Objective To evaluate whether combining clinical frailty with magnetic resonance imaging (MRI)-derived posterior paraspinal muscle degeneration identifies perioperative risk phenotypes in adults aged ≥75 years undergoing lumbar fusion.
Methods We retrospectively studied patients aged ≥75 years undergoing lumbar fusion with preoperative lumbar MRI. Frailty was assessed using the Fried phenotype (frail: score ≥3). Posterior paraspinal muscle degeneration across L1–S1 was quantified using automated segmentation and a composite posterior frailty index (PFI); severe degeneration was defined as the upper quartile of PFI. Patients were classified into 4 frailty×muscle phenotypes. Primary outcomes were any in-hospital complication and prolonged length of stay (LOS ≥16 days).
Results Among 248 patients, phenotypes A–D (A, nonfrail/nonsevere; B, frail/nonsevere; C, nonfrail/severe; D, frail/severe) comprised 132, 54, 20, and 42 patients, respectively. Any in-hospital complication occurred in 18.2% of phenotype A compared with 50.0%–57.1% in phenotypes B–D (p<0.001). Prolonged LOS (≥16 days; cohort 75th percentile) occurred in 0.8% of phenotype A versus 38.9% (B), 35.0% (C), and 78.6% (D) (p<0.001), corresponding to absolute risk increases of +34.2 to +77.8 percentage points. After adjustment, higher-risk phenotypes remained independently associated with increased odds of any complication and prolonged LOS; however, the prolonged-LOS odds estimates were imprecise due to sparse events in the reference group. Phenotype was not independently associated with 90-day readmission. Pain improvement (ΔVAS [visual analogue scale]) was attenuated in phenotypes B and D, while differences in ΔODI (Oswestry Disability Index) were not statistically significant.
Conclusion Integrating frailty and MRI-based posterior paraspinal degeneration provides actionable stratification of complication and prolonged LOS risk after lumbar fusion in older adults.
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Objective This study aims to overcome challenges in lumbar spine imaging, particularly lumbar spinal stenosis, by developing an automated segmentation model using advanced techniques. Traditional manual measurement and lesion detection methods are limited by subjectivity and inefficiency. The objective is to create an accurate and automated segmentation model that identifies anatomical structures in lumbar spine magnetic resonance imaging scans.
Methods Leveraging a dataset of 539 lumbar spinal stenosis patients, the study utilizes the residual U-Net for semantic segmentation in sagittal and axial lumbar spine magnetic resonance images. The model, trained to recognize specific tissue categories, employs a geometry algorithm for anatomical structure quantification. Validation metrics, like Intersection over Union (IOU) and Dice coefficients, validate the residual U-Net’s segmentation accuracy. A novel rotation matrix approach is introduced for detecting bulging discs, assessing dural sac compression, and measuring yellow ligament thickness.
Results The residual U-Net achieves high precision in segmenting lumbar spine structures, with mean IOU values ranging from 0.82 to 0.93 across various tissue categories and views. The automated quantification system provides measurements for intervertebral disc dimensions, dural sac diameter, yellow ligament thickness, and disc hydration. Consistency between training and testing datasets assures the robustness of automated measurements.
Conclusion Automated lumbar spine segmentation with residual U-Net and deep learning exhibits high precision in identifying anatomical structures, facilitating efficient quantification in lumbar spinal stenosis cases. The introduction of a rotation matrix enhances lesion detection, promising improved diagnostic accuracy, and supporting treatment decisions for lumbar spinal stenosis patients.
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Objective Hounsfield units (HU), vertebral bone quality (VBQ), and bone mineral density (BMD) can all serve as predictive indicators for thoracolumbar fragility fractures. This study aims to explore which indicator provides better risk prediction for thoracolumbar fragility fractures.
Methods Patients who have received medical attention from The First Affiliated Hospital of Anhui Medical University for thoracolumbar fragility fractures were selected. A total of 78 patients with thoracolumbar fragility fractures were included in the study. To establish a control group, 78 patients with degenerative spinal diseases were matched to the fracture group on the basis of gender, age, and body mass index. The lumbar vertebral HU, the VBQ, and the BMD were obtained for all the 156 patients through computed tomography, magnetic resonance imaging, and dual-energy x-ray absorptiometry (DEXA). The correlations among these parameters were analyzed. The area under curve (AUC) analysis was employed to assess the predictive efficacy and thresholds of lumbar vertebral HU, VBQ, and BMD in relation to the risk of thoracolumbar fragility fractures.
