Long-term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on magnetic resonance imaging

Clinical article

Mitsuru YagiOrthopedic Surgery, Kawasaki Municipal Hospital, Kawasaki City, Japan

Search for other papers by Mitsuru Yagi in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Ken NinomiyaOrthopedic Surgery, Kawasaki Municipal Hospital, Kawasaki City, Japan

Search for other papers by Ken Ninomiya in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Michiya KiharaOrthopedic Surgery, Kawasaki Municipal Hospital, Kawasaki City, Japan

Search for other papers by Michiya Kihara in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
, and
Yukio HoriuchiOrthopedic Surgery, Kawasaki Municipal Hospital, Kawasaki City, Japan

Search for other papers by Yukio Horiuchi in
jns
Google Scholar
PubMed
Close
 M.D., Ph.D.
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $384.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $624.00
USD  $45.00
USD  $384.00
USD  $624.00
Print or Print + Online Sign in

Object

The goal of this study was to determine the long-term clinical significance of and the risk factors for intramedullary signal intensity change on MR images in patients with cervical compression myelopathy (CCM), an entity most commonly seen with cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL).

Methods

One hundred seventy-four patients with CCM but without cervical disc herniation, severe OPLL (in which the cervical canal is < 10 mm due to OPLL), or severe kyphotic deformity (> 15° of cervical kyphosis) who underwent surgery were initially selected. One hundred eight of these patients were followed for > 36 months, and the 71 patients who agreed to MR imaging examinations both pre- and postsurgery were enrolled in the study (the mean follow-up duration was 60.6 months). All patients underwent cervical laminoplasty. The authors used the Japanese Orthopaedic Association (JOA) score and recovery ratio for evaluation of pre- and postoperative outcomes. The multifactorial effects of variables such as age, sex, a history of smoking, diabetes mellitus, duration of symptoms, postoperative expansion of the high signal intensity area of the spinal cord on MR imaging, sagittal arrangement of the cervical spine, presence of ventral spinal cord compression, and presence of an unstable cervical spine were studied.

Results

Change in intramedullary signal intensity was observed in 50 of the 71 patients preoperatively. The pre- and postoperative JOA scores and the recovery ratio were significantly lower in the patients with signal intensity change. The mean JOA score of the upper extremities was also significantly lower in these patients. Twenty-one patients showed hypointensity in their T1-weighted images, and a nonsignificant correlation was observed between intensity in the T1-weighted image and the mean JOA score and recovery ratio. The risk factors for signal intensity change were instability of the cervical spine (OR 8.255, p = 0.037) and ventral spinal cord compression (OR 5.502, p < 0.01). Among these patients, 16 had postoperative expansion of the high signal intensity area of the spinal cord. The mean JOA score and the recovery ratio at the final follow-up were significantly lower in these patients. The risk factor for postoperative expansion of the high signal intensity area was instability of the cervical spine (OR 5.509, p = 0.022). No significant correlation was observed between signal intensity on T1-weighted MR images and postoperative expansion of the intramedullary high signal intensity area on T2-weighted MR images.

Conclusions

Long-term clinical outcome was significantly worse in patients with intramedullary signal intensity changes on MR images. The risk factors were instability of the cervical spine and severe ventral spinal compression. The long-term clinical outcome was also significantly worse in patients with postoperative expansion of the high signal intensity area. The fact that cervical instability was a risk factor for the postoperative expansion of the high signal intensity indicates that this high signal intensity area occurred, not only from necrosis secondary to ischemia of the anterior spinal artery, but also from the repeated minor traumas inflicted on the spinal cord from an unstable cervical spine. The long-term neurological outcome found in the preliminary study of patients with CCM who had cervical instability and intramedullary signal intensity changes on MR images suggests that surgical treatment should include posterior fixation along with cervical laminoplasty or anterior spinal fusion.

