ObjectivesDegenerative cervical myelopathy (DCM) involves extrinsic spinal cord compression causing tissue injury and neurological dysfunction. Asymptomatic spinal cord compression (ASCC) is more common, but its significance is poorly defined. This study investigates if: (1) ASCC can be automatically diagnosed using spinal cord shape analysis; (2) multiparametric quantitative MRI can detect similar spinal cord tissue injury as previously observed in DCM.DesignProspective observational longitudinal cohort study.SettingSingle centre, tertiary care and research institution.Participants40 neurologically intact subjects (19 female, 21 male) divided into groups with and without ASCC.InterventionsNone.Outcome measuresClinical assessments: modified Japanese Orthopaedic Association score and physical examination. 3T MRI assessments: automated morphometric analysis compared with consensus ratings of spinal cord compression, and measures of tissue injury: cross-sectional area, diffusion fractional anisotropy, magnetisation transfer ratio and T2*-weighted imaging white to grey matter signal intensity ratio (T2*WI WM/GM) extracted from rostral (C1–3), caudal (C6–7) and maximally compressed levels.ResultsASCC was present in 20/40 subjects. Diagnosis with automated shape analysis showed area under the curve >97%. Five MRI metrics showed differences suggestive of tissue injury in ASCC compared with uncompressed subjects (p<0.05), while a composite of all 10 measures (average of z scores) showed highly significant differences (p=0.002). At follow-up (median 21 months), two ASCC subjects developed DCM.ConclusionsASCC appears to be common and can be accurately and objectively diagnosed with automated morphometric analysis. Quantitative MRI appears to detect subclinical tissue injury in ASCC prior to the onset of neurological symptoms and signs. These findings require further validation, but offer the intriguing possibility of presymptomatic diagnosis and treatment of DCM and other spinal pathologies.

BackgroundIn general, older patients with degenerative cervical myelopathy (DCM) are felt to have lower recovery potential following surgery due to increased degenerative pathology, comorbidities, reduced physiological reserves and age-related changes to the spinal cord. This study aims to determine whether age truly is an independent predictor of surgical outcome and to provide evidence to guide practice and decisionmaking. Methods A total of 479 patients with DCM were prospectively enrolled in the CSM-International study at 16 centres. Our sample was divided into a younger group (<65 years) and an elderly (≥65 years) group. A mixed model analytic approach was used to evaluate differences in the modified Japanese Orthopaedic Association (mJOA), Nurick, Short Form-36 (SF-36) and Neck Disability Index (NDI) scores between groups. We first created an unadjusted model between age and surgical outcome and then developed two adjusted models that accounted for variations in (1) baseline characteristics and (2) both baseline and surgical factors. Results Of the 479 patients, 360 (75.16%) were <65 years and 119 (24.84%) were ≥65 years. Elderly patients had a worse preoperative health status ( p<0.0001) and were functionally more severe ( p<0.0001). The majority of younger patients (64.96%) underwent anterior surgery, whereas the preferred approach in the elderly group was posterior (58.62%, p<0.0001). Elderly patients had a greater number of decompressed levels than younger patients ( p<0.0001). At 24 months after surgery, younger patients achieved a higher postoperative mJOA ( p<0.0001) and a lower Nurick score ( p<0.0001) than elderly patients. After adjustments for patient and surgical characteristics, these differences in postoperative outcome scores decreased but remained significant. Conclusions Older age is an independent predictor of functional status in patients with DCM. However, patients over 65 with DCM still achieve functionally significant improvement after surgical decompression.

Design: Systematic review. Objective: To conduct a systematic review to (1) summarize various classification systems used to describe cervical ossification of the posterior longitudinal ligament (OPLL) and (2) evaluate the diagnostic accuracy of various imaging modalities and the reliability of these classification systems.Methods: A search was performed to identify studies that used a classification system to categorize patients with OPLL. Furthermore, studies were included if they reported the diagnostic accuracy of various imaging modalities or the reliability of a classification system.Results: A total of 167 studies were deemed relevant. Five classification systems were developed based on X-ray: the 9-classification system (0.60%); continuous, segmental, mixed, localized or focal, circumscribed and others (92.81%); hook, staple, bridge, and total types (2.40%); distribution of OPLL (2.40%); and K-line classification (4.19%). Six methods were based on computed tomography scans: free-type, contiguous-type, and broken sign (0.60%); hill-, plateau-, square-, mushroom-, irregular-, or round-shaped (5.99%); rectangular, oval, triangular, or pedunculate (1.20%); centralized or laterally deviated (1.80%); plank-, spindle-, or rod-shaped (0.60%); and rule of nine (0.60%). Classification systems based on 3-dimensional computed tomography were bridging and nonbridging (1.20%) and flat, irregular, and localized (0.60%). A single classification system was based on magnetic resonance imaging: triangular, teardrop, or boomerang. Finally, a variation of methods was used to classify OPLL associated with the dura mater (4.19%).

