Application of Short T1 Inversion Recovery Sequence in Increased Signal Intensity Following Cervical Spondylotic Myelopathy.

OBJECTIVES: To compare magnetic resonance (MR) short T1 inversion recovery (STIR) sequence with MR T2-weighted (T2W) sequence for detecting increased signal intensity (ISI) and assessing outcomes of ISI in cervical spondylotic myelopathy (CSM). METHODS: Data of patients with CSM who showed ISI on MR imaging and had undergone cervical spine surgery were retrospectively reviewed. STIR and T2W images were examined to assess signal intensity ratio (SIR), length and grading of the ISI, maximal spinal cord compression, canal narrowing ratio, and ligamentum flavum hypertrophy. The patients were divided into good and poor groups based on their outcomes. χ2 tests and variance analysis were used to assess intergroup differences. Univariate and multivariate logistic regression analyses were performed to identify risk factors for poor outcomes, and receiver operating characteristic curves were plotted to detect prognostic effects. RESULTS: SIR and ISI lengths were significantly different between the STIR and T2 images. In the univariate logistic regression analysis, age, diabetes, SIRT2, SIRSTIR, and ISISTIR grading were significant factors. Accordingly, in the multivariate logistic regression analysis, age, diabetes, SIRT2, and SIRSTIR were included in the model. Among patients with diabetes, we observed a significant difference between SIRT2 and SIRSTIR. CONCLUSIONS: The STIR sequence demonstrated superior capability to the T2W sequence in detecting ISI; however, there was no obvious difference in predicted outcomes. STIR sequence has a better prognostic value than T2W sequence in patients with diabetes who have CSM. ISI grading based on the STIR sequence may be a clinically valuable indicator.

Assessment of Cervical Myelopathy Risk in Ossification of the Posterior Longitudinal Ligament Patients With Spinal Cord Compression Based on Segmental Dynamic Versus Static Factors.

OBJECTIVE: Using segmental dynamic and static factors, we aimed to elucidate the pathogenesis and relationship between ossification of the posterior longitudinal ligament (OPLL) and the severity of cervical myelopathy. METHODS: Retrospective analysis of 163 OPLL patients' 815 segments. Imaging was used to evaluate each segmental space available for the spinal cord (SAC), OPLL diameter, type, bone space, K-line, the C2-7 Cobb angle, each segmental range of motion (ROM), and total ROM. Magnetic resonance imaging was used to evaluate spinal cord signal intensity. Patients were divided into the myelopathy group (M group) and the without myelopathy group (WM group). RESULTS: Minimal SAC (p = 0.043), (C2-7) Cobb angle (p = 0.004), total ROM (p = 0.013), and local ROM (p = 0.022) were evaluated as an independent predictor of myelopathy in OPLL. Different from the previous report, the M group had a straighter whole cervical spine (p < 0.001) and poorer cervical mobility (p < 0.001) compared to the WM group. Total ROM was not always a risk factor for myelopathy, as its impact depended on SAC, when SAC > 5 mm, the incidence rate of myelopathy decreased with the increase of total ROM. Lower cervical spine (C5-6, C6-7) showing increased "Bridge-Formation," along with spinal canal stenosis and segmental instability (C2-3, C3-4) in the upper cervical spine, could cause myelopathy in M group (p < 0.05). CONCLUSION: Cervical myelopathy is linked to the OPLL's narrowest segment and its segmental motion. The hypermobility of the C2-3 and C3-4, contributes significantly to the development of myelopathy in OPLL.

Correlation Analysis of Surgical Efficacy and Risk Factors of Cervical Spondylotic Myelopathy with High Signal Intensity on MRI-T2WI.

OBJECTIVES: The purpose of this study was to investigate the surgical efficacy and risk factors of cervical spondylotic myelopathy (CSM) patients with increased signal intensity (ISI) on T2-weighted magnetic resonance imaging (MRI-T2WI). METHODS: We compared the surgical outcomes of CSM patients with and without ISI. In addition, we compared the efficacy of anterior and posterior cervical decompression in CSM patients with ISI. We also analyzed the risk factors of MRI-T2WI ISI in CSM patients. RESULTS: The incidence of ISI among 153 CSM patients was 71.89 %. The JOA score and JOA remission rate were better in the ISI-free than in the ISI group. The postoperative JOA score and JOA remission rate were better in the posterior than the anterior approach surgery group. The disease duration and vertebral canal volume were found to be risk factors for ISI in CSM patients. CONCLUSION: Among patients with CSM, the prognosis is worse for those with ISI than those without ISI. Posterior cervical decompression surgery produces a better curative effect than anterior cervical decompression surgery in CSM patients with ISI. CSM patients with longer disease duration and small vertebral canal volume should undergo surgical treatment as early as possible.

