Management of Degenerative Cervical Myelopathy and Spinal Cord Injury

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (15 January 2022) | Viewed by 58908

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Guest Editor
1. Spine Program; Krembil Brain Institute, University Health Network, Toronto, ON M5T 2S8, Canada
2. Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
Interests: scoliosis; kyphosis; spondylolisthesis; trauma; tumors; cervical myelopathy; lumbar stenosis; disc herniations; rheumatoid arthritis; infections; connective tissue disorders; syringomyelia; Chiari malformations

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Co-Guest Editor
Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
Interests: Degenerative Cervical Myelopathy (DCM); Magnetic Resonance Imaging (MRI); cervical canal stenosis; Subacute Combined Degeneration of the Spinal Cord (SACD); anemia and DCM; cervical spine surgery; surgical decision-making; surgical outcome prediction; Ossification of the Posterior Longitudinal Ligament (OPLL); cervical spondylolithesis
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Special Issue Information

Dear Colleagues,

Degenerative cervical myelopathy (DCM) and traumatic spinal cord injury (SCI) represent two of the most important conditions affecting the spinal cord, affecting millions of individuals worldwide and causing substantial disability. DCM and SCI are unique pathologies with marked differences in etiology and demographics, but they show many similarities in terms of anatomical features, pathophysiological mechanisms, and therapeutic challenges, offering several benefits to studying these conditions in parallel. Clinical management of these conditions has evolved substantially over several decades, including clinical assessments, imaging, electrophysiology studies, non-operative therapies, operative techniques, and rehabilitation strategies. Clinical decision-making is increasingly informed by clinical practice guidelines sponsored by neurosurgical and spine organizations, but these guidelines are a work in progress and leave many areas of uncertainty for clinicians. In the near future, we can expect the management of DCM and SCI to change dramatically as high-quality evidence and novel imaging tools, surgical technologies, and biological therapies become available. This issue of the Journal of Clinical Medicine offers a snapshot of current evidence and state-of-the-art clinical practice, and a forecast of what the future may look like for the management of DCM and SCI.

Dr. Allan R. Martin
Dr. Aria Nouri
Guest Editor

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Keywords

  • Degenerative cervical myelopathy (DCM)
  • Traumatic spinal cord injury (SCI)
  • Clinical assessments
  • Imaging
  • Electrophysiology
  • Non-operative therapies
  • Operative techniques
  • Rehabilitation strategies

Published Papers (15 papers)

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Editorial

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7 pages, 206 KiB  
Editorial
Degenerative Cervical Myelopathy and Spinal Cord Injury: Introduction to the Special Issue
by Khadija Soufi, Aria Nouri and Allan R. Martin
J. Clin. Med. 2022, 11(15), 4253; https://doi.org/10.3390/jcm11154253 - 22 Jul 2022
Cited by 1 | Viewed by 1262
Abstract
Damage to the spinal cord (SC) can arise from either traumatic or non-traumatic spinal cord injury (SCI) [...] Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)

Research

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13 pages, 280 KiB  
Article
Spinal Cord Signal Change on Magnetic Resonance Imaging May Predict Worse Clinical In- and Outpatient Outcomes in Patients with Spinal Cord Injury: A Prospective Multicenter Study in 459 Patients
by Thorsten Jentzsch, David W. Cadotte, Jefferson R. Wilson, Fan Jiang, Jetan H. Badhiwala, Muhammad A. Akbar, Brett Rocos, Robert G. Grossman, Bizhan Aarabi, James S. Harrop and Michael G. Fehlings
J. Clin. Med. 2021, 10(20), 4778; https://doi.org/10.3390/jcm10204778 - 18 Oct 2021
Cited by 11 | Viewed by 2480
Abstract
Prognostic factors for clinical outcome after spinal cord (SC) injury (SCI) are limited but important in patient management and education. There is a lack of evidence regarding magnetic resonance imaging (MRI) and clinical outcomes in SCI patients. Therefore, we aimed to investigate whether [...] Read more.
