Full endoscopic surgery for calcium pyrophosphate deposition disease (CPPD) in the cervical ligamentum flavum: report of two cervical myelopathy cases.

Calcium pyrophosphate deposition disease (CPPD), known as pseudogout, is characterized by the accumulation of calcium pyrophosphate crystals in musculoskeletal structures, primarily joints. While CPPD commonly affects various joints, involvement in the cervical spine leading to myelopathy is rare. Surgical intervention becomes necessary when conservative measures fail, but reports on full endoscopic surgeries are extremely rare. We present two successful cases where full endoscopic systems were used for CPPD removal in the cervical spine. The surgical technique involved a full endoscopic approach, adapting the previously reported technique for unilateral laminotomy bilateral decompression. Full-endoscopic removal of cervical CPPD inducing myelopathy were successfully removed with good clinical and radiologic outcomes. The scarcity of endoscopic cases for cervical ligamentum flavum CPPD is attributed to the condition's rarity. However, our successful cases advocate for endoscopic surgery as a potential primary treatment option for CPPD-induced cervical myelopathy, especially in elderly patients or those with previous cervical operation histories. This experience encourages the consideration of endoscopic surgery for managing cervical ligamentum flavum CPPD as a viable alternative.

Mycobacterial spindle cell pseudotumor of the spinal cord: Case report and literature review.

We report the first description of spinal cord mycobacterial spindle cell pseudotumor. A patient with newly diagnosed advanced HIV presented with recent-onset bilateral leg weakness and was found to have a hypermetabolic spinal cord mass on structural and molecular imaging. Biopsy and cultures from blood and cerebrospinal fluid confirmed spindle cell pseudotumor due to Mycobacterium avium-intracellulare. Despite control of HIV and initial reduction in pseudotumor volume on antiretrovirals and antimycobacterials (azithromycin, ethambutol, rifampin/rifabutin), he ultimately experienced progressive leg weakness due to pseudotumor re-expansion. Here, we review literature and discuss multidisciplinary diagnosis, monitoring and management challenges, including immune reconstitution inflammatory syndrome.

Novel Risk Factors for Cervical Facet Joint Degeneration in the Subaxial Cervical Spine: Correlation with Cervical Sagittal Alignment and Bone Mineral Density.

OBJECTIVE: The impact of cervical sagittal alignment on cervical facet joint degeneration (CFD) and the risk factors for CFD in patients with degenerative cervical myelopathy (DCM) were investigated in the current study. METHODS: A total of 250 surgical patients with DCM were recruited. The clinical data and radiographical characteristics, including CFD, cervical sagittal balance parameters, Hounsfield unit (HU) values, disc degeneration (DD), and modic change, were collected. The detailed correlation between these characteristics and CFD was analyzed. Characteristics, including CFD, were compared among the various cervical alignment types and different CFD groups. Finally, the risk factors for CFD were revealed via logistic regression. RESULTS: CFD was prevalent in DCM patients. Age, cervical sagittal vertical axis (cSVA), range of motion, T1 slope, thoracic inlet angle, DD, HU value, and modic change correlated with CFD segmentally and globally (P < 0.05). The lordosis and sigmoid types had a significantly higher CFD prevalence (P < 0.05). Furthermore, the average CFD threshold for the severe CFD group was 1.625 (area under the curve, 0.958). Additionally, 167 patients with average CFD <1.625 and 83 patients with CFD of ≥1.625 were classified into the mild CFD group and severe CFD group, respectively. Finally, multivariate analysis was performed, and age, cSVA, HU value, modic change, and DD were determined to be independent risk factors for CFD. CONCLUSIONS: The load distribution tends to shift to a more shear-like pattern in the sigmoid and kyphosis types and in those with a higher cSVA, thereby promoting CFD. Aging, cervical malalignment, low bone mineral density, DD, and modic change were revealed to result in high risks of CFD.

An infratentorial dural arteriovenous fistula mimicking cervical myelopathy: A case report.

