Degenerative Cervical Myelopathy Research Articles

Evidence-based commentary on the diagnosis, management, and further research of degenerative cervical spinal cord compression in the absence of clinical symptoms of myelopathy

Degenerative cervical myelopathy (DCM) represents the final consequence of a series of degenerative changes in the cervical spine, resulting in cervical spinal canal stenosis and mechanical stress on the cervical spinal cord. This process leads to subsequent pathophysiological processes in the spinal cord tissues. The primary mechanism of injury is degenerative compression of the cervical spinal cord, detectable by magnetic resonance imaging (MRI), serving as a hallmark for diagnosing DCM. However, the relative resilience of the cervical spinal cord to mechanical compression leads to clinical-radiological discordance, i.e., some individuals may exhibit MRI findings of DCC without the clinical signs and symptoms of myelopathy. This degenerative compression of the cervical spinal cord without clinical signs of myelopathy, potentially serving as a precursor to the development of DCM, remains a somewhat controversial topic. In this review article, we elaborate on and provide commentary on the terminology, epidemiology, natural course, diagnosis, predictive value, risks, and practical management of this condition—all of which are subjects of ongoing debate.

Quantifying neurodegeneration of the cervical cord and brain in degenerative cervical myelopathy: A multicentre study using quantitative magnetic resonance imaging.

Simultaneous assessment of neurodegeneration in both the cervical cord and brain across multiple centres can enhance the effectiveness of clinical trials. Thus, this study aims to simultaneously assess microstructural changes in the cervical cord and brain above the stenosis in degenerative cervical myelopathy (DCM) using quantitative magnetic resonance imaging (MRI) in a multicentre study. We applied voxelwise analysis with a probabilistic brain/spinal cord template embedded in statistical parametric mappin (SPM-BSC) to process multi parametric mapping (MPM) including effective transverse relaxation rate (R2*), longitudinal relaxation rate (R1), and magnetization transfer (MT), which are indirectly sensitive to iron and myelin content. Regression analysis was conducted to establish associations between neurodegeneration and clinical impairment. Thirty-eight DCM patients (mean age ± SD = 58.45 ± 11.47 years) and 38 healthy controls (mean age ± SD = 41.18 ± 12.75 years) were recruited at University Hospital Balgrist, Switzerland and Toronto Western Hospital, Canada. Remote atrophy was observed in the cervical cord (p = 0.002) and in the left thalamus (0.026) of the DCM group. R1 was decreased in the periaqueductal grey matter (p = 0.014), thalamus (p = 0.001), corpus callosum (p = 0.0001), and cranial corticospinal tract (p = 0.03). R2* was increased in the primary somatosensory cortices (p = 0.008). Sensory impairments were associated with increased iron-sensitive R2* in the thalamus and periaqueductal grey matter in DCM. Simultaneous assessment of the spinal cord and brain revealed DCM-induced demyelination, iron deposition, and atrophy. The extent of remote neurodegeneration was associated with sensory impairment, highlighting the intricate and expansive nature of microstructural neurodegeneration in DCM, reaching beyond the stenosis level.

Circulating microRNAs May Be Predictive of Degenerative Cervical Myelopathy.

Basic Science. The objective of this study was to identify a unique serum profile of circulating miRNAs and inflammatory markers in patients with degenerative cervical myelopathy (DCM) compared to healthy controls (HC). Currently, DCM is diagnosed with a combination of history, physical examination, and close correlation to advanced imaging. To date, no serum marker has been identified to be diagnostic of this condition. Whole venous blood was collected from patients with DCM as well as healthy age- and sex-matched controls. miRNA was extracted from venous blood and a screening analysis was initially conducted to identify miRNA dysregulation in DCM patients. RT-qPCR was used to analyze the expression of 2 specific miRNAs based on screening analysis and literature review. Bioinformatics analysis was used to identify gene networks and potential targets of the miRNA. In addition, the serum inflammatory profile of DCM and HC groups was differentiated using a pro-inflammatory panel. Thirty-six patients were enrolled in the DCM group (36.1% male, 61.5±9.5y) while 35 patients were enrolled in the HC group (31.4% male, 57.5±8.9y). Of the 15 total miRNAs differentially expressed between DCM and HC groups, two were selected for further analysis: miR-223-3p (upregulated) and miR-451a (downregulated). Functional gene network analysis revealed the highest-ranking gene network was involved in neurological disease, while the most overexpressed miRNA in this network (miR-233-3p) was noted to have over 100 targets including CDKN1B and the insulin receptor. Serum cytokine analysis showed significant upregulation of several pro-inflammatory cytokines in the DCM cohort compared to the HC group. DCM patients demonstrated a set of unique circulating miRNAs in addition to a different serum inflammatory profile compared to HC. These miRNAs may potentially serve as targets for future therapeutic intervention or diagnostic/prognostic testing.

