The August 2023 Spine Roundup360 looks at: Changes in paraspinal muscles correspond to the severity of degeneration in patients with lumbar stenosis; Steroid injections are not effective in the prevention of surgery for degenerative cervical myelopathy; A higher screw density is associated with fewer mechanical complications after surgery for adult spinal deformity; Methylprednisolone following minimally invasive lumbar decompression: a large prospective single-institution study; Occupancy rate of pedicle screw below 80% is a risk factor for upper instrumented vertebral fracture following adult spinal deformity surgery; Deterioration after surgery for degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network.

In multilevel posterior cervical instrumented fusions, extending the fusion across the cervico-thoracic junction at T1 or T2 (CTJ) has been associated with decreased rate of re-operation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient reported outcomes (PROs) remains unclear. The primary objective was to determine whether extending the fusion through the CTJ influenced PROs at 3 and 12 months after surgery. Secondary objectives were to compare the number of patients reaching the minimally clinically important difference (MCID) for the PROs and mJOA, operative time duration, intra-operative blood loss (IOBL), length of stay (LOS), discharge disposition, adverse events (AEs), re-operation within 12 months of the surgery, and patient satisfaction. This is a retrospective analysis of prospectively collected data from a multicenter observational cohort study of patients with degenerative cervical myelopathy. Patients who underwent a posterior instrumented fusion of 4 levels of greater (between C2-T2) between January 2015 and October 2020 with 12 months follow-up were included. PROS (NDI, EQ5D, SF-12 PCS and MCS, NRS arm and neck pain) and mJOA were compared using ANCOVA, adjusted for baseline differences. Patient demographics, comorbidities and surgical details were abstracted. Percentafe of patient reaching MCID for these outcomes was compared using chi-square test. Operative duration, IOBL, AEs, re-operation, discharge disposittion, LOS and satisfaction were compared using chi-square test for categorical variables and independent samples t-tests for continuous variables. A total of 206 patients were included in this study (105 patients not crossing the CTJ and 101 crossing the CTJ). Patients who underwent a construct extending through the CTJ were more likely to be female and had worse baseline EQ5D and NDI scores (p> 0.05). When adjusted for baseline difference, there was no statistically significant difference between the two groups for the PROs and mJOA at 3 and 12 months. Surgical duration was longer (p 0.05). Satisfaction with the surgery was high in both groups but significantly different at 12 months (80% versus 72%, p= 0.042 for the group not crossing the CTJ and the group crossing the CTJ, respectively). The percentage of patients reaching MCID for the NDI score was 55% in the non-crossing group versus 69% in the group extending through the CTJ (p= 0.06). Up to 12 months after the surgery, there was no statistically significant differences in PROs between posterior construct extended to or not extended to the upper thoracic spine. The adverse event profile did not differ significantly, but longer surgical time and blood loss were associated with construct extending across the CTJ

The ability to calculate quality-adjusted life-years (QALYs) for degenerative cervical myelopathy (DCM) would enhance treatment decision making and facilitate economic analysis. QALYs are calculated using utilities, or health-related quality-of-life (HRQoL) weights. An instrument designed for cervical myelopathy disease would increase the sensitivity and specificity of HRQoL assessments. The objective of this study is to develop a multi-attribute utility function for the modified Japanese Orthopedic Association (mJOA) Score. We recruited a sample of 760 adults from a market research panel. Using an online discrete choice experiment (DCE), participants rated 8 choice sets based on mJOA health states. A multi-attribute utility function was estimated using a mixed multinomial-logit regression model (MIXL). The sample was partitioned into a training set used for model fitting and validation set used for model evaluation. The regression model demonstrated good predictive performance on the validation set with an AUC of 0.81 (95% CI: 0.80-0.82)). The regression model was used to develop a utility scoring rubric for the mJOA. Regression results revealed that participants did not regard all mJOA domains as equally important. The rank order of importance was (in decreasing order): lower extremity motor function, upper extremity motor function, sphincter function, upper extremity sensation. This study provides a simple technique for converting the mJOA score to utilities and quantify the importance of mJOA domains. The ability to evaluate QALYs for DCM will facilitate economic analysis and patient counseling. Clinicians should use these findings in order to offer treatments that maximize function in the attributes viewed most important by patients

