectional ◽

Fast Spin

Background: The prevalence of spinal cord lesions is high in multiple sclerosis particularly in the cervical cord, and their detection can assist in both the diagnosis and follow-up of the patients. For spinal multiple sclerosis, MRI is considered the first line investigation. Objective: To evaluate the value of sagittal 1.5 Tesla proton density-fast spin echo (PD-FSE) MRI in the detecting and increasing conspicuity of multiple sclerosis lesions in cervical cord in comparison with sagittal T2 fast spin-echo (T2-FSE) MRI. Patients and Methods: A cross sectional study carried out from 3rd of January 2017 to 1st of January 2018 in the MRI department of Al-Imamein Al-Kadhimein Medical City, and included 60 selected patients with a known diagnosis of multiple sclerosis. All patients were examined with 1.5 T sagittal PD-FSE, T2-FSE and axial gradient recalled-echo (GRE) MRI. Results: Sixty patients with cervical multiple sclerosis were enrolled in the study, 146 (100%) lesions were detected by PD-FSE imaging, while T2 detected 105 (71.9%), 41 more lesions (28%) were detected by PD-FSE imaging, (P-value <0.001). All extra lesions were confirmed on axial imaging. In 13 patients (21.6%) one lesion or more had been detected on sagittal PD-FSE imaging while on sagittal T2-FSE imaging, no lesion were detected. On PD-FSE imaging, 17 long lesions were detected in 16 patients (26.7%) while 7 long lesions in 7 patients (11.7%) were detected by T2-FSE imaging. So, in 9 patients (16.7%) 10 lesions were detected as long in PD-FSE while short lesion in T2– FSE, the detection of long lesions by PD-FSE was significantly higher than in T2– FSE (100% vs 71.9% with p- value of 0.002). The mean lesion contrast to cord ratio was significantly higher in PD-FSE as compared to T2-FSE (PD-FSE, 79±2.0, against T2-FSE, 61± 2.6; P-value <0.001). Conclusion: Sagittal proton density was more efficient and more accurate in the detection of cervical cord lesions than sagittal T2-FSE sequence, when used in conjunction with sagittal T2-FSE; it can raise the diagnostic assurance via improving the visualization of the lesions.

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Scoping review of existing funding sources for DCM research: opportunities and challenges for targeting the AO Spine RECODE-DCM research priorities (Preprint)

10.2196/preprints.36194 ◽

2022 ◽

Author(s):

Henry Michael William Bestwick ◽

Jye Quan Teh ◽

Oliver Mowforth ◽

Ben Grodzinski ◽

Mark Kotter ◽

...

Keyword(s):

Cervical Spinal Cord ◽

Research Priorities ◽

Research Capacity ◽

Cord Compression ◽

Research Activity ◽

Non Profit ◽

Funding Sources ◽

Significant Research ◽

The Usa ◽

Degenerative Cervical Myelopathy

BACKGROUND Degenerative Cervical Myelopathy (DCM) is a common, disabling condition of symptomatic cervical spinal cord compression that requires significant research advances to improve patient outcomes. AO Spine RECODE-DCM recently identified the top research priorities for DCM. To effectively address these priorities, appropriate funding of DCM research is essential. OBJECTIVE This review characterises current funding in DCM research to consider its significance and highlight future opportunities. METHODS A systematic review of Web of Science for “cervical” AND “myelopathy” was conducted. Papers exclusively studying DCM, with declared funding, and published between January 1, 1995 and March 21, 2020 were considered eligible. Funding sources were classified by country of origin and organisation type. A grant search was also conducted using Dimensions.ai (Digital Science Ltd, London, United Kingdom). RESULTS A total of 621 papers were included, with 300 unique funding bodies. The top funders were AO Spine (n=87), National Institutes of Health, USA (n=63) and National Natural Science Foundation, China (n=63). The USA (n=242) funded the most DCM research, followed by China (n=209) and Japan (n=116). Funding in the USA was primarily provided by corporate or non-profit organisations (60.3%); in China, by institutions (99.5%). Dimensions.ai data showed 180 DCM research grants explicitly awarded, with a total value of US$45.6 million since 1996. CONCLUSIONS DCM funding appears to be predominantly from USA, China and Japan, aligning with areas of high DCM research activity and underpinning the importance of funding to increasing research capacity. The existing funding sources differ from medical research in general, representing opportunities for future investment in DCM.

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