'Tumour-like' lesion caused by cervical discal instability.

We present the case of a man in his 40s who sought medical attention due to central cord syndrome. MRI findings demonstrated contrast uptake, spinal swelling, syrinx formation and narrowing of the spinal canal. We encountered two potential scenarios:when malignancy is suspected, the patient would undergo a biopsy. However, if the lesion is ultimately determined to be benign, the patient would have been subjected to an avoidable risk of neurological damage associated with the procedure. Conversely, addressing the lesion as a result of a degenerative process (discal instability), performing an anterior approach for interbody fusion with an underlying malignant process could lead to substantial delays in the diagnosis, finally producing a poor outcome. A comprehensive imaging workup was conducted to rule out malignancy. We hypothesised that discal instability was responsible for the observed findings. The patient was successfully treated with anterior cervical decompression and fusion, without complications. Follow-up evaluations confirmed remission of the condition.

Isolated Rosai-Dorfman disease of the spine: A systematic literature review.

INTRODUCTION: Rosai-Dorfman disease (RDD) is a rare non-Langerhans cell histiocytosis involving the central nervous system in 5% of cases. Spinal location occurs in less than 1% of extranodal RDD and can be responsible for neurological manifestations. We present a systematic review of cases of isolated spinal RDD. We also report a new case of isolated spinal RDD revealed by spinal cord compression. MATERIALS AND METHODS: The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline using the MEDLINE and SCOPUS databases and included case reports and case series describing isolated RDD of the spine. RESULTS: There were 53 patients with isolated spinal RDD (including our case). The mean age was 35.85±16.48 years. Neurological deficit was the most frequent clinical presentation (89%). RDD lesions were mainly located in the thoracic spine (51%), then the cervical spine (32%). The lesion was reported to be extradural (57%), intradural extramedullary (26%), intramedullary (7%), and in the vertebral body (10%). Histological examination showed emperipolesis in 73%. Histocytes were positive for S-100 protein in 83%. Treatment was based on surgery 96%), radiotherapy, chemotherapy, and adjunctive steroid therapy were indicated in four, one, and eight cases. After a mean follow-up period of 14.84±13.00 months, recurrence of RDD was noted in 15%. CONCLUSION: Spinal RDD is a rare condition, requiring meticulous histological examination for accurate diagnosis. Complete surgical resection is the treatment of choice. Adjuvant chemotherapy and radiotherapy can also be indicated in patients demonstrating partial improvement following surgery.

Invasive cellular blue nevus in the cervical spine: A case report.

INTRODUCTION: Cellular blue nevus is an uncommon neoplasm in the spine. PATIENT CONCERNS: Here, we present a case of a 24 years old male with a 2 months history of numbness in the right upper limb and shoulder. DIAGNOSIS: Cervical spine and subcutaneous tissue invasive cellular blue nevus. INTERVENTIONS: The patient underwent C4 laminectomy and partial C3 and C5 laminectomy for total resection of the lesion. Histopathology revealed a nodular tumor with unclear boundaries, which was composed of heavily pigmented dendritic cells and more pigmented spindle cells. OUTCOMES: There was no recurrence during 3 years follow-up. CONCLUSION: Invasive cellular blue nevus of the spine can be wrongly diagnosed as spinal meningeal melanocytoma and meningeal melanoma due to its special cell behavior and rarity. Therefore, it is important to understand its pathological and clinical characteristics to avoid over-treatment.

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.

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.

Current concepts in adult cervical spine deformity surgery.

Cervical spine deformity surgery has significantly evolved over recent decades. There has been substantial work performed, which has furthered the true understanding of alignment and advancements in surgical technique and instrumentation. Concomitantly, understanding of cervical spine pathology and the contributing drivers have also improved, which have influenced the development of classification systems for cervical spine deformity and the development of treatment-guiding algorithms. This article aims to provide a synopsis of the current knowledge surrounding cervical spine deformity to date, with particular focus on preoperative expected alignment targets, perioperative optimization, and the whole operative strategy.