Results Among the cohort of 156 patients, lumbar vertebral HU exhibited a positive correlation with BMD (p < 0.01). Conversely, VBQ showed a negative correlation with HU, BMD (p < 0.05). HU and BMD displayed a favorable predictive efficacy for thoracolumbar fragility fractures (p < 0.01), with HU (AUC = 0.863) showcasing the highest predictive efficacy, followed by the DEXA-measured BMD (AUC = 0.813). VBQ (AUC = 0.602) ranked lowest among the 3 indicators. The thresholds for predicting thoracolumbar fragility fractures were as follows: HU (88),VBQ (3.37), and BMD (0.81).
Conclusion All 3 of these indicators, HU, VBQ, and BMD, can predict thoracolumbar fragility fractures. Notably, lumbar vertebral HU exhibits the highest predictive efficacy, followed by the BMD obtained through DEXA scanning, with VBQ demonstrating the lowest predictive efficacy.
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Objective To investigate the characteristics of functional muscle and muscle size in patients with basilar invagination (BI) and explore the effects of atlantoaxial dislocation.
Methods Eighty BI patients (BI group) and 80 age- and sex-matched asymptomatic people (control group) were included. Axial T2 magnetic resonance imaging image was used to measure the cross-sectional area (CSA) and functional CSA (FCSA). The sternocleidomastoid (SCM), longus capitis and longus colli (LCap & LC), trapezius (Trap), splenius capitis (SpCap), splenius cervicis (SpC), semispinalis capitis (SSCap), semispinalis cervicis (SSC), multifidus (MS), levator scapulae (LS) and posterior deep layer muscles (PDLM) were evaluated. Correlations between age, atlantodental interval (ADI), Chamberlain distance and muscles were observed.
Results BI group (39.4 ± 18.4 years; 33 males/47 females) exhibited significantly lower FCSA/CSA ratios than the control group in all extensor and flexor muscles, and presented smaller CSAs on the right and left Trap, SSC, LS, SCM, and left LCap & LC. FCSA/CSA ratios were significantly lower in BI patients with dislocation on the right Trap, SpCap, SpC, SSCap, MS, LS, LCap & LC, and PDLM, and the left SSCap, MS, and LCap & LC than in patients without deformity. Additionally, functional muscles of all parameters decreased with age in BI patients. Excluding children, the Trap, SpC, MS, and LS muscle sizes of BI patients tended to increase with age. ADI and Chamberlain distance tended to correlate negatively with FCSA/CSA ratio.
Conclusion The BI patients, especially those with atlantoaxial dislocation, had less functional muscles compared with the control group. Moreover, their functional muscles decreased with age more obviously.
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Neurospine 2023;20(3):747-755. Published online June 20, 2023
Objective This study was aimed to report the clinical characteristics of intramedullary schwannomas and discuss imaging findings and treatment strategies.
Methods The inclusion criterion was consecutive patients with intramedullary schwannomas who were surgically treated at 8 centers between 2009 and 2020. Clinical characteristics included age, sex, clinical presentation, disease duration, and follow-up period. The modified McCormick scale was used to compare the preoperative and postoperative conditions. Pre- and postoperative magnetic resonance images (MRI) of each case were analyzed.
Results The mean age of the total 11 patients at the operation was 50.2 years. The mean duration of the symptoms was 23 months, with limb paresthesia being the most common clinical presentation. The cervical spine was the most common localization level of the tumor in 6 cases. The mean follow-up duration was 49.4 months. Gross total resection (GTR) and subtotal resection (STR) was achieved in 9 and 2 cases, respectively. According to the modified McCormick scale at 6 months postoperatively, 7 cases (63.6%) had improved and 4 cases (36.3%) had unchanged grades. Typical MRI findings of the intramedullary schwannoma included ring-like enhancement, syringomyelia, cystic formation, intramedullary edema, and hemosiderin deposition. Gadolinium enhancement was homogenous in 8 cases (72.7%). The tumor margins were well demarcated in all cases.
