Outcomes of Surgical Decompression in Patients With Very Severe Degenerative Cervical Myelopathy.
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ABSTRACT:
SUBMITTER: Kopjar B
PROVIDER: S-EPMC6066419 | biostudies-literature | 2018 Aug
REPOSITORIES: biostudies-literature
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Project description:Background: Degenerative cervical myelopathy (DCM), also known as cervical spondylotic myelopathy is the leading cause of spinal cord compression in adults. The mainstay of treatment is surgical decompression, which leads to partial recovery of symptoms, however, long term prognosis of the condition remains poor. Despite advances in treatment methods, the underlying pathobiology is not well-known. A better understanding of the disease is therefore required for the development of treatments to improve outcomes following surgery. Objective: To systematically evaluate the pathophysiology of DCM and the mechanism underlying recovery following decompression. Methods: A total of 13,808 published articles were identified in our systematic search of electronic databases (PUBMED, WEB OF SCIENCE). A total of 51 studies investigating the secondary injury mechanisms of DCM or physiology of recovery in animal models of disease underwent comprehensive review. Results: Forty-seven studies addressed the pathophysiology of DCM. Majority of the studies demonstrated evidence of neuronal loss following spinal cord compression. A number of studies provided further details of structural changes in neurons such as myelin damage and axon degeneration. The mechanisms of injury to cells included direct apoptosis and increased inflammation. Only four papers investigated the pathobiological changes that occur in spinal cords following decompression. One study demonstrated evidence of axonal plasticity following decompressive surgery. Another study demonstrated ischaemic-reperfusion injury following decompression, however this phenomenon was worse when decompression was delayed. Conclusions: In preclinical studies, the pathophysiology of DCM has been poorly studied and a number of questions remain unanswered. The physiological changes seen in the decompressed spinal cord has not been widely investigated and it is paramount that researchers investigate the decompressed spinal cord further to enable the development of therapeutic tools, to enhance recovery following surgery.
| S-EPMC7203415 | biostudies-literature
Project description:Previous studies aimed at identifying predictors of clinical outcomes following surgical decompression for degenerative cervical myelopathy (DCM) are limited by multicollinearity among predictors, whereby the high degree of correlation between covariates precludes detection of potentially significant findings. We apply partial least squares (PLS), a data-driven approach, to model multi-dimensional variance and dissociate patient phenotypes associated with functional, disability, and quality of life (QOL) outcomes in DCM. This was a post-hoc analysis of DCM patients enrolled in the prospective, multi-center AOSpine CSM-NA/CSM-I studies. Baseline clinical covariates evaluated as predictors included demographic (e.g., age, sex), clinical presentation (e.g., signs and symptoms), and treatment (e.g., surgical approach) characteristics. Outcomes evaluated included change in functional status (∆mJOA), disability (∆NDI), and QOL (∆SF-36) at 2 years. PLS was used to derive latent variables (LVs) relating specific clinical covariates with specific outcomes. Statistical significance was estimated using bootstrapping. Four hundred and seventy-eight patients met eligibility criteria. PLS identified 3 significant LVs. LV1 indicated an association between presentation with hand muscle atrophy, treatment by an approach other than laminectomy alone, and greater improvement in physical health-related QOL outcomes (e.g., SF-36 Physical Component Summary). LV2 suggested the presence of comorbidities (respiratory, rheumatologic, psychological) was associated with lesser improvements in functional status post-operatively (i.e., mJOA score). Finally, LV3 reflected an association between more severe myelopathy presenting with gait impairment and poorer mental health-related QOL outcomes (e.g., SF-36 Mental Component Summary). Using PLS, this analysis uncovered several novel insights pertaining to patients undergoing surgical decompression for DCM that warrant further investigation: (1) comorbid status and frailty heavily impact functional outcome; (2) presentation with hand muscle atrophy is associated with better physical QOL outcomes; and (3) more severe myelopathy with gait impairment is associated with poorer mental QOL outcomes.
| S-EPMC7527550 | biostudies-literature
Project description:(1) Background: Cervical vertigo (CV) represents a controversial entity, with a prevalence ranging from reported high frequency to negation of CV existence. (2) Objectives: To assess the prevalence and cause of vertigo in patients with a manifest form of severe cervical spondylosis-degenerative cervical myelopathy (DCM) with special focus on CV. (3) Methods: The study included 38 DCM patients. The presence and character of vertigo were explored with a dedicated questionnaire. The cervical torsion test was used to verify the role of neck proprioceptors, and ultrasound examinations of vertebral arteries to assess the role of arteriosclerotic stenotic changes as hypothetical mechanisms of CV. All patients with vertigo underwent a detailed diagnostic work-up to investigate the cause of vertigo. (4) Results: Symptoms of vertigo were described by 18 patients (47%). Causes of vertigo included: orthostatic dizziness in eight (22%), hypertension in five (14%), benign paroxysmal positional vertigo in four (11%) and psychogenic dizziness in one patient (3%). No patient responded positively to the cervical torsion test or showed significant stenosis of vertebral arteries. (5) Conclusions: Despite the high prevalence of vertigo in patients with DCM, the aetiology in all cases could be attributed to causes outside cervical spine and related nerve structures, thus confirming the assumption that CV is over-diagnosed.