Chronic neck pain in a child: a case of osteoblastoma of the C5 cervical vertebra.

Osteoblastoma is a primary bone-forming tumour that usually occurs in the second decade with an affinity to the posterior elements when found in the spine. Its occurrence in the early first decade is uncommon and often causes a diagnostic dilemma. It usually has a late presentation and the symptoms may be non-specific which may lead the clinician to overlook this particular entity. We present a case of osteoblastoma of the posterior elements of the C5 vertebra in a pre-adolescent child who was diagnosed and successfully managed with surgical resection in a timely fashion that led to favourable recovery postoperatively.

Odontoid incidence: a constant cervical anatomical feature evident in standing plain radiographs and supine magnetic resonance images.

OBJECTIVE: To assess whether there is a difference between measurements of odontoid incidence (OI) and other cervical sagittal parameters by X-ray radiography and those by supine magnetic resonance imaging (MRI). METHODS: Standing X-ray and supine MRI images of 42 healthy subjects were retrospectively analyzed. Surgimap software was employed to measure cervical sagittal parameters including OI, odontoid tilt (OT), C2 slope (C2S), C0-2 angle, C2-7 angle, T1 slope (T1S) and T1S-cervical lordosis (CL). Paired samples t-test was applied to determine the difference between parameters measured by standing X-ray and those by supine MRI. In addition, the statistical correlation between the parameters were compared. The prediction of CL was performed and validated using the formula CL = 0.36 × OI - 0.67 × OT - 0.69 × T1S. RESULTS: Significant correlations and differences were found between cervical sagittal parameters determined by X-ray and those by MRI. OI was verified to be a constant anatomic parameter and the formula CL = 0.36 × OI - 0.67 × OT - 0.69 × T1S can be used to predict CL in cervical sagittal parameters. CONCLUSIONS: OI is verified as a constant anatomic parameter, demonstrating the necessity of a combined assessment of cervical sagittal balance by using standing X-ray and supine MRI. The formula CL = 0.36 × OI - 0.67 × OT - 0.69 × T1S can be applied to predict CL in cervical sagittal parameters.

Risk factors of instrumentation failure after laminectomy and posterior cervical fusions (PCF).

BACKGROUND: For patients with multilevel degenerative cervical myelopathy, laminectomy and posterior cervical fusions (PCF) with instrumentation are widely accepted techniques for symptom relief. However, hardware failure is not rare and results in neck pain or even permanent neurological lesions. There are no in-depth studies of hardware-related complications following laminectomy and PCF with instrumentation. METHODS: The present study was a retrospective, single centre, observational study. Patients who underwent laminectomy and PCF with instrumentation in a single institution between January 2019 and January 2021 were included. Patients were divided into hardware failure and no hardware failure group according to whether there was a hardware failure. Data, including sex, age, screw density, end vertebra (C7 or T1), cervical sagittal alignment parameters (C2-C7 cervical lordosis, C2-C7 sagittal vertical axis, T1 slope, Cervical lordosis correction), regional Hounsfield units (HU) of the screw trajectory and osteoporosis status, were collected and compared between the two groups. RESULTS: We analysed the clinical data of 56 patients in total. The mean overall follow-up duration was 20.6 months (range, 12-30 months). Patients were divided into the hardware failure group (n = 14) and no hardware failure group (n = 42). There were no significant differences in the general information (age, sex, follow-up period) of patients between the two groups. The differences in fusion rate, fixation levels, and screw density between the two groups were not statistically significant (p > 0.05). The failure rate of fixation ending at T1 was lower than that at C7 (9% vs. 36.3%) (p = 0.019). The regional HU values of the pedicle screw (PS) and lateral mass screw (LMS) in the failure group were lower than those in the no failure group (PS: 267 ± 45 vs. 368 ± 43, p = 0.001; LMS: 308 ± 53 vs. 412 ± 41, p = 0.001). The sagittal alignment parameters did not show significant differences between the two groups before surgery or at the final follow-up (p > 0.05). The hardware failure rate in patients without osteoporosis was lower than that in patients with osteoporosis (14.3% vs. 57.1%) (p = 0.001). CONCLUSIONS: Osteoporosis, fixation ending at C7, and low regional HU value of the screw trajectory were the independent risk factors of hardware failure after laminectomy and PCF. Future studies should illuminate if preventive measures targeting these factors can help reduce hardware failure and identified more risk factors, and perform long-term follow-up.