Conclusion Intramedullary schwannoma should be considered when sharp margins and well-enhanced tumors are present at the cervical spine level and the initial symptoms are relatively mild, such as dysesthesia. When GTR cannot be achieved, STR for tumor decompression is recommended.
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Objective Although cervical spondylotic myelopathy (CSM) can be easily diagnosed using magnetic resonance imaging (MRI), prediction of surgical effect using preoperative radiological examinations remains difficult. In previous studies, it was reported that diffusion tensor imaging (DTI) may be used for the prediction of surgical effect; however, these studies did not consider the influences of spinal cord compression even though the values of DTI indexes can be distorted by compressive lesions in patients with CSM. Therefore, it is uncertain whether preoperative DTI indexes can actually predict the surgical effect. The aim of this study was to investigate DTI metrics that are hardly affected by spinal cord compression and can accurately predict neurological status after decompressive surgery.
Methods Twenty-one patients with CSM who underwent surgery and 10 healthy volunteers were enrolled in this study. The subjects underwent cervical MRI, and values of DTI indexes including axial diffusivity (AD), radial diffusivity (RD), apparent diffusion coefficient (ADC), and fractional anisotropy (FA) were recorded at each intervertebral level. Further, the Japanese Orthopaedic Association (JOA) score of each patient with CSM was recorded before and after surgery for neurological status evaluation. Preoperative and postoperative values of DTI indexes were compared, and correlations between preoperative DTI parameters and postoperative neurological recovery were assessed.
Results After surgery, the lesion-adjacent (LA) ratios of RD and ADC increased (p = 0.04 and p = 0.062, respectively), while the LA ratio of FA decreased (p = 0.075). In contrast, the LA ratio of AD hardly changed. A negative correlation was observed between preoperative LA ratio of AD and JOA recovery rate 6 months after surgery (r = -0.379, p = 0.091). Based on preoperative LA ratio of AD, the patients were divided into a low AD group and a high AD group, and JOA recovery rate 6 months after surgery was found to be higher in the low AD group than in the high AD group (p = 0.024).
Conclusion In patients with CSM, preoperative LA ratio of AD is seldom affected by spinal cord compression, and it negatively correlates with JOA recovery rate 6 months after surgery.
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Objective Spinal meningiomas are neurosurgical rarities that manifest with progressive paraor tetraparesis. The effect of timing of surgery on the recovery after the loss of walking ability is poorly known. We studied the effect of timing of surgery on restoring walking ability in surgically-treated spinal meningioma patients.
Methods Using electronic health records, we retrospectively identified ≥ 18-year-old patients operated on during 2010–2020. The patients were followed until 30th September 2020, death or emigration.
Results We identified 108 patients (81% women) with operated spinal meningiomas. The mean age of the patients was 64 years (range, 18–94 years). A gross total resection was achieved in 101 (94%), and 21 patients (19%) suffered from perioperative complications. Of the 108 patients operated on, 49 (45%) could not walk without assistance prior to surgery. At the time of first postoperative visit (mean, 3.1 months; range, 1.3–13.1 months), 14 out of 24 patients (58%) operated on within 29 days and 8 out of 20 patients (40%) operated on later than 29 days since the loss of walking ability without assistance, were able to walk without assistance. Also, 3 out of 5 paraplegic patients who underwent surgery later than 29 days after they lost the walking ability, were able to at least walk with assistance at first postoperative visit.
Conclusion Early surgical treatment following the loss of walking ability restores walking ability in a substantial number of patients. However, even late surgery may restore walking ability.
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Objective The purpose of this study is to find the clinical and radiographic characteristics of traumatic craniocervical junction (CCJ) injuries requiring occipitocervical fusion (OC fusion) for early diagnosis and surgical intervention.
Methods We retrospectively reviewed 12 patients with CCJ injuries presenting to St. Michaels Hospital in Toronto who underwent OC fusion and looked into the following variables; (1) initial trauma data on emergency room arrival, (2) associated injuries, (3) imaging characteristics of computed tomography (CT) scan and magnetic resonance imaging (MRI), (4) surgical procedures, surgical complications, and neurological outcome.