Clinical and radiographic characteristics of increased signal intensity of the spinal cord at the vertebral body level in patients with cervical myelopathy.

BACKGROUND: Increased signal intensity (ISI) is usually recognized at the disc level of the responsible lesion in the patients with cervical myelopathy. However, it is occasionally seen at the vertebral body level, below the level of compression. We aimed to investigate the clinical significance and the radiographic characteristics of ISI at the vertebral body level. METHODS: This retrospective study included 135 patients with cervical spondylotic myelopathy who underwent surgery and with local ISI. We measured the local and C2-7 angle at flexion, neutral, and extension. We also evaluated the local range of motion (ROM) and C2-7 ROM. The patients were classified into group D (ISI at disc level) and group B (ISI at vertebral body level). RESULTS: The prevalence was 80.7% (109/135) and 19.3% (26/135) for groups D and B, respectively. Local angle at flexion and neutral were more kyphotic in group B than in group D. The local ROM was larger in group B than in group D. Moreover, C2-7 angle at flexion, neutral and extension were more kyphotic in group B than in group D. Two years later, local angle at flexion, neutral, and extension were also kyphotic in group B than group D; however, local and C2-7 ROM was not significantly different between the two groups. There was no significant difference of clinical outcomes 2 years postoperatively between both groups. CONCLUSIONS: Group B was associated with the kyphotic alignment and local greater ROM, compared to group D. As the spinal cord is withdrawn in flexion, the ISI lesion at vertebral body might be displaced towards the disc level, which impacted by the anterior components of the vertebrae. ISI at the vertebral body level might be related to cord compression or stretching at flexion position. This should be different from the conventionally held pincer-mechanism concept.

Predictive Nomogram for Clinical Prognosis in Cervical Spondylotic Myelopathy With Intramedullary T2-Weighted Increased Signal Intensity: A Novel Digital Tool for Patient Prognosis Education.

Aims: To establish a predictive nomogram for clinical prognosis in cervical spondylotic myelopathy (CSM) with intramedullary T2-weighted increased signal intensity (ISI). Methods: The clinical data of 680 patients with CSM with intramedullary T2-weighted ISI were retrospectively analyzed. The patients were divided into the modeling group (476) and the validation group (204) by using a random number table at a ratio of 7:3. The independent prognostic factors were screened using multivariate logistic regression analysis. The factors were subsequently incorporated into the establishment of the predictive nomogram. The area under the receiver operating characteristic (ROC) curve (AUC) was undertaken to estimate the discrimination of the predictive nomogram. The calibration curve and the Hosmer-Lemeshow test were used to assess the calibration of the predictive nomogram. The clinical usefulness of the predictive nomogram was evaluated by decision curve analysis (DCA). Results: Based on the pre-operative Japanese Orthopedic Association (JOA) score, maximal canal compromise (MCC), and maximal spinal cord compression (MSCC), we established a predictive nomogram. The AUCs in the modeling group and validation group were 0.892 (95% CI: 0.861~0.924) and 0.885 (95% CI: 0.835~0.936), respectively, suggesting good discrimination of the nomogram. Calibration curves showed a favorable consistency between the predicted probability and the actual probability. In addition, the values of P of the Hosmer-Lemeshow were 0.253 and 0.184, respectively, suggesting good calibration of the nomogram. DCA demonstrated that the nomogram had good clinical usefulness. Conclusion: We established and validated a predictive nomogram for the clinical prognosis in CSM with intramedullary T2-weighted ISI. This predictive nomogram could help clinicians and patients identify high-risk patients and educate them about prognosis, thereby improving the prognosis of high-risk patients.

Predictors of neurologic outcome after surgery for cervical ossification of the posterior longitudinal ligament differ based on myelopathy severity: a multicenter study.