Introduction. Degenerative cervical myelopathy (DCM) is associated with progressive neurological deterioration. Surgical decompression can halt but not reverse this progression. The Modified Japanese Orthopaedic Assessment (MJOA) tool is recommended by international guidelines to grade disease severity into mild, moderate and severe, where moderate and severe are both recommended to undergo surgical intervention. During Covid-19 Nottingham University Hospitals (NUH) NHS Trust, identified DCM patients as high risk for sustaining permanent neurological damage due to surgical delay. The Advanced Spinal Practitioner (ASP) team implemented a surveillance project to evaluate those at risk. Methods. A spreadsheet was compiled of all DCM patients known to the service. Patients were telephoned (Oct-Nov 2021) by an ASP. MJOA score was recorded and those describing progressive deterioration were reviewed by the ASP team on a spinal same day emergency assessment unit. Incident forms were completed for clinical deterioration and recorded as severe harm. Acute, progressive neurological deterioration was fast tracked for emergency surgical decompression. Results. 45 patients were telephoned, 18 (40%) had deteriorated. Of the 18, 9 underwent urgent surgical decompression, 6 still await surgery and 3 continue to be monitored. Those who had deteriorated were sent a formal apology and duty of candour letter. Conclusion. It appears that patients with a diagnosis of DCM deteriorate over time. Delays to timely surgical intervention can have a deleterious effect on patient's neurological function. Baseline assessment should be clearly documented and scoring system such as MJOA considered for effective monitoring. Safety netting for deterioration should be standard practice, and a clear pathway for emergency presentation identified. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Aims. The aim of this study was to use diffusion tensor imaging (DTI) to investigate changes in diffusion metrics in patients with cervical spondylotic myelopathy (CSM) up to five years after decompressive surgery. We correlated these changes with clinical outcomes as scored by the Modified Japanese Orthopedic Association (mJOA) method, Neck Disability Index (NDI), and Visual Analogue Scale (VAS). Methods. We used multi-shot, high-resolution, diffusion tensor imaging (ms-DTI) in patients with cervical spondylotic myelopathy (CSM) to investigate the change in diffusion metrics and clinical outcomes up to five years after anterior cervical interbody discectomy and fusion (ACDF). High signal intensity was identified on T2-weighted imaging, along with DTI metrics such as fractional anisotropy (FA). MJOA, NDI, and VAS scores were also collected and compared at each follow-up point. Spearman correlations identified correspondence between FA and clinical outcome scores. Results. Significant differences in mJOA scores and FA values were found between preoperative and postoperative timepoints up to two years after surgery. FA at the level of maximum cord compression (MCL) preoperatively was significantly correlated with the preoperative mJOA score. FA postoperatively was also significantly correlated with the postoperative mJOA score. There was no statistical relationship between NDI and mJOA or VAS. Conclusion. ms-DTI can detect microstructural changes in affected cord segments and reflect functional improvement. Both FA values and mJOA scores showed maximum recovery two years after surgery. The DTI metrics are significantly associated with pre- and postoperative mJOA scores. DTI metrics are a more sensitive, timely, and quantifiable surrogate for evaluating patients with CSM and a potential quantifiable biomarker for spinal cord dysfunction. Cite this article: Bone Joint J 2020;102-B(9):1210–1218

Aims. Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness. Patients and Methods. Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain. Results. There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group. Conclusion. This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis. Cite this article: Bone Joint J 2018;100-B:81–7

Introduction: Cervical kyphosis is failure of posterior osteo-ligamento-muscular restraint secondary to a deficient anterior column. Prospective studies of stand-alone anterior construct in correction and maintainence of cervical column that would otherwise require combined ant & post surgeries is sparse. Objectives: To evaluate the role of stand-alone anterior surgery for cervical kyphosis, determine its efficacy and analyse complications. Methods: 42 consecutive patients aged 6 – 70 yrs (Av 31.4 yrs) who had a Kyphosis angle of more than 100 with its apex between lower end-plate of C2 and C7 on a lateral x-ray and underwent anterior only surgery for cervical kyphosis over 6 yrs (2000–06) formed the population for this prospective study. The average follow-up was 2.2 yrs (1 – 5 yrs). The mean pre-op kyphosis was 20.820 (100 – 780). Etiology was tuberculosis in 25, dysplasia in 7, trauma in 6 and tumors in 4 cases respectively. 39 of the 42 patients had myelopathic signs. Mean pre-op mJOA score was 7.4 (0–11). A left anterior cervical approach was used in all cases. Modified manubriotomy was required in 5 cases to instrument the caudal vertebra. Tricortical iliac crest strut graft was used in 40 and cylindrical mesh cage in 2 cases. Correction of kyphosis was achieved by intra-op adjustment of the head assembly & controlled distraction. Post-operatively all wore cervical orthosis for 3 mo. Results: 41 patients were available for analysis (1 lost for f/u). The average number of corpectomies required were 2.5 (1–4) and the mean anterior column defect reconstructed was 27.3mm (22–42mm). The average graft subsidence was 3mm (0–10mm). 2 patients required revision surgery within 6 weeks for implant failure/graft resorption. Fusion occurred in rest of 39 patients. No further graft subsidence was noticed at 4 years in 17 patients. Spontaneous fusion at 3 mo was seen in normal adjacent segment due to plate overlapping in 2 cases. The average correction achieved was 15.220 (−40–730). The mortality rate was 2.12% (1 case). Visceral complications occurred in 3 cases (esophageal perforation in 1 and recurrent laryngeal nerve palsy in 2). The mean post-operative mJOA score was 14 (9 – 17). There was 1 deep and 1 superficial infection. Conclusion: Ant decompression & reconstruction with instrumentation facilitates neurological recovery restoring alignment. Intra-op maneuvering allows the graft to be placed in an optimal position that allows fusion under compression