Prognostic factors for clinical outcome after spinal cord (SC) injury (SCI) are limited but important in patient management and education. There is a lack of evidence regarding magnetic resonance imaging (MRI) and clinical outcomes in SCI patients. Therefore, we aimed to investigate whether baseline MRI features predicted the clinical course of the disease. This study is an ancillary to the prospective North American Clinical Trials Network (NACTN) registry. Patients were enrolled from 2005–2017. MRI within 72 h of injury and a minimum follow-up of one year were available for 459 patients. Patients with American Spinal Injury Association impairment scale (AIS) E were excluded. Patients were grouped into those with (n = 354) versus without (n = 105) SC signal change on MRI T2-weighted images. Logistic regression analysis adjusted for commonly known a priori confounders (age and baseline AIS). Main outcomes and measures: The primary outcome was any adverse event. Secondary outcomes were AIS at the baseline and final follow-up, length of hospital stay (LOS), and mortality. A regression model adjusted for age and baseline AIS. Patients with intrinsic SC signal change were younger (46.0 (interquartile range (IQR) 29.0 vs. 50.0 (IQR 20.5) years, p = 0.039). There were no significant differences in the other baseline variables, gender, body mass index, comorbidities, and injury location. There were more adverse events in patients with SC signal change (230 (65.0%) vs. 47 (44.8%), p < 0.001; odds ratio (OR) = 2.09 (95% confidence interval (CI) 1.31–3.35), p = 0.002). The most common adverse event was cardiopulmonary (186 (40.5%)). Patients were less likely to be in the AIS D category with SC signal change at baseline (OR = 0.45 (95% CI 0.28–0.72), p = 0.001) and in the AIS D or E category at the final follow-up (OR = 0.36 (95% CI 0.16–0.82), p = 0.015). The length of stay was longer in patients with SC signal change (13.0 (IQR 17.0) vs. 11.0 (IQR 14.0), p = 0.049). There was no difference between the groups in mortality (11 (3.2%) vs. 4 (3.9%)). MRI SC signal change may predict adverse events and overall LOS in the SCI population. If present, patients are more likely to have a worse baseline clinical presentation (i.e., AIS) and in- or outpatient clinical outcome after one year. Patients with SC signal change may benefit from earlier, more aggressive treatment strategies and need to be educated about an unfavorable prognosis. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
13 pages, 7449 KiB  
Article
Sex-Dependent Cortical Volume Changes in Patients with Degenerative Cervical Myelopathy
by Talia C. Oughourlian, Chencai Wang, Noriko Salamon, Langston T. Holly and Benjamin M. Ellingson
J. Clin. Med. 2021, 10(17), 3965; https://doi.org/10.3390/jcm10173965 - 1 Sep 2021
Cited by 4 | Viewed by 2600
Abstract
Degenerative cervical myelopathy (DCM) is a progressive condition characterized by degeneration of osseocartilaginous structures within the cervical spine resulting in compression of the spinal cord and presentation of clinical symptoms. Compared to healthy controls (HCs), studies have shown DCM patients experience structural and [...] Read more.
Degenerative cervical myelopathy (DCM) is a progressive condition characterized by degeneration of osseocartilaginous structures within the cervical spine resulting in compression of the spinal cord and presentation of clinical symptoms. Compared to healthy controls (HCs), studies have shown DCM patients experience structural and functional reorganization in the brain; however, sex-dependent cortical differences in DCM patients remains largely unexplored. In the present study, we investigate the role of sex differences on the structure of the cerebral cortex in DCM and determine how structural differences may relate to clinical measures of neurological function. T1-weighted structural MRI scans were acquired in 85 symptomatic and asymptomatic patients with DCM and 90 age-matched HCs. Modified Japanese Orthopedic Association (mJOA) scores were obtained for patients. A general linear model was used to determine vertex-level significant differences in gray matter volume (GMV) between the following groups (1) male HCs and female HCs, (2) male patients and female patients, (3) male patients and male HCs, and (4) female patients and female HCs. Within patients, males exhibited larger GMV in motor, language, and vision related brain regions compared to female DCM patients. Males demonstrated a significant positive correlation between GMV and mJOA score, in which patients with worsening neurological symptoms exhibited decreasing GMV primarily across somatosensory and motor related cortical regions. Females exhibited a similar association, albeit across a broader range of cortical areas including those involved in pain processing. In sensorimotor regions, female patients consistently showed smaller GMV compared with male patients, independent of mJOA score. Results from the current study suggest strong sex-related differences in cortical volume in patients with DCM, which may reflect hormonal influence or differing compensation mechanisms. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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15 pages, 1599 KiB  
Article
Spinal Cord Motion in Degenerative Cervical Myelopathy: The Level of the Stenotic Segment and Gender Cause Altered Pathodynamics
by Katharina Wolf, Marco Reisert, Saúl Felipe Beltrán, Jan-Helge Klingler, Ulrich Hubbe, Axel J. Krafft, Nico Kremers, Karl Egger and Marc Hohenhaus
J. Clin. Med. 2021, 10(17), 3788; https://doi.org/10.3390/jcm10173788 - 25 Aug 2021
Cited by 11 | Viewed by 1932
Abstract
In degenerative cervical myelopathy (DCM), focally increased spinal cord motion has been observed for C5/C6, but whether stenoses at other cervical segments lead to similar pathodynamics and how severity of stenosis, age, and gender affect them is still unclear. We report a prospective [...] Read more.