OBJECTIVE: The purpose of this retrospective multicenter study was to compare prognostic factors for neurological recovery in patients undergoing surgery for cervical ossification of the posterior longitudinal ligament (OPLL) based on their presenting mild, moderate, or severe myelopathy. METHODS: The study included 372 consecutive patients with OPLL who underwent surgery for cervical myelopathy between 2006 and 2016 in East Asian countries with a high OPLL prevalence. Baseline and postoperative clinical outcomes were assessed using the Japanese Orthopaedic Association (JOA) myelopathy score and recovery ratio. Radiographic assessment included occupying ratio, cervical range of motion, and sagittal alignment parameters. Patient myelopathy was classified as mild, moderate, or severe based on the preoperative JOA score. Linear and multivariate regression analyses were performed to identify patient and surgical factors associated with neurological recovery stratified by baseline myelopathy severity. RESULTS: The mean follow-up period was 45.4 months (range 25-140 months). The mean preoperative and postoperative JOA scores and recovery ratios for the total cohort were 11.7 ± 3.0, 14.5 ± 2.7, and 55.2% ± 39.3%, respectively. In patients with mild myelopathy, only age and diabetes correlated with recovery. In patients with moderate to severe myelopathy, older age and preoperative increased signal intensity on T2-weighted imaging were significantly correlated with a lower likelihood of recovery, while female sex and anterior decompression with fusion (ADF) were associated with better recovery. CONCLUSIONS: Various patient and surgical factors are correlated with likelihood of neurological recovery after surgical treatment for cervical OPLL, depending on the severity of presenting myelopathy. Older age, male sex, intramedullary high signal intensity, and posterior decompression are associated with less myelopathy improvement in patients with worse baseline function. Therefore, myelopathy-specific preoperative counseling regarding prognosis for postoperative long-term neurological improvement should include consideration of these individual and surgical factors.

A Novel Scoring System for Ossification of Posterior Longitudinal Ligament of the Cervical Spine Based on Magnetic Resonance Imaging-CSFM Scoring System.

OBJECTIVE: To establish a new scoring system to assess spinal cord compression of ossification of posterior longitudinal ligament (OPLL) of the cervical spine. METHODS: Literature review and expert advice were used to determine variables of the novel CSFM scoring system. The CSFM score included 4 variables: curvature of spinal cord (C), increased signal intensity of spinal cord (S), cerebrospinal fluid imaging (F), and cross-section morphology of spinal cord (M). From June 2015 to June 2018, clinical and imaging data of 387 patients with cervical OPLL were retrospectively analyzed. The 4 variables were measured and recorded. Different scores were assigned based on analysis of the relationship between the variables and the Japanese Orthopaedic Association score. Two spine surgeons scored the patients according to the CSFM score and analyzed the internal consistency and reliability of the CSFM score. RESULTS: The CSFM scoring system consisted of 4 variables, each of which was divided into 4 grades. Each variable was assigned a score of 0-3 according to different grades. The total possible score was 12, and the minimum score was 0. A higher score indicated more severe spinal cord compression. CONCLUSIONS: The CSFM scoring system can effectively reflect the degree of spinal cord compression for cervical OPLL.

The association between cervical focal kyphosis and myelopathy severity in patients with cervical spondylotic myelopathy before surgery.

PURPOSE: Cervical focal kyphosis could often be observed in patients with cervical spondylotic myelopathy (CSM). However, the association between it and myelopathy severity remains unclear. This study aims to elucidate the association between cervical focal kyphosis and myelopathy severity before surgery. METHODS: A retrospective review of 191 consecutive patients treated for CSM from 2017 to 2019 was surveyed. Seven MRI and five radiographic parameters were measured, clinical parameters were included. Patients were divided into two sagittal focal angle groups (lordosis/kyphosis) and two disc herniation severity groups (severe/non-severe). The potential risk factors of myelopathy symptoms were analysed. RESULTS: Significant correlations between cervical sagittal focal angles, several other imaging findings and myelopathy severity were found in both total patients (R2 = 0.51, P < 0.001) and non-severe disc herniation patients (R2 = 0.73, P < 0.001) in multivariate regression models. Compression ratio of spinal cord exhibited the strongest correlation with JOA scores (r = - 0.567, P < 0.001). Cervical focal angles on MRI exhibited a stronger negative correlation with JOA scores (r = - 0.429, P < 0.001) than did angles on the other three postures on radiographs. Dramatic differences in JOA scores could be found in patients with non-severe cervical disc herniation, when a subgroup analysis was performed between cervical lordosis group and more than 4° kyphosis group (14.2 ± 1.7 vs. 11.1 ± 1.7, P < 0.001). CONCLUSION: Cervical focal kyphosis associates with severe myelopathy symptoms in patients with CSM, especially without severe disc herniation. This association may indicate an optimal cervical focal angle in surgical plan. It appeared feasible to assess both the cervical focal angles and spinal cord compression on supine MRI.

