Clinical Outcomes in Patients With COVID-19 and Hematologic Disease.

BACKGROUND: Patients with hematologic diseases are at higher risk of the SARS-CoV-2 infection and more severe clinical outcomes of the coronavirus disease. CHRONOS19 is an observational prospective cohort study with the aim to determine the short and longer-term clinical outcomes, risk factors for disease severity and mortality, and rates of postinfectious immunity in patients with malignant and nonmalignant hematologic diseases and COVID-19. PATIENTS AND METHODS: Overall, 666 patients were enrolled in the study, of which 626 were included in the final data analysis. The primary endpoint was 30-days all-cause mortality. Secondary endpoints included COVID-19 complications, rates of ICU admission and mechanical ventilation, outcomes of a hematologic disease in SARS-CoV-2 infected patients, overall survival, and risk factors for disease severity and mortality. Data from 15 centers were collected at 30, 90, and 180 days after COVID-19 was diagnosed and were managed using a web-based e-data capture platform. All evaluations were performed in the pre-omicron period of COVID-19 pandemic. RESULTS: Thirty-days all-cause mortality was 18.9%. The predominant cause of death (in 80% of cases) were COVID-19 complications. At 180 days, the majority (70%) of additional deaths were due to hematologic disease progression. At a median follow-up of 5.7 [0.03-19.04] months, 6-months overall survival was 72% [95% CI: 0.69-0.76]. One-third of patients had severe SARS-CoV-2 disease. The rate of ICU admission was 22% with 77% of these patients requiring mechanical ventilation, with poor survival rate. A univariate analysis revealed that older age (≥ 60 years), male sex, malignant hematologic disease, myelotoxic agranulocytosis, transfusion dependence, refractory disease or relapse, diabetes among comorbidities, any complications, especially ARDS alone or in combination with CRS, admission to an ICU, and mechanical ventilation were associated with higher risks of mortality. Treatment of the hematologic disease was changed, postponed, or canceled in 63% of patients. At a longer follow-up (90 and 180 days), the status of the hematologic disease changed in 7.5% of patients. CONCLUSION: Patients with hematologic disease and COVID-19 have high mortality rates, predominantly due to COVID-19 complications. At a longer-term follow-up, no significant impact of COVID-19 on the course of a hematologic disease was revealed.

Predictors of outcome in patients with degenerative cervical spondylotic myelopathy undergoing surgical treatment: results of a systematic review.

PURPOSE: To conduct a systematic review of the literature to determine important clinical predictors of surgical outcome in patients with cervical spondylotic myelopathy (CSM). METHODS: A literature search was performed using MEDLINE, MEDLINE in Process, EMBASE and Cochrane Database of Systematic Reviews. Selected articles were evaluated using a 14-point modified SIGN scale and classified as either poor (<7), good (7-9) or excellent (10-14) quality of evidence. For each study, the association between various clinical factors and surgical outcome, evaluated by the (modified) Japanese Orthopaedic Association scale (mJOA/JOA), Nurick score or other measures, was defined. The results from the EXCELLENT studies were compared to the combined results from the EXCELLENT and GOOD studies which were compared to the results from all the studies. RESULTS: The initial search yielded 1,677 citations. Ninety-one of these articles, including three translated from Japanese, met the inclusion and exclusion criteria and were graded. Of these, 16 were excellent, 38 were good and 37 were poor quality. Based on the excellent studies alone, a longer duration of symptoms was associated with a poorer outcome evaluated on both the mJOA/JOA scale and Nurick score. A more severe baseline score was related with a worse outcome only on the mJOA/JOA scale. Based on the GOOD and EXCELLENT studies, duration of symptoms and baseline severity score were consistent predictors of mJOA/JOA, but not Nurick. Age was an insignificant predictor of outcome on any of the functional outcomes considered. CONCLUSION: The most important predictors of outcome were preoperative severity and duration of symptoms. This review also identified many other valuable predictors including signs, symptoms, comorbidities and smoking status.

Do quantitative magnetic resonance imaging parameters correlate with the clinical presentation and functional outcomes after surgery in cervical spondylotic myelopathy? A prospective multicenter study.