Towards a personalized approach: The promising horizon of degenerative cervical myelopathy.

Towards a personalized approach: The promising horizon of degenerative cervical myelopathy.

Focal compression of the cervical spinal cord alone does not indicate high risk of neurological deterioration in patients with a diagnosis of mild degenerative cervical myelopathy

Degenerative Cervical Myelopathy (DCM) is the functional derangement of the spinal cord resulting from vertebral column spondylotic degeneration. Typical neurological symptoms of DCM include gait imbalance, hand/arm numbness, and upper extremity dexterity loss. Greater spinal cord compression is believed to lead to a higher rate of neurological deterioration, although clinical experience suggests a more complex mechanism involving spinal canal diameter (SCD). In this study, we utilized machine learning clustering to understand the relationship between SCD and different patterns of cord compression (i.e. compression at one disc level, two disc levels, etc.) to identify patient groups at risk of neurological deterioration. 124 MRI scans from 51 non-operative DCM patients were assessed through manual scoring of cord compression and SCD measurements. Dimensionality reduction techniques and k-means clustering established patient groups that were then defined with their unique risk criteria. We found that the compression pattern is unimportant at SCD extremes (≤14.5 mm or > 15.75 mm). Otherwise, severe spinal cord compression at two disc levels increases deterioration likelihood. Notably, if SCD is normal and cord compression is not severe at multiple levels, deterioration likelihood is relatively reduced, even if the spinal cord is experiencing compression. We elucidated five patient groups with their associated risks of deterioration, according to both SCD range and cord compression pattern. Overall, SCD and focal cord compression alone do not reliably predict an increased risk of neurological deterioration. Instead, the specific combination of narrow SCD with multi-level focal cord compression increases the likelihood of neurological deterioration in mild DCM patients.

Impact of postsurgical rehabilitation on outcomes for degenerative cervical myelopathy.

Despite widespread use, there is limited evidence to support postsurgical rehabilitation to enhance neurological recovery after surgery for degenerative cervical myelopathy (DCM). Outcomes research for DCM seldom accounts for the effect of postsurgical rehabilitation. The aim of this study was to quantify the impact of postsurgical rehabilitation on outcomes after surgery for DCM. This was a retrospective analysis of prospectively collected data from a single center. The study enrolled 66 patients who underwent spinal surgery for DCM. In addition to patient demographic, imaging, and surgical data, chart review was performed to document the timing, type, duration, and outcomes of postsurgical rehabilitation therapy. Outcomes were collected prospectively, including the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI) score, and SF-36 physical component summary (PCS) score. Linear regression models were created to determine the independent effects of type and timing of postsurgical occupational therapy (OT) and physical therapy (PT) on outcomes. A total of 66 patients were included in the analysis. Multivariate regression analysis showed that postsurgical OT was associated with significantly greater improvement in 12-month SF-36 PCS scores (p = 0.009) and mJOA scores (p = 0.019). In the subset of patients who received therapy, delayed therapy (> 42 days after surgery) compared to early therapy (< 42 days after surgery) was associated with less improvement in SF-36 PCS scores (p = 0.03). Postsurgical outpatient rehabilitation was independently associated with improved postsurgical outcomes within the 1st year after surgery for DCM, and early therapy (< 42 days) was associated with superior outcomes compared to delayed therapy. This is one of the first studies to use a prospective database to demonstrate an independent effect for postsurgical rehabilitation on outcomes after surgery for DCM.