Postoperative changes in spinal cord signal intensity in patients with spinal cord injury without major bone injury: comparison between preoperative and postoperative magnetic resonance images.

OBJECTIVE: Although increased signal intensity (ISI) on MRI is observed in patients with cervical spinal cord injury (SCI) without major bone injury, alterations in ISI have not been evaluated. The association between postoperative ISI and surgical outcomes remains unclear. This study elucidated whether or not the postoperative classification and alterations in MRI-based ISI of the spinal cord reflected the postoperative symptom severity and surgical outcomes in patients with SCI without major bone injury. METHODS: One hundred consecutive patients with SCI without major bone injury (79 male and 21 female) with a mean age of 55 years (range 20-87 years) were included. All patients were treated with laminoplasty and underwent MRI pre- and postoperatively (mean 12.5 ± 0.8 months). ISI was classified into three groups on the basis of sagittal T2-weighted MRI: grade 0, none; grade 1, light (obscure); and grade 2, intense (bright). The neurological statuses were evaluated according to the Japanese Orthopaedic Association (JOA) scoring system and the American Spinal Injury Association Impairment Scale (AIS). RESULTS: Preoperatively, 8 patients had grade 0 ISI, 49 had grade 1, and 43 had grade 2; and postoperatively, 20 patients had grade 0, 24 had grade 1, and 56 had grade 2. The postoperative JOA scores and recovery rate (RR) decreased significantly with increasing postoperative ISI grade. The postoperative ISI grade tended to increase with the postoperative AIS grade. Postoperative grade 2 ISI was observed in severely paralyzed patients. The postoperative ISI grade improved in 23 patients (23%), worsened in 25 (25%), and remained unchanged in 52 (52%). Patients with an improved ISI grade had a better RR than those with a worsened ISI grade. CONCLUSIONS: Postoperative ISI reflected postoperative symptom severity and surgical outcomes. Alterations in ISI were seen postoperatively in 48 patients (48%) and were associated with surgical outcomes.

Outcome and predictive factors in rapid progressive cervical spondylotic myelopathy: A retrospective case-control study.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a major cause of cervical spinal cord dysfunction in people over 55 years of age. Most patients with CSM usually present with chronic and phased compression, however, some patients with CSM develop rapid severe neurological dysfunction without any trauma. To our knowledge, markers that can be used for early identification of patients with potential to develop rapid neurological deterioration have not been totally identified. Here, we evaluate epidemiological, clinical and radiographic features associated with the development and prognosis of rapid progressive cervical spondylotic myelopathy (rp-CSM). METHODS: A retrospective study was carried out for 175 patients diagnosed with CSM between March 2011 and January 2017 at West China Hospital. Patients were divided into rp-CSM group and chronic CSM (c-CSM) group based on the time taken for neurological deterioration to occur and the severity of preoperative neurological dysfunction. The clinical outcomes were assessed using the Modified Japanese Orthopaedic Association (mJOA) score, and imaging parameters such as Torg-Pavlov Ratio (TPR), intervertebral disc level compression ratio and increased signal intensity (ISI) on T2W1. Multivariate analysis was used to compare the outcomes between the two groups and identify potential predictors for rapid neurological dysfunction in CSM patients. RESULTS: Out of the 175 patients enrolled in the study, 25 developed rp-CSM (18 males; median age 59.04 ± 12.81 years) and the remaining 75 (54 males; median age 56.88 ± 12.31 years) were used as controls for the study (c-CSM group). The average time taken to develop severe neurological deterioration was 0.8 month in rp-CSM group and 24 month in c-CSM group (p = 0.001), while the preoperative mJOA scores were 6 in rp-CSM patients and 12 in c-CSM patients (p = 0.014). In addition, rp-CSM patients demonstrated worse outcomes than the controls in one year after surgery (mJOA improvement rate 54.5 % and 80 %, respectively, p = 0.021). There were no differences in the clinical parameters evaluated between the two groups except for the history of diabetes and smoking. Analysis of radiographic parameters indicated that TPR MRI, intervertebral disc level compression ratio and increased signal intensity (ISI) on T2W1 were poor in rp-CSM patients compared to c-CSM patients. Regression analysis also showed that the history of diabetes, TPR MRI < 0.4, compression ratio ≥50 %, and the sagittal diameter of ISI ≥ 50 % of spinal canal diameter on T2W1 were strongly associated with the rapid progressive neurological dysfunction in patients with CSM. CONCLUSION: The prognosis of rapid progressive CSM is worse than that of common chronic CSM. The rapid neurological deterioration can be identified by TPR MRI (<0.4), compression ratio (≥50 %), sagittal diameter of ISI (≥50 % of spinal canal diameter). Besides, a history of diabetes is a risk factor for the development of rp-CSM.