In degenerative cervical myelopathy (DCM), focally increased spinal cord motion has been observed for C5/C6, but whether stenoses at other cervical segments lead to similar pathodynamics and how severity of stenosis, age, and gender affect them is still unclear. We report a prospective matched-pair controlled trial on 65 DCM patients. A high-resolution 3D T2 sampling perfection with application-optimized contrasts using different flip angle evolution (SPACE) and a phase-contrast magnetic resonance imaging (MRI) sequence were performed and automatically segmented. Anatomical and spinal cord motion data were assessed per segment from C2/C3 to C7/T1. Spinal cord motion was focally increased at a level of stenosis among patients with stenosis at C4/C5 (n = 14), C5/C6 (n = 33), and C6/C7 (n = 10) (p < 0.033). Patients with stenosis at C2/C3 (n = 2) and C3/C4 (n = 6) presented a similar pattern, not reaching significance. Gender was a significant predictor of higher spinal cord dynamics among men with stenosis at C5/C6 (p = 0.048) and C6/C7 (p = 0.033). Age and severity of stenosis did not relate to spinal cord motion. Thus, the data demonstrates focally increased spinal cord motion depending on the specific level of stenosis. Gender-related effects lead to dynamic alterations among men with stenosis at C5/C6 and C6/C7. The missing relation of motion to severity of stenosis underlines a possible additive diagnostic value of spinal cord motion analysis in DCM. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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10 pages, 1362 KiB  
Article
Clinical Outcomes between Stand-Alone Zero-Profile Spacers and Cervical Plate with Cage Fixation for Anterior Cervical Discectomy and Fusion: A Retrospective Analysis of 166 Patients
by Samuel Sommaruga, Joaquin Camara-Quintana, Kishan Patel, Aria Nouri, Enrico Tessitore, Granit Molliqaj, Shreyas Panchagnula, Michael Robinson, Justin Virojanapa, Xin Sun, Fjodor Melnikov, Luis Kolb, Karl Schaller, Khalid Abbed and Joseph Cheng
J. Clin. Med. 2021, 10(14), 3076; https://doi.org/10.3390/jcm10143076 - 12 Jul 2021
Cited by 9 | Viewed by 3330
Abstract
Stand-alone (SA) zero-profile implants are an alternative to cervical plating (CP) in anterior cervical discectomy and fusion (ACDF). In this study, we investigate differences in surgical outcomes between SA and CP in ACDF. We conducted a retrospective analysis of 166 patients with myelopathy [...] Read more.
