Unveiling the Unexpected: Co‐Occurrence of Brain Tumor and Spine Pathology Revealed After Spinal Surgery

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction.1 The condition presents insidiously and is defined in terms of its clinical symptoms (gait instability, bladder dysfunction, fine finger motor difficulties) and signs (hyperreflexia, weakness, alteration of joint position sense). CSM is caused by dynamic repeated compression of the spinal cord from degenerative arthritis of the cervical spine.2 Proposed mechanisms include axonal stretch-associated injury2 and spinal cord ischemia from compression of larger vessels and impaired microcirculation.3,4 Surgery to decompress and stabilize the spine is often advocated for severe or progressive symptoms, with mixed results. About two-thirds of patients improve with surgery, while surgery does not result in improvement in 15%-30%.5 Over 112,400 cervical spine operations for degenerative spondylosis are performed annually in the US (100% increase over the past decade),6 with CSM accounting for nearly 20% of cervical spine operations in the US.7 Annual hospital charges for CSM surgery exceeds 2 billion dollars per year.6 In addition, CSM is associated with substantial postoperative outpatient expenses (e.g., physician visits, imaging, physical therapy, medications). Recently, the Institute of Medicine designated CSM as one of the top 100 national health research priorities for comparative effectiveness research.8 There is a great need for modern prospective studies with validated outcomes tools to assess the effectiveness of surgical treatments for CSM. Most American cervical spine experts (both orthopaedic and neurological surgeons) believe that there is sufficient clinical equipoise to support a comparative randomized clinical trial (RCT) if the study population is carefully defined.9 Most experts feel that surgery can prevent the progression of spinal cord dysfunction and can, in many cases, improve the symptoms of cervical spondylotic myelopathy. It is unclear, however, what the optimal surgical technique might be (ventral versus dorsal), and in up to 30% of cases the clinical outcome is not satisfactory.5 Furthermore, the complication rate for CSM surgery is high (17% in a recent prospective study),10 particularly in patients over 74 years of age,11 which is a growing segment of the US population.12 Lastly, the 5-year re-operation rate following surgery for CSM is nearly 15%.13

BackgroundCervical compressive myelopathy (CCM) is a progressive, degenerative spine disease and the most common cause of spinal cord dysfunction in older individuals. Current clinical guidelines for spinal surgery recommend multimodal intraoperative monitoring (IOM) during spinal surgery as a reliable and valid diagnostic adjunct to assess spinal cord integrity. The aim of this study was to evaluate the effect of positive changes during IOM on the functional status in patients with CCM.MethodsPatients who underwent spinal surgery with IOM due to CCM were enrolled. During the surgery, patients underwent IOM using motor evoked potential (MEP) and somatosensory evoked potential (SEP). MEP and SEP were checked before and immediately after decompression. A decrease in latency >10% or an increase in amplitude >50% was regarded as a “positive changes”. Subjects were divided according to the presence of positive changes. Motor scores of American Spinal Injury Association (ASIA) impairment scale and Korean version of Modified Barthel Index (K-MBI) were evaluated before and after operation.ResultsTwenty-nine patients underwent spinal surgery due to CCM. Eleven patients showed positive changes in MEP during IOM. When the two groups were compared, improvement rate in the ASIA motor score and K-MBI were significantly higher in patients with positive changes than in patients without positive changes at 1 month after surgery. However, 6 months after surgery, there were no significance differences between the groups. Regardless of positive change, nearly all patients suffered from neuropathic pain after operation.ConclusionPositive changes in MEP during IOM may affect functional improvement 1 month after operation and early discharge without significant complications in CCM patients. However, they do not affect the neuropathic pain and long-term functional outcome. Thus, tailored proper management is needed to achieve maximal functional recovery in each patient after cervical spinal decompression surgery.

