Degenerative Cervical Myelopathy: Clinical Presentation, Assessment, and Natural History

Degenerative cervical myelopathy (DCM) is a leading cause of spinal cord injury and a major contributor to morbidity resulting from narrowing of the spinal canal due to osteoarthritic changes. This narrowing produces chronic spinal cord compression and neurologic disability with a variety of symptoms ranging from mild numbness in the upper extremities to quadriparesis and incontinence. Clinicians from all specialties should be familiar with the early signs and symptoms of this prevalent condition to prevent gradual neurologic compromise through surgical consultation, where appropriate. The purpose of this review is to familiarize medical practitioners with the pathophysiology, common presentations, diagnosis, and management (conservative and surgical) for DCM to develop informed discussions with patients and recognize those in need of early surgical referral to prevent severe neurologic deterioration.

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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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The Natural History of Degenerative Cervical Myelopathy and the Rate of Hospitalization Following Spinal Cord Injury: An Updated Systematic Review

Global Spine Journal ◽

10.1177/2192568217700396 ◽

2017 ◽

Vol 7 (3_suppl) ◽

pp. 28S-34S ◽

Cited By ~ 23

Author(s):

Lindsay A. Tetreault ◽

Spyridon Karadimas ◽

Jefferson R. Wilson ◽

Paul M. Arnold ◽

Shekar Kurpad ◽

...

Keyword(s):

Systematic Review ◽

Spinal Cord ◽

Spinal Cord Injury ◽

Natural History ◽

Cervical Myelopathy ◽

Cochrane Collaboration ◽

Level Of Evidence ◽

Cord Injury ◽

History Of ◽

Degenerative Cervical Myelopathy

Study Method: Systematic review (update). Objective: Degenerative cervical myelopathy (DCM) is a degenerative spine disease and the most common cause of spinal cord dysfunction in adults worldwide. The objective of this study is to determine the natural history of DCM by updating the systematic review by Karadimas et al. The specific aims of this review were (1) to describe the natural history of DCM and (2) to determine potential risk factors of disease progression. Method: An updated search based on a previous protocol was conducted in PubMed and the Cochrane Collaboration library for studies published between November 2012 and February 15, 2015. Results: The updated search yielded 3 additional citations that met inclusion criteria and reported the incidence of spinal cord injury and severe disability in patients with DCM. Based on 2 retrospective cohort studies, the incidence rate of hospitalization for spinal cord injury is 13.9 per 1000 person-years in patients with cervical spondylotic myelopathy and 4.8 per 1000 person-years in patients with myelopathy secondary to ossification of the posterior longitudinal ligament (OPLL). In a third small prospective study, the risk of being wheelchair bound or bedridden was 66.7% in DCM patients with OPLL. Conclusion: The overall level of evidence for these estimated rates of hospitalization following spinal cord injury was rated as low.

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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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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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Cervical Myelopathy

Spinal Neurosurgery ◽

10.1093/med/9780190887773.003.0008 ◽

2018 ◽

pp. 71-80

Author(s):

Mario Ganau ◽

So Kato ◽

Michael G. Fehlings

Keyword(s):

Spinal Cord ◽

Cervical Myelopathy ◽

Deformity Correction ◽

Kyphotic Deformity ◽

Surgical Team ◽

Comprehensive Management ◽

Cord Injury ◽

Pros And Cons ◽

Spinal Cord Decompression ◽

Degenerative Cervical Myelopathy

Patients with kyphotic deformity and degenerative cervical myelopathy are at elevated risk for traumatic and nontraumatic spinal cord injury and require comprehensive management entailing a careful clinical assessment with dedicated functional scales and radiological study of spinal balance. Surgical strategies to address this clinical scenario including anterior, posterior, and combined approaches. Whatever the choice, the surgical plan should always envisage spinal cord decompression and stabilization along with deformity correction. The surgical team should discuss pros and cons of the most appropriate surgical plan with the patient, anticipate possible complications, and propose alternate strategies. This chapter details the most important practical aspects of surgical management, ranging from technical advantages of multiple osteotomies and selection of implants for instrumented fusion, to the surgical and anesthesiological nuances to avoid intraoperative and postoperative complications. An overview is provided of scientific literature regarding the correction of kyphotic deformity and ongoing clinical trials.