Results All patients were treated as acute spinal injuries and underwent OC fusion on an emergency basis. Patients consisted of 10 males and 2 females with an average age of 47 years (range, 18–82 years). All patients sustained high-energy injuries. Three patients out of 6 patients with normal BAI (basion-axial interval) and BDI (basion-dens interval) values showed visible CCJ injuries on CT scans. However, the remaining 3 patients had no clear evidence of occipitoatlantal instability on CT scans. MRI clearly described several findings indicating occipitoatlantal instability. The 8 patients with normal values of ADI (atlantodens interval interval) demonstrated atlantoaxial instability on CT scan, however, all MRI more clearly and reliably demonstrated C1/2 facet injury and/or cruciate ligament injury.
Conclusion We advocate measures to help recognize CCJ injury at an early stage in the present study. Occipitoatlantal instability needs to be carefully investigated on MRI in addition to CT scan with special attention to facet joint and ligament integrity.
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This comprehensive review article aims to provide some definitive statements on the factors like clinical syndromes, radiological findings, and decompressive surgery, that may influence the outcomes in cervical spinal cord injury management. Literature search on these factors published in the last decade were analyzed and definite statements prepared and voted for consensus opinion by the WFNS Spine Committee members and experts in this field at a meeting in Moscow in June 2019 using Delphi method. This was re-evaluated in a meeting in Pakistan in November 2019. Finally, the consensus statements were brought out as recommendations by the committee to the world literature. Traumatic Spinal Cord Syndromes have good prognosis except in elderly and when the presenting neurological deficit was very poor. Though conservative management provides satisfactory results, results can be improved with surgery when instability and progressive compression was present. Locked facet with spinal cord injury denotes poor prognosis. Magnetic resonance imaging T2 imaging is the essential prognostic indicator that apart from sagittal grade, length of injury, maximum canal compromise, maximum spinal cord compression, axial grading (BASIC) score. Diffusion tensor imaging is the next promising predictor in the pipeline. Decompressive surgery when done earlier especially within 24 hours of injury provides better result and there is no clear evidence to show medical management is better or equivalent to delayed surgical management. Clinical syndromes, radiological syndromes, and surgical decompression have strong impact on the out comes in the management of cervical spinal cord injury. Our comprehensive review and final recommendations on this subject will be of great importance in understanding the complex treatment methods in use.
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Objective Spinal meningioma is mostly benign, but they can exhibit neurological deficit. The relationship between neurological impairment and its radiographic findings, including intratumor magnetic resonance imaging (MRI) gadolinium enhancement and calcification in computed tomography (CT) scan, has not been studied. The purpose of this study was to investigate the association of preoperative image findings with neurological status in spinal meningioma.
Methods Patients histologically diagnosed with spinal meningioma (n = 24), with an average age of 65.4 years, were included. The patients were classified into 2 groups, the homogeneous and heterogeneous groups, based on the contrast-enhanced T1-weighted MRI findings. Further, baseline demographics (age, sex, presence of preoperative paralysis [manual muscle testing 3 or worse neurological deficit in upper and/or lower limbs], tumor level, tumor length, and tumor occupation ratio), histological findings (Ki-67 index and histological subtypes), and CT findings (presence of intratumor calcification and Hounsfield unit [HU] value) were examined.
Results Preoperative paralysis was observed in 33.3% (8 of 24) of the patients. These patients exhibited frequent heterogeneous contrast-enhanced MRI findings than those without preoperative paralysis (57.1% vs. 14.3%, p = 0.040). Further, preoperative paralysis did not associate with tumor level, tumor length, tumor-occupied ratio, Ki-67 index, and histological subtypes. The heterogeneous group showed 100% intratumor calcification and higher maximum HU than the homogeneous group (1,109.8 vs. 379.2, p = 0.001).
Conclusion The heterogeneous contrast-induced MRI findings in the spinal meningioma were significantly associated with preoperative neurological impairment. Moreover, the intratumor contrast-deficient region in the heterogeneously enhanced tumors reflected marked calcification. The tumor hardness due to calcification may be related to preoperative neurological deficit.
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James D. Baker, Garrett K. Harada, Youping Tao, Philip K. Louie, Bryce A. Basques, Fabio Galbusera, Frank Niemeyer, Hans-Joachim Wilke, Howard S. An, Dino Samartzis
Neurospine 2020;17(1):190-203. Published online March 31, 2020
Objective To assess the impact of Modic changes (MC) on preoperative symptoms, and postoperative outcomes in anterior cervical discectomy and fusion (ACDF) patients.