The effect of positive changes during intraoperative monitoring on the functional improvement in patients with cervical compressive myelopathy

87. Effects of spinal decompression on the gait efficiency and balance of cervical spondylotic myelopathy patients: preliminary results

Study DesignThis was a retrospective study.PurposeThe purpose of this study was to study the relationship between prevalence of pyramidal signs and the severity of cervical myelopathy. The study is focused on patients having increased signal intensity in T2-weighted magnetic resonance imaging.Overview of LiteratureCervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in elderly population. It is the consequence of spondylotic changes leading to cervical cord injury with resulting clinical deficits. Diagnosis in such patients is made based on clinical and radiographic features. A patient must have both symptoms and signs consistent with cervical cord injury as well as radiographic evidence of damage to spondylotic cord.MethodsForty-six patients with complaint of cervical spondylotic myelopathy with increased signal intensity in T2-weighted magnetic resonance imaging were included in the study. The neurological finding of the patients was reviewed for the presence of pyramidal signs. The prevalence of each pyramidal sign was calculated and correlated to severity of cervical myelopathy. The motor function scores of the upper and lower extremities for cervical myelopathy set by the Japanese Orthopedic Association (motor Japanese Orthopaedic Association score, m-JOA) scores were used to assess severity of myelopathy.ResultsThe most prevalent signs were hyperreflexia (89.1%), Hoffmann reflex (80.4%), Babiniski sign (56.5%), and ankle clonus (39.1%). Babiniski sign, ankle clonus, and Hoffmann reflex showed significant association with the lower m-JOA score.ConclusionsIn patients with cervical myelopathy, hyperreflexia exhibited highest sensitivity whereas ankle clonus demonstrated lowest sensitivity. The prevalence of the pyramidal signs is correlated with increasing severity of myelopathy.

Cervical spondylotic myelopathy (CSM) represents the most commonly acquired cause of spinal cord dysfunction among individuals over 55 years old. The pathophysiology of the condition involves mechanical factors, which result to injury of the cervical spinal cord. In T-2 weighted magnetic resonance (MR) images of the spine the site of injury is depicted as a region of high intensity signal within the cervical spine cord. The present study aims to investigate whether texture analysis of MR signal in CSM could provide novel quantitative prognostic factors, rendering possible the prognostic estimation of the outcome of a therapeutic surgical intervention for CSM. The sample of the study comprised 12 MR images of the cervical spine, corresponding to 6 CSM patients, who had undergone surgical intervention with anterior cervical discectomy and spinal canal decompression. Following a specific MR imaging protocol a pair of T2-weighted sagittal images of the spine, corresponding to pre- and post-operative MR scans, were obtained for each of the patients. Employing custom developed software, the region of high intensity signal, associated to CSM, was automatically segmented from each MR image. Utilizing custom developed algorithms a number of textural features were extracted from the segmented ROIs and employed in the design of a classification system, based on the Quadratic classifier. The latter was used for the discrimination between pre-operative and post-operative MR images. Statistical analysis revealed the existence of statistically significant differences between textural features, corresponding to pre- and post-operative CSM MR signals. The quadratic classifier characterized correctly all the pre- and post-operative MR images (100% classification accuracy). The results of the present study indicate that textural features, generated from MR images of the spine, may serve as prognostic factors regarding the prediction of the post-operative outcome of CSM patients.