Stand-alone (SA) zero-profile implants are an alternative to cervical plating (CP) in anterior cervical discectomy and fusion (ACDF). In this study, we investigate differences in surgical outcomes between SA and CP in ACDF. We conducted a retrospective analysis of 166 patients with myelopathy and/or radiculopathy who had ACDF with SA or CP from Jan 2013–Dec 2016. We measured surgical outcomes including Bazaz dysphagia score at 3 months, Nurick grade at last follow-up, and length of hospital stay. 166 patients (92F/74M) were reviewed. 92 presented with radiculopathy (55%), 37 with myelopathy (22%), and 37 with myeloradiculopathy (22%). The average operative time with CP was longer than SA (194 ± 69 vs. 126 ± 46 min) (p < 0.001), as was the average length of hospital stay (2.1 ± 2 vs. 1.5 ± 1 days) (p = 0.006). At 3 months, 82 patients (49.4%) had a follow-up for dysphagia, with 3 patients reporting mild dysphagia and none reporting moderate or severe dysphagia. Nurick grade at last follow-up for the myelopathy and myeloradiculopathy cohorts improved in 63 patients (85%). Prolonged length of stay was associated with reduced odds of having an optimal outcome by 0.50 (CI = 0.35–0.85, p = 0.003). Overall, we demonstrate that there is no significant difference in neurological outcome or rates of dysphagia between SA and CP, and that both lead to overall improvement of symptoms based on Nurick grading. However, we also show that the SA group has shorter length of hospital stay and operative time compared to CP. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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16 pages, 2867 KiB  
Article
The Long-Term Effect of Treatment Using the Transcranial Magnetic Stimulation rTMS in Patients after Incomplete Cervical or Thoracic Spinal Cord Injury
by Agnieszka Wincek, Juliusz Huber, Katarzyna Leszczyńska, Wojciech Fortuna, Stefan Okurowski, Krzysztof Chmielak and Paweł Tabakow
J. Clin. Med. 2021, 10(13), 2975; https://doi.org/10.3390/jcm10132975 - 2 Jul 2021
Cited by 18 | Viewed by 2448
Abstract
Repetitive transcranial magnetic stimulation (rTMS) may support motor function recovery in patients with incomplete spinal cord injury (iSCI). Its effectiveness mainly depends on the applied algorithm. This clinical and neurophysiological study aimed to assess the effectiveness of high-frequency rTMS in iSCI patients at [...] Read more.
Repetitive transcranial magnetic stimulation (rTMS) may support motor function recovery in patients with incomplete spinal cord injury (iSCI). Its effectiveness mainly depends on the applied algorithm. This clinical and neurophysiological study aimed to assess the effectiveness of high-frequency rTMS in iSCI patients at the C2–Th12 levels. rTMS sessions (lasting 3–5 per month, from 2 to 11 months, 5 months on average) were applied to 26 iSCI subjects. The motor cortex was bilaterally stimulated with a frequency at 20–25 Hz and a stimulus strength that was 70–80% of the resting motor threshold (15.4–45.5% maximal output) during one therapeutic session. Surface electromyography (sEMG) recordings at rest and during maximal contractions and motor evoked potential (MEP) recordings were performed from the abductor pollicis brevis (APB) and the tibialis anterior (TA) muscles. The same neurophysiological studies were also performed in patients treated with kinesiotherapy only (K group, n = 25) and compared with patients treated with both kinesiotherapy and rTMS (K + rTMS). A decrease in sEMG amplitudes recorded at rest from the APB muscles (p = 0.001) and an increase in sEMG amplitudes during the maximal contraction of the APB (p = 0.001) and TA (p = 0.009) muscles were found in the K + rTMS group. A comparison of data from MEP studies recorded from both APB and TA muscles showed significant changes in the mean amplitudes but not in latencies, suggesting a slight improvement in the transmission of spinal efferent pathways from the motor cortex to the lower spinal centers. The application of rTMS at 20–25 Hz reduced spasticity in the upper extremity muscles, improved the recruitment of motor units in the upper and lower extremity muscles, and slightly improved the transmission of efferent neural impulses within the spinal pathways in patients with C2–Th12 iSCI. Neurophysiological recordings produced significantly better parameters in the K + rTMS group of patients after therapy. These results may support the hypothesis about the importance of rTMS therapy and possible involvement of the residual efferent pathways including propriospinal neurons in the recovery of the motor control of iSCI patients. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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12 pages, 843 KiB  
Article
Vertigo in Patients with Degenerative Cervical Myelopathy
by Zdenek Kadanka, Jr., Zdenek Kadanka, Sr., Rene Jura and Josef Bednarik
J. Clin. Med. 2021, 10(11), 2496; https://doi.org/10.3390/jcm10112496 - 4 Jun 2021
Cited by 4 | Viewed by 4285
Abstract
(1) Background: Cervical vertigo (CV) represents a controversial entity, with a prevalence ranging from reported high frequency to negation of CV existence. (2) Objectives: To assess the prevalence and cause of vertigo in patients with a manifest form of severe cervical spondylosis–degenerative cervical [...] Read more.