Technical aspects of total spondylectomy of C2.

BACKGROUND: Tumorous involvement of the second cervical vertebra is an infrequent, but severe disease. Primary tumors and solitary metastases can be addressed by a radical procedure, a complete removal of the whole compartment. The second cervical vertebra has a highly complex anatomy, and its operation requires considerable surgical skills. The aim of this retrospective study is to present technical aspects of complete resection of C2 for tumor indications, clinical and radiological evaluation of our group of patients and comparison of results of recent reports on surgery in this region in the literature. METHODS: Between 2006 and 2019 we performed 10 total resections of C2 for primary bone tumor or solitary metastasis at our department. Operation was indicated for chordoma in 4 cases and for other diagnoses (plasmacytoma, EWSA, metastases of papillary thyroid carcinoma, medullary thyroid carcinoma, lung carcinoma and sinonasal carcinoma) in one case each. The operative procedure was in all cases performed in two steps. It always started with the posterior approach. The anterior procedure was scheduled according to the patient's condition after an average interval of 16.9 days (range 7-21). RESULTS: A stable upper cervical spine was achieved in all patients. A solid bone fusion over the whole instrumentation was present in all living patients and they returned to their preoperative activity level. By the final follow-up 6 patients died: one patient died on the 5th postop day because of diffuse uncontrollable bleeding from surgical wound, three patients died of generalization of the underlying disease and two patients due to complications associated with local recurrence of the disease. In addition to regular follow-ups, the surviving patients (N.=4) were also examined upon completion of the study, i.e., on average 91 months (range 17-179 months) postoperatively. With exclusion of an early deceased patient, the average follow-up period of deceased patients was 34.6 months (range 9-55) (N.=5). The average follow-up of the whole group of patients was 59,7 months (N.=9). CONCLUSIONS: Total spondylectomy of C2 is an exceptional surgical procedure associated with risk of serious complications but offers chance for a complete recovery of the patient. Defining indications accurately, especially in solitary metastases, is very difficult even with current level of imaging and other testing. The quality of life of long-term surviving patients in our study was not significantly impacted.

A Convolutional Neural Network for Automated Detection of Cervical Ossification of the Posterior Longitudinal Ligament using Magnetic Resonance Imaging.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: We aimed to develop and validate a convolutional neural network (CNN) model to distinguish between cervical ossification of posterior longitudinal ligament (OPLL) and multilevel degenerative spinal stenosis using Magnetic Resonance Imaging (MRI) and to compare the diagnostic ability with spine surgeons. SUMMARY OF BACKGROUND DATA: Some artificial intelligence models have been applied in spinal image analysis and many of promising results were obtained; however, there was still no study attempted to develop a deep learning model in detecting cervical OPLL using MRI images. MATERIALS AND METHODS: In this retrospective study, 272 cervical OPLL and 412 degenerative patients underwent surgical treatment were enrolled and divided into the training (513 cases) and test dataset (171 cases). CNN models applying ResNet architecture with 34, 50, and 101 layers of residual blocks were constructed and trained with the sagittal MRI images from the training dataset. To evaluate the performance of CNN, the receiver operating characteristic curves of 3 ResNet models were plotted and the area under the curve were calculated on the test dataset. The accuracy, sensitivity, and specificity of the diagnosis by the CNN were calculated and compared with 3 senior spine surgeons. RESULTS: The diagnostic accuracies of our ResNet34, ResNet50, and ResNet101 models were 92.98%, 95.32%, and 97.66%, respectively; the area under the curve of receiver operating characteristic curves of these models were 0.914, 0.942, and 0.971, respectively. The accuracies and specificities of ResNet50 and ResNet101 models were significantly higher than all spine surgeons; for the sensitivity, ResNet101 model achieved better values than that of the 2 surgeons. CONCLUSION: The performance of our ResNet model in differentiating cervical OPLL from degenerative spinal stenosis using MRI is promising, better results were achieved with more layers of residual blocks applied.

