Correlation of imaging characteristics of degenerative cervical myelopathy and the surgical approach with improvement for postoperative neck pain and neural function: a retrospective cohort study

Abstract

Background: Complex degenerative cervical spondylotic myelopathy (DCM) is characterized by a variety of complex imaging features. The surgical method for DCM remains controversial. This study aimed to examine the correlation between the imaging characteristics of DCM with varying degrees of complexity and the surgical approach and clinical outcome.

Methods: A retrospective cohort study involving retrospective data collection was performed. A total of 139 patients with DCM who underwent surgery between January 2015 and January 2018 in the Orthopedics Department of Shanxi Bethune Hospital were divided into 3 groups according to the complexity of imaging features: 18 patients in the mild group, 66 patients in the moderate group, and 55 patients in the severe group. The Visual Analog Scale (VAS) and Japanese Orthopaedic Association (JOA) scores were used to compare the effects of neck pain and neural function prior to surgery according to the rate of improvement as of the last follow-up. Routine X-ray films were obtained at the follow-up of 3-6 months. The necessity of computed tomography (CT) and magnetic resonance imaging (MRI) examinations was determined based on clinical findings and X-ray images. Analysis of variance (ANOVA) was used to compare groups, the least significant difference (LSD) test was used for multiple comparisons, and the Chi-square test was used to compare classification indicators (imaging manifestations, gender), with P<0.05 being statistically significant. Binary logistic regression analysis was performed to determine the primary influencing factors of the JOA recovery rate.

Results: In all three groups, JOA and VAS scores at the final follow-up were significantly higher than those before surgery (P<0.001). There were significant differences in the preoperative VAS and JOA scores between any two groups, as well as in the VAS and JOA scores and improvement rates at the last follow-up between the mild group and the moderate group and between the mild group and the severe group (P<0.001). Age, preoperative JOA scores, MRI intramedullary hyperintensity signal, and the degree of spinal cord compression were primarily related to the nervous system recovery rate (P<0.001).

Conclusions: Age, MRI intramedullary hyperintensity signal, degree of spinal cord compression, and other variables were associated with the improvement of neural function in patients with DCM. Therefore, in addition to the JOA improvement rate or VAS score, additional factors, such as the patient's condition, the improvement in quality of life, and the patient's financial capacity, should be considered in evaluating the improvement of postoperative neck pain and neural function.

Keywords: Cervical spondylotic myelopathy; Japanese Orthopaedic Association scores (JOA scores); imaging; surgical approach.

Figure 1

Images from a 61-year-old male in the mild group before undergoing hybrid surgery. (A) The lateral or neutral X-ray revealed a straightened cervical curvature. (B,C) C4–5 and C6–7 intervertebral instability detected via dynamic X-ray imaging. (D) Sagittal CT revealed moderate C5–6 intervertebral space stenosis (arrow). (E-H) Sagittal T2WI and axial MRI revealed disc herniation at the C3–4 and C5–7 vertebrae, as well as spinal cord compression (arrows). CT, computed tomography; T2WI, T2-weighted imaging; MRI, magnetic resonance imaging.

Figure 2

Images from a 61-year-old male in the mild group at the last follow-up after hybrid surgery. (A-D) The cervical curvature, range of motion, and position of the prosthesis were all in good condition on lateral or neutral dynamic X-rays and sagittal CT scans. (E-H) Sagittal T2WI and axial MRI demonstrated complete spinal cord decompression. CT, computed tomography; T2WI, T2-weighted imaging; MRI, magnetic resonance imaging.

Figure 3

Images from a 49-year-old male in the moderate group before ACDF plus ACCF surgery. (A-C) Lateral, neutral, and dynamic X-rays revealed intervertebral instability at the C2–3 and C5–6 level with kyphosis (arrows). (D) Sagittal CT revealed severe stenosis of the C5–6 intervertebral space and osteophyte formation at the posterior margin of the vertebrae. (E-H) Sagittal T2WI revealed intramedullary hyperintensity signal at the C3–4 vertebrae, and axial MRI showed C3–6 disc herniation and spinal cord compression at the C3–6 vertebrae (arrows). ACDF, anterior cervical discectomy and fusion; ACCF, anterior cervical corpectomy decompression and fusion; CT, computed tomography; T2WI, T2-weighted imaging; MRI, magnetic resonance imaging.

Figure 4

Images from a 49-year-old male in the moderate group at the last follow-up after ACDF plus ACCF surgery. (A-D) Lateral or neutral dynamic X-rays and sagittal CT images revealed the recovery of the cervical spine’s physiological curvature, and the prosthesis was in good position. (E-H) Sagittal T2WI and axial MRI demonstrated complete spinal cord decompression. ACDF, anterior cervical discectomy and fusion; ACCF, anterior cervical corpectomy decompression and fusion; CT, computed tomography; T2WI, T2-weighted imaging; MRI, magnetic resonance imaging.

Figure 5

Images from a 74-year-old female in the severe group before laminectomy. (A) The lateral or neutral X-ray revealed dysgenesis of the posterior arch of the atlas (arrow) as well as anterior displacement of the posterior arch. (B,C) Dynamic X-ray revealed C2–3 intervertebral instability (arrows). (D) Sagittal CT revealed severe stenosis and hyperostosis of the C3–6 intervertebral space (arrows). (E) Sagittal T2WI demonstrated hypertrophy of the transverse ligament of the atlas, anterior displacement of the posterior arch of the atlas (arrows), compression of the anterior and posterior spinal cord margins at the C1 and C3–7 vertebrae, and intramedullary hyperintensity signals at the corresponding level. (F-K) Axial MRI demonstrated obvious horizontal spinal cord compression at the C1–7 vertebrae (arrows). CT, computed tomography; T2WI, T2-weighted imaging; MRI, magnetic resonance imaging.

Figure 6

Images from a 74-year-old female in the severe group during laminectomy and at the last follow-up. (A,B) The screw-rod system was in satisfactory position during surgery, and the dural sac was exposed after laminectomy and decompression of the C1–7 vertebrae. (C-F) Anteroposterior and lateral X-rays, along with 3D reconstruction CT, revealed that the implants were in a satisfactory position. (G,H) Sagittal T1WI demonstrated complete decompression of the C1–7 spinal cord, while T2WI demonstrated an intramedullary hyperintense signal. 3D, three-dimensional; CT, computed tomography; T1WI, T1-weighted imaging; T2WI, T2-weighted imaging.