Background Cervical myelopathy is a dysfunction of the spinal cord. It is often caused by a narrowing of the cervical spinal canal. Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the elderly. Ossification of the posterior longitudinal ligament (OPLL) is a rare but potentially devastating cause of degenerative cervical myelopathy (DCM). The pathogenesis of OPLL is poorly understood. Some have suggested it as a variant of diffuse idiopathic skeletal hyperostosis (DISH). Purpose The purpose of the study is to perform a systematic review and meta-analysis to evaluate the Clinical results of anterior and posterior approaches for the treatment of cervical compressive myelopathy Due to cervical ossification of the posterior longitudinal ligament (OPLL). Methods Randomized clinical trials, prospective cohort, retrospective observational cohort, and case-control Studies that compare the surgical outcome of an anterior versus a posterior approach for cervical myelopathy due to OPLL from January 2006 to October 2021. Databases (PubMed, EMBASE, Cochrane library). A total of 12 studies (1070patients) were included in this systematic review and meta-analysis. Results indicated that no statistically significant differences between the anterior group and posterior group in terms of preoperative mJOA score [P = 0.23, SMD = 0.9; heterogeneity: (P = 0.85); I2 = 18%, while the postoperative JOA score was significantly higher in the anterior surgery group compared with the posterior surgery group [P 0.004, SMD = 0.67; heterogeneity: P < 0.001; I2 = 82%. The recovery rate was significantly higher in the anterior surgery group compared with the posterior surgery group of patients with canal-occupying ratio < 50%- ≥ 60% [P < 0.01, SMD = 0, 43; heterogeneity: (P < 0.57); I 2 = 91%]. The overall recovery rate (regardless the canal occupying ratio) was significantly higher in the anterior surgery group compared with the posterior surgery group [P < 0.01 SMD = 0.84. It also revealed that the postoperative complication rate [P < 0.01 OR = 1.88, operation time [P < 0.01 SMD = 1.52, intra operative blood loss [P = 0.04 SMD = 0.74 are higher in the anterior group. Conclusion Based on the results of this meta-analysis, anterior approach surgery was associated with better overall (Regardless of the canal-occupying ratio) postoperative neural function than posterior approach in the treatment of cervical compressive myelopathy due to OPLL. We thought anterior approach especially preferable to patients with canal-occupying ratio > 50%-60%, although it leads to a higher surgical trauma and incidence of surgery- related complications. Posterior approach surgery was relatively safer with lower surgical trauma and incidence of complications. We also suggest posterior approach for patients with canal-occupying ratio < 50%-60%.

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction, potentially leading to severe disability. Abnormal cervical spine magnetic resonance imaging (MRI) and motor evoked potentials (MEPs) are independent predictors of disease progression. Abnormal MRI is accompanied by various activation changes in functional brain MRI (fMRI), whereas preoperative and postoperative fMRI adaptations associated with abnormal preoperative MEP remain unknown. Twenty patients (9 males, average age 56.6) with evidence of spinal cord compression on MRI and clinical signs of mild CSM were included. Participants were classified according to their preoperative MEP and underwent three brain fMRI examinations: before surgery, 6, and 12months after surgery while performing repeated extension-flexion of each wrist. Functional MRI activation was compared between two subsets of patients, with normal and clearly abnormal MEP (right wrist: 8 vs. 8; left wrist: 7 vs. 9). At baseline, abnormal MEPs were associated with hyperactivation in the cerebellum. At the first follow-up, further hyperactivations emerged in the contralateral sensorimotor cortices and persisted for 1year. In normal baseline MEP, activation mostly decreased in the ipsilateral sensorimotor cortex postoperatively. The ipsilateral sensorimotor activation after 1-year follow-up correlated with baseline MEP. Abnormal corticospinal MEP findings in cervical spondylotic myelopathy were associated with differences in brain activation, which further increased after spinal cord decompression and did not resolve within 12-month follow-up. In summary, surgery may come too late for those patients with abnormal MEP to recover completely despite their mild clinical signs and symptoms.

Introduction Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction among adults over the age of 55?In China the morbidity of CSM is 10%. However, the pathobiology of CSM is still unclear which limits therapeutic advances for this common cause of neurological dysfunction. The clinical course of the disease remains unpredictable. The lack of reliable animal models of CSM has been a restriction to advancing the field. Up to now, various animal model of CSM have been made. Although some of these studies have impressive progress, they also have significant defects. Many of these models fail to model the chronic and progressive nature of the disease since they do not accurately reproduce the main human neuropathological and clinical features of CSM, In this study we report a new model of CSM in sheep. It is more accurate and stable than previous models. Moreover, the entire course of compression is digitized. Materials and Methods A Silicone sealed compression device is assembled with a stepping motor, gear reducer and a push rod. The compression device is connected to a circuit board which contains a bluetooth module and a control chip. Power supply is a lithium battery. Circuit board is also well sealed with silicone. It is controlled via an Android cellphone in vitro. Six male small tailed han sheep were divided into two groups randomly, four in experimental group and two in control group. The compression device was implanted into intervertebral space of C4/C5 and fixed. Circuit board was implanted subcutaneously. The control group ran no compression after surgery. Animals of each group were carried on a routine CT inspection right after the surgery. The front end of the push rod was adjusted to the posterior edge of the cervical vertebral. The experimental group pushed 0.4 mm each week while awake. Tarlov scores were assessed in each group before and after push. Results In the course of the experiment, one sheep of the experimental group appeared malfunction of the circuit board subskin. The dysfunctional board was replaced during an extra operation. The Tarlov sores of the experimental group didn't change before and after each time of push. No behavioral changes were noted in control group. While sheep in the experimental group showed gradually changes of gait. The final Tarlov score was four in three sheep and three in one sheep of the experimental group and the final radiological findings showed that the average spinal canal encroachment rate was 60.6% in the experimental group after 18 weeks’ observation. Conclusion This animal model can be used to generate controllable compression to spine operated by a digitized system. No invasive procedures were applied during the experiment. In next stage of experiment we could get specimens and run pathological tests. Disclosure of Interest None declared

