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.
Introduction The primary objective of this work was to define the neurological benefit conferred by surgical intervention to patients with degenerative cervical myelopathy (DCM). Secondary objectives included assessing how preoperative disease severity and duration impacted on that benefit and defining the surgical complications encountered by these patients. Material and Methods A search was undertaken for articles published until May 2015 evaluating the operative treatment of DCM using electronic databases. Prospective studies of adult surgical myelopathic patients were included. Extracted data included study design, patient demographics, diagnosis, surgical approach, preoperative and postoperative neurological status (mJOA, NDI, Nurick, VAS), and complications. Preoperative disease severity and duration of symptoms were recorded. Risk of bias (Newcastle-Ottawa Scale) and quality of evidence (Grades of Recommendation Assessment, Development and Evaluation) were assessed. Primary outcomes included assessment of change in neurological (graded by mJOA, NDI, and Nurick scores) and pain (graded by VAS score) following surgical intervention for myelopathic patients. Secondary outcomes were also assessed for dependency on preoperative duration of symptoms and preoperative disease severity. Safety of surgery was assessed by pooled estimates of perioperative complications encountered. Results Among 32 included studies, surgical intervention for DCM patients provided clinically-significant improvement in neurological dysfunction and pain. This improvement occurred at short-term assessment (fewer than 12 months) and was durable in longer-term (greater than 36 months), consistent over several different scoring systems. Shorter duration of symptoms may be associated with a higher likelihood of neurological recovery. Conclusion Surgical intervention for DCM is an appropriate evidence-based therapy with an acceptably low rate of perioperative complication. Further work is important to define optimal surgical approach and timing.
Abstract BACKGROUND Congenital spinal stenosis (CSS) of the cervical spine is a risk factor for acute spinal cord injury and development of degenerative cervical myelopathy (DCM). OBJECTIVE To develop magnetic resonance imaging (MRI)-based criteria to diagnose preexisting CSS and evaluate differences between patients with and without CSS. METHODS A secondary analysis of international prospectively collected data between 2005 and 2011 was conducted. We examined the data of 349 surgical DCM patients and 27 controls. Spinal canal and cord anteroposterior diameters were measured at noncompressed sites to calculate spinal cord occupation ratio (SCOR). Torg–Pavlov ratios and spinal canal diameters from radiographs were correlated with SCOR. Clinical and MRI factors were compared between patients with and without CSS. Surgical outcomes were also assessed. RESULTS Calculation of SCOR was feasible in 311/349 patients. Twenty-six patients with CSS were identified (8.4%). Patients with CSS were younger than patients without CSS ( P = .03) and had worse baseline severity as measured by the modified Japanese Orthopedic Association score ( P = .04), Nurick scale ( P = .05), and Neck Disability Index ( P < .01). CSS patients more commonly had T2 cord hyperintensity changes ( P = .09, ns) and worse SF-36 Physical Component scores ( P = .06, ns). SCOR correlated better with Torg–Pavlov ratio and spinal canal diameter at C3 than C5. Patients with SCOR ≥ 65% were also younger but did not differ in baseline severity. CONCLUSION SCOR ≥ 70% is an effective criterion to diagnose CSS. CSS patients develop myelopathy at a younger age and have greater impairment and disability than other patients with DCM. Despite this, CSS patients have comparable duration of symptoms, MRI presentations, and surgical outcomes to DCM patients without CSS.
Study Design This study is a scoping review. Objective There is a broad variability in the definition of degenerative cervical myelopathy (DCM) and no standardized set of diagnostic criteria to date. Methods We interrogated the Myelopathy.org database, a hand-indexed database of primary clinical studies conducted exclusively on DCM in humans between 2005-2021. The DCM inclusion criteria used in these studies were inputted into 3 topic modeling algorithms: Hierarchical Dirichlet Process (HDP), Latent Dirichlet Allocation (LDA), and BERtopic. The emerging topics were subjected to manual labeling and interpretation. Results Of 1676 reports, 120 papers (7.16%) had well-defined inclusion criteria and were subjected to topic modeling. Four topics emerged from the HDP model: disturbance from extremity weakness and motor signs; fine-motor and sensory disturbance of upper extremity; a combination of imaging and clinical findings is required for the diagnosis; and “reinforcing” (or modifying) factors that can aid in the diagnosis in borderline cases. The LDA model showed the following topics: disturbance to the patient is required for the diagnosis; reinforcing factors can aid in the diagnosis in borderline cases; clinical findings from the extremities; and a combination of imaging and clinical findings is required for the diagnosis. BERTopic identified the following topics: imaging abnormality, typical clinical features, range of objective criteria, and presence of clinical findings. Conclusions This review provides quantifiable data that only a minority of past studies in DCM provided meaningful inclusion criteria. The items and patterns found here are very useful for the development of diagnostic criteria for DCM.