Presence of Cerebrospinal Fluid on Preoperative Imaging and the Associated Cervical Myelopathy Diagnosis and Outcome.

Retrospective chart review. The objective of this study is to determine whether the presence of cerebrospinal fluid is associated with the severity of degenerative cervical myelopathy or postoperative outcomes. Degenerative cervical myelopathy (DCM) is a clinical diagnosis characterized as neurologic dysfunction. Preoperative imaging is used to determine the source of cord compression. In clinical practice, cerebrospinal fluid (CSF) around the cord is often used as an indicator to determine whether stenosis is relevant. It is unclear if the presence of CSF around the cord can serve as a metric for clinically relevant cord compression. Patients undergoing single-level anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy were identified from our institution's surgical database. Pre- and postoperative patient-reported health outcomes visual analog scale for neck pain (VAS-NP) and modified Japanese Orthopaedic Association (mJOA) were collected. The level of ACDF plus one level above and below were assessed for the presence of cerebrospinal fluid, as well as measuring the area of the spinal canal and spinal cord on preoperative magnetic resonance imaging. Two hundred forty-nine patients were included. Spearman correlation test comparing cord/canal ratios at the level of compression and preoperative mJOA shows a significant negative correlation (Rho = -0.206, P= 0.043). There was no significant correlation with postoperative change in mJOA scores (Rho = -0.002, P= 0.986). The presence of CSF around the cord was weakly correlated with the severity of myelopathy; however, it had no correlation with postoperative outcomes. The presence of CSF around the cord should not in isolation be used to rule in or rule out operative levels in cervical myelopathy.

Cost-effectiveness of surgery for degenerative cervical myelopathy in the United Kingdom

Purpose Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord dysfunction worldwide, for which surgery is the mainstay of treatment. At present, there is limited literature on the costs associated with the surgical management of DCM, and none from the United Kingdom (UK). This study aimed to evaluate the cost-effectiveness of DCM surgery within the National Health Service, UK. Materials and Methods Incidence of DCM was identified from the Hospital Episode Statistics (HES) database for a single year using five ICD-10 diagnostic codes to represent DCM. Health Resource Group (HRG) data was used to estimate the mean incremental surgery (treatment) costs compared to non-surgical care, and the incremental effect (quality adjusted life year (QALY) gain) was based on data from a previous study. A cost per QALY value of <£30,000/QALY (GBP) was considered acceptable and cost-effective, as per the National Institute for Health and Clinical Excellence (NICE) guidance. A sensitivity analysis was undertaken (±5%, ±10% and ±20%) to account for variance in both the cost of admission and QALY gain. Results The total number of admissions for DCM in 2018 was 4,218. Mean age was 62 years, with 54% of admissions being of working age (18–65 years). The overall estimated cost of admissions for DCM was £38,871,534 for the year. The mean incremental (per patient) cost of surgical management of DCM was estimated to be £9,216 (ranged £2,358 to £9,304), with a QALY gain of 0.64, giving an estimated cost per QALY value of £14,399/QALY. Varying the QALY gain by ±20%, resulted in cost/QALY figures between £12,000 (+20%) and £17,999 (−20%). Conclusions Surgery is estimated to be a cost-effective treatment of DCM amongst the UK population.

Clinical results after surgical treatment for degenerative cervical myelopathy: a retrospective 1-year follow-up descriptive analysis

Background Degenerative cervical myelopathy (DCM) poses a significant challenge globally, often requiring surgical intervention for moderate to severe cases. Choosing between anterior and posterior surgical approaches remains controversial, highlighting the need to consider various factors such as sagittal balance and compression severity. Methods This retrospective cohort study described patients with DCM who underwent surgery at Carlos Van Buren Hospital between 2014 and 2021. Inclusion criteria involved clinical evidence of myelopathy and cervical spinal cord compression at two or more levels, with data collected preoperatively and postoperatively at 12 months. Results Of the 66 patients analyzed, both anterior and posterior approaches demonstrated substantial clinical improvements postoperatively, with 83% of patients showing overall improvement and 59.1% achieving the minimal clinically important difference (MCID) in mJOA scores. Notably, anterior surgeries showed slightly higher rates of MCID achievement and fewer instances of disease progression postoperatively compared to posterior surgeries. Conclusions Our descriptive findings underscore the benefits of both anterior and posterior surgical approaches for DCM, with slight outcome variations. Individualized treatment, considering factors such as clinical symptoms, compression type, and cervical alignment, is crucial. Future research should prioritize comprehensive outcome measures to inform treatment strategies.