Single-institution Series of Hirayama Disease in North America.

STUDY DESIGN: A retrospective chart review. OBJECTIVE: The aims of this study were to review pathophysiology, workup, and treatment for Hirayama disease (HD); and to assess outcomes from a single institution. SUMMARY OF BACKGROUND DATA: HD is a rare, painless, cervical myelopathy with distal upper extremity weakness, muscle wasting, and spinal cord atrophy. Disease progression-a consequence of repeat flexion injury-occurs up to 5 years from the initial diagnosis. METHODS: Single-institution review of pediatric HD patients from 2010 to 2020. RESULTS: Patients (n=10 male, n=2 female) presented in the second decade (14-20 y) with painless progressive distal upper extremity weakness and atrophy without sensory loss. Electromyography (n=12) demonstrated denervation in C7-T1 myotomes and flexion/extension magnetic resonance imaging showed focal cord atrophy and anterior displacement of the posterior dura with epidural enhancement in flexion. Treatment included observation and external orthoses (n=9) and anterior cervical discectomy with fusion (n=3). One of the 9 patients managed conservatively experienced further deterioration; no patient who underwent anterior cervical discectomy with fusion progressed. CONCLUSIONS: Patients with HD require a multidisciplinary approach to diagnosis and treatment to preserve function. Treatment is preventive and aims to minimize flexion injury by inhibiting motion across involved joints. First-line management is avoidance of neck flexion and use of rigid orthosis; in cases of failed conservative management and/or rapid clinical deterioration, surgical fixation can be offered.

Impact of Frailty and Cervical Radiographic Parameters on Postoperative Dysphagia Following Anterior Cervical Spine Surgery.

STUDY DESIGN: Retrospective review of a prospectively collected registry. OBJECTIVE: The purpose of the present study was to investigate the impact of frailty and radiographical parameters on postoperative dysphagia after anterior cervical spine surgery (ACSS). SUMMARY OF BACKGROUND DATA: There is a growing body of literature indicating an association between frailty and increased postoperative complications following various surgeries. However, few studies have investigated the relationship between frailty and postoperative dysphagia after anterior cervical spine surgery. MATERIALS AND METHODS: Patients who underwent anterior cervical spine surgery for the treatment of degenerative cervical pathology were included. Frailty and dysphagia were assessed by the modified Frailty Index-11 (mFI-11) and Eat Assessment Tool 10 (EAT-10), respectively. We also collected clinical demographics and cervical alignment parameters previously reported as risk factors for postoperative dysphagia. Multivariable logistic regression was performed to identify the odds ratio (OR) of postoperative dysphagia at early (2-6 weeks) and late postoperative time points (1-2 years). RESULTS: Ninety-five patients who underwent ACSS were included in the study. Postoperative dysphagia occurred in 31 patients (32.6%) at the early postoperative time point. Multivariable logistic regression identified higher mFI-11 score (OR, 4.03; 95% CI: 1.24-13.16; P =0.021), overcorrection of TS-CL after surgery (TS-CL, T1 slope minus C2-C7 lordosis; OR, 0.86; 95% CI: 0.79-0.95; P =0.003), and surgery at C3/C4 (OR, 12.38; 95% CI: 1.41-108.92; P =0.023) as factors associated with postoperative dysphagia. CONCLUSIONS: Frailty, as assessed by the mFI-11, was significantly associated with postoperative dysphagia after ACSS. Additional factors associated with postoperative dysphagia were overcorrection of TS-CL and surgery at C3/C4. These findings emphasize the importance of assessing frailty and cervical alignment in the decision-making process preceding ACSS.

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.

Utility of a 2D kinematic HASTE sequence in magnetic resonance imaging assessment of adjacent segment degeneration following anterior cervical discectomy and fusion.