Dural arteriovenous fistulas may have insidious clinical presentations and are often challenging to diagnose. A small number of cases have been associated with perimedullary venous congestion and cord oedema, mimicking common pathologies, such as cervical myelopathy. We describe a case report of a patient presenting with a constellation of symptoms and radiological signs mimicking C5/6 cervical myelopathy secondary to disc herniation. The patient was managed with anterior cervical discectomy and fusion, with postoperative neurological deterioration unresponsive to steroid therapy. This prompted further investigation of other pathologies. An infratentorial Cognard 5 and Borden type 3 dural arteriovenous fistula was diagnosed on 6-vessel DSA and managed with onyx embolization. Marked improvement of neurological symptoms, notably bilateral lower limb weakness, was achieved postoperatively. In summary, this case demonstrates the importance of considering alternative, less common pathologies that involve the cervical spinal cord when neurological improvement is not achieved following decompressive surgery for cervical myelopathy.

Free-hand technique of C7 pedicle screw insertion using a simply defined entry point without fluoroscopic guidance for cervical spondylotic myelopathy patients with C3 to C6 instrumented by lateral mass screws: a retrospective cohort study.

BACKGROUND: Nowadays, both lateral mass screw (LMS) and pedicle screw were effective instrumentation for posterior stabilization of cervical spine. This study aims to evaluate the feasibility of a new free-hand technique of C7 pedicle screw insertion without fluoroscopic guidance for cervical spondylotic myelopathy (CSM) patients with C3 to C6 instrumented by lateral mass screws. METHODS: A total of 53 CSM patients underwent lateral mass screws instrumentation at C3 to C6 levels and pedicle screw instrumentation at C7 level were included. The preoperative 3-dimenional computed tomography (CT) reconstruction images of cervical spine were used to determine 2 different C7 pedicle screw trajectories. Trajectory A passed through the axis of the C7 pedicle while trajectory B selected the midpoint of the base of C7 superior facet as the entry point. All these 53 patients had the C7 pedicle screw inserted through trajectory B by free-hand without fluoroscopic guidance and the postoperative CT images were obtained to evaluate the accuracy of C7 pedicle screw insertion. RESULTS: Trajectory B had smaller transverse angle, smaller screw length, and smaller screw width but both similar sagittal angle and similar pedicle height when compared with trajectory A. A total of 106 pedicle screws were inserted at C7 through trajectory B and only 8 screws were displaced with the accuracy of screw placement as high as 92.5%. CONCLUSION: In CSM patients with C3 to C6 instrumented by LMS, using trajectory B for C7 pedicle screw insertion is easy to both identify the entry point and facilitate the rod insertion.

Prospective Investigation of the Posterior Longitudinal Ligament and Disc Complex after Posterior Stabilization and Decompression Surgery in Patients With Non-OPLL (Ossification of the Posterior Longitudinal Ligament) Cervical Spondylotic Myelopathy.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a prevalent cause of spinal cord dysfunction in adults, primarily from degenerative changes. The efficacy of treatment strategies, especially surgical approaches, remains debated. OBJECTIVE: This study aimed to assess the long-term impact of posterior fusion laminectomy on the posterior longitudinal ligament (PLL) thickness, disc complex, and myelomalacia signal changes in CSM patients. METHODS: A single-centre, prospective study from January 2020 to December 2021 included CSM patients without ossified posterior longitudinal ligament (OPLL). Magnetic resonance imaging (MRI) data from baseline, 6, and 12 months postoperatively were collected. Measurements on the MRI were performed using the Osirix MD software, focusing on the PLL width, myelopathic foci dimensions, and canal diameter. RESULTS: Out of the 82 initially enrolled patients, 64 were considered for analysis. Postoperatively, a significant reduction in PLL width and myelopathic foci dimensions was observed, alongside a considerable increase in the canal diameter. Clinical outcomes based on the Modified Japanese Orthopaedic Association (mJOA) scale also showcased marked improvements post-surgery. CONCLUSIONS: Posterior fusion laminectomy effectively reduces anterior pressure in CSM patients. This treatment may represent an optimal surgical approach for selected CSM cases. Furthermore, more extensive studies with extended follow-up are advocated.

Structural Myelopathies.