Racial and Socioeconomic Disparities in Laminoplasty Versus Laminectomy With Fusion in Patients With Cervical Spondylosis.

A retrospective cohort study using prospectively collected data. The aim of this study was to investigate preoperative differences in racial and socioeconomic factors in patients undergoing laminoplasty (LP) versus laminectomy and fusion (LF) for degenerative cervical myelopathy (DCM). DCM is prevalent in the United States, requiring surgical intervention to prevent neurological degeneration. While LF is utilized more frequently, LP is an emerging alternative. Previous studies have demonstrated similar neurological outcomes for both procedures. However, treatment selection is primarily at the discretion of the surgeon and may be influenced by social determinants of health that impact surgical outcomes. The Quality Outcome Database (QOD), a national spine registry, was queried for adult patients who underwent either LP or LF for the management of DCM. Covariates associated with socioeconomic status, pain and disability, and demographic and medical history were collected. Multivariate logistic regression was performed to assess patient factors associated with undergoing LP versus LF. Of 1673 DCM patients, 157 (9.4%) underwent LP and 1516 (90.6%) underwent LF. A significantly greater proportion of LP patients had private insurance (P<0.001), a greater than high school level education (P<0.001), were employed (P<0.001), and underwent primary surgery (P<0.001). LP patients reported significantly lower baseline neck/arm pain and Neck Disability Index (P<0.001). In the multivariate regression model, lower baseline neck pain [odds ratio (OR)=0.915, P=0.001], identifying as non-Caucasian (OR=2.082, P<0.032), being employed (OR=1.592, P=0.023), and having a greater than high school level education (OR=1.845, P<0.001) were associated with undergoing LP rather than LF. In DCM patients undergoing surgery, factors associated with patients undergoing LP versus LF included lower baseline neck pain, non-Caucasian race, higher education, and employment. While symptomatology may influence the decision to choose LP over LF, there may also be socioeconomic factors at play. The trend of more educated and employed patients undergoing LP warrants further investigation.

Postoperative C5 Palsy after Anterior or Posterior Decompression for Degenerative Cervical Myelopathy: A Subgroup Analysis of the Multicenter, Prospective, Randomized, Phase III, CSM-Protect Clinical Trial.

Retrospective cohort study of prospectively accrued data. To evaluate a large, prospective, multicentre dataset of surgically-treated DCM cases on the contemporary risk of C5 palsy with surgical approach. The influence of surgical technique on postoperative C5 palsy after decompression for degenerative cervical myelopathy (DCM) is intensely debated. Comprehensive analyses are needed using contemporary data and accounting for covariates. Patients with moderate to severe DCM were prospectively enrolled in the multicenter, randomized CSM-Protect clinical trial and underwent either anterior or posterior decompression between Jan 31, 2012, to May 16, 2017. The primary outcome was the incidence of postoperative C5 palsy, defined as onset of muscle weakness by at least one grade in manual muscle test at the C5 myotome with slight or absent sensory disruption after cervical surgery. Two comparative cohorts were made based on anterior or posterior surgical approach. Multivariate hierarchical mixed-effects logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI) for C5 palsy. A total of 283 patients were included, and 53.4% underwent posterior decompression. The total incidence of postoperative C5 palsy was 7.4% and was significantly higher in patients that underwent posterior decompression compared to anterior decompression (11.26% vs. 3.03%, P=0.008). After multivariable regression, posterior approach was independently associated with greater than four times the likelihood of postoperative C5 palsy (P=0.017). Rates of C5 palsy recovery were comparable between the two surgical approaches. The odds of postoperative C5 palsy are significantly higher after posterior decompression compared to anterior decompression for DCM. This may influence surgical decision-making when there is equipoise in deciding between anterior and posterior treatment options for DCM. Therapeutic Level II.