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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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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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Prospects of cell replacement therapy for the treatment of degenerative cervical myelopathy

Reviews in the Neurosciences ◽

10.1515/revneuro-2020-0075 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Graham Ka Hon Shea ◽

Paul Aarne Koljonen ◽

Ying Shing Chan ◽

Kenneth Man Chee Cheung

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Replacement Therapy ◽

Cervical Myelopathy ◽

Neurological Function ◽

Traumatic Spinal Cord Injury ◽

Cell Replacement Therapy ◽

Cell Replacement ◽

Cord Injury ◽

Degenerative Cervical Myelopathy

AbstractDegenerative cervical myelopathy (DCM) presents insidiously during middle-age with deterioration in neurological function. It accounts for the most common cause of non-traumatic spinal cord injury in developed countries and disease prevalence is expected to rise with the aging population. Whilst surgery can prevent further deterioration, biological therapies may be required to restore neurological function in advanced disease. Cell replacement therapy has been inordinately focused on treatment of traumatic spinal cord injury yet holds immense promise in DCM. We build upon this thesis by reviewing the pathophysiology of DCM as revealed by cadaveric and molecular studies. Loss of oligodendrocytes and neurons occurs via apoptosis. The tissue microenvironment in DCM prior to end-stage disease is distinct from that following acute trauma, and in many ways more favourable to receiving exogenous cells. We highlight clinical considerations for cell replacement in DCM such as selection of cell type, timing and method of delivery, as well as biological treatment adjuncts. Critically, disease models often fail to mimic features of human pathology. We discuss directions for translational research towards clinical application.

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Clinical Assessment of Cervical Myelopathy

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2014.janfeb03 ◽

2014 ◽

Vol 19 (1) ◽

pp. 10-11

Author(s):

Marjorie Eskay-Auerbach ◽

Charles N. Brooks

Keyword(s):

Spinal Cord ◽

Cervical Myelopathy ◽

Correct Diagnosis ◽

Neurological Impairment ◽

Cord Compression ◽

Imaging Studies ◽

Current Standard ◽

Electrodiagnostic Testing ◽

Objective Evidence ◽

Cord Injury

Abstract Myelopathy literally indicates any pathology of the spinal cord, but the term most commonly is used when the cord pathology results from degenerative disease. Specific names usually are used if the disorder is traumatic (spinal cord injury), infectious (myelitis), or neoplastic (the name of the tumor is used). Cervical myelopathy (CM) may result in symptoms such as clumsiness, loss of dexterity, imbalance or poor coordination; muscle weakness; pain; and, in severe cases, bowel, bladder, or sexual dysfunction. When impairment is rated, if the evaluator finds objective evidence of myelopathy when the individual is at maximum medical improvement, neurological impairment is combined with that for the spine. A detailed and thorough neurologic examination is the current standard for the diagnosis of CM, but diagnosis is challenging in the early stages. Correlation of patient symptoms and imaging studies, both plain radiographs and magnetic resonance imaging scans, is essential for correct diagnosis. When imaging studies are equivocal or insensitive, other studies such as electrodiagnostic testing and cerebrospinal fluid analysis may be considered. When CM is defined as the presence of more than one long-tract sign, spinal cord compression in isolation did not cause myelopathy, and up to 20% of those with cord compression did not exhibit CM.

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The Relationship Between Preoperative Clinical Presentation and Quantitative Magnetic Resonance Imaging Features in Patients With Degenerative Cervical Myelopathy

Neurosurgery ◽

10.1227/neu.0000000000001420 ◽

2016 ◽

Vol 80 (1) ◽

pp. 121-128 ◽

Cited By ~ 15

Author(s):

Aria Nouri ◽

Lindsay Tetreault ◽

Kristian Dalzell ◽

Juan J. Zamorano ◽

Michael G. Fehlings

Keyword(s):

Magnetic Resonance Imaging ◽

Spinal Cord ◽

Magnetic Resonance ◽

Lower Limb ◽

Cervical Myelopathy ◽

Clinical Presentation ◽

Resonance Imaging ◽

Mri Features ◽

Degenerative Cervical Myelopathy ◽

The Relationship

Abstract BACKGROUND: Degenerative cervical myelopathy encompasses a group of conditions resulting in progressive spinal cord injury through static and dynamic compression. Although a constellation of changes can present on magnetic resonance imaging (MRI), the clinical significance of these findings remains a subject of controversy and discussion. OBJECTIVE: To investigate the relationship between clinical presentation and quantitative MRI features in patients with degenerative cervical myelopathy. METHODS: A secondary analysis of MRI and clinical data from 114 patients enrolled in a prospective, multicenter study was conducted. MRIs were assessed for maximum spinal cord compression (MSCC), maximum canal compromise (MCC), signal changes, and a signal change ratio (SCR). MRI features were compared between patients with and those without myelopathy symptoms with the use of t tests. Correlations between MRI features and duration of symptoms were assessed with the Spearman ρ. RESULTS: Numb hands and Hoffmann sign were associated with greater MSCC (P < .05); broad-based, unstable gait, impairment of gait, and Hoffmann sign were associated with greater MCC (P < .05); and numb hands, Hoffmann sign, Babinski sign, lower limb spasticity, hyperreflexia, and T1 hypointensity were associated with greater SCR (P < .05). Patients with a T2 signal hyperintensity had greater MSCC and MCC (P < .001). CONCLUSION: MSCC was associated with upper limb manifestations, and SCR was associated with upper limb, lower limb, and general neurological deficits. Hoffmann sign occurred more commonly in patients with a greater MSCC, MCC and SCR. The Lhermitte phenomenon presented more commonly in patients with a lower SCR and may be an early indicator of mild spinal cord involvement. Research to validate these findings is required.

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