Introduction: Formulation of surgical protocol in CSM is marred by the diversity in clinico-radiological presentation. Prospective data that assigns a specific surgery with identifiable similarities in clinico-radiological attributes is sparse. Objectives:. To identify radiological patterns of compression (POC) of the spinal cord. To develop a surgical protocol based on POC and determine its efficacy. To identify parameters predicting outcome of surgery. Methods: 135 consecutive patients aged 32–75 yrs (mean 48.1yr) operated for CSM from 1999–2005 formed the study group for this prospective series. The objectives were to identify radiological patterns of compression (POC), develop a surgical algorithm based on POC and evaluate outcome. Four POC were identified on MRI. Pattern I – predominant one/two level compression in normal/narrow canal. Pattern II – anterior & posterior compression at one/ two levels (pincer cord). Pattern III – Three or more levels of predominant anterior compression with a normal canal. Pattern III(A) – Pattern III in a patient with multiple medical co-morbidities. Pattern IV – Three/more levels of anterior compression in narrow canal +/− posterior compression (beaded cord). Pattern IV(A) – Pattern IV with one/two level severe compression amongst the multiple anterior compressions. Mean follow-up was 3 yrs (2–8). ACDF was performed for patterns I, II & III and posterior decompression for pattern IV and III(A). For pattern IV(A), a two stage primary posterior decompression followed by targeted ACDF at the site of maximal compression was performed. The clinical outcome was measured by modified JOA (mJOA) score, Hirayabashi Recovery Rate (HRR) and functional outcome by modified Neck Disability Index (NDI). Results: The mean pre & post-op mJOA score was 10.40±3.33 & 15.76±1.45 respectively with average HRR of 80.10 ± 26.38. The difference in the mJOA scores was statistically significant (unpaired t test) for each POC. In multilevel CSM, anterior surgery in POC type III had statistically better post op mJOA as compared to those who underwent posterior surgery viz POC types IV and III & IV variants although the difference in their HRR and NDI were not statistically significant. Conclusion: Anterior surgery has better neurological outcome in judiciously selected patients with multilevel CSM. Surgical decision-making guided by patterns of compression (POC) is pivotal for optimal functional outcome

A retrospective review, comparing outcome following circumferential versus anterior decompression and fusion for patients with cervical spondylotic myelopathy (CSM). To assess the safety and efficacy of the circumferential operation for CSM. Cervical spondylotic myelopathy has traditionally been managed by anterior or posterior decompression with/ without fusion. However, there is a considerable variation in neurological recovery and clinical outcome following these procedures. While circumferential decompression and fusion has been shown to provide superior neurological outcome in selected patients with cervical trauma and tumours, its role in the management of CSM has yet to be clearly defined. Fifteen patients who underwent a 360° operation (Groupl) for CSM were matched (age, number of levels operated and follow-up duration) with patients (Group 2, n=15), that underwent anterior decompression and fusion for the same problem. All patients were operated by a single surgeon and reviewed independently. Charts, radiographs, patient interviews and MODEMS Cervical Spine Outcome questionnaires were the basis for assessment. The operative time, blood loss, in-hospital stay and post-operative complications were higher in group l. The pseudoarthrosis rate was comparable though a trend towards increased graft and hardware problems was noted in group 2. Neurological improvement as measured by the mJOA Myelopathy Scale was significantly better (p = 0. 039) in group 1. 87% of those in group1 and 67% in group 2 showed improved function. Patients in group1 also performed better (p=0. 056) in the neurological domain and treatment expectation scales of the cervical spine questionnaire, though the incidence of post-op, neck pain was higher. Single stage circumferential spinal decompression and fusion permits consistent neurological recovery in selected patients with cervical spondylotic myelopathy and it can be performed with limited morbidity