Imaging of Cervical Spine Trauma: Update of Techniques and Clinical Relevance.

Imaging of cervical spine trauma most commonly begins with computed tomography (CT) for initial osseous and basic soft tissue evaluation, followed by magnetic resonance imaging (MRI) for complementary evaluation of the neural structures (i.e., spinal cord, nerves) and soft tissues (i.e., ligaments). Although CT and conventional MRI sequences have been the mainstay of trauma imaging for decades, there have been significant advances in CT processing, imaging sequences and techniques made possible by hardware and software development, and artificial intelligence. These advancements may provide advantages in increasing sensitivity for detection of pathology as well as in decreasing imaging and interpretation time. Unquestionably, the most important role of imaging is to provide information to help direct patient care, including diagnosis, next steps in treatment plan, and prognosis. As such, there has been a growing body of research investigating the clinical relevance of imaging findings to clinical outcomes in the setting of spinal cord injury. This article will focus on these recent advances in imaging of cervical spinal trauma.

Artificial Intelligence-Generated Editorials in Radiology: Can Expert Editors Detect Them?

BACKGROUND AND PURPOSE: We aimed to evaluate GPT-4's ability to write radiology editorials and to compare these with human-written counterparts, thereby determining their real-world applicability for scientific writing. MATERIALS AND METHODS: Sixteen editorials from eight journals were included. To generate the AI-written editorials, the summary of 16 human-written editorials was fed into GPT-4. Six experienced editors reviewed the articles. First, an unpaired approach was used. The raters were asked to evaluate the content of each article using a 1-5 Likert scale across specified metrics. Then, they determined whether the editorials were written by humans or AI. The articles were then evaluated in pairs to determine which article was generated by AI and which should be published. Finally, the articles were analyzed with an AI detector and for plagiarism. RESULTS: The human-written articles had a median AI probability score of 2.0%, whereas the AI-written articles had 58%. The median similarity score among AI-written articles was 3%. 58% of unpaired articles were correctly classified regarding authorship. Rating accuracy was increased to 70% in the paired setting. AI-written articles received slightly higher scores in most metrics. When stratified by perception, human-written perceived articles were rated higher in most categories. In the paired setting, raters strongly preferred publishing the article they perceived as human-written (82%). CONCLUSIONS: GPT-4 can write high-quality articles that iThenticate does not flag as plagiarized, which may go undetected by editors, and that detection tools can detect to a limited extent. Editors showed a positive bias toward human-written articles. ABBREVIATIONS: AI = Artificial intelligence; LLM = large language model; SD = standard deviation.

Patient and Provider Characteristics Associated with Receipt of Image-guided Interventions for Low Back Pain.

BACKGROUND AND PURPOSE: Low back pain commonly causes disability, often managed with conservative image-guided interventions before surgery. Research has documented racial disparities with these and other non-pharmacologic treatments. We posited that individual chart reviews may provide insight into the disparity of care types through documented patient/provider discussions and their effect on treatment plans. MATERIALS AND METHODS: This retrospective analysis involved adults newly diagnosed with low back pain within a large Utah healthcare system. The primary outcome was the association of provider and patient variables with the frequency of image-guided interventions received within one year of low back pain diagnosis between White/non-Hispanic and underrepresented minority cohorts. Secondary outcomes were receipt of additional treatment types (physical therapy and lumbar surgery), time to any treatment, time to image-guided intervention, and discussion/receipt of therapy between cohorts within one year of diagnosis. RESULTS: Among 812 subjects (41% underrepresented minority and 59% White/non-Hispanic), more White/non-Hispanic patients had at least one image-guided intervention within 12 months compared to underrepresented minority patients (7.2% vs. 12.5%, p = .001), despite underrepresented minorities having higher presenting pain scores (64.5% vs. 49.3%; pain intensity > 5, p = .001). Underrepresented minority patients more often saw generalists (71.7% vs. 52.6%, p < .001) and advanced practice clinician providers (33.6% vs. 25.6%, p < .02) compared to the White/non-Hispanic cohort. Both cohorts were referred to a specialist at the same rate (17.7% vs. 19.8%, p = .20); however, referral completion was noted less often (60.4% vs. 77.7%, p = .02) and took longer to complete in underrepresented minority patients (54 vs. 27.5; mean day, p = .003). CONCLUSIONS: Underrepresented minority patients had more severe low back pain on presentation but received image-guided interventions less often than White/non-Hispanic patients. Our in-depth chart analysis supports the lack of referral completion and evaluation from a spine specialist provider as the main deterrent to the receipt of image-guided interventions in this cohort. While there may be systematic provider barriers, such as absence of a decision-making discussion, data do not support provider bias as a contributing factor to differences in receipt of image-guided interventions. ABBREVIATIONS: IGI = image-guided intervention; LBP = low back pain; URM = underrepresented minority; WNH = White/non-Hispanic; ICC = intraclass correlation coefficient.