Methods We performed a retrospective study of prospectively collected data of ACDF patients at a single institution. Preoperative magnetic resonance imagings were used to assess the presence of MC. MC were stratified by type and location, and compared to patients without MC. Associations with symptoms, patient-reported measures, and surgical outcomes were assessed.
Results A total of 861 patients were included, with 356 patients with MC (41.3%). MC more frequently occurred at C5–6 (15.1%), and type II was the most common type (61.2%). MC were associated with advanced age (p < 0.001), more levels fused (p < 0.001), a longer duration of symptoms, but not with specific symptoms. MC at C7–T1 resulted in higher postoperative disability (p < 0.001), but did not increase risk of adjacent segment degeneration or reoperation.
Conclusion This study is the first to systematically examine the impact of cervical MC, stratified by type and location, on outcomes in ACDF patients. Patients with MC were generally older, required larger fusions, and had longer duration of preoperative symptoms. While MC may not affect specific outcomes following ACDF, they may indicate a more debilitating preoperative state for patients.
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Machine learning represents a promising frontier in epidemiological research on spine surgery. It consists of a series of algorithms that determines relationships between data. Machine learning maintains numerous advantages over conventional regression techniques, such as a reduced requirement for a priori knowledge on predictors and better ability to manage large datasets. Current studies have made extensive strides in employing machine learning to a greater capacity in spinal cord injury (SCI). Analyses using machine learning algorithms have been done on both traumatic SCI and nontraumatic SCI, the latter of which typically represents degenerative spine disease resulting in spinal cord compression, such as degenerative cervical myelopathy. This article is a literature review of current studies published in traumatic and nontraumatic SCI that employ machine learning for the prediction of a host of outcomes. The studies described utilize machine learning in a variety of capacities, including imaging analysis and prediction in large epidemiological data sets. We discuss the performance of these machine learning-based clinical prognostic models relative to conventional statistical prediction models. Finally, we detail the future steps needed for machine learning to become a more common modality for statistical analysis in SCI.
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Objective This study presents the results of a systematic literature review conducted to determine most up-to-date information on the natural outcome of cervical spondylotic myelopathy (CSM) and the most reliable diagnostic techniques.
Methods A literature search was performed for articles published during the last 10 years.
Results The natural course of patients with cervical stenosis and signs of myelopathy is quite variable. In patients with no symptoms, but significant stenosis, the risk of developing myelopathy with cervical stenosis is approximately 3% per year. Myelopathic signs are useful for the clinical diagnosis of CSM. However, they are not highly sensitive and may be absent in approximately one-fifth of patients with myelopathy. The electrophysiological tests to be used in CSM patients are motor evoked potential (MEP), spinal cord evoked potential, somatosensory evoked potential, and electromyography (EMG). The differential diagnosis of CSM from other neurological conditions can be accomplished by those tests. MEP and EMG monitoring are useful to reduce C5 root palsy during CSM surgery. Notable spinal cord T2 hyperintensity on cervical magnetic resonance imaging (MRI) is correlated with a worse outcome, whereas lighter signal changes may predict better outcomes. T1 hypointensity should be considered a sign of more advanced disease.
Conclusion The natural course of CSM is quite variable. Signal changes on MRI and some electrophysiological tests are valuable adjuncts to diagnosis.
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This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick’s grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski’s sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.
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The assessment, diagnosis, operative and nonoperative management of degenerative cervical myelopathy (DCM) have evolved rapidly over the last 20 years. A clearer understanding of the pathobiology of DCM has led to attempts to develop objective measurements of the severity of myelopathy, including technology such as multiparametric magnetic resonance imaging, biomarkers, and ancillary clinical testing. New pharmacological treatments have the potential to alter the course of surgical outcomes, and greater innovation in surgical techniques have made surgery safer, more effective and less invasive. Future developments for the treatment of DCM will seek to improve the diagnostic accuracy of imaging, improve the objectivity of clinical assessment, and increase the use of surgical technology to ensure the best outcome is achieved for each individual patient.
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