OBJECTIVE: This article illustrates the clinical importance, diagnosis, and management of degenerative and nondegenerative structural myelopathies. It also aims to create a diagnostic approach for the evaluation of patients with suspected degenerative myelopathies. LATEST DEVELOPMENTS: There is considerable interest in developing diagnostic methods that can assist in deciding if surgery is indicated in patients with structural myelopathy and the optimal timing for surgery. Diffusion tensor imaging has emerged as a promising imaging modality although it is not used routinely in clinical practice. Neuroprotective medications and interventions are being studied in patients with degenerative myelopathies. ESSENTIAL POINTS: Structural myelopathies and particularly degenerative myelopathies are common disorders that are routinely encountered in clinical practice, with symptoms that frequently overlap with other neurologic disorders. The prompt diagnosis and treatment of patients are essential in achieving good functional outcomes.

Diagnostic efficacy of tract-specific diffusion tensor imaging in cervical spondylotic myelopathy with electrophysiological examination validation.

PURPOSE: This study aimed to investigate the effectiveness of tract-specific diffusion tensor imaging (DTI) metrics in identifying the responsible segments for neurological dysfunction in cervical spondylotic myelopathy (CSM). METHODS: The study encompassed nineteen participants diagnosed with CSM, including 10 males and 9 females. Additionally, a control group consisting of ten healthy caregivers (5 males and 5 females) were recruited with no symptoms and no compressions on magnetic resonance imaging (MRI). All participants underwent a comprehensive physical examination, MRI assessment, and DTI examination conducted by a senior chief physician. Several parameters were collected from the MR images, including the aspect ratio (defined as the anteroposterior diameter / the transverse diameter of the corresponding segment's spinal cord), transverse ratio (defined as the transverse diameter of the corresponding segment's spinal cord / the transverse diameter of the spinal cord at C2/3), and T2 high signal of the spinal cord. Furthermore, quantitative DTI metrics, such as axial diffusivity (AD), mean diffusivity (MD), radial diffusivity (RD), and fractional anisotropy (FA), were calculated using automatic region-of-interest (ROI) analysis for both whole spinal cord column and dorsal column. Receiver operating characteristic (ROC) curves were constructed to evaluate the diagnostic efficacy of the aspect ratio, transverse ratio, and DTI parameters. The area under the curve (AUC), sensitivity, and specificity were calculated. Intraoperative spinal cord electrophysiological examination was performed as the objective measure of spinal cord function during surgery. RESULTS: As determined by electrophysiological examination, neurological dysfunction was found in 2 patients due to C3/4 compression, in 10 patients due to C4/5 compression, in 6 patients due to C5/6 compression, and in 1 patient due to C6/7 compression. The modified Japanese Orthopedic Association scale (mJOA) was 12.71 ± 1.55 in the CSM group, with 4.87 ± 0.72 for sensory nerve function and 5.05 ± 1.35 for motor nerve function. For the control group, none of the volunteers had neurological dysfunction. T2 high signal was found at the most stenotic segment in 13 patients of the CSM group. Considering all the cervical segments, the aspect ratio (AUC = 0.823, P = 0.001, Sensitivity = 68.42%, Specificity = 82.47%) was more capable of determining the responsible segment than transverse ratio (AUC = 0.661, P = 0.027, Sensitivity = 68.42%, Specificity = 67.01%). AD, MD, and RD were significantly higher while FA was significantly lower in the responsible segment than in the irresponsible segment (P < 0.05). The AUC of DTI-Dorsal column parameters (AD, MD, RD, FA) was larger than the corresponding parameters of the DTI (Whole spinal cord). AD of DTI-Dorsal Column possessed the greatest efficacy (AUC = 0.823, sensitivity = 84.21%, specificity = 77.32%) to determine the responsible segment, larger than AD of DTI-Whole spinal cord (AUC = 0.822, P = 0.001, Sensitivity = 89.47%, Specificity = 77.32%), aspect ratio (AUC = 0.823, P = 0.001, Sensitivity = 68.42%, Specificity = 82.47%) and transverse ratio (AUC = 0.661, P = 0.027, Sensitivity = 68.42%, Specificity = 67.01%). Subgroup analysis revealed that the diagnostic efficacy of DTI and MRI parameters was influenced by cervical spine segment. CONCLUSIONS: When considering all cervical segments, AD from the DTI-Dorsal Column exhibited the most significant potential in identifying responsible segments. This potential was found to be superior to that of DTI-Whole spinal cord, aspect ratio, the most stenotic segment, T2 high signals, transverse ratio, motor nerve dysfunction, and sensory nerve dysfunction. The diagnostic effectiveness of both DTI and MRI parameters was notably influenced by the specific cervical spine segment.