Diagnostic and Therapeutic Challenges of Rare Concurrent Intracranial Meningioma and Oligodendroglioma.

Introduction: Concurrent primary brain tumors are rare clinical entities, with a prevalence ranging from 0.1 to 0.5% of all diagnosed brain tumors. The co-occurrence of meningioma and oligodendroglioma is particularly uncommon, posing unique diagnostic and therapeutic challenges. We describe the case of a patient diagnosed with concurrent meningioma and oligodendroglioma and review the existing literature on this rare phenomenon. Case Presentation: A 55-year-old female patient with a history of seizures presented to the emergency department with worsening headaches, nausea, and vomiting. She had a known right frontoparietal intracranial mass but had previously declined surgery. Magnetic resonance imaging revealed extensive fluid-attenuated inversion recovery /T2 hyperintensity around the lesion, which had slowly increased over 5 years; the growth of the lesion was producing a mass effect with a significant midline shift. The patient underwent urgent hemicraniectomy with subsequent resection. Clinical evaluation, imaging studies, and histopathological examination were conducted to confirm the diagnosis. Genetic and molecular analyses were also performed to explore potential underlying mechanisms. Histopathological findings confirmed a diagnosis of an isocitrate dehydrogenase-mutated World Health Organization Grade II oligodendroglioma with 1p/19q codeletion, along with a Grade I meningioma. Conclusion: The coexistence of meningioma and oligodendroglioma represents a rare clinical event. Surgical management remains the cornerstone of treatment. Further investigation into the genetic and environmental factors that contribute to the co-occurrence of such tumors could pave the way for more targeted therapeutic strategies.

The Treatment of Symptomatic Diffuse Proliferative Cerebral Angiopathy With Cilostazol: A Case Report.

Diffuse proliferative cerebral angiopathy (DPCA) is a rare form of cerebral vascular malformation responsible for 3.4% of all cerebral arteriovenous malformations (AVMs). The relative risk of rupture for DPCA is lower than for classic AVMs, so they are often managed medically. Despite the somewhat lower rupture risk, the risk of rebleeding is paradoxically higher than in classical AVMs, and there is a potential for significant morbidity and mortality. The aim of this article is to describe a case of a patient with symptomatic DPCA who experienced symptomatic improvement after treatment with the vasodilating agent cilostazol. This is a case report of a patient who presented with aphasia and was found to have DPCA. CT perfusion with acetazolamide challenge confirmed that the patient's symptoms were due to steal phenomena. Subsequently, the patient was treated with 50 mg of cilostazol daily to mediate a vasodilatory response within the arterial tree. Within three days of treatment with cilostazol, the patient showed significant improvement in his aphasia. The patient returned to the clinic a month later and reported continued improvement in his aphasia with speech therapy. Patients who present with neurological deficits from steal phenomena caused by DPCA are difficult to treat surgically because DPCAs often involve normal parenchyma. We present an example of a noninterventional alternative, oral cilostazol paired with functional rehabilitation, for alleviating symptoms associated with DPCA.

Disparities in Provider Ordering Practices of Image-Guided Interventions and Surgery for Patients With Low Back Pain: A Cohort Study.