STUDY DESIGN: A prospective multicenter cohort study. OBJECTIVE: To establish the relationship between preoperative quantitative magnetic resonance imaging (MRI) parameters and clinical presentation and postoperative outcomes in patients with cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: Correlation of magnetic resonance imaging with clinical presentation and outcomes in cervical spondylotic myelopathy is poorly understood. METHODS: A total of 134 magnetic resonance imaging scans were reviewed from 12 sites across North America. The transverse area (TA) of the spinal cord at the site of maximal compression was computed, and spinal cord signal intensity (SI) changes on T1-/T2-weighted imaging (WI) were evaluated. Detailed clinical assessments--neurological signs, symptoms, Nurick grade, modified Japanese Orthopaedic Association, segmental-tract score, and long-tract score of modified Japanese Orthopaedic Association, 30-m walk test, Short-Form 36 questionnaire, and neck disability index were performed at admission, 6 months, and 12 months postoperatively. RESULTS: The total number of neurological signs in a patient correlated with TA (P = 0.01) and SI changes on T1-/T2WI (P = 0.05). Pre- and postoperative Nurick grade (P = 0.03, P = 0.02), modified Japanese Orthopaedic Association score (P = 0.005, P = 0.001), segmental-tract score (P = 0.05, P = 0.006), and long-tract score (P = 0.006, P = 0.002), 30-m walk test (P = 0.002, P = 0.01) correlated with TA. There was no significant difference in pre- and postoperative clinical scores in patients with/without SI changes. Patients with severe cord compression showed SI changes on T1-/T2WI more frequently (r =-0.27, r =-0.38). Pyramidal signs--plantar response, Hoffmann reflex and hyper-reflexia correlated with TA (P = 0.003, P = 0.0004, P = 0.024, respectively) and SI changes on T1/T2WI (P = 0.02). CONCLUSION: TA closely mirrors the clinical presentation of cervical spondylotic myelopathy and may be used in predicting surgical outcomes. Pyramidal signs correlated with TA and/or SI changes on T1-/T2WI. The total number of neurological signs in a patient correlated with TA. There was no significant relationship between TA, age and duration of symptoms. LEVEL OF EVIDENCE: 3.

Assessment of spinal cord compression by magnetic resonance imaging--can it predict surgical outcomes in degenerative compressive myelopathy? A systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: We sought to conduct a systematic review to examine the role of magnetic resonance imaging in predicting outcomes after surgery and to evaluate the evidence currently available critically. SUMMARY OF BACKGROUND DATA: Degenerative compressive myelopathy is a common clinical problem associated with adverse health outcomes. Although a number of studies have investigated the association between preoperative magnetic resonance imaging characteristics and outcomes after surgery for degenerative compressive myelopathy, the conclusions of these studies have often yielded differing results. METHODS: Articles examining the predictive value of magnetic resonance imaging were obtained from MEDLINE, EMBASE, and PubMed databases (1980-2011). Thirty publications that met the inclusion criteria were reviewed. Two reviewers independently assessed each study regarding the level of evidence (using the criteria proposed by Sackett) and methodological quality based on revised Cochrane quality assessment checklist. RESULTS: Three excellent, 1 good, and 10 poor quality studies assessed cord compression--transverse area (4), compression ratio (5), and anteroposterior diameter (1). Relationship between signal intensity (SI) changes and surgical outcomes were reviewed by 28 studies--8 excellent, 9 good, and 13 poor quality studies. SI changes within the spinal cord included the presence of SI on T2-weighted image (WI) (17), area of SI on T2WI (8), degree of SI on T2WI (5), presence of SI on both T1-/T2WI (2), SI ratio on T2WI (2), and the position of SI on T2WI (1). CONCLUSION: Based on a combination of excellent and good quality studies, transverse area correlates with recovery ratio but not with postoperative functional score assessed by Japanese Orthopaedic Association/modified Japanese Orthopaedic Association scores. SI changes defined by (1) its presence on T2WI, (2) its extent (focal or multisegmental), (3) its brightness, and (4) its presence on both T1-/T2WI can predict surgical outcomes in degenerative compressive myelopathy.

Predictors of surgical outcome in cervical spondylotic myelopathy.