(1) Background: Cervical vertigo (CV) represents a controversial entity, with a prevalence ranging from reported high frequency to negation of CV existence. (2) Objectives: To assess the prevalence and cause of vertigo in patients with a manifest form of severe cervical spondylosis–degenerative cervical myelopathy (DCM) with special focus on CV. (3) Methods: The study included 38 DCM patients. The presence and character of vertigo were explored with a dedicated questionnaire. The cervical torsion test was used to verify the role of neck proprioceptors, and ultrasound examinations of vertebral arteries to assess the role of arteriosclerotic stenotic changes as hypothetical mechanisms of CV. All patients with vertigo underwent a detailed diagnostic work-up to investigate the cause of vertigo. (4) Results: Symptoms of vertigo were described by 18 patients (47%). Causes of vertigo included: orthostatic dizziness in eight (22%), hypertension in five (14%), benign paroxysmal positional vertigo in four (11%) and psychogenic dizziness in one patient (3%). No patient responded positively to the cervical torsion test or showed significant stenosis of vertebral arteries. (5) Conclusions: Despite the high prevalence of vertigo in patients with DCM, the aetiology in all cases could be attributed to causes outside cervical spine and related nerve structures, thus confirming the assumption that CV is over-diagnosed. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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12 pages, 695 KiB  
Article
Walk and Run Test in Patients with Degenerative Compression of the Cervical Spinal Cord
by Zdenek Kadanka, Jr., Zdenek Kadanka, Sr., Tomas Skutil, Eva Vlckova and Josef Bednarik
J. Clin. Med. 2021, 10(5), 927; https://doi.org/10.3390/jcm10050927 - 1 Mar 2021
Cited by 3 | Viewed by 1912
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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18 pages, 1411 KiB  
Article
Spinal Cord Morphology in Degenerative Cervical Myelopathy Patients; Assessing Key Morphological Characteristics Using Machine Vision Tools
by Kalum Ost, W. Bradley Jacobs, Nathan Evaniew, Julien Cohen-Adad, David Anderson and David W. Cadotte
J. Clin. Med. 2021, 10(4), 892; https://doi.org/10.3390/jcm10040892 - 23 Feb 2021
Cited by 9 | Viewed by 3136
Abstract
Despite Degenerative Cervical Myelopathy (DCM) being the most common form of spinal cord injury, effective methods to evaluate patients for its presence and severity are only starting to appear. Evaluation of patient images, while fast, is often unreliable; the pathology of DCM is [...] Read more.
Despite Degenerative Cervical Myelopathy (DCM) being the most common form of spinal cord injury, effective methods to evaluate patients for its presence and severity are only starting to appear. Evaluation of patient images, while fast, is often unreliable; the pathology of DCM is complex, and clinicians often have difficulty predicting patient prognosis. Automated tools, such as the Spinal Cord Toolbox (SCT), show promise, but remain in the early stages of development. To evaluate the current state of an SCT automated process, we applied it to MR imaging records from 328 DCM patients, using the modified Japanese Orthopedic Associate scale as a measure of DCM severity. We found that the metrics extracted from these automated methods are insufficient to reliably predict disease severity. Such automated processes showed potential, however, by highlighting trends and barriers which future analyses could, with time, overcome. This, paired with findings from other studies with similar processes, suggests that additional non-imaging metrics could be added to achieve diagnostically relevant predictions. Although modeling techniques such as these are still in their infancy, future models of DCM severity could greatly improve automated clinical diagnosis, communications with patients, and patient outcomes. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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15 pages, 613 KiB  
Article
Frailty Is a Better Predictor than Age of Mortality and Perioperative Complications after Surgery for Degenerative Cervical Myelopathy: An Analysis of 41,369 Patients from the NSQIP Database 2010–2018
by Jamie R. F. Wilson, Jetan H. Badhiwala, Ali Moghaddamjou, Albert Yee, Jefferson R. Wilson and Michael G. Fehlings
J. Clin. Med. 2020, 9(11), 3491; https://doi.org/10.3390/jcm9113491 - 29 Oct 2020
Cited by 71 | Viewed by 2691
Abstract
Background: The ability of frailty compared to age alone to predict adverse events in the surgical management of Degenerative Cervical Myelopathy (DCM) has not been defined in the literature. Methods: 41,369 patients with a diagnosis of DCM undergoing surgery were collected from the [...] Read more.