| S-EPMC8201049 | biostudies-literature
Project description:Cervical spondylotic myelopathy is a common clinical problem. No study has examined the pattern of neurological recovery after surgical decompression. We conducted a prospective study on the pattern of neurological recovery after surgical decompression in patients with cervical spondylotic myelopathy. Patients suffering from cervical spondylotic myelopathy and requiring surgical decompression from January 1995 to December 2000 were prospectively included. Upper limbs, lower limbs and sphincter functions were assessed using the Japanese Orthopaedic Association (JOA) score. Assessment was done before the operation, at 1 week, 2 weeks, 1 month, 3 months, 6 months, 1 year and then yearly after surgery. Results were analysed with the t-test. Differences with P-values less than 0.05 were regarded as statistically significant. Fifty-five patients were included. The average follow-up period was 53 months. Thirty-nine patients (71%) had neurological improvement after the operation with a mean recovery rate of 55%. The JOA score improved after surgery, reaching statistical significance at 3 months and a plateau at 6 months. Thirty-six patients (65%) had improvement of upper limb function. Twenty-four patients (44%) had improvement of lower limb function. Eleven patients (20%) had improvement of sphincter function. The recovery rate of upper limb function was 37%, of lower limb function was 23% and of sphincter function was 17%. Surgical decompression worked well in patients with cervical spondylotic myelopathy. Seventy-one percent of patients had neurological improvement after the operation. The neurological recovery reached a plateau at 6 months after the operation. The upper limb function had the best recovery, followed by lower limb and sphincter functions.
| S-EPMC2269013 | biostudies-other
Project description:INTRODUCTION:Degenerative cervical myelopathy (DCM) is a disabling spinal disorder characterised by sensorimotor deficits of upper and lower limbs, neurogenic bladder dysfunction and neuropathic pain. When suspected, cervical MRI helps to reveal spinal cord compression and rules out alternative diagnoses. However, the correlation between radiological findings and symptoms is weak. Cerebrospinal fluid pressure (CSFP) analysis may complement the appreciation of cord compression and be used for intraoperative and postoperative monitorings in patients undergoing surgical decompression. METHODS AND ANALYSIS:Twenty patients diagnosed with DCM undergoing surgical decompression will receive standardised lumbar CSFP monitoring immediately before, during and 24?hours after operation. Rest (ie, opening pressure, CSF pulsation) and stimulated (ie, Valsalva, Queckenstedt's) CSFP-findings in DCM will be compared with 20 controls and results from CSFP monitoring will be related to clinical and neurophysiological findings. Arterial blood pressure will be recorded perioperatively and postoperatively to calculate spinal cord perfusion pressure and spinal vascular reactivity index. Furthermore, measures of CSFP will be compared with markers of spinal cord compression by means of MR imaging. ETHICS AND DISSEMINATION:The study protocol conformed to the latest revision of the Declaration of Helsinki and was approved by the local Ethics Committee of the University Hospital of Zurich (KEK-ZH number PB-2016-00623). The main publications from this study will cover the CSFP fluid dynamics and pressure analysis preoperative, perioperative and postoperative correlated with imaging, clinical scores and neurophysiology. Other publications will deal with preoperative and postoperative spinal perfusion. Furthermore, we will disseminate an analysis on waveform morphology and the correlation with blood pressure and ECG. Parts of the data will be used for computational modelling of cervical stenosis. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov Registry (NCT02170155).
| S-EPMC7507854 | biostudies-literature
Project description:Few studies have investigated associations between hand grip strength (HGS) and the surgical outcomes of degenerative cervical myelopathy (DCM). This study was designed as a prospective observational study of 203 patients who had undergone fusion surgery for DCM. We divided the patients according to sex and HGS differences. Clinical outcome parameters, including HGS, a fall diary and four functional mobility tests (alternative step test, six-meter walk test, timed up and go test, and sit-to-stand test) were measured preoperatively, at 3 months and 1 year after surgery. Mean patient ages were 59.93 years in the male group and 67.33 years in the female group (p = 0.000; independent t-test). The mean HGS of both hands improved significantly at postoperative 3 months and 1 year in all patients (p = 0.000 for both; ANOVA). In male patients, preoperative risk of falls was negatively correlated with HGS (p = 0.000). In female patients, pre- and postoperative risk of falls were correlated negatively with HGS (p = 0.000). The postoperative incidence of falls decreased in both groups (p = 0.000) Conclusions: Postoperative HGS in patients with DCM is correlated with postoperative falls and functional outcome differently, when comparing male and female patients, for predicting favorable outcomes and neurologic deficit recovery after surgery in DCM patients.