OBJECTIVES: To evaluate a dynamic half-Fourier acquired single turbo spin echo (HASTE) sequence following anterior cervical discectomy and fusion (ACDF) at the junctional level for adjacent segment degeneration comparing dynamic listhesis to radiographs and assessing dynamic cord contact and deformity during flexion-extension METHODS: Patients with ACDF referred for cervical spine MRI underwent a kinematic flexion-extension sagittal 2D HASTE sequence in addition to routine sequences. Images were independently reviewed by three radiologists for static/dynamic listhesis, and compared to flexion-extension radiographs. Blinded assessment of the HASTE sequence was performed for cord contact/deformity between neutral, flexion, and extension, to evaluate concordance between readers and inter-modality agreement. Inter-reader agreement for dynamic listhesis and impingement grade and inter-modality agreement for dynamic listhesis on MRI and radiographs was assessed using the kappa coefficient and percentage concordance. RESULTS: A total of 28 patients, mean age 60.2 years, were included. Mean HASTE acquisition time was 42 s. 14.3% demonstrated high grade dynamic stenosis (> grade 4) at the adjacent segment. There was substantial agreement for dynamic cord impingement with 70.2% concordance (kappa = 0.62). Concordance across readers for dynamic listhesis using HASTE was 81.0% (68/84) (kappa = 0.16) compared with 71.4% (60/84) (kappa = 0.40) for radiographs. Inter-modality agreement between flexion-extension radiographs and MRI assessment for dynamic listhesis across the readers was moderate (kappa = 0.41; 95% confidence interval: 0.16 to 0.67). CONCLUSIONS: A sagittal flexion-extension HASTE cine sequence provides substantial agreement between readers for dynamic cord deformity and moderate agreement between radiographs and MRI for dynamic listhesis. CLINICAL RELEVANCE STATEMENT: Degeneration of the adjacent segment with instability and myelopathy is one of the most common causes of pain and neurological deterioration requiring re-operation following cervical fusion surgery. KEY POINTS: • A real-time kinematic 2D sagittal HASTE flexion-extension sequence can be used to assess for dynamic listhesis, cervical cord, contact and deformity. • The additional kinematic cine sequence was well tolerated and the mean acquisition time for the 2D HASTE sequence was 42 s (range 31-44 s). • A sagittal flexion-extension HASTE cine sequence provides substantial agreement between readers for dynamic cord deformity and moderate agreement between radiographs and MRI for dynamic listhesis.

Monomelic Amyotrophy/Hirayama Disease: Surgical Outcome in a Large Cohort of Indian Patients.

BACKGROUND: Hirayama disease (HD) is a cervical compressive myelopathy. Anterior cervical discectomy and fusion (ACDF) is identified as the best surgical approach. We evaluated surgical outcomes and factors influencing ACDF in HD. METHODS: Between 2015 and 2019, 126 patients with HD underwent ACDF. Contrast magnetic resonance imaging of the cervical spine in full flexion was performed. Clinical examination and preoperative/postoperative assessment of hand function using Fugl-Meyer assessment, Jebsen-Taylor hand function test, and handheld dynamometry were performed at 3-monthly intervals for 1 year. Surgical outcomes were assessed as per the Odom criteria and Hirayama outcome questionnaire. RESULTS: Age at onset and duration of illness were 12-31 years (mean, 18 ± 2.7) and 1-96 months (32.7 ± 24.4), respectively. All patients had progressive weakness and wasting of the affected limb. Cord atrophy was seen in 97.1%, with epidural detachment and engorgement of the posterior epidural venous plexus in all. All patients underwent ACDF. Of these patients, 54% had an excellent/good outcome and 39% had a satisfactory outcome as per the Odom scale at last follow-up (mean, 44.9 ± 16.5 months) after surgery. Handheld dynamometry showed improvement from preoperative values to 1 year follow-up. Duration of illness and age at onset had a negative correlation and the preoperative Fugl-Meyer score had a positive correlation with improvement. CONCLUSIONS: ACDF resulted in remarkable improvement or stabilization in neurologic deficits in many patients with HD. Because motor disability ensues over time, early surgical intervention during the progressive phase is advocated.