OBJECTIVE: To assess individual- and neighborhood-level sociodemographic factors associating with providers' ordering of nonpharmacologic treatments for patients with low back pain (LBP), specifically physical therapy, image-guided interventions, and lumbar surgery. METHODS: Our cohort included all patients diagnosed with LBP from 2000 to 2017 in a statewide database of all hospitals and ambulatory surgical facilities within Utah. We compared sociodemographic and clinical characteristics of (1) patients with LBP who received any treatment with those who received none and (2) patients with LBP who received invasive LBP treatments with those who only received noninvasive LBP treatments using the Student's t test, Wilcoxon's rank-sum tests, and Pearson's χ2 tests, as applicable, and two separate multivariate logistic regression models: (1) to determine whether sociodemographic characteristics were risk factors for receiving any LBP treatments and (2) risk factors for receiving invasive LBP treatments. RESULTS: Individuals in the most disadvantaged neighborhoods were less likely to receive any nonpharmacologic treatment orders (odds ratio [OR] 0.74 for most disadvantaged, P < .001) and received fewer invasive therapies (0.92, P = .018). Individual-level characteristics correlating with lower rates of treatment orders were female sex, Native Hawaiian or other Pacific Islander race (OR 0.50, P < .001), Hispanic ethnicity (OR 0.77, P < .001), single or unmarried status (OR 0.69, P < .001), and no insurance or self-pay (OR 0.07, P < .001). CONCLUSION: Neighborhood and individual sociodemographic variables associated with treatment orders for LBP with Area Deprivation Index, sex, race or ethnicity, insurance, and marital status associating with receipt of any treatment, as well as more invasive image-guided interventions and surgery.

MR-Guided Focused Ultrasound Thalamotomy in the Setting of Aneurysm Clip.

We report on a 75-year-old woman with a history of right MCA aneurysm clipping and medically refractive right-hand tremor. We successfully performed focused ultrasound thalamotomy of the left ventral intermediate nucleus under MR imaging-guidance at 3T. A thorough pretreatment evaluation of MR thermometry was critical to ensure that adequate precision could be achieved at the intended target. The tremor showed a 75% decrease at 24 hours postprocedure and a 50% decrease at a 3-month follow-up. There were no immediate adverse events.

The Brain Tumor Segmentation (BraTS) Challenge 2023: Focus on Pediatrics (CBTN-CONNECT-DIPGR-ASNR-MICCAI BraTS-PEDs).

Pediatric tumors of the central nervous system are the most common cause of cancer-related death in children. The five-year survival rate for high-grade gliomas in children is less than 20%. Due to their rarity, the diagnosis of these entities is often delayed, their treatment is mainly based on historic treatment concepts, and clinical trials require multi-institutional collaborations. The MICCAI Brain Tumor Segmentation (BraTS) Challenge is a landmark community benchmark event with a successful history of 12 years of resource creation for the segmentation and analysis of adult glioma. Here we present the CBTN-CONNECT-DIPGR-ASNR-MICCAI BraTS-PEDs 2023 challenge, which represents the first BraTS challenge focused on pediatric brain tumors with data acquired across multiple international consortia dedicated to pediatric neuro-oncology and clinical trials. The BraTS-PEDs 2023 challenge focuses on benchmarking the development of volumentric segmentation algorithms for pediatric brain glioma through standardized quantitative performance evaluation metrics utilized across the BraTS 2023 cluster of challenges. Models gaining knowledge from the BraTS-PEDs multi-parametric structural MRI (mpMRI) training data will be evaluated on separate validation and unseen test mpMRI dataof high-grade pediatric glioma. The CBTN-CONNECT-DIPGR-ASNR-MICCAI BraTS-PEDs 2023 challenge brings together clinicians and AI/imaging scientists to lead to faster development of automated segmentation techniques that could benefit clinical trials, and ultimately the care of children with brain tumors.

Non-invasive central nervous system assessment of a porcine model of neuropathic pain demonstrates increased latency of somatosensory-evoked potentials.