Degenerative Cervical Myelopathy: A Concept Review and Clinical Approach.

STUDY DESIGN: Narrative review. OBJECTIVE: To provide an overview of the evaluation and diagnosis of degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: DCM describes several etiologies of degenerative, nontraumatic spinal cord impairment. Early diagnosis and intervention can decrease neurological decline. METHODS: An extensive literature review was conducted. RESULTS: The incidence and prevalence of DCM are increasing worldwide. Asymptomatic spinal cord compression can progress to cervical myelopathy. Static and dynamic factors contribute to spinal cord compression. Patients frequently present with decreased manual dexterity, gait instability, and neck pain. On physical exam, patients frequently present with upper motor neuron signs, a Lhermitte sign, a failed Romberg test, global proprioceptive dysfunction, and decreased pain sensation. Anatomic variation may complicate physical exam interpretation. The modified Japanese Orthopaedic Association Scale and Nurick Classification, based on functional impairment, provide diagnostic utility. Magnetic Resonance Imaging imaging is useful in narrowing the differential diagnosis, evaluating the severity of neurological impairment, and predicting disease progression. CONCLUSIONS: Understanding the pathophysiology of DCM and the diagnostic utility of the signs and symptoms of DCM is critical. The decision for anterior cervical discectomy and fusion (ACDF), laminoplasty, or combined ACDF and posterior cervical fusion is individualized for each patient.

Comparison of efficacy between endoscope-assisted anterior cervical discectomy and fusion (ACDF) and open ACDF in the treatment of single-segment cervical spondylotic myelopathy.

BACKGROUND: In this study, we compared the clinical efficacy of endoscope-assisted anterior cervical discectomy and fusion (ACDF) with open ACDF in the treatment of single-segment cervical spondylotic myelopathy. METHODS: A retrospective analysis was performed on 52 patients with single-segment cervical spondylotic myelopathy between June 2021 and February 2022, including 33 males and 19 females, with a mean age of 58.42 ± 9.26) years. Among them, 28 patients were treated with endoscope-assisted ACDF (Group A), including 2 cases of C4/5 segment, 16 cases of C5/6 segment, and 10 cases of C6/7 segment; 24 patients were treated with open ACDF (Group B), including 4 cases of C4/5 segment, 11 cases of C5/6 segment, and 9 cases of C6/7 segment. The operation time, intraoperative blood loss, hospital stay, and complications were recorded and compared between the two groups. The Visual Analogue Scale (VAS) and the Japanese Orthopaedic Association (JOA) score were used for clinical evaluation during the follow-up in the 1st month and 3rd month after surgery, and at the final follow-up. RESULTS: The 52 patients were followed up on average for 13.04 months (12-17 months). The operation time in Group A and Group B was (105.18 + 8.66) minutes and (81.88 + 6.05) minutes, the intraoperative blood loss was (84.29 + 13.45) mL and (112.92 + 17.81) mL, and the hospital stay was (6.75 + 1.29) days and (7.63 + 1.41) days, respectively. The difference between the two groups was statistically significant (P < 0.05). The VAS and JOA scores in the 1st month and the 3rd month after surgery and the last follow-up significantly improved in both groups compared with those before surgery (P < 0.05). The VAS and JOA scores of Group A in the 1st month, 3rd month after surgery, and the last follow-up were better than those in Group B (P < 0.05). The complication rate in Group A was 7% (2/28), which was not significantly different from the 17% (4/24) in Group B (P > 0.05). CONCLUSION: Both endoscope-assisted ACDF and open ACDF can achieve satisfactory clinical efficacy in the treatment of single-segment cervical spondylotic myelopathy. Although the operation time of endoscope-assisted ACDF is prolonged, it has the advantages of clear vision, thorough decompression, less blood loss, and reduced risk of nerve damage, and is worthy of clinical promotion and application.

Predictive value of magnetic resonance imaging indications of spinal cord swelling for cervical spondylotic myelopathy prognosis.

