Degenerative Cervical Myelopathy: How to Identify the Best Responders to Surgery?

Abstract

Surgery is the only definitive treatment for degenerative cervical myelopathy (DCM), however, the degree of neurological recovery is often unpredictable. Here, we assess the utility of a multidimensional diagnostic approach, consisting of clinical, neurophysiological, and radiological parameters, to identify patients likely to benefit most from surgery. Thirty-six consecutive patients were prospectively analyzed using the modified Japanese Orthopedic Association (mJOA) score, MEPs/SSEPs and advance and conventional MRI parameters, at baseline, and 3- and 12-month postoperatively. Patients were subdivided into “normal” and “best” responders (<50%, ≥50% improvement in mJOA), and correlation between Diffusion Tensor Imaging (DTI) parameters, mJOA, and MEP/SSEP latencies were examined. Twenty patients were “best” responders and 16 were “normal responders”, but there were no statistical differences in age, T2 hyperintensity, and midsagittal diameter between them. There was a significant inverse correlation between the MEPs central conduction time and mJOA in the preoperative period (p = 0.0004), and a positive correlation between fractional anisotropy (FA) and mJOA during all the phases of the study, and statistically significant at 1-year (r = 0.66, p = 0.0005). FA was significantly higher amongst “best responders” compared to “normal responders” preoperatively and at 1-year (p = 0.02 and p = 0.009). A preoperative FA > 0.55 was predictor of a better postoperative outcome. Overall, these results support the concept of a multidisciplinary approach in the assessment and management of DCM.

The Functional Relevance of Diffusion Tensor Imaging in Patients with Degenerative Cervical Myelopathy

“…The patients with severe DCM, who presented a higher FA value at the compressed level, were most likely to achieve a better functional recovery after decompression surgery [37]. This might identify FA as a potential positive predicting factor of postoperative outcomes: Therefore, DTI could be considered not only a complementary diagnostic analysis, but rather a crucial tool in order to identify the best candidates to surgery [38].…”

Degenerative Cervical Myelopathy: Review of Surgical Outcome Predictors and Need for Multimodal Approach

“…The length of T2WI hyperintensity and the presence of T1 hypointensity have been related with worse baseline neurological severity and the presence of clinical signs and symptoms (18). There is also evidence that both T2WI hyperintensity length and T1 hypointensity are predictive of surgical outcome, while the presence or absence of T2 hyperintensity does not seem to discriminate between those that do well versus those that do not (18,21,22,53). This is partially due to its high prevalence.…”

“…It has also been shown that microstructural changes can be used to evaluate progression of the disease, and outcome (7,26,27). Recent studies suggested that patients with an FAvalue >0.55 represent the best responders to surgery at 1-year (27,53). Additional advanced MRI techniques such as magnetization transfer, T2* and spectroscopy as well as others, are also promising techniques that remain the subject of ongoing investigations (28).…”

“…Tessitore et al first proposed an approach based on a synthesis of all these three findings (20,53). In their experience, FA in "best responders" were significantly higher than those of the "normal responders", both preoperatively and 1-year follow-up.…”

Degenerative Cervical Myelopathy and the Aging Spine: Introduction to the Special Issue

“…The editors of the issue contributed to this introductory review and decided to limit each of the past, present, and future sections to three themes in an effort to stay focused on the most important topics. The remaining 11 articles included 9 research papers and 2 systematic reviews focusing on different aspects, ranging from genetic factors [ 6 ] to clinical assessments [ 7 , 8 ], imaging [ 9 , 10 ], sagittal balance [ 11 ], surgical treatment [ 12 ], and outcome prediction [ 13 , 14 , 15 , 16 ] ( Table 1 ). These articles represented contributions from a diverse group of researchers coming from multiple countries, including Switzerland, Germany, Italy, United Kingdom, United States, South Korea, and Canada.…”