BACKGROUND Preoperative duration of symptoms may significantly impact outcomes in patients treated surgically for degenerative cervical myelopathy (DCM). OBJECTIVE To (i) analyze whether duration of symptoms is associated with preoperative functional impairment, disability, and quality of life and (ii) determine the optimal timing for decompressive surgery. METHODS Patients with DCM were prospectively enrolled in either the AOSpine North American or International study at 26 global sites (n = 757). Postoperative functional impairment was evaluated at 1-yr using the modified Japanese Orthopaedic Association (mJOA) score. Change scores between baseline and 1-yr were computed for the mJOA. Duration of symptoms was dichotomized into a “short” and “long” group at several cut-offs. Analysis of covariance was used to evaluate differences in change scores on the mJOA between duration of symptoms groups in 4-mo increments. RESULTS Our cohort consisted of 424 men and 255 women, with a mean duration of symptoms of 26.1 ± 36.4 mo (0.25-252 mo). Duration of symptoms was not correlated with preoperative mJOA, Nurick, Neck Disability Index, or Short-Form (SF)-36 Physical and Mental Component Scores. Patients with a duration of symptoms shorter than 4 mo had significantly better functional outcomes on the mJOA than patients with a longer duration of symptoms (>4 mo). Thirty-two months was also a significant cut-off. CONCLUSION Patients who are operated on within 4 mo of symptom presentation have better mJOA outcomes than those treated after 4 mo. It is recommended that patients with DCM are diagnosed in a timely fashion and managed appropriately.

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Study Design Prospective study. Objective To evaluate the prevalence of Klippel-Feil syndrome (KFS) in a prospective data set of patients undergoing surgical treatment for cervical spondylotic myelopathy (CSM) and to evaluate if magnetic resonance imaging (MRI) features in patients with KFS are more pronounced than those of non-KFS patients with CSM. Methods A retrospective analysis of baseline MRI data from the AOSpine prospective and multicenter CSM-North American study was conducted. All the patients presented with at least one clinical sign of myelopathy and underwent decompression surgery. The MRIs and radiographs were reviewed by three investigators. The clinical and imaging findings were compared with patients without KFS but with CSM. Results Imaging analysis discovered 5 of 131 patients with CSM (∼3.82%) had single-level congenital fusion of the cervical spine. The site of fusion differed for all the patients. One patient underwent posterior surgery and four patients received anterior surgery. Postoperative follow-up was available for four of the five patients with KFS and indicated stable or improved functional status. All five patients demonstrated pathologic changes of adjacent segments and hyperintensity signal changes in the spinal cord on T2-weighted MRI. Multiple MRI features, most notably maximum canal compromise (p = 0.05) and T2 signal hyperintensity area (p = 0.05), were worse in patients with CSM and KFS. Conclusions The high prevalence of KFS in our surgical series of patients with CSM may serve as an indication that these patients are prone to increased biomechanical use of segments adjacent to fused vertebra. This supposition is supported by a tendency of patients with KFS to present with more extensive MRI evidence of degeneration than non-KFS patients with CSM.

Introduction Currently, the global population is experiencing a shift in its age structure. With this aging of the population, clinicians worldwide will be required to manage an increasing number of patients with degenerative cervical myelopathy (DCM). However, there is controversy whether surgical decompression is equally effective and safe in elderly patients as it is in younger patients. This study aims to determine whether age truly is an independent predictor of surgical outcome and to provide evidence to guide practice and decision-making. Material and Methods A total of 479 symptomatic DCM patients were prospectively enrolled in the CSM-International study at 16 centers. Our sample was divided into a younger (<65years) and elderly (≥65years) group. Each subject was neurologically examined at baseline and 24-months postoperatively and evaluated using a variety of functional outcome measures, including the Neck Disability Index (NDI), SF-36 physical component summary (PCS) and mental component summary (MCS), and the modified Japanese Orthopaedic Association scale (mJOA). A mixed model analytic approach was used to evaluate differences in these outcome measures between groups. We first created an unadjusted model between age and surgical outcome and then developed two adjusted models that accounted for variations in 1) baseline characteristics and 2) both baseline and surgical factors. Results Of the 479 patients, 360 (75.16%) were < 65 years and 119 (24.84%) were ≥65 years. There were no significant differences in gender (p = 0.82) or duration of symptoms (p = 0.82) between the two age groups. However, elderly patients had a significantly higher number of co-morbidities (p < 0.0001). In addition, elderly patients were functionally more impaired preoperatively based on the mJOA (p < 0.0001) and Nurick (p < 0.0001) scales and had a lower SF-36 PCS (p = 0.048). The majority of younger patients (64.96%) underwent anterior surgery, whereas the preferred approach in the elderly group was posterior (58.62%) (p < 0.0001). Elderly patients had a greater number of decompressed levels (4.14 ± 1.30) than younger patients (3.50 ± 1.23) (p < 0.0001). Three hundred and eight-nine patients (81.21%) attended their 24-month follow-up appointment. Younger patients achieved a higher postoperative mJOA (p < 0.0001) and a lower Nurick score (p < 0.0001) than elderly patients. SF-36 PCS scores were also significantly higher in the younger group (p = 0.033). There were no significant differences in postoperative NDI or SF-36 MCS between age groups. After adjustments for patient and surgical characteristics, these differences in postoperative outcome scores decreased but remained significant. On average, elderly patients had a significantly longer length of postoperative hospital stay (12.99 ± 13.56 days) than younger patients (9.53 ± 8.67 days) (p = 0.0086). There were no significant differences between the two age groups with respect to rates of perioperative complications (p = 0.47). Conclusion Older age is an independent ...