BACKGROUND: Magnetic resonance imaging (MRI) is the preferred examination approach for patients with suspected cervical spondylotic myelopathy (CSM). OBJECTIVE: To investigate the predictive value of MRI spinal cord swelling on the prognosis of decompression surgery in patients with CSM. METHODS: A retrospective analysis of 115 patients with CSM who underwent decompression surgery was performed. According to whether cervical MRI showed spinal cord swelling, they were divided into a spinal cord swelling group and non-swelling group. The Modified Japanese Orthopaedic Association (MJOA) score, MJOA improvement rate and abnormal spinal cord enhancement rate in the two groups were compared before and after surgery. Multiple linear regression was used to analyse the influencing factors of the MJOA improvement rate. RESULTS: The time from symptom onset to operation (t= 2.400, p= 0.018) and preoperative MJOA score in the spinal cord swelling group were lower than those in the non-swelling group (t= 3.253, p= 0.002). The body mass index (t= 2.895, p= 0.005), anteroposterior diameter of the spinal canal (t= 4.421, p< 0.001), cross-sectional area (t= 3.136, p= 0.002), postoperative improvement rate (t= 4.277, p< 0.001) and proportion of abnormal enhancement of the spinal cord in the swelling group were higher than those in the non-swelling group (χ2= 3.136, p= 0.002). The preoperative MJOA score in the swelling group was lower than that in the non-swelling group (t= 2.583, p= 0.013). A multivariate linear regression model revealed that age and spinal cord swelling were independent predictors of MJOA score improvement, explaining 33.2% of the total variation. CONCLUSION: Patients with CSM with spinal cord swelling have less time from symptoms to surgery, and the degree of preoperative neurological deterioration is more obvious. Spinal cord swelling is an independent predictor of surgical prognosis in patients with CSM.

Spinal extradural arachnoid cysts: a rare entity and review of the literature.

OBJECTIVE: Spinal extradural arachnoid cysts (SEDC) are rare primary spinal lesions, accounting for less than 1% of all spinal epidural lesions. The literature contains only case reports of this pathology, and treatment remains controversial due to its rarity. Major reported SEDC cases are caused by leaking out of cerebrospinal fluid through a dural defect in the thecal sac forming an extradural cyst. Other reports describe non-communicating SEDC cases where the dural defect was not identified. We report a literature review on SEDC and the case of a 53 year­old female who presented with type IA extradural cyst with subarachnoid space communication. METHODS: Literature review, preoperative imaging and surgical technique. RESULTS: The extradural cyst was excised completely and the dural defect was repaired. After surgical decompression, neurological symptoms gradually recovered. CONCLUSIONS: The extradural arachnoid cyst is an uncommon entity. Preoperative imaging is one of the determining elements in orienting the therapeutic management of the SEDCs. The choice of the surgical technique must be the least invasive in order to avoid postoperative complications. Subtotal or complete excision of the cyst, followed by obliteration of the communication stalk and repair of the dural defect is the gold standard treatment.

Comparison of Cervical Sagittal Parameters among Patients with Neck Pain and Patients with Cervical Spondylotic Radiculopathy and Cervical Spondylotic Myelopathy.

OBJECTIVE: Previous studies have shown that cervical sagittal alignment is strongly associated with cervical deformity, myelopathy, and cervical adjacent-segmental disease, and these cervical sagittal parameters are correlated with health-related quality of life. However, less attention has been paid to cervical sagittal balance in various cervical disorders. This study aimed to compare cervical sagittal parameters between patients with nonspecific neck pain (NS-NP) and patients with cervical spondylotic radiculopathy (CSR) and cervical spondylotic myelopathy (CSM). METHODS: We retrospectively examined 236 patients from between January 2020 and October 2022. We divided them into three groups (NS-NP, CSR, and CSM) and collected general information and cervical sagittal parameters for these patients. The variation of parameters between the size of these parameters and gender differences was analyzed. Pearson's or Spearman's correlation was applied to analyze the association of cervical sagittal parameters of all patients between the three groups. RESULTS: There were significant differences in age and sex among the three groups (p < 0.001), with the NS-NP group being the youngest and NS-NP being more common in women. The parameters of cervical sagittal position significantly differed among the three groups (p < 0.05). Pearson's or Spearman's correlation result showed that the C2-C7 Cobb angle was negatively associated with the C2-C7 sagittal vertical angle (SVA), and the C2-C7 Cobb angle and T1 slope (T1s) were negatively associated with the spino-cranial angle (SCA). There was a positive correlation between the C2-C7 Cobb angle and C7 slope (C7s), C2-C7 SVA and T1s, C2-C7 SVA and SCA, and C7s and T1s. CONCLUSION: This study showed that between the three groups, patients with nonspecific neck pain had smaller SCA, and among patients with NS-NP, women had more significant SCA. The smaller anteroposterior diameter of the thorax in women might explain this difference.