Background: The ability of frailty compared to age alone to predict adverse events in the surgical management of Degenerative Cervical Myelopathy (DCM) has not been defined in the literature. Methods: 41,369 patients with a diagnosis of DCM undergoing surgery were collected from the National Surgical Quality Improvement Program (NSQIP) Database 2010–2018. Univariate analysis for each measure of frailty (modified frailty index 11- and 5-point; MFI-11, MFI-5), modified Charlson Co-morbidity index and ASA grade) were calculated for the following outcomes: mortality, major complication, unplanned reoperation, unplanned readmission, length of hospital stay, and discharge to a non-home destination. Multivariable modeling of age and frailty with a base model was performed to define the discriminative ability of each measure. Results: Age and frailty have a significant effect on all outcomes, but the MFI-5 has the largest effect size. Increasing frailty correlated significantly with the risk of perioperative adverse events, longer hospital stay, and risk of a non-home discharge destination. Multivariable modeling incorporating MFI-5 with age and the base model had a robust predictive value (0.85). MFI-5 had a high categorical assessment correlation with a MFI-11 of 0.988 (p < 0.001). Conclusions and Relevance: Measures of frailty have a greater effect size and a higher discriminative value to predict adverse events than age alone. MFI-5 categorical assessment is essentially equivalent to the MFI-11 score for DCM patients. A multivariable model using MFI-5 provides an accurate predictive tool that has important clinical applications. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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Review

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34 pages, 1563 KiB  
Review
The Role of Magnetic Resonance Imaging to Inform Clinical Decision-Making in Acute Spinal Cord Injury: A Systematic Review and Meta-Analysis
by Arash Ghaffari-Rafi, Catherine Peterson, Jose E. Leon-Rojas, Nobuaki Tadokoro, Stefan F. Lange, Mayank Kaushal, Lindsay Tetreault, Michael G. Fehlings and Allan R. Martin
J. Clin. Med. 2021, 10(21), 4948; https://doi.org/10.3390/jcm10214948 - 26 Oct 2021
Cited by 14 | Viewed by 2800
Abstract
The clinical indications and added value of obtaining MRI in the acute phase of spinal cord injury (SCI) remain controversial. This review aims to critically evaluate evidence regarding the role of MRI to influence decision-making and outcomes in acute SCI. A systematic review [...] Read more.
The clinical indications and added value of obtaining MRI in the acute phase of spinal cord injury (SCI) remain controversial. This review aims to critically evaluate evidence regarding the role of MRI to influence decision-making and outcomes in acute SCI. A systematic review and meta-analysis were performed according to PRISMA methodology to identify studies that address six key questions (KQs) regarding diagnostic accuracy, frequency of abnormal findings, frequency of altered decision-making, optimal timing, and differences in outcomes related to obtaining an MRI in acute SCI. A total of 32 studies were identified that addressed one or more KQs. MRI showed no adverse events in 156 patients (five studies) and frequently identified cord compression (70%, 12 studies), disc herniation (43%, 16 studies), ligamentous injury (39%, 13 studies), and epidural hematoma (10%, two studies), with good diagnostic accuracy (seven comparative studies) except for fracture detection. MRI findings often altered management, including timing of surgery (78%, three studies), decision to operate (36%, 15 studies), and surgical approach (29%, nine studies). MRI may also be useful to determine the need for instrumentation (100%, one study), which levels to decompress (100%, one study), and if reoperation is needed (34%, two studies). The available literature consistently concluded that MRI was useful prior to surgical treatment (13 studies) and after surgery to assess decompression (two studies), but utility before/after closed reduction of cervical dislocations was unclear (three studies). One study showed improved outcomes with an MRI-based protocol but had a high risk of bias. Heterogeneity was high for most findings (I2 > 0.75). MRI is safe and frequently identifies findings alter clinical management in acute SCI, although direct evidence of its impact on outcomes is lacking. MRI should be performed before and after surgery, when feasible, to facilitate improved clinical decision-making. However, further research is needed to determine its optimal timing, effect on outcomes, cost-effectiveness, and utility before and after closed reduction. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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13 pages, 993 KiB  