Abbreviations used in this paper:

CCM = cervical compression myelopathy; JOA = Japanese Orthopaedic Association; OPLL = ossification of posterior longitudinal ligament.
  • Collapse
  • Expand
  • 1

    Alafifi T, , Kern R, & Fehlings M: Clinical and MRI predictors of outcome after surgical intervention for cervical spondylotic myelopathy. J Neuroimaging 17:315322, 2007

    • Search Google Scholar
    • Export Citation
  • 2

    Al-Mefty O, , Harkey LH, , Middleton TH, , Smith RR, & Fox JL: Myelopathic cervical spondylotic lesions demonstrated by magnetic resonance imaging. J Neurosurg 68:217222, 1988

    • Search Google Scholar
    • Export Citation
  • 3

    Benzel EC, , Lancon J, , Kesterson L, & Hadden T: Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. J Spinal Disord 4:286295, 1991

    • Search Google Scholar
    • Export Citation
  • 4

    Boakye M, , Patil CG, , Santarelli J, , Ho C, , Tian W, & Lad SP: Cervical spondylotic myelopathy: complications and outcomes after spinal fusion. Neurosurgery 62:455461, 2008

    • Search Google Scholar
    • Export Citation
  • 5

    Chen CJ, , Lyu RK, , Lee ST, , Wong YC, & Wang LJ: Intramedullary high signal intensity on T2-weighted MR images in cervical spondylotic myelopathy: prediction of prognosis with type of intensity. Radiology 221:789794, 2001

    • Search Google Scholar
    • Export Citation
  • 6

    Faiss JH, , Schroth G, , Grodd W, , Koenig E, , Will B, & Thron A: Central spinal cord lesions in stenosis of the cervical canal. Neuroradiology 32:117123, 1990

    • Search Google Scholar
    • Export Citation
  • 7

    Fenger-Gron J, , Kock K, , Nielsen RG, , Leth PM, & Illum N: Spinal cord injury at birth: a hidden causative factor. Acta Paediatr 97:824826, 2008

    • Search Google Scholar
    • Export Citation
  • 8

    Hasegawa K, , Hirano T, , Shimoda H, , Homma T, & Morita O: Indications for cervical pedicle screw instrumentation in nontraumatic lesions. Spine (Phila Pa 1976) 33:22842289, 2008

    • Search Google Scholar
    • Export Citation
  • 9

    Hilibrand AS, , Fye MA, , Emery SE, , Palumbo MA, & Bohlman HH: Impact of smoking on the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone Joint Surg Am 83:668673, 2001

    • Search Google Scholar
    • Export Citation
  • 10

    Jankowski R, , Nowak S, , Zukiel R, , Czekanowska-Szlandrowicz R, & Blok T: Surgical treatment of spinal instability: a clinical analysis of 196 cases. Ortop Traumatol Rehabil 30:5964, 2000

    • Search Google Scholar
    • Export Citation
  • 11

    Jinkins JR, , Bashir R, , Al-Mefty O, , Al-Kawi MZ, & Fox JL: Cystic necrosis of the spinal cord in compressive cervical myelopathy: demonstration by iopamidol CT-myelography. AJR Am J Roentgenol 147:767775, 1986

    • Search Google Scholar
    • Export Citation
  • 12

    Koop SE, , Winter RB, & Lonstein JE: The surgical treatment of instability of the upper part of the cervical spine in children and adolescents. J Bone Joint Surg Am 66:403411, 1984

    • Search Google Scholar
    • Export Citation
  • 13

    Lee TT, , Manzano GR, & Green BA: Modified open-door cervical expansive laminoplasty for spondylotic myelopathy: operative technique, outcome, and predictors for gait improvement. J Neurosurg 86:6468, 1997

    • Search Google Scholar
    • Export Citation
  • 14

    Li H, , Jiang LS, & Dai LY: A review of prognostic factors for surgical outcome of ossification of the posterior longitudinal ligament of cervical spine. Eur Spine J 17:12771288, 2008

    • Search Google Scholar
    • Export Citation
  • 15

    Liao KK, , Ju TH, , Wang SJ, , Chen IH, & Wu ZA: Tobacco intolerance in a habitual smoker with cervical myelopathy. Neurology 43:1435, 1993

  • 16

    Madhusudanan M, , Gracykutty M, & Cherian M: Athetosis-dystonia in intramedullary lesions of spinal cord. Acta Neurol Scand 92:308312, 1995

    • Search Google Scholar
    • Export Citation
  • 17

    Mastronardi L, , Elsawaf A, , Roperto R, , Bozzao A, , Caroli M, & Ferrante M, et al.: Prognostic relevance of the postoperative evolution of intramedullary spinal cord changes in signal intensity on magnetic resonance imaging after anterior decompression for cervical spondylotic myelopathy. J Neurosurg Spine 7:615622, 2007

    • Search Google Scholar
    • Export Citation
  • 18

    Matsuda Y, , Miyazaki K, , Tada K, , Yasuda A, , Nakayama T, & Murakami H, et al.: Increased MR signal intensity due to cervical myelopathy. Analysis of 29 surgical cases. J Neurosurg 74:887892, 1991