Postoperative Changes of Spinopelvic Sagittal Parameters After Cervical Laminoplasty for Cervical Spondylotic Myelopathy.

STUDY DESIGN: A retrospective analysis of prospectively collected data. OBJECTIVE: To investigate postoperative changes of spinopelvic sagittal parameters after laminoplasty for cervical spondylotic myelopathy (CSM) accompanying postoperative cervical kyphotic deformity or cervical regional sagittal imbalance. SUMMARY OF BACKGROUND DATA: To the best of our knowledge, no study has been reported concerning postoperative changes of spinopelvic sagittal parameters accompanying postoperative deterioration of cervical sagittal alignment or balance after cervical laminoplasty. METHODS: Forty-five CSM patients without preoperative cervical kyphosis who underwent laminoplasty were included. None of the 45 patients had a medical history of previous spine surgery, hip joint surgery, or knee joint surgery. The patients were divided into 2 groups (kyphosis and lordosis groups) according to postoperative C2-7 angle, and they were also divided into 2 other groups (imbalance and balance groups) according to postoperative C1-7 sagittal vertical axis. Postoperative changes (Δ) of T1 slope (T1S), thoracic kyphosis, thoracolumbar kyphosis (TLK), lumbar lordosis (LL), Pelvic tilt, and C7 sagittal vertical axis were measured comparing lateral radiographs of the whole spine in the standing position taken at 1 year postoperatively with those before surgery. RESULTS: Both T1S and TLK significantly decreased after cervical laminoplasty in the kyphosis group compared with the lordosis group. On the other hand, both T1S and TLK increased significantly, and LL significantly decreased after surgery in the imbalance group compared with the balance group. CONCLUSIONS: At 1 year after laminoplasty for CSM, both T1S and TLK significantly decreased accompanying postoperative cervical kyphotic deformity as a compensatory action for postoperative cervical kyphosis to maintain the global sagittal balance of the spine, whereas both T1S and TLK increased significantly, and LL significantly decreased accompanying postoperative cervical reginal sagittal imbalance which resulted in postoperative forward inclination of the whole spine.

Predictive Value of the Diffusion Magnetic Resonance Imaging Technique for the Postoperative Outcome of Cervical Spondylotic Myelopathy.

BACKGROUND: Diffusion magnetic resonsance imaging (dMRI) can potentially predict the postoperative outcome of cervical spondylotic myelopathy (CSM). PURPOSE: To explore preoperative dMRI parameters to predict the postoperative outcome of CSM through multifactor correlation analysis. STUDY TYPE: Prospective. POPULATION: Post-surgery CSM patients; 102 total, 73 male (52.42 ± 10.60 years old) and 29 female (52.0 ± 11.45 years old). FIELD STRENGTH/SEQUENCE: 3.0 T/Turbo spin echo T1/T2-weighted, T2*-weighted multiecho gradient echo and dMRI. ASSESSMENT: Spinal cord function was evaluated using modified Japanese Orthopedic Association (mJOA) scoring at different time points: preoperative and 3, 6, and 12 months postoperative. Single-factor correlation and t test analyses were conducted based on fractional anisotropy (FA), mean diffusivity, intracellular volume fraction, isotropic volume fraction, orientation division index, increased signal intensity, compression ratio, age, sex, symptom duration and operation method, and multicollinearity was calculated. The linear quantile mixed model (LQMM) and the linear mixed-effects regression model (LMER) were used for multifactor correlation analysis using the combinations of the above variables. STATISTICAL TESTS: Distance correlation, Pearson's correlation, multiscale graph correlation and t tests were used for the single-factor correlation analyses. The variance inflation factor (VIF) was used to calculate multicollinearity. LQMM and LMER were used for multifactor correlation analyses. P < 0.05 was considered statistically significant. RESULTS: The single-factor correlation between all variables and the postoperative mJOA score was weak (all r < 0.3). The linear relationship was stronger than the nonlinear relationship, and there was no significant multicollinearity (VIF = 1.10-1.94). FA values in the LQMM and LMER models had a significant positive correlation with the mJOA score (r = 5.27-6.04), which was stronger than the other variables. DATA CONCLUSION: The FA value based on dMRI significantly positively correlated with CSM patient postoperative outcomes, helping to predict the surgical outcome and formulate a treatment plan before surgery. EVIDENCE LEVEL: 1 TECHNICAL EFFICACY: Stage 2.