Does three-grade classification of T2-weighted increased signal intensity reflect the severity of myelopathy and surgical outcomes in patients with cervical compressive myelopathy? A systematic review and meta-analysis.

The three-grade classification of increased signal intensity (ISI) on T2-weighted magnetic resonance imaging (MRI) is used extensively in patients with cervical compressive myelopathy (CCM). However, the efficacy and value in the prediction of this classification are still unclear and no systematic review and meta-analysis have been conducted on this topic. The objective of this study is to investigate the efficacy and value in prediction of the three-grade classification of ISI on the severity of myelopathy and surgical outcomes. Randomized or non-randomized controlled studies using three-grade classification of ISI (grade 0, none; grade 1, light or obscure; and grade 2, intense or bright) in patients with CCM were sought in the following databases: PubMed, Embase, and Cochrane Library. The pooled Japanese Orthopedic Association (JOA)/modified JOA (mJOA) score, neuro-functional recovery rate, C2-C7 lordotic angle, and range of motion (ROM) were calculated. A total of 8 studies containing 1101 patients were included in this review. Patients in grade 0 had the highest preoperative and postoperative JOA/mJOA score and recovery rate, while those parameters for patients in grade 2 were the lowest. Nevertheless, no statistically significant difference was found regarding the preoperative C2-C7 lordotic angle and ROM among three grades. Our meta-analysis suggests that the three-grade classification of ISI on T2-weighted MRI can reflect the severity of myelopathy and surgical outcomes in patients with CCM. The higher ISI grade indicates more severe myelopathy and surgical outcomes. Overall, the three-grade classification of ISI is instructive and should be used universally.

Value of quantitative MRI T2WI parameters in predicting surgical outcome of thoracic ossification of the ligamentum flavum / 中国组织工程研究

BACKGROUND: MRI has high sensitivity to thoracic myelopathy, which can assess the spinal cord injury by morphology and magnitude of cervical spinal cord compression. Additionally, it is a valuable tool for the prognosis evaluation of thoracic spinal stenosis. OBJECTIVE: To explore the value of quantitative MRI T2WI parameters in predicting surgical outcome of thoracic ossification of the ligamentum flavum, and to establish the prediction model of poor prognosis, so as to provide reference for prognosis evaluation. METHODS: From January 2010 to January 2019 at Cangzhou Central Hospital, clinical and imaging data of 87 cases of thoracic ossification of the ligamentum flavum treated by thoracic laminectomy were reviewed retrospectively. According to the JOA recovery rate at 6-month follow-up, the patients were divided into good recovery group (≥ 50%) and poor recovery group (< 50%). Age, sex, duration of disease, JOA score, Sato type of ossification, maximum spinal cord compression, cross-sectional area, distribution of hyperintense signal, signal intensity ratio, intramedullary signal size, local kyphosis, kyphosis correction, number of decompressed levels and incidence of cerebrospinal fluid were compared between two groups. Univariate analysis was used to analyze indicators with significant differences. Receiver operating characteristic curve was plotted to analyze prognosis. Areas under the curve and cut-off values were recorded. The independent predictors of poor recovery were estimated through multivariate logistic regression analysis and the prediction model was established. RESULTS AND CONCLUSION: (1) The duration of disease, JOA score, maximum spinal cord compression, cross-sectional area, signal intensity ratio and intramedullary signal size showed significant difference between good recovery and poor recovery groups (P < 0.05). (2) Receiver operating characteristic curve analysis showed that the area under the curve of the duration of disease, JOA score, maximum spinal cord compression, cross-sectional area, signal intensity ratio and intramedullary signal size was 0.670, 0.733, 0.647, 0.715, 0.753 and 0.765 respectively. The cut-off value was duration of 13 months, score 4, 29.8%, 0.25 cm2, 1.593 and 13.64 mm respectively. The duration of disease and maximum spinal cord compression had low discrimination power (the area under the curve < 0.7) in predicting poor recovery, whereas the JOA score, cross-sectional area, signal intensity ratio and intramedullary signal size had moderate discrimination power (the area under the curve 0.7-0.9). The area under the curve indicates good ability of signal intensity ratio and intramedullary signal size in combination (the area under the curve=0.791). (3) Logistic multivariate regression analysis showed that JOA score, cross-sectional area and combination of signal intensity ratio and intramedullary signal size were independent risk factors of poor recovery. A predicting model was built according to the result of the logistic regression analysis. It was shown that the area under the curve of this model was 0.890, which was significantly higher than that of the JOA score, cross-sectional area and combination of signal intensity ratio and intramedullary signal size (P < 0.05). (4) Combination of signal intensity ratio and intramedullary signal size had higher predictive ability than other MRI parameters. JOA score, together with quantitative MRI T2WI parameters may have a better predictive value for the risk of poor recovery in patients with thoracic ossification of the ligamentum flavum.