Use Of Diffusion Tensor Tractography as an Adjunct In The Diagnosis and Support in the Timely Treatment of Degenerative Cervical Myelopathy

Use Of Diffusion Tensor Tractography as an Adjunct In The Diagnosis and Support in the Timely Treatment of Degenerative Cervical Myelopathy

Modular organization of functional brain networks in patients with degenerative cervical myelopathy

Previous studies have indicated that brain functional plasticity and reorganization in patients with degenerative cervical myelopathy (DCM). However, the effects of cervical cord compression on the functional integration and separation between and/or within modules remain unclear. This study aimed to address these questions using graph theory. Functional MRI was conducted on 46 DCM patients and 35 healthy controls (HCs). The intra- and inter-modular connectivity properties of the whole-brain functional network and nodal topological properties were then calculated using theoretical graph analysis. The difference in categorical variables between groups was compared using a chi-squared test, while that between continuous variables was evaluated using a two-sample t-test. Correlation analysis was conducted between modular connectivity properties and clinical parameters. Modules interaction analyses showed that the DCM group had significantly greater inter-module connections than the HCs group (DMN-FPN: t = 2.38, p = 0.02); inversely, the DCM group had significantly lower intra-module connections than the HCs group (SMN: t = − 2.13, p = 0.036). Compared to HCs, DCM patients exhibited higher nodal topological properties in the default-mode network and frontal–parietal network. In contrast, DCM patients exhibited lower nodal topological properties in the sensorimotor network. The Japanese Orthopedic Association (JOA) score was positively correlated with inter-module connections (r = 0.330, FDR p = 0.029) but not correlated with intra-module connections. This study reported alterations in modular connections and nodal centralities in DCM patients. Decreased nodal topological properties and intra-modular connection in the sensory-motor regions may indicate sensory-motor dysfunction. Additionally, increased nodal topological properties and inter-modular connection in the default mode network and frontal-parietal network may serve as a compensatory mechanism for sensory-motor dysfunction in DCM patients. This could provide an implicative neural basis to better understand alterations in brain networks and the patterns of changes in brain plasticity in DCM patients.

245 Linking Cervical Spinal Cord White Matter Magnetization Transfer Ratio to NIH Toolbox Based Analyses of Motor Function in Degenerative Cervical Myelopathy

INTRODUCTION: Traditional spine imaging technique present disparity between degenerative cervical myelopathy (DCM) disease severity and prognosis. Advancement in spine neuroimaging has unveiled key changes that enhance our understanding of DCM pathogenesis. We investigated region- and tract-specific SC white matter (WM) damage and their relationship to motor deficit in DCM. METHODS: A cohort of 20 DCM and 23 age-matched HC participants were recruited in a cross-sectional study. We utilized a consensus MT-imaging protocol, Spinal cord Toolbox, and objective motor assessment tool battery to assess the extent of WM injury and functional deficits in DCM. The SC WM region- and tract-based MTR were calculated in three different ROIs: maximum compressed level (MCL), caudal uncompressed level (C7), and central region of compression. RESULTS: DCM patients demonstrated significant functional deficits compared to HC in motor assessments. DCM exhibited reduced MTR measures denoting WM injury in the anterior region of the SC and within selected motor tracts in the ROIs. MTR values in reticulospinal, vestibulospinal, and lateral corticospinal tracts were significantly associated with dexterity and grip strength measures. CONCLUSIONS: Our methodology enables precise mapping of ROIs within the SC allowing us to demonstrate an association between tract-specific WM damage and functional motor deficits in DCM patients. Additionally, the observation of decreased MTR measures in seemingly uncompressed SC regions indicates the pathophysiology of DCM that may provide insight into the varying presentations of DCM. Identification of specific WM injury may help better understand DCM deficits that can be targeted for effective interventions to improve patient outcomes

370 Is There an Optimal Surgical Approach in Degenerative Cervical Myelopathy?: An Individual Participant Data Meta-Analysis