T2-weighted Imaging Hyperintensity and Transcranial Motor-evoked Potentials During Cervical Spine Surgery: Effects of Sevoflurane in 150 Consecutive Cases.

BACKGROUND: There is debate on the impact of inhalational esthetic agents on transcranial motor evoked potentials (TcMEPs) during intraoperative neuromonitoring. Current guidelines advise their avoidance, which contrasts with common clinical practice. METHODS: This retrospective cohort study of 150 consecutive cervical spine surgeries at a single institution compared stimulation voltages and TcMEP amplitudes in patients who did and did not receive sevoflurane as part of a balanced anesthetic technique. Patients were divided into 3 groups stratified by the presence or absence of increased signal intensity within the cervical spinal cord on T2-weighted magnetic resonance imaging (indicative or myelopathy/spinal cord injury [SCI]) and sevoflurane use. RESULTS: Patients with no magnetic resonance imaging evidence of myelopathy/SCI that received sevoflurane (n=80) had the lowest stimulation voltages and largest TcMEP amplitude responses in the lower extremities compared with those with no magnetic resonance imaging evidence of myelopathy/SCI (n=30). In patients with evidence of myelopathy/SCI who did not receive sevoflurane (n=19), lower extremity TcMEP amplitudes were similar to patients with a myelopathy/SCI that received sevoflurane. Six of these 19 patients had initial low-dose sevoflurane discontinued because of concerns of low/absent baseline TcMEP amplitudes. CONCLUSIONS: Balanced anesthesia with 0.5 MAC sevoflurane in patients with and without radiological evidence of myelopathy/SCI allows reliable TcMEP monitoring. However, in communication with surgical and neuromonitoring teams, it may be advisable in a subset of patients to avoid or discontinue sevoflurane in favor of a propofol/opioid-based anesthetic to ensure adequate and reproducible TcMEPs.

Irreversible Intrathecal Chemotherapy-induced Myelopathy in a Patient with Diffuse Large B-cell Lymphoma.

Intrathecal chemotherapy is often administered for prophylaxis and treatment of central nervous system involvement in hematological malignancies. However, it may rarely cause neurotoxicity as a side effect. We herein report a 74-year-old woman with diffuse large B-cell lymphoma including a spinal lesion. She received systemic and intrathecal chemotherapy. After five doses of intrathecal chemotherapy, she developed intrathecal chemotherapy-induced myelopathy. Intrathecal treatment was discontinued, and she was administered vitamin B12 and folic acid, along with steroid pulses. However, her symptoms did not improve. Intrathecal chemotherapy-induced myelopathy is rare, but may be irreversible; therefore, clinicians should be aware of this potential complication.

Laminoplasty in Motion: Evolving Techniques and Complications.

Cervical laminoplasty is an increasingly popular surgical option for the treatment of cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL). Over the past few decades, there have been substantial developments in both surgical technique and hardware options. As the field of cervical surgery rapidly evolves, there is a timely need to reassess the evolving complications associated with newer techniques. This review aims to synthesize the available literature on cervical laminoplasty and associated mechanical complications pertaining to different laminoplasty hinge fixation options.

Predictive value of intraoperative contrast-enhanced ultrasound in functional recovery of non-traumatic cervical spinal cord injury.