Comparison between quantitative measurements of diffusion tensor imaging and T2 signal intensity in a large series of cervical spondylotic myelopathy patients for assessment of disease severity and prognostication of recovery.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction. Recently, it has been shown that diffusion tensor imaging (DTI) may be a better biomarker than T2-weighted signal intensity (T2SI) on MRI for CSM. However, there is very little literature on a comparison between the quantitative measurements of DTI and T2SI in the CSM patient population to determine disease severity and recovery. METHODS: A prospective analysis of 46 patients with both preoperative DTI and T2-weighted MRI was undertaken. Normalized T2SI (NT2SI), regardless of the presence or absence of T2SI at the level of maximum compression (LMC), was determined by calculating the T2SI at the LMC/T2SI at the level of the foramen magnum. Regression analysis was performed to determine the relationship of fractional anisotropy (FA), a quantitative measure derived from DTI, and NT2SI individually as well their combination with baseline preoperative modified Japanese Orthopaedic Association (mJOA) score and ∆mJOA score at the 3-, 6-, 12-, and 24-month follow-ups. Goodness-of-fit analysis was done using residual diagnostics. In addition, mixed-effects regression analysis was used to evaluate the impact of FA and NT2SI individually. A p value < 0.05 was selected to indicate statistical significance. RESULTS: Regression analysis showed a significant positive correlation between FA at the LMC and preoperative mJOA score (p = 0.041) but a significant negative correlation between FA at the LMC and the ΔmJOA score at the 12-month follow-up (p = 0.010). All other relationships between FA at the LMC and the baseline preoperative mJOA score or ∆mJOA score at the 3-, 6-, and 24-month follow-ups were not statistically significant. For NT2SI and the combination of FA and NT2SI, no significant relationships with preoperative mJOA score or ∆mJOA at 3, 6, and 24 months were seen on regression analysis. However, there was a significant correlation of combined FA and NT2SI with ∆mJOA score at the 12-month follow-up. Mixed-effects regression revealed that FA measured at the LMC was the only significant predictor of ΔmJOA score (p = 0.03), whereas NT2SI and time were not. Goodness-of-fit analysis did not show any evidence of lack of fit. CONCLUSIONS: In this large prospective study of CSM patients, FA at LMC appears to be a better biomarker for determining long-term outcomes following surgery in CSM patients than NT2SI or the combination values at LMC.

Comparison of Three Anterior Techniques in the Surgical Treatment of Three-Level Cervical Spondylotic Myelopathy with Intramedullary T2-Weighted Increased Signal Intensity.

OBJECTIVE: To compare the clinical and radiologic outcomes of 3 anterior surgical techniques for the treatment of 3-level cervical spondylotic myelopathy (CSM) and the evolution of intramedullary T2-weighted increased signal intensity (ISI). METHODS: A total of 98 consecutive patients (61 males, 37 females) with 3-level CSM who underwent anterior cervical surgery between January 2006 and January 2016 were retrospectively enrolled. Based on different anterior reconstructive techniques, the patients were divided into 3 groups: anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and hybrid decompression and fusion (HDF) groups. The Japanese Orthopaedic Association score and its recovery rate were used to evaluate the clinical outcomes. The cervical alignment and range of motion were used to assess radiologic outcomes. In addition, the signal change ratio and length of ISI were used to measure the ISI. RESULTS: No statistical differences in preoperative factors were found among the 3 groups (P > 0.05). Although the HDF group had intermediate surgery time and blood loss compared with other groups (P < 0.05), it achieved greater postoperative Japanese Orthopaedic Association score and recovery rate than other groups (P < 0.05). The postoperative C2-C7 lordotic angle and postoperative range of motion in the HDF group were similar to that in the ACDF group (P > 0.05), both greater than that in the ACCF group (P < 0.05). The incidence of complications in the HDF group was close to the ACDF group (P > 0.05), and both groups were lower than that in the ACCF group (P < 0.05). In addition, the postoperative signal change ratio in the HDF group was lower than in other groups (P < 0.05). The postoperative length of ISI in the HDF group was similar to the ACCF group (P > 0.05), which was both shorter than that in the ACDF group (P < 0.05). CONCLUSIONS: For patients with 3-level CSM with ISI on T2-weighted MRI, HDF can be considered as the optimal technique that achieves better clinical and radiologic outcomes than the ACDF or ACCF procedure. HDF also has a better postoperative regression of ISI compared with the ACDF or ACCF procedure, which may potentially be an important indicator for improving surgical outcomes.