INTRODUCTION: Contradictions exist about impact of anterior vs. posterior surgical approach on outcomes of degenerative cervical myelopathy (DCM). METHODS: Individual patient data of subjects who underwent surgery for DCM was identified from a pooled dataset of the AO Spine CSM-North America, CSM-International, and CSM-Protect clinical studies. Primary outcomes were changes in short form 36 Physical Component Summary score (SF36-PCS) and mJOA score at 12 months. Secondary outcomes were change in total Neck Disability Index (NDI) score and SF36 Mental Component Summary score (SF36-MCS). Two comparison cohorts were created: i) anterior surgery and ii) posterior surgery. One-stage mixed-effects meta-analysis with study and treatment exposure as random effects was performed and reported with mean differences and 95% confidence intervals. A subgroup analysis planned a priori in mild DCM patients (mJOA 15-17) was performed. RESULTS: A total of 979 patients met eligibility criteria. Patients who had anterior decompressive surgery experienced greater improvements at 1yr of follow-up than those who underwent posterior decompressive surgery in SF36-PCS score (adjusted MD 1.57 [95% CI 0.11 to 3.03], p = 0.0348) and NDI score (adjusted MD 3.32 [95% CI 0.58 to 6.05], p = 0.0172). A greater proportion of patients that underwent anterior surgery achieved clinically important recovery of their NDI (OR 1.49 [95% CI 1.15 to 1.93], p = 0.002; aOR 1.46 [95% CI 1.08 to 1.96], p = 0.013) and SF36-PCS scores at 1yr (OR 1.45 [95% CI 1.12 to 1.88], p = 0.004, aOR 1.34 [95% CI 1.00 to 1.80], p = 0.052). In patients with mild DCM (n = 186), patients who underwent anterior decompressive surgery experienced greater improvements in SF36-PCS score, mJOA score, and Neck Disability Index score than posterior surgical patients. CONCLUSIONS: Anterior surgical decompression for DCM is associated with greater improvements in 1yr patient-reported outcomes than posterior surgical decompression.

1075 The Effect of Regional Procedural Preference on Outcomes After Posterior Decompression for Degenerative Cervical Myelopathy: Individual Participant Data Meta-Analysis of a Prospective, Multinational Dataset of 1047 Cases

INTRODUCTION: There is considerable debate regarding the relative effectiveness of laminoplasty vs. laminectomy and fusion for posterior surgical decompression of degenerative cervical myelopathy (DCM). METHODS: Subjects with DCM that underwent posterior decompression was derived from three independent, prospective, multicentre clinical trials (CSM-NA, CSM-I, CSM-Protect). Primary endpoint was change in SF36-PCS (minimum clinically important difference [MCID] 4) at 1yr compared to pre-operative assessment. Secondary endpoints were change in mJOA (MCID 2) score, Neck Disability Index (NDI; MCID 15) score, NDI Pain Intensity score, and SF36-MCS (MCID 4) score. Two comparison cohorts were created: i) laminoplasty (LP) and ii) laminectomy and fusion (LF). One-stage hierarchical mixed-effects meta-analyses with study and treatment exposure as random effects were performed. As subgroup analysis, the influence of procedural volume between LP-predominant sites, LF-predominant sites, and volume-equivalent sites was investigated. RESULTS: From a total of 1047 patients with DCM, 369 patients met eligibility criteria. There was geographic variability in surgical choice with higher rates of laminectomy and fusion in Brazil and Canada and higher laminoplasty rates in Japan and India. USA had similar rates of LF and LP. When compared to LF-predominant sites, LP-predominant sites achieved greater rates of MCID for mJOA at 1yr (85.4% v. 68.7%, p=0.036) with their predominant technique. There were no significant differences in MCID rates of NDI, SF36-PCS, or SF36-MCS. When comparing LF-predominant and LP-predominant sites with USA, a volume equivalent site, there were no significant differences in MCID rates of all outcomes. CONCLUSIONS: Sites that primarily used LP achieved greater rate of MCID in mJOA with laminoplasty than laminectomy with fusion from primarily LF sites. This suggests that experience with either LP or LF can drive outcomes which has interesting healthcare delivery implications.