| S-EPMC8125546 | biostudies-literature
Project description:Study Design Retrospective clinical study. Objective To investigate the age-related surgical outcomes of laminoplasty. Methods One hundred patients who underwent an en bloc laminoplasty for cervical spondylotic myelopathy from 2004 to 2008 and were followed for at least 1 year were included in this study. The clinical outcomes were assessed with the Japanese Orthopaedic Association (JOA) score. Acquired points (postoperative JOA score minus preoperative JOA score) were also calculated. To investigate the age-related effect for laminoplasty, two analyses were conducted: (1) the correlation between age and clinical outcome; and (2) the clinical outcomes by decade. Patients were divided into four groups according to their age at the time of operation as follows: group 50s, 50 to 59 years old; group 60s, 60 to 69 years; group 70s, 70 to 79 years; and group 80s, 80 to 89 years. The pre- and postoperative JOA scores, acquired points, preoperative comorbidities, and postoperative complications were then compared among the groups. Results Significant correlations were detected between age and JOA scores at the preoperative (p = 0.03), postoperative maximum (p < 0.0001), and final assessments (p < 0.0001). An age-related decline of JOA scores was observed over all periods. The analysis by decades showed the same results. On the other hand, the significant differences were not found for acquired points over all periods by either method. The preoperative comorbidities of hypertension and diabetes mellitus increased with age. Delirium was more common postoperatively in elderly patients. Conclusions Although an age-related decline of JOA scores was found over all periods, there were no severe sequelae and no differences in the acquired points that were age-related.
| S-EPMC4369199 | biostudies-other
Project description:Degenerative cervical myelopathy (DCM) is the most common cause of nontraumatic spinal cord injury in adults worldwide. Surgical decompression is generally effective in improving neurological outcomes and halting progression of myelopathic deterioration. However, a subset of patients experience suboptimal neurological outcomes. Given the emerging evidence that apolipoprotein E4 (ApoE4) allelic status influences neurodegenerative conditions, we examined whether the presence of the ApoE4 allele may account for the clinical heterogeneity of treatment outcomes in patients with DCM. Our results demonstrate that human ApoE4+ DCM patients have a significantly lower extent of improvement after decompression surgery. Functional analysis of our DCM mouse model in targeted-replacement mice expressing human ApoE4 revealed delayed gait recovery, forelimb grip strength, and hind limb mechanical sensitivity after decompression surgery, compared with their ApoE3 counterparts. This was accompanied by an exacerbated proinflammatory response resulting in higher concentrations of TNF-α, IL-6, CCL3, and CXCL9. At the site of injury, there was a significant decrease in gray matter area, an increase in the activation of microglia/macrophages, and increased astrogliosis after decompression surgery in the ApoE4 mice. Our study is the first to our knowledge to investigate the pathophysiological underpinnings of ApoE4 in DCM, which suggests a possible personalized medicine approach for the treatment of DCM in ApoE4 carriers.
| S-EPMC8410082 | biostudies-literature
Project description:Cervical spondylotic myelopathy (CSM) is the most common spinal cord disorder and a major cause of disability in adults. Improvements following surgical decompression are limited and patients often remain severely disabled. Post mortem studies indicate that CSM is associated with profound axonal loss. However, our understanding of the pathophysiology of CSM remains limited.To investigate the hypothesis that axonal plasticity plays a role in the recovery following surgical decompression, we adopted a novel preclinical model of mild to moderate CSM. Spinal cord compression resulted in significant locomotor deterioration, increased expression of the axonal injury marker APP, and loss of serotonergic fibres. Surgical decompression partially reversed the deficits and attenuated APP expression. Decompression was also associated with axonal sprouting, reflected in the restoration of serotonergic fibres and an increase of GAP43 expression. The re-expression of synaptophysin indicated the restoration of functional synapses following decompression. Promoting axonal plasticity may therefore be a therapeutic strategy for promoting neurological recovery in CSM.
| S-EPMC4994254 | biostudies-literature
Project description:Study Design Commentary. Objective This commentary aims to discuss the practical applications of a clinical prediction rule (CPR) developed to predict functional status in patients undergoing surgery for the treatment of degenerative cervical myelopathy. Methods Clinical cases from the AOSpine CSM-North America study were used to illustrate the application of a prediction rule in a surgical setting and to highlight how this CPR can be used to ultimately enhance patient care. Results A CPR combines signs and symptoms, patient characteristics, and other predictive factors to estimate disease probability, treatment prognosis, or risk of complications. These tools can influence allocation of health care resources, inform clinical decision making, and guide the design of future research studies. In a surgical setting, CPRs can be used to (1) manage patients' expectations of outcome and, in turn, improve overall satisfaction; (2) facilitate shared decision making between patient and physician; (3) identify strategies to optimize surgical results; and (4) reduce heterogeneity of care and align surgeons' perceptions of outcome with objective evidence. Conclusions Valid and clinically-relevant CPRs have tremendous value in a surgical setting.
| S-EPMC4671907 | biostudies-other