Is the Cervical Anterior Spinal Artery Compromised in Cervical Spondylotic Myelopathy Patients? Dual-Energy Computed Tomography Analysis of Cervical Anterior Spinal Artery

Operative fusion of multilevel cervical spondylotic myelopathy: Impact of patient demographics

Introduction: Degenerative cervical myelopathy stands as the primary non-traumatic cause of spinal cord dysfunction in adults. Neurological assessment tools rooted in functionality, such as the Nurick scale and the Japanese Orthopaedic Association Score (JOA), are commonly employed. The latter was revised and culturally adapted to Western norms by Chiles et al. in 1999, resulting in the modified JOA score (mJOA). This study aims to translate, cross-culturally validate, and assess the reproducibility of the Nurick scale into Brazilian Portuguese among patients with cervical degenerative myelopathy. Material And Methods: This study comprised two phases: initial translation, back-translation, final version assessment, and application test evaluation. A total of 70 individuals were evaluated, with 36 in the cervical myelopathy group and 34 in the control group. Subsequently, both groups underwent assessment using the mJOA and the NURICK-BRAZIL version, with data collection following. Data analysis employed Mann-Whitney tests and Spearman’s correlation tests. Analyses were executed using the statistical package R, with a significance level set at 5%. Results: Mann-Whitney comparison tests revealed significant differences in the NURICK-BRAZIL scale between the control and patient groups. Spearman’s correlation coefficient indicated a robust negative correlation between the NURICK-BRAZIL and mJOA scales. These findings suggest that the adapted Nurick scale in Brazilian Portuguese (NURICK-BRAZIL) holds potential for validation in evaluating patients with degenerative cervical myelopathy. Conclusion: The translation, adaptation, and validation of the original Nurick scale in Brazilian Portuguese (NURICK-BRAZIL) demonstrate similarity, applicability, good comprehension, and significant potential for widespread utilization as a valuable clinical and scientific evaluation tool for cervical myelopathy patients. Level of evidence III; Case-control study.