Review
The Relative Merits of Posterior Surgical Treatments for Multi-Level Degenerative Cervical Myelopathy Remain Uncertain: Findings from a Systematic Review
by Xiaoyu Yang, Aref-Ali Gharooni, Rana S. Dhillon, Edward Goacher, Edward W. Dyson, Oliver Mowforth, Alexandru Budu, Guy Wynne-Jones, Jibin Francis, Rikin Trivedi, Marcel Ivanov, Sashin Ahuja, Kia Rezajooi, Andreas K. Demetriades, David Choi, Antony H. Bateman, Nasir Quraishi, Vishal Kumar, Manjul Tripathi, Sandeep Mohindra, Erlick A. Pereira, Giles Critchley, Michael G. Fehlings, Peter J. A. Hutchinson, Benjamin M. Davies and Mark R. N. Kotteradd Show full author list remove Hide full author list
J. Clin. Med. 2021, 10(16), 3653; https://doi.org/10.3390/jcm10163653 - 18 Aug 2021
Cited by 10 | Viewed by 2270
Abstract
Objectives: To assess the reporting of study design and characteristics in multi-level degenerative cervical myelopathy (DCM) treated by posterior surgical approaches, and perform a comparison of clinical and radiographic outcomes between different approaches. Methods: A literature search was performed in Embase and MEDLINE [...] Read more.
Objectives: To assess the reporting of study design and characteristics in multi-level degenerative cervical myelopathy (DCM) treated by posterior surgical approaches, and perform a comparison of clinical and radiographic outcomes between different approaches. Methods: A literature search was performed in Embase and MEDLINE between 1995–2019 using a sensitive search string combination. Studies were selected by predefined selection criteria: Full text articles in English, with >10 patients (prospective) or >50 patients (retrospective), reporting outcomes of multi-level DCM treated by posterior surgical approach. Results: A total of 75 studies involving 19,510 patients, conducted worldwide, were identified. Laminoplasty was described in 56 studies (75%), followed by laminectomy with (36%) and without fusion (16%). The majority of studies were conducted in Asia (84%), in the period of 2016–2019 (51%), of which laminoplasty was studied predominantly. Twelve (16%) prospective studies and 63 (84%) retrospective studies were identified. The vast majority of studies were conducted in a single centre (95%) with clear inclusion/exclusion criteria and explicit cause of DCM. Eleven studies (15%) included patients with ossification of the posterior longitudinal ligament exclusively with cohorts of 57 to 252. The clinical and radiographic outcomes were reported with heterogeneity when comparing laminoplasty, laminectomy with and without fusion. Conclusions: Heterogeneity in the reporting of study and sample characteristics exists, as well as in clinical and radiographic outcomes, with a paucity of studies with a higher level of evidence. Future studies are needed to elucidate the clinical effectiveness of posterior surgical treatments. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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12 pages, 2167 KiB  
Review
Degenerative Cervical Myelopathy: Clinical Presentation, Assessment, and Natural History
by Melissa Lannon and Edward Kachur
J. Clin. Med. 2021, 10(16), 3626; https://doi.org/10.3390/jcm10163626 - 17 Aug 2021
Cited by 19 | Viewed by 6301
Abstract
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 [...] Read more.
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. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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25 pages, 2243 KiB  
Review
Degenerative Cervical Myelopathy: Insights into Its Pathobiology and Molecular Mechanisms
by Ji Tu, Jose Vargas Castillo, Abhirup Das and Ashish D. Diwan
J. Clin. Med. 2021, 10(6), 1214; https://doi.org/10.3390/jcm10061214 - 15 Mar 2021
Cited by 30 | Viewed by 16770
Abstract
Degenerative cervical myelopathy (DCM), earlier referred to as cervical spondylotic myelopathy (CSM), is the most common and serious neurological disorder in the elderly population caused by chronic progressive compression or irritation of the spinal cord in the neck. The clinical features of DCM [...] Read more.