The objective of this guideline is to outline the role of magnetic resonance imaging (MRI) in clinical decision making and outcome prediction in patients with traumatic spinal cord injury (SCI).A systematic review of the literature was conducted to address key questions related to the use of MRI in patients with traumatic SCI. This review focused on longitudinal studies that controlled for baseline neurologic status. A multidisciplinary Guideline Development Group (GDG) used this information, their clinical expertise, and patient input to develop recommendations on the use of MRI for SCI patients. Based on GRADE (Grading of Recommendation, Assessment, Development and Evaluation), a strong recommendation is worded as "we recommend," whereas a weaker recommendation is indicated by "we suggest."Based on the limited available evidence and the clinical expertise of the GDG, our recommendations were: (1) "We suggest that MRI be performed in adult patients with acute SCI prior to surgical intervention, when feasible, to facilitate improved clinical decision-making" (quality of evidence, very low) and (2) "We suggest that MRI should be performed in adult patients in the acute period following SCI, before or after surgical intervention, to improve prediction of neurologic outcome" (quality of evidence, low).These guidelines should be implemented into clinical practice to improve outcomes and prognostication for patients with SCI.
Narrative review.To discuss the importance of establishing diagnostic criteria in Degenerative Cervical Myelopathy (DCM), including factors that must be taken into account and challenges that must be overcome in this process.Literature review summarising current evidence of establishing diagnostic criteria for DCM.Degenerative Cervical Myelopathy (DCM) is characterised by a degenerative process of the cervical spine resulting in chronic spinal cord dysfunction and subsequent neurological disability. Diagnostic delays lead to progressive neurological decline with associated reduction in quality of life for patients. Surgical decompression may halt neurologic worsening and, in many cases, improves function. Therefore, making a prompt diagnosis of DCM in order to facilitate early surgical intervention is a clinical priority in DCM.There are often extensive delays in the diagnosis of DCM. Presently, no single set of diagnostic criteria exists for DCM, making it challenging for clinicians to make the diagnosis. Earlier diagnosis and subsequent specialist referral could lead to improved patient outcomes using existing treatment modalities.
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.
A retrospective analysis of 169 adult patients operated for a conventional spinal schwannoma from the AOSpine Multicenter Primary Spinal Tumors Database.The aim of this study is to identify risk factors for local recurrence of conventional spinal schwannoma in patients who had surgery.Schwannomas account for up to 30% of all adult spinal tumors. Total resection is the gold standard for patients with sensory or motor deficits. Local recurrence is reported to be approximately 5% and usually occurs several years after surgery.Rates and time of local recurrence of spinal schwannoma were quantified. Predictive value of various clinical factors was assessed, including age, gender, tumor size, affected spinal segment, and type of surgery. Descriptive statistics and univariate regression analyses were performed.Nine (5.32%) out the 169 patients in this study experienced local recurrence approximately 1.7 years postoperatively. Univariate analyses revealed that recurrence tended to occur more often in younger patients (39.33 ± 14.58 versus 47.01 ± 15.29 years) and in the lumbar segment (55.56%), although this did not reach significance [hazard ratio (HR) 0.96, P = 0.127; and P = 0.195, respectively]. Recurrence also arose in the cervical and sacral spine (22.22%, respectively) but not in the thoracic area. Tumors were significantly larger in patients with recurrence (6.97 ± 4.66 cm versus 3.81 ± 3.34 cm), with extent in the cranial caudal direction posing the greatest hazard (HR = 1.321, P = 0.002). The location of the tumor, whether epidural, intradural, or both (P = 0.246), was not significantly related to recurrence. Regarding surgical technique, over 4 times as many patients who underwent intralesional resection experienced a recurrence proportionally to patients who underwent en bloc resection (HR = 4.178, P = 0.033).The pre-operative size of the conventional spinal schwannoma and intralesional resection are the main risk factors for local postoperative recurrence.3.