Pre-operative expectations of patients with degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network

BACKGROUNDDespite an abundance of literature on degenerative cervical myelopathy (DCM), little is known about pre-operative expectations of these patients. PURPOSEThe primary objective was to describe patient pre-operative expectations. Secondary objectives included identifying patient characteristics associated with high pre-operative expectations and to determine if expectations varied depending on myelopathy severity. STUDY DESIGNThis was a retrospective study of a prospective multicenter, observational cohort of patients with DCM. PATIENT SAMPLEPatients who consented to undergo surgical treatment between January 2019 and September 2022 were included. OUTCOMES MEASURESAn 11-domain expectation questionnaire was completed pre-operatively whereby patients quantified the expected change in each domain. METHODSThe most important expected change was captured. A standardized expectation score was calculated as the sum of each expectation divided by the maximal possible score. The high expectation group was defined by patients who had an expectation score above the 75th percentile. Predictors of patients with high expectations were determined using multivariable logistic regression models. RESULTSThere were 262 patients included. The most important patient expectation was preventing neurological worsening (40.8%) followed by improving balance when standing or walking (14.5%), improving independence in everyday activities (10.3%), and relieving arm tingling, burning and numbness (10%). Patients with mild myelopathy were more likely to select no worsening as the most important expected change compared to patients with severe myelopathy (p<.01). Predictors of high patient expectations were: having fewer comorbidities (OR -0.30 for every added comorbidity, 95% CI -0.59 to -0.10, p=.01), a shorter duration of symptoms (OR 0.92, 95% CI 0.35–1.19, p=.02), no contribution from “failure of other treatments” on the decision to undergo surgery (OR 1.49, 95% CI 0.56–2.71, p=.02) and more severe neck pain (OR 0.19 for 1 point increase, 95% CI 0.05–0.37, p=.01). CONCLUSIONSMost patients undergoing surgery for DCM expect prevention of neurological decline, better functional status, and improvement in their myelopathic symptoms. Stopping neurological deterioration is the most important expected outcomes by patients.

Advanced MRI metrics improve the prediction of baseline disease severity for individuals with degenerative cervical myelopathy

Background contextDegenerative cervical myelopathy (DCM) is the most common form of atraumatic spinal cord injury globally. Degeneration of spinal discs, bony osteophyte growth and ligament pathology results in physical compression of the spinal cord contributing to damage of white matter tracts and grey matter cellular populations. This results in an insidious neurological and functional decline in patients which can lead to paralysis. Magnetic resonance imaging (MRI) confirms the diagnosis of DCM and is a prerequisite to surgical intervention, the only known treatment for this disorder. Unfortunately, there is a weak correlation between features of current commonly acquired MRI scans (“community MRI, cMRI”) and the degree of disability experienced by a patient. PurposeThis study examines the predictive ability of current MRI sequences relative to “advanced MRI” (aMRI) metrics designed to detect evidence of spinal cord injury secondary to degenerative myelopathy. We hypothesize that the utilization of higher fidelity aMRI scans will increase the effectiveness of machine learning models predicting DCM severity and may ultimately lead to a more efficient protocol for identifying patients in need of surgical intervention. Study design/settingSingle institution analysis of imaging registry of patients with DCM. Patient sample296 patients in the cMRI group and 228 patients in the aMRI group. Outcome measuresPhysiologic measures: Accuracy of machine learning algorithms to detect severity of DCM assessed clinically based on the modified Japanese Orthopedic Association (mJOA) scale. MethodsPatients enrolled in the Canadian Spine Outcomes Research Network registry with DCM were screened and 296 cervical spine MRIs acquired in cMRI were compared with 228 aMRI acquisitions. aMRI acquisitions consisted of diffusion tensor imaging, magnetization transfer, T2-weighted, and T2*-weighted images. The cMRI group consisted of only T2-weighted MRI scans. Various machine learning models were applied to both MRI groups to assess accuracy of prediction of baseline disease severity assessed clinically using the mJOA scale for cervical myelopathy. ResultsThrough the utilization of Random Forest Classifiers, disease severity was predicted with 41.8% accuracy in cMRI scans and 73.3% in the aMRI scans. Across different predictive model variations tested, the aMRI scans consistently produced higher prediction accuracies compared to the cMRI counterparts. ConclusionsaMRI metrics perform better in machine learning models at predicting disease severity of patients with DCM. Continued work is needed to refine these models and address DCM severity class imbalance concerns, ultimately improving model confidence for clinical implementation.