The Impact of Cervical Degeneration and Sagittal Balance on Retro-Odontoid Soft-Tissue Thickness.

OBJECTIVE: To investigate whether retro-odontoid soft-tissue thickness (ROSTT) is associated with cervical degeneration, cervical spine mobility, and sagittal balance of cervical spine. METHODS: The data of 151 patients who presented at our hospital with cervical spondylosis were reviewed. The ROSTT was measured using T1-weighted sagittal cervical magnetic resonance imaging findings. The assessment of the degree of cervical intervertebral disc degeneration (IVDD) was conducted using sagittal T2-weighted imaging. The T1 slope (T1S), C0-C2 angle, C1-C2 angle, C2-C7 angle, C1-C7 sagittal vertical axis and C2-C7 sagittal vertical axis were measured. The range of motion was assessed by measuring the flexion-extension radiographs. According to the ROSTT, those measuring less than 3 mm were classified as normal group and those measuring larger than 3 mm were classified as thickened group. RESULTS: The thickened group had larger cervical IVDD grade, age, C2-C7 angle, and T1S compared to the normal group (all P < 0.05). Additionally, the C0-C2 angle was significantly smaller in the thickened group than in the normal group (P < 0.05). ROSTT showed a negative correlation with C0-C2 angle (r = -0.181, P < 0.05), but positive correlations with both C2-C7 angle (r = 0.255, P < 0.05) and T1S (r = 0.240, P < 0.05). Furthermore, ROSTT was positively correlated with age (r = 0277, P < 0.05) and cervical IVDD grade (Spearman, r = 0.299, P < 0.05). CONCLUSIONS: Cervical sagittal balance and cervical degeneration have a significant impact on ROSTT. Patients with a higher T1S and severe cervical degeneration are more likely to result in greater ROSTT.

Utility of Magnetic Resonance Imaging for Ligamentous Injury in Cervical Spine Trauma: A 2-Year Consecutive Case Cohort.

BACKGROUND: Magnetic resonance imaging (MRI) is increasingly used as an adjunct to spinal soft tissue evaluation in cervical spine (C-spine) trauma; however, the utility of this information remains controversial. In this consecutive observational study, we reviewed the utility of MRI in patients with C-spine trauma. METHODS: We identified patients in real time over a 2-year period as they presented to our level 1 trauma center for C-spine computed tomography (CT) scan followed by MRI. MRI was obtained by the trauma team prior to the spine service consultation if (1) they were unable to clear the C-spine according to protocol or (2) if the on-call radiologist reported a concern for ligamentous integrity from the CT findings. RESULTS: Thirty-three patients, including 19 males (58%) and 14 females, with a mean age of 54 years, were referred to the spine service for concerns of ligamentous instability. The most common mechanisms of injury were motor vehicle accidents (n = 13) and falls (n = 11). MRI demonstrated ligamentous signal change identified by the radiologist as potentially unstable in all patients. Fifteen patients (45%) had multiple C-spine ligaments affected. The interspinous ligament was involved most frequently (28%), followed by the ligamentum flavum (21%) and supraspinous ligament (15%). All patients underwent dynamic upright C-spine X-rays that were interpreted by both the ordering surgeon and radiologist. There was no evidence of instability in any patient; concurrence between X-ray interpretation was 100%. The cervical collar was successfully removed in all cases. No patients required late surgical intervention, and there were no return visits to the emergency department of a spinal nature. CONCLUSIONS: MRI signal change within the ligaments of the C-spine should be interpreted with caution in the setting of trauma. To physicians less familiar with spinal biomechanics, MRI findings may be perceived in an inadvertently alarming manner. Bony alignment and, when indicated, dynamic upright X-rays remain the gold standard for evaluating the ligamentous integrity of the C-spine.

[Diagnosis and treatment of 11 patients with cevical spondylotic amyotrophy].