STUDY DESIGN: Prospective study. OBJECTIVE: To determine whether magnetic resonance imaging and clinical and demographic findings in patients with cervical spondylotic myelopathy (CSM) were independently associated with baseline functional scores and whether these were also predictive of postoperative functional outcomes. SUMMARY OF BACKGROUND DATA: There are considerable limitations in current literature that prevent making formal recommendations regarding the use of clinical and radiological prognostic factors in patients with CSM. METHODS: This prospective study included 65 consecutive patients with CSM treated in a tertiary referral center. The modified Japanese Orthopaedic Association (mJOA) scale was used to quantify disability at admission and at 12-month follow-up. Age, sex, duration of symptoms, severity of myelopathy, spinal column alignment, surgical technique, levels of compression, anteroposterior diameter and transverse area at the site of maximal cord compression, and magnetic resonance imaging signal intensity changes were assessed. Data were analyzed using Spearman rank correlation test, analysis of variance, Mann-Whitney U test, and stepwise multivariate regression. RESULTS: Higher baseline mJOA scores were associated with younger age (P = 0.0002), shorter duration of symptoms (P = 0.03), and greater transverse area (P = 0.02). Better recovery ratio was associated with younger age (P = 0.005) and higher baseline mJOA score (P = 0.003). Greater changes in mJOA score were associated with higher baseline mJOA score (P < 0.0001). Using multivariate analysis, the functional outcomes after surgery were best predicted by baseline mJOA score and age of patient. CONCLUSION: Age and baseline mJOA scores were highly predictive of outcome for patients undergoing surgical treatment of CSM. The degree of spinal cord compression and patterns of signal intensity changes on T1/T2 weighted images were not independently predictive of outcome, but it was found to correlate with the functional status at the time of presentation and age of the patient. The duration of symptoms correlated well with preoperative functional status but did not seem to affect the postoperative outcome.

Reliability of quantitative magnetic resonance imaging methods in the assessment of spinal canal stenosis and cord compression in cervical myelopathy.

STUDY DESIGN: Prospective, blinded reliability study of quantitative magnetic resonance imaging (MRI) measures in patients with cervical myelopathy. OBJECTIVE: To assess the intra- and interobserver reliability of commonly used quantitative MRI measures such as transverse area (TA) of spinal cord, compression ratio (CR), maximum canal compromise (MCC), and maximum spinal cord compression (MSCC). SUMMARY OF BACKGROUND DATA: There is no consensus on an optimal quantitative MRI method(s) in assessing canal stenosis and cord compression. METHODS: Seven surgeons performed measurements on 17 digital MR images, on 4 separate occasions. The degree of stenosis was evaluated by measuring TA and CR on axial T2, MCC, and MSCC on midsagittal T1- and T2-weighted MRI sequences, respectively. Statistical analyses included repeated-measures analysis of variance and intraclass correlation coefficients (ICCs). RESULTS: The mean ± SD for intraobserver ICC was 0.88 ± 0.1 for MCC, 0.76 ± 0.08 for MSCC, 0.92 ± 0.07 for TA, and 0.82 ± 0.13 for CR. In addition, the interobserver ICC was 0.75 ± 0.04 for MCC, 0.79 ± 0.09 for MSCC, 0.80 ± 0.05 for CR, and 0.86 ± 0.03 for TA. Higher degree of canal compromise (MCC) was associated with lower modified version of Japanese Orthopaedic Association Scale score (P = 0.05). Also, a strong association was found between MSCC and lower modified version of Japanese Orthopaedic Association Scale score, greater number of steps, and longer walking time (P < 0.05). CONCLUSION: All 4 measurement techniques demonstrated a good to moderately high degree of intra- and interobserver reliability. Highest reliability was noted in the assessment of T2-weighted sequences and axial MRI. Our results show that the measurements of MCC, MSCC, and CR are sufficiently reliable and correlate well with clinical severity of cervical myelopathy.

Postoperative magnetic resonance imaging can predict neurological recovery after surgery for cervical spondylotic myelopathy: a prospective study with blinded assessments.