The relationship between preoperative factors and the presence of intramedullary increased signal intensity on T2-weighted magnetic resonance imaging in patients with cervical spondylotic myelopathy.

OBJECTIVE: To investigate preoperative factors affecting the presence of intramedullary increased signal intensity (ISI) on T2-weighted magnetic resonance imaging (MRI) in patients with cervical spondylotic myelopathy (CSM) and the impact of ISI on clinical manifestations. PATIENTS AND METHODS: Eighty-nine patients with CSM were retrospectively reviewed from January 2013 to December 2016 in our hospital. Based on the presence or absence of ISI on axial and sagittal T2-weighted MRI, patients were divided into ISI group (48 cases) and non-ISI group (41 cases). Factors such as age, sex, body mass index (BMI), duration of symptoms, clinical symptoms and signs, number and distribution of spinal cord compression levels, preoperative Japanese Orthopedic Association (JOA) score, preoperative C2-C7 lordotic angle, preoperative C2-C7 range of motion (ROM), maximal canal compromise (MCC) and maximal spinal cord compression (MSCC) were initially compared using univariate analysis. Factors with significant result in univariate analysis were included in multivariate logistic regression analysis. Receiver operating characteristic (ROC) curve and the area under the curve (AUC) were applied to evaluate the reliability of multivariate logistic regression model. RESULTS: Univariate analysis showed that the number of spinal cord compression levels, preoperative JOA score, MCC and MSCC might be related to the presence of ISI (P < 0.05). Furthermore, multivariate logistic regression analysis revealed that the number of spinal cord compression levels (OR = 0.203, P < 0.05), preoperative JOA score (OR = 4.274, P < 0.05) and MSCC (OR = 0.250, P < 0.05) were independent preoperative risk factors associated with the presence of ISI, yielding an AUC of 0.9558. Patients with ISI showed a trend of increasing clinical symptoms and signs, and also exhibited statistically significantly increased frequencies of clumsy hands, lower limb spasticity, impairment of gait, broad-based, unstable gait, weakness and motor deficits (P < 0.05). CONCLUSION: Multilevel spinal cord compression, lower preoperative JOA score and greater MSCC are independent preoperative risk factors related to the presence of ISI on T2-weighted MRI in patients with CSM. Patients with ISI tend to have more clinical symptoms and signs, especially in lower limb manifestations and motor deficits.

MR T2 image classification in adult patients of cervical spinal cord injury without radiographic abnormality: A predictor of surgical outcome.

OBJECTIVES: Although patients with cervical spinal cord injury without radiographic abnormality (SCIWORA) present increased signal intensity (ISI) on magnetic resonance imaging (MRI), its degree has not been examined. This study evaluated the clinical effectiveness of MRI-based ISI in adult patients of SCIWORA. Its predictive value for symptom severity was also evaluated. PATIENTS AND METHODS: One-hundred consecutive SCIWORA patients who had undergone expansive laminoplasty were enrolled. Among them, 79 were male and 21 were female. The mean age was 55 years (range 20-87). All patients underwent MRI in the acute phase, and ISI was classified into three groups based on sagittal T2-weighted MRI: Grade 0, none; Grade 1, light (obscure); and Grade 2, intense (bright). The pre- and postoperative neurological status was evaluated using the Japanese Orthopaedic Association scoring system for cervical myelopathy (JOA score) and the ASIA impairment scale (AIS). RESULTS: Preoperative MRI showed Grade 0 in 8 patients, Grade 1 in 49 patients, and Grade 2 in 43 patients. There were no differences in age and gender among three groups. The pre- and postoperative JOA scores decreased significantly with an increasing ISI grade. The recovery rate of JOA score decreased with the ISI grade. The ISI grade tended to increase with the pre- and postoperative AIS grades. ISI Grade 2 on MRI was observed in severely paralyzed cases. CONCLUSIONS: MRI-based ISI classification is correlated with preoperative symptom severity in adult patients with SCIWORA and can be a predictor of surgical outcome.