BACKGROUND: The study of chronic pain and its treatments requires a robust animal model with objective and quantifiable metrics. Porcine neuropathic pain models have been assessed with peripheral pain recordings and behavioral responses, but thus far central nervous system electrophysiology has not been investigated. This work aimed to record non-invasive, somatosensory-evoked potentials (SEPs) via electroencephalography in order to quantitatively assess chronic neuropathic pain induced in a porcine model. NEW METHOD: Peripheral neuritis trauma (PNT) was induced unilaterally in the common peroneal nerve of domestic farm pigs, with the contralateral leg serving as the control for each animal. SEPs were generated by stimulation of the peripheral nerves distal to the PNT and were recorded non-invasively using transcranial electroencephalography (EEG). The P30 wave of the SEP was analyzed for latency changes. RESULTS: P30 SEPs were successfully recorded with non-invasive EEG. PNT resulted in significantly longer P30 SEP latencies (p < 0.01 [n = 8]) with a median latency increase of 14.3 [IQR 5.0 - 17.5] ms. Histological results confirmed perineural inflammatory response and nerve damage around the PNT nerves. COMPARISON WITH EXISTING METHOD(S): Control P30 SEPs were similar in latency and amplitude to those previously recorded invasively in healthy pigs. Non-invasive recordings have numerous advantages over invasive measures. CONCLUSIONS: P30 SEP latency can serve as a quantifiable neurological measure that reflects central nervous system processing in a porcine model of chronic pain. Advancing the development of a porcine chronic pain model will facilitate the translation of experimental therapies into human clinical trials.

Conventional and Advanced Imaging of Spinal Cord Tumors.

Spinal cord tumors are best identified by conventional MR imaging with contrast. Most intramedullary spinal cord tumors have characteristic MR imaging features that allow an accurate preoperative diagnosis. The spinal cord tumors reviewed in this article include the most common tumors, ependymomas and astrocytomas, as well as the less common tumors such as hemangioblastomas and metastases. Rare tumors such as primary CNS lymphoma and melanocytic tumors are also described. Advanced imaging techqniques of more common intramedullary tumors are also reviewed.

ACR Appropriateness Criteria® Management of Vertebral Compression Fractures: 2022 Update.

Vertebral compression fractures (VCFs) can have a variety of etiologies, including trauma, osteoporosis, or neoplastic infiltration. Osteoporosis related fractures are the most common cause of VCFs and have a high prevalence among all postmenopausal women with increasing incidence in similarly aged men. Trauma is the most common etiology in those >50 years of age. However, many cancers, such as breast, prostate, thyroid, and lung, have a propensity to metastasize to bone, which can lead to malignant VCFs. Indeed, the spine is third most common site of metastases after lung and liver. In addition, primary tumors of bone and lymphoproliferative diseases such as lymphoma and multiple myeloma can be the cause of malignant VCFs. Although patient clinical history could help raising suspicion for a particular disorder, the characterization of VCFs is usually referred to diagnostic imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Time for change? Radiologists highly concordant assessing change in stenoses on follow-up cervical spine MRI.

OBJECTIVE: There is considerable variability among radiologists when grading spinal canal and foraminal stenosis on MRI. However, to date, studies have not evaluated radiologists' agreement when assessing interval change in cervical spine stenoses. The purpose of this study was to evaluate radiologists' concordance for change in cervical spine stenoses on follow-up MRIs, a major indication for these exams. METHODS: Initial and follow-up cervical MRIs were retrospectively reviewed by three blinded radiologists. Spinal canal and foramina from C1 through T1 were rated for interval change and concordance between the blinded raters was calculated. The original MRI reports were also reviewed for specific language assessing interval change on the follow-up exams. RESULTS: 40 cervical MRI exams and 40 corresponding MRI follow-ups were assessed. Agreement for interval change in spinal canal and foraminal stenosis was near perfect amongst all readers (kappa values of 0.78-0.94). 97% of the original MRI reports used the standard severity scale. 68% of follow-up MRI reports specifically assessed for change. DISCUSSION: Blinded radiologists had high agreement when assessing for change in spinal canal and foraminal stenosis on follow-up cervical spine MRIs. Because of inter-rater variability in stenosis grading, reports that do not emphasize change assessment, may imply change that is not truly present. For clarity and consistency in reporting of cervical spine stenoses, change assessment should be emphasized and added to structured reporting templates.

Magnetic Resonance Imaging of the Lumbar Spine: Recommendations for Acquisition and Image Evaluation from the BACPAC Spine Imaging Working Group.