362 Enhanced Measures to Quantify Gait and Balance Impairment in Degenerative Cervical Myelopathy: A Prospective Cohort Study

INTRODUCTION: Gait and balance impairment are among the cardinal symptoms of Degenerative Cervical Myelopathy, however, utilizing objective measurements of these functions is highly challenging. METHODS: A prospective cross-sectional cohort study with manual and quantitative gait/balance testing using a Protokinetics Zeno Walkway electronic pressure mat (self/fast-paced, tandem gait/stance, Romberg, one foot standing). RESULTS: 95 DCM and 78 healthy subjects were included. For quantitave gait assesment, Velocity (p = 4.56x 10-8, 3.39x10-7), Gait Variability Index (p = 1.788x10-8, p = 0.00169), and stability ratio, single stance time/ double stance time, (p = 4.167x10^-7, p = 1.438x10^-5) were significantly different between groups for both self and fast-paced gait assessments, respectively. Balance was assessed by the variability of the center of pressure (COP). The standard deviation variability of COP in both the X (p = 0.00171) and Y directions (p = 0.000104) and cadence (p = 0.00175) were significant for tandem gait, walking heel-to-toe. Standing on either the Left or Right foot also showed a difference in the variability of COP in both directions X (p = 4.21x10^-7 Left Foot, p = 8.27x10^-7 Right Foot) and Y (p = 6.64x10^-4 Left Foot, p = 1.32x10^-4 Right Foot). On, manual assesment, DCM patients scored significantly worse in all parameters such as self-paced (p = 5.54x10^-2), fast-paced (p = 6.28x10^-2), tandem gait (p = 3.60x10^-8), Romberg eyes open (p = 1.58x10^-2), Romberg eyes closed (p = 1.90x10^-2), L foot stance (p = 6.78x10^-6), R foot stance (2.1x10^-6), and tandem stance (p = 8.83x10^-5). CONCLUSIONS: Quantitative parameters from an electronic pressure mat can be used to assess gait and balance impairment with high sensitivity and strong correlation with subjective measures. Manual scoring of tandem gait, standing on one foot, and tandem stance also provided robust differences and can be easily adopted into routine assessment of DCM patients.

Deep Learning-Enhanced Hand Grip and Release Test for Degenerative Cervical Myelopathy: Shortening Assessment Duration to 6 Seconds.

Hand clumsiness and reduced hand dexterity can signal early signs of degenerative cervical myelopathy (DCM). While the 10-second grip and release (10-s G&R) test is a common clinical tool for evaluating hand function, a more accessible method is warranted. This study explores the use of deep learning-enhanced hand grip and release test (DL-HGRT) for predicting DCM and evaluates its capability to reduce the duration of the 10-s G&R test. The retrospective study included 508 DCM patients and 1,194 control subjects. Propensity score matching (PSM) was utilized to minimize the confounding effects related to age and sex. Videos of the 10-s G&R test were captured using a smartphone application. The 3D-MobileNetV2 was utilized for analysis, generating a series of parameters. Additionally, receiver operating characteristic curves were employed to assess the performance of the 10-s G&R test in predicting DCM and to evaluate the effectiveness of a shortened testing duration. Patients with DCM exhibited impairments in most 10-s G&R test parameters. Before PSM, the number of cycles achieved the best diagnostic performance (area under the curve [AUC], 0.85; sensitivity, 80.12%; specificity, 74.29% at 20 cycles), followed by average grip time. Following PSM for age and gender, the AUC remained above 0.80. The average grip time achieved the highest AUC of 0.83 after 6 seconds, plateauing with no significant improvement in extending the duration to 10 seconds, indicating that 6 seconds is an adequate timeframe to efficiently evaluate hand motor dysfunction in DCM based on DL-HGRT. DL-HGRT demonstrates potential as a promising supplementary tool for predicting DCM. Notably, a testing duration of 6 seconds appears to be sufficient for accurate assessment, enhancing the test more feasible and practical without compromising diagnostic performance.