    • Search Google Scholar
    • Export Citation
  • 19

    Matsumoto M, , Toyama Y, , Ishikawa M, , Chiba K, , Suzuki N, & Fujimura Y: Increased signal intensity of the spinal cord on magnetic resonance images in cervical compressive myelopathy. Does it predict the outcome of conservative treatment?. Spine (Phila Pa 1976) 25:677682, 2000

    • Search Google Scholar
    • Export Citation
  • 20

    Mehalic TF, & Pezzuti RT: Increased MR signal intensity and myelopathy. J Neurosurg 76:171173, 1992

  • 21

    Mehalic TF, , Pezzuti RT, & Applebaum BI: Magnetic resonance imaging and cervical spondylotic myelopathy. Neurosurgery 26:217227, 1990

  • 22

    Mizuno J, , Nakagawa H, , Inoue T, & Hashizume Y: Clinicopathological study of “snake-eye appearance” in compressive myelopathy of the cervical spinal cord. J Neurosurg 99:2 Suppl 162168, 2003

    • Search Google Scholar
    • Export Citation
  • 23

    Morio Y, , Teshima R, , Nagashima H, , Nawata K, , Yamasaki D, & Nanjo Y: Correlation between operative outcomes of cervical compression myelopathy and mri of the spinal cord. Spine 26:12381245, 2001

    • Search Google Scholar
    • Export Citation
  • 24

    Okais N, , Moussa R, & Hage P: Value of increased MRI signal intensity in cervical arthrosis in myelopathies. Neurochirurgie 43:285290, 1997

    • Search Google Scholar
    • Export Citation
  • 25

    Onari K: Surgical treatment for cervical spondylotic myelopathy associated with athetoid cerebral palsy. J Orthop Sci 5:439448, 2000

  • 26

    Shimomura T, , Sumi M, , Nishida K, , Maeno K, , Tadokoro K, & Miyamoto H, et al.: Prognostic factors for deterioration of patients with cervical spondylotic myelopathy after nonsurgical treatment. Spine 32:24742479, 2007

    • Search Google Scholar
    • Export Citation
  • 27

    Sorar M, , Seçkin H, , Hatipoglu C, , Budakoglu II, , Yigitkanli K, & Bavbek M, et al.: Cervical compression myelopathy: is fusion the main prognostic indicator?. J Neurosurg Spine 6:531539, 2007

    • Search Google Scholar
    • Export Citation
  • 28

    Suda K, , Abumi K, , Ito M, , Shono Y, , Kaneda K, & Fujiya M: Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine 28:12581262, 2003

    • Search Google Scholar
    • Export Citation
  • 29

    Suri A, , Chabbra RP, , Mehta VS, , Gaikwad S, & Pandey RM: Effect of intramedullary signal changes on the surgical outcome of patients with cervical spondylotic myelopathy. Spine J 3:3345, 2003

    • Search Google Scholar
    • Export Citation
  • 30

    Wada E, , Yonenobu K, , Suzuki S, , Kanazawa A, & Ochi T: Can intramedullary signal change on magnetic resonance imaging predict surgical outcome in cervical spondylotic myelopathy?. Spine 24:455462, 1999

    • Search Google Scholar
    • Export Citation
  • 31

    White AA III, , Johnson RM, , Panjabi MM, & Southwick WO: Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop Relat Res 109:8596, 1975

    • Search Google Scholar
    • Export Citation
  • 32

    Wong AS, , Massicotte EM, & Fehlings MG: Surgical treatment of cervical myeloradiculopathy associated with movement disorders: indications, technique, and clinical outcome. J Spinal Disord Tech 18:S107S114, 2005

    • Search Google Scholar
    • Export Citation
  • 33

    Yukawa Y, , Kato F, , Ito K, , Horie Y, , Hida T, & Machino M, et al.: Postoperative changes in spinal cord signal intensity in patients with cervical compression myelopathy: comparison between preoperative and postoperative magnetic resonance images. J Neurosurg Spine 8:524528, 2008

    • Search Google Scholar
    • Export Citation
  • 34

    Yukawa Y, , Kato F, , Yoshihara H, , Yanase M, & Ito K: MR T2 image classification in cervical compression myelopathy: predictor of surgical outcomes. Spine 32:16751678, 2007

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1093 318 85
Full Text Views 224 39 3
PDF Downloads 278 49 6
EPUB Downloads 0 0 0