Management of patients suffering from low back pain (LBP) is challenging and requires development of diagnostic techniques to identify specific patient subgroups and phenotypes in order to customize treatment and predict clinical outcome. The Back Pain Consortium (BACPAC) Research Program Spine Imaging Working Group has developed standard operating procedures (SOPs) for spinal imaging protocols to be used in all BACPAC studies. These SOPs include procedures to conduct spinal imaging assessments with guidelines for standardizing the collection, reading/grading (using structured reporting with semi-quantitative evaluation using ordinal rating scales), and storage of images. This article presents the approach to image acquisition and evaluation recommended by the BACPAC Spine Imaging Working Group. While the approach is specific to BACPAC studies, it is general enough to be applied at other centers performing magnetic resonance imaging (MRI) acquisitions in patients with LBP. The herein presented SOPs are meant to improve understanding of pain mechanisms and facilitate patient phenotyping by codifying MRI-based methods that provide standardized, non-invasive assessments of spinal pathologies. Finally, these recommended procedures may facilitate the integration of better harmonized MRI data of the lumbar spine across studies and sites within and outside of BACPAC studies.

Extrarenal malignant rhabdoid tumor infiltrating the brachial plexus and spinal canal.

Extrarenal malignant rhabdoid tumors are rare, aggressive lesions that primarily affect infants and children with characteristic SMARCB1/INI1 mutations. While rhabdoid tumors are most commonly found in the kidneys and central nervous system, they have been reported in virtually every soft tissue in the body. A 20-year-old previously healthy male presented with a 4-month history of left upper extremity weakness and pain and a 1-week history of lower extremity weakness. MRI showed a combined intradural and extradural mass arising from the C8 root and involving the lower trunk of the brachial plexus. CT guided biopsy followed with onsite cytologic analysis initially concerning for plasma cell etiology. Full body PET/CT showed no evidence of metastases. The tumor was surgically resected and debulked. Extensive immunohistochemical testing on the resected specimen revealed a diagnosis of extrarenal malignant rhabdoid tumor. Recurrence invading paraspinous muscles, left lateral paravertebral space, left apical lung, and brachial plexus was noted within 2 months. Radiation and chemotherapy were initiated. Here we present imaging findings, image-guided biopsy, surgical management, and pathologic diagnosis of a rare case of extrarenal, extracranial malignant rhabdoid tumor of the brachial plexus and surrounding paraspinous muscles in a young adult male.

Ultrahigh-b diffusion-weighted imaging for quantitative evaluation of myelination in shiverer mouse spinal cord.

PURPOSE: To perform a quantitative evaluation of myelination on WT and myelin-deficient (shiverer) mouse spinal cords using ultrahigh-b diffusion-weighted imaging (UHb-DWI). METHODS: UHb-DWI of ex vivo on spinal cord specimens of two shiverer (C3HeB/FeJ-shiverer, homozygous genotype for MbPshi ) and six WT (Black Six, C3HeB/FeJ) mice were acquired using 3D multishot diffusion-weighted stimulated-echo EPI, a homemade RF coil, and a small-bore 7T MRI system. Imaging was performed in transaxial plane with 75 × 75 µm2 in-plane resolution, 1-mm-slice thickness, and radial DWI using bmax = 42,890 s/mm2 . Histological evaluation was performed on upper thoracic sections using optical and transmission electron microscopy. Numerical Monte Carlo simulations (MCSs) of water diffusion were performed to facilitate interpretation of UHb-DWI signal-b curves. RESULTS: The white matter ultrahigh-b radial DWI (UHb-rDWI) signal-b curves of WT mouse cords behaved biexponentially with high-b diffusion coefficient DH < 0.020 × 10-3 mm2 /s. However, as expected with less myelination, the signal-b of shiverer mouse cords behaved monoexponentially with significantly greater DH = 0.162 × 10-3 , 0.142 × 10-3 , and 0.164 × 10-3 mm2 /s at anterodorsal, posterodorsal, and lateral columns, respectively. The axial DWI signals of all mouse cords behaved monoexponentially with D = (0.718-1.124) × 10-3 mm2 /s. MCS suggests that these elevated DH are mainly induced by increased water exchange at the myelin sheath. Microscopic results were consistent with the UHb-rDWI findings. CONCLUSION: UHb-DWI provides quantitative differences in myelination of spinal cords from myelin-deficit shiverer and WT mice. UHb-DWI may become a powerful tool to evaluate myelination in demyelinating disease models that may translate to human diseases, including multiple sclerosis.