OBJECTIVE: To explore clinical features, treatment methods and clinical effects of cervical spondylosis with proximal muscular atrophy. METHODS: Eleven patients with proximal-type cervical spondylotic amyotrophy were retrospectively studied from September 2016 to November 2020, including 7 males and 4 females, aged 38 to 68 years old. Clinical symptoms, MRI and neuroelectrophysiological manifestations were analyzed, and patients were treated with conservative treatment or anterior cervical decompression fusion surgery, respectively. The efficacy was evaluated by manual muscle test (MMT) before and after treatment, and patients' satisfaction was followed up at the same time. RESULTS: All patients were followed up for 6 to 19 months. All 11 patients were unilateral, mainly manifested by atrophy of deltoid muscle, supraspinatus muscle and infraspinatus muscle, and may be accompanied by ipsilateral neck and shoulder pain at early stage. MRI showed lesions at C4,5, C5,6 segments were more common. Electrophysiological examination showed the affected muscle was denervated, and amplitude of compound muscle action potential (CMAP) of innervated nerve on the affected side was lower than that on the healthy side. All patients were obtained bone fusion. One patient who were underwent anterior cervical corpectomy and fusion (ACCF) occurred developed contralateral C5 nerve root paralysis after operation, which recovered completely after 10 weeks of symptomatic treatment. At 12 months after operation, the efficacy was evaluated according to MMT, 3 patients were treated conservatively, 2 patients excellent and 1 good;in 8 patients treated by operation, 3 patients were excellent, 4 good, and 1 moderate. CONCLUSION: The incidence of cervical spondylosis with proximal muscular atrophy is low, which is manifested as unilateral proximal muscle atrophy and may be accompanied by ipsilateral neck and shoulder pain in the early stage. Combined with MRI and neuroelectrophysiological examination, misdiagnosis could be reduced. In the early stage of disease, especially in the case of nucleus pulposus protrusion leading to nerve compression, conservative treatment could be taken. When the conservative treatment is ineffective or the pain cannot be tolerated, anterior decompression surgery is recommended, and the overall effect is satisfactory.

Spinal Cord Signal Intensity Predicts Functional Outcomes in the Operative Management of Degenerative Cervical Myelopathy.

STUDY DESIGN: Prospective single institutional cohort study on degenerative cervical myelopathy (DCM) from 2009 to 2022. OBJECTIVE: This study aims to assess the relationship among preoperative spinal cord signal change, postoperative signal change evolution, and functional outcome in patients undergoing surgery for DCM. SUMMARY OF BACKGROUND DATA: There is conflicting evidence on whether spinal cord signal intensity influences functional outcomes in patients with DCM. PATIENTS AND METHODS: This prospective study investigated 104 patients with DCM that underwent both preoperative and routine postoperative cervical spine magnetic resonance imaging (MRI) as part of a research protocol. Signal intensity/grade, modified Japanese Orthopedic Association (mJOA) scores, signal resolution, and patient demographics were assessed. RESULTS: Sixty-eight of the subjects were found to have abnormal T2 spinal cord signal intensity changes on their preoperative MRI. The total mean preoperative mJOA score was 13.6, increasing postoperatively to 16 (P < 0.001). The presence or absence of preoperative spinal cord signal change was not associated with the change in mJOA score or neurological recovery rate after surgery. Of the 68 patients with preoperative T2 signal change, 36 were found to have an improvement in the T2-weighted signal grade after surgery and 32 had no change in postoperative signal grade. The mean improvement in mJOA score (3.7) and neurological recovery rate (70.3%) was significantly higher in the patients with preoperative signal change whose postoperative MRI signal change grade improved by at least one point compared with those that did not (2.0, 50.5%), (P < 0.001, P < 0.003). CONCLUSIONS: The presence of preoperative T2-weighted signal change was associated with lower preoperative mJOA scores, but no change in mJOA after surgery or postoperative neurological recovery rate. However, improvement in T2-weighted spinal cord signal grade on postoperative MRI was significantly associated with a degree of neurological improvement after surgery.