BACKGROUND: Factors that can predict the recovery of cervical spondylotic myelopathy (CSM) patients postoperatively are of significant interest to physicians and patients and their families. Magnetic resonance imaging (MRI) scans are a common method of examination after surgery, and thus of interest as a predictor of outcome. OBJECTIVE: To investigate whether findings on MRI at 6 months postoperatively could predict recovery at 1 year in CSM patients. METHODS: In 52 consecutive prospective patients, MRI was performed preoperatively and 6 months postoperatively. T1 and T2 signal change (area, height, and segmentation) and spinal cord re-expansion were measured. Outcome measures evaluated at 1 year postoperatively were compared with preoperative values. Univariate and stepwise multiple regressions were undertaken. RESULTS: Using univariate analysis, patients whose cord failed to re-expand had poorer outcome according to the modified Japanese Orthopedic Association score and Nurick score (P = .014) and grip test (P = .006) postoperatively. Stepwise multivariate regression showed lack of cord re-expansion to be predictive of prognosis postoperatively in the modified Japanese Orthopedic Association score (P = .013) and Berg Balance Scale (P = .014), and walking test (P = .011). Postoperative hyperintense T2 signal change was predictive of worse outcome on the Berg Balance Scale (P = .014) and walking test (P = .020), Nurick score (P = .001), and Short Form-36 scores (P = .020). In cases in which the T2 signal intensified, there was a poorer outcome on Nurick scores (P = .013), grip test (P = .017), and Short Form-36 scores (P = .030). CONCLUSION: Findings on postoperative MRI at 6 months is of predictive value in determining outcomes in CSM patients. The persistence and type of T2 signal change and lack of re-expansion of the cord correlate with poorer recovery and likely reflect irreversible structural changes in the spinal cord.

Accuracy and reliability of MRI quantitative measurements to assess spinal cord compression in cervical spondylotic myelopathy: a prospective study.

STUDY TYPE: Reliability study Introduction: Cervical spondylotic myelopathy (CSM) is the most common spinal cord disorder in persons more than 55 years old. Despite multiple neuroimaging approaches proposed to quantify the spinal cord compromise in CSM patients, magnetic resonance imaging (MRI) remains the procedure of choice by providing helpful information for clinical decision making, determining optimal subpopulations for treatment, and selecting the optimal treatment strategies. However, the validity, reliability, and accuracy of the MRI quantitative measurements have not yet been addressed. OBJECTIVE: To assess the intra- and inter-observer reliability of MRI quantitative measurements of the spinal cord compromise in CSM patients. METHODS: Seventeen CSM patients (13 male) of mean age 54.5 years old were selected from the AOSpine North America database. The patients had different combinations of stenotic levels (1-4 levels) and the clinical severity (range mJOA baseline: 8-18). Asymptomatic or previous surgically treated CSM, active infection, neoplastic disease, rheumatoid arthritis, ankylosing spondylitis, trauma, or concomitant lumbar stenosis were excluded. The patients underwent preoperative MRI using 1.5T (15 patients) and 3T (two patients) scanner, including mid-sagittal T1-weighted, axial and mid-sagittal T2-weighted series. MRI data were analyzed (Mango 2.0 software; Multi-Image Analysis GUI) by four blind raters in three different sessions. Four measurements were analysed: transverse area (TA) (Figure 1), compression ratio (CR) (Figure 2), maximal canal compromise (MCC), and maximal spinal cord compression (MSCC) (Figure 3). The differences for each measurement were evaluated using mixed-effect ANOVA models (ratter, session, ratter x session). The intra- and inter-rater reliability was evaluated with intraclass correlation coefficients (ICC) (Figure 4). Figure 1 Transverse area (TA)Figure 2 Compression ratio (CR = AP/W)Figure 3 Maximal canal compromise (MCC), and maximal spinal cord compression (MSCC). MCC(%) = 1-[Dx/(Da+Db)/2] × 100%; MSCC(%) = 1-[dx/(da+db)/2] × 100%Figure 4 Intraclass correlation coefficients (ICC) Results: The principal findings were: (i) for TA (71.48 ± 12.99mm2), the intra-rater agreement was 0.97 (95% CI, range 0.94-0.99) and the inter-rater agreement was 0.76 (95% CI, range 0.49-0.90); (ii) for CR (0.35 ± 0.04%), 0.94 (95% CI, range 0.88-0.98), and 0.79 (95% CI, range 0.57-0.91) respectively; (iii) for MCC (83.21 ± 2.08%), 0.95 (95% CI, range 0.89-0.98), and 0.64 (95% CI, range 0.28-0.85) respectively; and (iv) for MSCC (82.87 ± 1.52%), 0.93 (95% CI, range 0.86-0.97), and 0.84 (95% CI, range 0.65-0.93) respectively. CONCLUSIONS: Our data suggest that three out of four measurements (TA, CR and MSCC) have acceptable intra- and interreliability coefficients (ICC > 0.75). However, for the maximal canal compromise measure, although the intrareliability was acceptable, the inter-rater reliability was not acceptable (0.64). Based on this study, we recommend that three MRI measures: transverse area, compression ratio and maximal spinal cord compression should be used in the imaging assessment of the spinal cord in CSM patients.