<p><strong>Background: </strong>Cervical spondylotic myelopathy (CSM) is considered the commonest cause of spinal cord dysfunction in individuals above 55 years of age and if left untreated, permanent cord damage may occur. This could contribute to increased dependence and reduced quality of life in older individuals. A prospective cohort study done in patients with cervical myelopathy who were admitted and operated after considering inclusion and exclusion criteria.<strong></strong></p><p><strong>Methods</strong>: A prospective cohort study done in patients with cervical myelopathy who were admitted and operated after considering inclusion and exclusion criteria. Total 30 patients included in study. patients were operated according to patterns of compression. Anterior/posterior decompression SOS instrumentation was done according to POC. Pre-op and post-op Nurick’s grading, pre-op and post-op modified Japanese orthopaedics association (mJOA) scores were used for comparison. Patients were followed up for period of 1 year from surgical intervention. Recovery rate calculated using preop and post op mJOA scores.</p><p><strong>Results</strong>: Overall satisfactory surgical outcome found in patients of cervical myelopathy<sub>, </sub>out of 30 patients, 9 patients of pattern of compression I (POC I) had recovery rate (RR) of (91.6±7.8) , 8 patients of POC II had RR of (78.4±14.8), 6 patients of POC III had RR of (73.5±11.1), 4 patients of POC IV had RR of (74.9±29.2), 3 patients of POC IVv had RR of (80.4±4.1).the assessment of the final outcome was done using mJOA scoring system and Nurick’s grading system.</p><p><strong>Conclusions: </strong>Anterior cervical discectomy and fusion (ACDF) for POC I (one- or two-level anterior cord compression) and POC II (one or two levels of anterior and posterior cord compression) give good surgical outcome. Cervical laminectomy and SOS instrumentation is recommended for POC III (3 levels of anterior cord compression), IV (3 or more levels of anterior compression and development of narrow canal with multiple posterior compression) and IV variant (similar to POC IV with one or two levels, being more significant than the others).earlier diagnosis, prompt radiological investigations, individualizing surgical protocol, proper surgical techniques and proper follow-up evaluation are key in management of patients of cervical myelopathy.</p>

Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction in the elderly population. It is a degenerative disease that classically presents with fine motor dysfunction of the hands and gait instability. These symptoms can easily be masked by old age, complex medical history, and more benign diseases. We describe the case of a 67-year-old male who was referred to orthopedic surgery for bilateral hand numbness and weakness attributed to carpal tunnel syndrome (CTS). The patient had trouble ambulating, rhythmic clonus in his ankles, and a bilateral positive Hoffman sign resulting in a referral to neurosurgery for an emergent spinal cord decompression. To our knowledge, few case reports exist demonstrating how cervical myelopathy can mimic more benign peripheral nerve diseases such as CTS. We describe how difficult early recognition can be, as well as the importance of primary care doctors maintaining a high degree of suspicion for a disease that has nonspecific examination findings and can easily mimic more benign processes.

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction.7 The condition presents insidiously and is defined in terms of its clinical symptoms (gait instability, bladder dysfunction, fine finger motor difficulties) and signs (hyperreflexia, weakness, alteration of joint position sense). Cervical spondylotic myelopathy is caused by dynamic repeated compression of the spinal cord from degenerative arthritis of the cervical spine.2 Proposed mechanisms include axonal stretch-associated injury3 and spinal cord ischemia from compression of larger vessels and impaired microcirculation.1,2 Surgery to decompress and stabilize the spine often is advocated for severe or progressive symptoms, with mixed results. About two-thirds of patients improve with surgery, while surgery is not successful in 15%–30% of cases.5 Over 112,400 cervical spine operations for degenerative spondylosis are performed annually in the US. This represents a 100% increase over the previous decade.4 Cervical spondylotic myelopathy accounts for nearly 20% of cervical spine operations in the US,6 with annual hospital charges for CSM surgery exceeding 2 billion dollars per year.4 In addition, CSM is associated with substantial postsurgical outpatient expenses (for example, physician visits, imaging, physical therapy, medications). Cervical spondylotic myelopathy represents a major health burden in our society and there is a need for more original research to guide our clinical approach to this underdiagnosed condition. In this issue, we are pleased to include 11 original manuscripts that add to our understanding of CSM in several unique ways. First, we begin with a manuscript that discusses the challenge in diagnosing this clinical entity. We include manuscripts that discuss new insights that are related to imaging, monitoring, epidemiology, and minimally invasive approaches. An evidence-based review on the management of central cord syndrome is also included. The major debate in the literature over the last 50 years has been the choice of approach: ventral versus dor sal. We include a comparative study on this topic that examines ventral fusion versus laminoplasty and also a comprehensive review of the literature that compares ventral fusion to dorsal fusion for CSM. Unfortunately, randomized controlled trials for CSM have yet to be performed. Nevertheless, there exists valuable information in the original manuscripts presented here. We hope that each will provide both interest and value to the reader and that the care of patients with CSM will be improved by the information transmitted. (http://thejns.org/doi/abs/10.3171/2013.5.FOCUS13211)