Diffusion Tensor Imaging as a Prognostic Investigation in Cervical Myelopathy-Comparison of Pre- and Postsurgical Decompression DTI Indices and Tractography in 56 subjects

Abstract

Introduction We present the first study in literature that documents the changes in diffusion tensor imaging (DTI) indices and tractography after surgical decompression in patients with cervical myelopathy. DTI, an established tool for tracking nerve fibers in brain, is now widely evaluated for its usefulness in spine pathologies. Although there are many studies directly comparing DTI indices of control and cervical myelopathic patients, there are no studies that have evaluated the prognostic applicability of DTI indices. The present study analyzes the pre- and postdecompression DTI indices and tractography in cervical myelopathic patients and its prognostic value. Materials and Methods Total 56 subjects including 16 cervical myelopathy patients who required surgical decompression (mean age: 53.5  ± 12.3 years, males: 15, females: (1) and forty normal controls (mean age: 38.18 ± 13.74 years, males: 20, females: 20) were included in the study. DTI of cervical spine was obtained using an axial single shot echo-planar parallel diffusion-weighted imaging sequence in a 1.5 tesla magnetic resonance imaging (MRI). Apparent diffusion coefficient (ADC), fractional anisotropy (FA), and Eigen values (E1, E2, and E3) were obtained at each region of interest (cervical disk level) from C1-C2 to C7-T1. The DTI indices of myelopathic patients were compared with normal volunteers after matching was done based on sex, cord level, and cord size. Postoperatively, the patients were followed up after 6 months and DTI scan was performed again. The clinical improvement and the DTI indices observed at the follow-up were compared with the preoperative values. Results Analysis showed significant differences between the controls and patients in all the indices (p<0.05) at the site of compression. At the compressed levels, FA decreased while all the other indices increased as compared to the controls. The mean DTI indices of myelopathic patients before surgery at the sites of spinal cord compression were as follows: FA (0.49 ± 0.092), ADC (1.8 ± 0.32 µm2/ms), E1 (2.80 ± 0.44 µm2/ms), E2 (1.63 ± 0.45 µm2/ms), E3 (0.95 ± 0.23 µm2/ms). The average DTI indices of matched controls were as follows: FA (0.55 ± 0.033), ADC (1.47 ± 0.066 µm2/ms), E1 (2.49 ± 0.150 µm2/ms), E2 (1.16 ± 0.050 µm2/ms), E3 (0.77 ± 0.058 µm2/ms. The Nurick grading distribution in patients before surgery was as follows: Grade 2 = 2, Gr 3 = 8, Gr 4 = 2, Gr 5 = 4. Postoperatively, all the patients had improvement of neurology by at least one Nurick grade except for one patient who had no improvement. The Nurick grading distribution in patients during 6 months follow-up after surgery was as follows: Grade 0 = 3, Gr 1 = 6, Gr 2 = 2, Gr 3 = 3, Gr 4 = 2. Mean postoperative values of ADC, E1, and E2 showed improvement towards normal values especially in patients with preoperative Nurick grade 2 and 3 (Table 1). Patients with Nurick grade 4 and 5 did not show any significant change. The mean FA and E3 values worsened when compared to preoperative DTI indices. The postoperative DTI indices for the patients who had neurological improvement are as follows: FA (0.45 ± 0.087), ADC (1.73 ± 0.31 µm2/ms), E1 (2.59 ± 0.28 µm2/ms), E2 (1.56 ± 0.38 µm2/ms), E3 (1.07 ± 0.31 µm2/ms. Tractography also showed interruption of nerve fibre tract continuity at the level of severe compression in patients with myelopathy. At levels of moderate compression over the spinal cord, the changes in direction of nerve fibres due to bulging disc-osteophytes were evident as changes in color coding of the tracts. After surgical decompression, the restitution of fibre tract pathways was clearly demonstrated in DT tractography. Conclusion For the first time, the prognostic applicability of DTI by comparing pre- and postoperative indices of cervical myelopathy patients has been described. All preoperative DTI indices at compressed levels showed significant differences from controls indicating abnormality in neuronal integrity. All but one of the patients showed clinical improvement at 6 months. The postoperative DTI values (ADC, E1 and E2) of patients with Nurick grading 2 and 3 were observed to approach normal values indicating restoration of linear diffusion in neuronal tracts. DTI indices in patients with Nurick grade 4 and 5 remained same or worsened more. This could probably indicate persistent axonal damage. At 6 months postsurgery, DTI indices show evidence of improvement towards normal values, even though the values did not match the true extent of clinical improvement. Further DTI evaluation at 12 months and 2 years is required to analyze the extent of usefulness of DTI indices in evaluating cervical myelopathy. The results suggest that DTI indices, especially ADC and Eigen vectors can be promising indicators in the evaluation and prognostic assessment of myelopathy patients. I confirm having declared any potential conflict of interest for all authors listed on this abstract Yes Disclosure of Interest None declared