OBJECTIVES: To evaluate the ability of intraoperative CEUS to predict neurological recovery in patients with degenerative cervical myelopathy (DCM). METHODS: Twenty-six patients with DCM who underwent laminoplasty and intraoperative ultrasound (IOUS) were included in this prospective study. The modified Japanese Orthopaedic Association (mJOA) scores and MRI were assessed before surgery and 12 months postoperatively. The anteroposterior diameter (APD), maximum spinal cord compression (MSCC), and area of signal changes in the cord at the compressed and normal levels were measured and compared using MRI and IOUS. Conventional blood flow and CEUS indices (time to peak, ascending slope, peak intensity (PI), and area under the curve (AUC)) at different levels during IOUS were calculated and analysed. Correlations between all indicators and the neurological recovery rate were evaluated. RESULTS: All patients underwent IOUS and intraoperative CEUS, and the total recovery rate was 50.7 ± 33.3%. APD and MSCC improved significantly (p < 0.01). The recovery rate of the hyperechoic lesion group was significantly worse than that of the isoechoic group (p = 0.016). 22 patients were analysed by contrast analysis software. PI was higher in the compressed zone than in the normal zone (24.58 ± 3.19 versus 22.43 ± 2.39, p = 0.019). ΔPI compress-normal and ΔAUC compress-normal of the hyperechoic lesion group were significantly higher than those of the isoechoic group (median 2.19 versus 0.55, p = 0.017; 135.7 versus 21.54, p = 0.014, respectively), and both indices were moderately negatively correlated with the recovery rate (r = - 0.463, p = 0.030; r = - 0.466, p = 0.029). CONCLUSIONS: Signal changes and microvascular perfusion evaluated using CEUS during surgery are valuable predictors of cervical myelopathy prognosis. CLINICAL RELEVANCE STATEMENT: In the spinal cord compression area of degenerative cervical myelopathy, especially in the hyperechoic lesions, intraoperative CEUS showed more significant contrast agent perfusion than in the normal area, and the degree was negatively correlated with the neurological prognosis. KEY POINTS: • Recovery rates in patients with hyperechoic findings were lower than those of patients without lesions detected during intraoperative ultrasound. • The peak intensity of CEUS was higher in compressed zones than in the normal parts of the spinal cord. • Quantitative CEUS comparisons of the peak intensity and area under the curve at the compressed and normal levels of the spinal cord revealed differences that were inversely correlated to the recovery rate.

Abnormal preoperative fMRI signal variability in the pain ascending pathway is associated with the postoperative axial pain intensity in degenerative cervical myelopathy patients.

BACKGROUND CONTEXT: The moment-to-moment variability of resting-state brain activity has been suggested to play an active role in chronic pain. PURPOSE: To investigate preoperative alterations in regional blood-oxygen-level-dependent signal variability (BOLDsv) and inter-regional dynamic functional connectivity (dFC) in individuals with degenerative cervical myelopathy (DCM), and their potential association with postoperative axial pain severity. STUDY DESIGN: Cross-sectional study. PATIENT SAMPLE: Resting-state functional magnetic resonance imaging was obtained in 42 migraine individuals and 40 healthy controls (HCs). OUTCOME MEASURES: We calculated the standard deviation (SD) of the BOLD time-series at each voxel and the SD and mean of the dynamic conditional correlation between the brain regions which showed significant group differences in BOLDsv. METHODS: A group comparison was conducted using whole-brain voxel-wise analysis of the standard deviation (SD) of the BOLD time-series which was a measure of the BOLDsv. The brain areas displaying notable group discrepancies in BOLDsv were utilized to outline regions of interest (ROIs). To determine the strength/variability of the dFC, the mean and SD of the dynamic conditional correlation were calculated within these ROIs. Moreover, the postoperative axial pain (PAP) severity of patients was evaluated. RESULTS: Our results revealed that DCM patients with postoperative axial pain (PAP) demonstrated considerably increased BOLDsv in the bilateral thalamus and right insular, but significantly lower BOLDsv in the right S1. By applying dynamic functional connectivity (dFC) analysis, we found that DCM patients with PAP exhibited greater fluctuation of dFC in the thalamo-cortical pathway (specifically, thalamus-S1), when compared to HCs and patients without PAP (nPAP). Lastly, we established that dysfunctional BOLDsv and dFC in the ascending pain pathway were positively associated with the severity of PAP in DCM patients. CONCLUSION: Our results indicate a potential correlation between impaired pain ascending pathway and postoperative axial pain in DCM patients. These findings could potentially spark novel treatment approaches for individuals experiencing preoperative axial pain.