Comparison of the Prognostic Value of Different Quantitative Measurements of Increased Signal Intensity on T2-Weighted MRI in Cervical Spondylotic Myelopathy.

OBJECTIVE: To investigate whether different quantitative measurements of increased signal intensity (ISI) on T2-weighted magnetic resonance imaging are useful for predicting surgical outcome in patients with cervical spondylotic myelopathy (CSM). METHODS: We retrospectively reviewed 108 patients with ISI who underwent surgery for CSM. Clinical outcome was evaluated via the Japanese Orthopaedic Association (JOA) score and the recovery rate. Patients were divided into 2 groups based on the JOA recovery rate: good (≥50%) and fair (<50%). The quantitative measurements of ISI included the maximum vertical length and the signal change ratio (SCR). C2-C7 sagittal alignment, C2-C7 sagittal vertical axis, C2-C7 range of motion, maximum spinal cord compression, and maximum canal compromise also were assessed. RESULTS: There were no significant differences in cervical sagittal alignment parameters between the groups. Multivariate analysis showed that a longer duration of symptoms, a lower preoperative JOA score, a longer preoperative ISI length, and a greater preoperative SCR were negatively associated with clinical outcomes. Receiver operating characteristic curve analysis showed that the best cutoff values of ISI length and SCR as negative predictors of surgical outcome were 15.50 mm and 1.56, respectively, and the areas under the receiver operating characteristic curve of preoperative ISI length, SCR that discriminate recovery rate of JOA score (≥50%, <50%) were 0.8507, 0.8422, respectively, and was 0.8903 for a combination of the 2. CONCLUSIONS: Duration of symptoms, preoperative JOA score, preoperative ISI length, and SCR can reflect surgical outcome in patients with CSM; however, cervical sagittal alignment may not affect surgical outcome. Combining ISI length and SCR to depict ISI on T2-weighted magnetic resonance imaging is optimal and accurate. Patients with ISI length >15.50 mm and SCR >1.56 have fair surgical recovery.

Clinical and Radiologic Results of Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy in Elderly Patients with T2-Weighted Increased Signal Intensity.

OBJECTIVE: To investigate clinical and radiologic results of anterior cervical discectomy and fusion for cervical spondylotic myelopathy in elderly patients with T2-weighted increased signal intensity (ISI), focusing specifically on the quantitative analysis of ISI. METHODS: We retrospectively reviewed 88 patients with cervical spondylotic myelopathy with ISI who underwent anterior cervical discectomy and fusion with a minimum 1-year follow-up. Patients were divided into 2 groups: patients older than 65 (elderly group, 36 patients) or younger (young group, 52 patients). The Japanese Orthopaedic Association (JOA) score was used to evaluate the neurologic status. The signal change ratio (SCR) was defined as the grayscale of ISI region divided by that at C7-T1 disc level. The C2-C7 sagittal alignment, range of motion, SCR, and ISI length were measured. RESULTS: There was no statistically significant difference between the 2 groups in C2-C7 sagittal alignment and range of motion. However, the JOA score at 1-year follow-up and recovery rate in elderly group were significantly lower than in young group (P < 0.001). SCR and ISI length were significantly greater in elderly group than in young group, whereas their changes were significantly lower in elderly group (P < 0.05). Multivariate logistic regression analysis showed that an older age, a lower preoperative JOA score, a greater preoperative SCR, and a longer preoperative ISI length at 1-year follow-up were negatively correlated with the clinical outcomes in the elderly group (P < 0.05). CONCLUSIONS: Compared with young patients with ISI, the elderly patients had a lower preoperative JOA score, a greater preoperative SCR, and a longer preoperative ISI length, indicating poor surgical outcomes.

Sensitivity of Pyramidal Signs in Patients with Cervical Spondylotic Myelopathy.

STUDY DESIGN: This was a retrospective study. PURPOSE: The 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 LITERATURE: Cervical 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. METHODS: Forty-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. RESULTS: The 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. CONCLUSIONS: In 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.

Sensitivity of Pyramidal Signs in Patients with Cervical Spondylotic Myelopathy

STUDY DESIGN: This was a retrospective study. PURPOSE: The 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 LITERATURE: Cervical 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. METHODS: Forty-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. RESULTS: The 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. CONCLUSIONS: In 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.