Article Review 4

Author’s Name

Andrei F. Joaquim, Enrico Ghizoni, Helder Tedeschi, Wellington K. Hsu, Alpesh A. Patel

Article Title

Management of Degenerative Cervical Myelopathy – An Update (2016)

Journal Name

Revista Da Associação Médica Brasileira

1) Bibliography

Joaquim, A. F., Ghizoni, E., Tedeschi, H., Hsu, W. K., & Patel, A. A. (2016). Management of degenerative cervical myelopathy – An update. Revista Da Associação Médica Brasileira, 62(9), 886-894. doi:10.1590/1806-9282.62.09.886

2) Purpose of the Article

The purpose of this article was to discuss the most important factors involved in the surgical management of degenerative cervical myelopathy (DCM), including the approaches. 

3) Brief Description of Procedure and Findings/Results

This article summarizes the different imaging approaches as an additional work-up in managing DCM:

i) Plain radiography - Initial investigation of DCM is based on simple plain cervical radiographs, including flexion-extension exams to detect occult instability. Based on simple plain cervical radiographs, the Pavlov ratio can be measured to estimate congenital narrowing of the spinal canal, a major risk of DCM, and the mean value of the spinal canal in the anteroposterior (AP) diameter. Radiographs may be useful for assessment of global sagittal balance in patients with severe cervical deformity and concordant thoracolumbar deformity and dynamic flexion-extension x-rays are also used for detecting segmental instability and also an assessment of cervical flexibility.

ii) Magnetic resonance imaging (MRI) is the modality of choice to evaluate the neural elements, with multiplanar images and high accuracy in detecting spinal cord compression secondary to degenerative changes. In addition to diagnosis, MRI can provide prognostic information: patients with high T2 signal intensity and concomitant a low T1 signal intensity in the spinal cord generally have unfavourable outcomes. Some new studies using new MRI techniques, such as diffusion tensor imaging (DTI) and fibre tractography can demonstrate spinal cord changes and DCM earlier than conventional sequences.

iii) CT scan can demonstrate a small diameter of the spinal canal, osteophytes and degenerative changes but has a poor visualization of the spinal cord. It provides detailed information of the bone anatomy, with superiority when compared to X-rays and even MRI. CT scan is important for surgical planning when spinal instrumentation will be required for preoperative anatomical study including that of the upper cervical spine.

iv) In patients with contra-indications for an MRI study or those with previous surgeries and spinal instrumentation that may affect image quality, CT myelography can demonstrate indirect cord and nerve root compression. CT myelography can also be used for calculating the compression ratio, a relationship between the smallest sagittal diameter of the spinal canal / transverse diameter x 100 (%). A compression rate of less than 0.4 correlates with clinical evidence of DCM and with a less favourable clinical outcome.

4) Conclusions and Comments

The article concludes that the diagnosis can be made clinically and confirmed with a cervical MRI. MRI is the gold standard modality for confirming the diagnosis of DCM.

5) Opinion of the Article

I thought this article was very easy to understand. It gave me a better understanding of how DCM is diagnosed and treated using different imaging modalities and current imaging techniques.