Degenerative cervical myelopathy (DCM), earlier referred to as cervical spondylotic myelopathy (CSM), is the most common and serious neurological disorder in the elderly population caused by chronic progressive compression or irritation of the spinal cord in the neck. The clinical features of DCM include localised neck pain and functional impairment of motor function in the arms, fingers and hands. If left untreated, this can lead to significant and permanent nerve damage including paralysis and death. Despite recent advancements in understanding the DCM pathology, prognosis remains poor and little is known about the molecular mechanisms underlying its pathogenesis. Moreover, there is scant evidence for the best treatment suitable for DCM patients. Decompressive surgery remains the most effective long-term treatment for this pathology, although the decision of when to perform such a procedure remains challenging. Given the fact that the aged population in the world is continuously increasing, DCM is posing a formidable challenge that needs urgent attention. Here, in this comprehensive review, we discuss the current knowledge of DCM pathology, including epidemiology, diagnosis, natural history, pathophysiology, risk factors, molecular features and treatment options. In addition to describing different scoring and classification systems used by clinicians in diagnosing DCM, we also highlight how advanced imaging techniques are being used to study the disease process. Last but not the least, we discuss several molecular underpinnings of DCM aetiology, including the cells involved and the pathways and molecules that are hallmarks of this disease. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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12 pages, 1274 KiB  
Systematic Review
How Is Spinal Cord Function Measured in Degenerative Cervical Myelopathy? A Systematic Review
by Khadija H. Soufi, Tess M. Perez, Alexis O. Umoye, Jamie Yang, Maria Burgos and Allan R. Martin
J. Clin. Med. 2022, 11(5), 1441; https://doi.org/10.3390/jcm11051441 - 5 Mar 2022
Cited by 10 | Viewed by 2376
Abstract
Degenerative cervical myelopathy (DCM) is a prevalent condition in which spinal degeneration causes cord compression and neurological dysfunction. The spinal cord is anatomically complex and operates in conjunction with the brain, the musculoskeletal system, and numerous organs to control numerous functions, including simple [...] Read more.
Degenerative cervical myelopathy (DCM) is a prevalent condition in which spinal degeneration causes cord compression and neurological dysfunction. The spinal cord is anatomically complex and operates in conjunction with the brain, the musculoskeletal system, and numerous organs to control numerous functions, including simple and coordinated movement, sensation, and autonomic functions. As a result, accurate and comprehensive measurement of spinal cord function in patients with DCM and other spinal pathologies is challenging. This project aimed to summarize the neurological, functional, and quality of life (QoL) outcome measures currently in use to quantify impairment in DCM. A systematic review of the literature was performed to identify prospective studies with at least 100 DCM subjects that utilized one or more quantitative neurological, functional, or QoL outcome measures. A total of 148 studies were identified. The most commonly used instruments were subjective functional scales including the Japanese Orthopedic Association (JOA) (71 studies), modified JOA (mJOA) (66 studies), Neck Disability Index (NDI) (54 studies), and Nurick (39 studies), in addition to the QoL measure Short-Form-36 (SF-36, 52 studies). A total of 92% (320/349) of all outcome measures were questionnaires, whereas objective physical testing of neurological function (strength, gait, balance, dexterity, or sensation) made up 8% (29/349). Studies utilized an average of 2.36 outcomes measures, while 58 studies (39%) utilized only a single outcome measure. No studies were identified that specifically assessed the dorsal column sensory pathway or respiratory, bowel, or sexual function. In the past five years, there were no significant differences in the number of total, functional, or QoL outcome measures used, but physical testing of neurological function has increased (p = 0.005). Prior to 2017, cervical spondylotic myelopathy (CSM) was the most frequently used term to describe the study population, whereas in the last five years, DCM has become the preferred terminology. In conclusion, clinical studies of DCM typically utilize limited data to characterize impairment, often relying on subjective, simplistic, and non-specific measures that do not reflect the complexity of the spinal cord. Although accurate measurement of impairment in DCM is challenging, it is necessary for early diagnosis, monitoring for deterioration, and quantifying recovery after therapeutic interventions. Clinical decision-making and future clinical studies in DCM should employ a combination of subjective and objective assessments to capture the multitude of spinal cord functions to improve clinical management and inform practice guidelines. Full article
(This article belongs to the Special Issue Management of Degenerative Cervical Myelopathy and Spinal Cord Injury)
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