ACR Appropriateness Criteria® Low Back Pain: 2021 Update.

In the United States, acute low back pain, with or without radiculopathy, is the leading cause of years lived with disability and the third ranking cause of disability-adjusted life-years. Uncomplicated acute low back pain and/or radiculopathy is a benign, self-limited condition that does not warrant any imaging studies. Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain. It is also considered for those patients presenting with red flags, raising suspicion for a serious underlying condition, such as cauda equina syndrome, malignancy, fracture, or infection. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Plexopathy: 2021 Update.

Plexopathy may be caused by diverse pathologies, including trauma, nerve entrapment, neoplasm, inflammation, infection, autoimmune disease, hereditary disease, and idiopathic etiologies. For patients presenting with brachial or lumbosacral plexopathy, dedicated plexus MRI is the most appropriate initial imaging modality for all clinical scenarios and can identify processes both intrinsic and extrinsic to the nerves. Other imaging tests may be appropriate for initial imaging depending on the clinical scenario. This document addresses initial imaging strategies for brachial and lumbosacral plexopathy in the following clinical situations: nontraumatic plexopathy with no known malignancy, traumatic plexopathy (not perinatal), and plexopathy occurring in the context of a known malignancy or posttreatment syndrome. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Suspected Spine Infection.

Spine infection is both a clinical and diagnostic imaging challenge due to its relatively indolent and nonspecific clinical presentation. The diagnosis of spine infection is based upon a combination of clinical suspicion, imaging evaluation and, when possible, microbiologic confirmation performed from blood cultures or image-guided percutaneous or open spine biopsy. With respect to the imaging evaluation of suspected spine infection, MRI without and with contrast of the affected spine segment is the initial diagnostic test of choice. As noncontrast MRI of the spine is often used in the evaluation of back or neck pain not responding to conservative medical management, it may show findings that are suggestive of infection, hence this procedure may also be considered in the evaluation of suspected spine infection. Nuclear medicine studies, including skeletal scintigraphy, gallium scan, and FDG-PET/CT, may be helpful in equivocal or select cases. Similarly, radiography and CT may be appropriate for assessing overall spinal stability, spine alignment, osseous integrity and, when present, the status of spine instrumentation or spine implants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Preoperative Magnetic Resonance Imaging Abnormalities Predict Symptomatic Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion.

Introduction Anterior cervical discectomy and fusions (ACDFs) are generally limited to the levels causing neurological symptoms, but whether adjacent asymptomatic levels should be included if they demonstrate severe radiographic degeneration is a matter of controversy. We evaluated whether asymptomatic preoperative magnetic resonance imaging (MRI) abnormalities at adjacent levels were predictive of reoperation for symptomatic adjacent-segment degeneration (ASD) after the initial ACDF. Methods We reviewed patients treated with ACDF in 2000-2010 who had MRIs preoperatively and again ≥3 years after the index surgery to evaluate new neurological symptoms. Patients were stratified by ASD severity score, calculated based on MRI features. The associations between preoperative ASD severity score and reoperation for ASD were evaluated with logistic and Cox regressions after adjusting for covariates. Results Of 1038 patients who underwent ACDF, 96 (9%) had MRI evaluation ≥3 years postoperatively (mean follow-up 78 months). Of the 195 adjacent segments evaluated, 14 (7%) were included in subsequent fusion procedures. The 10-year surgery-free survival estimate was 82.7% (73.4-93.2%). After adjusting for covariates, ASD severity scores were predictive of reoperation only for patients with the highest score (hazard ratio [HR] 4.5 [1.0-19.8]) and those with foraminal stenosis (HR 4.2 [.4-12.7]). However, the prevalence of reoperation for ASD in these groups was only 16% and 15%, respectively. Conclusion The prevalence of reoperation for ASD was low for patients who presented with new symptoms ≥3 years after the index ACDF. Our findings do not support including asymptomatic levels in an anterior fusion construct, even if severe MRI abnormalities are present preoperatively.