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Low T1 Cord Signal Predicts Poor Outcome in Cervical Spondylotic Myelopathy

February 13, 2008
Written by: , Filed in: Neuroradiology
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The objective of a recent study was to determine whether clinical findings correlate with MRI findings in cervical spondylotic myelopathy (CSM), and to what extent these findings are predictive of postsurgical outcome and reversibility of symptoms.

The study has concluded that foci of low T1/high T2 cord signal in patients with CSM are predictive of a relatively poor outcome compared with normal T1/high T2. This latter group can expect good outcome in the absence of clonus or spasticity.

Participants
76 patients who underwent surgery for CSM between 1993 and 2003 and who had undergone preoperative and postoperative MRI. All patients had abnormal preoperative findings referable to upper motor neurons.

Methodology
MRI studies were performed with sagittal T1- and T2- and axial T1- and T2-weighted gradient echo. All studies were done with a thickness of 3-4 mm and a gap of 1 mm. Clinical evaluation was performed with Nurick’s score (quantifies neurological impairment) and Odom’s score, which is an outcome measurement ranging from excellent (all preoperative findings resolved) to poor (findings unchanged or worse).

Neuroradiology Review

The Johns Hopkins University School of Medicine
Course Directors: David Yousem, MD, MBA and Doris Lin, MD, PhD Maintaining certification requires not only medical knowledge to deliver quality care but also other essential elements that must be developed and maintained throughout every radiologist’s career. Therefore, this program serves as a comprehensive review of neuro-radiology and prepares the participants to tackle imaging of the brain, spine, head and neck, as well as the vascular anatomy of the central nervous system. Click here to read more or order: Neuroradiology Review

Results of the Study
Signal change in the cord was graded as N/N (group A, n=45) for normal T1 and T2, N/Hi (group B, n=31) for normal T1 and increased T2, and Lo/Hi (group C, n=8) for decreased T1 and increased T2.

A significantly higher proportion of patients in groups B and C (abnormal MRIs) had certain abnormal physical findings than in group A (normal MRIs). These findings included hand muscle atrophy, hyperreflexia, Babinski sign, leg spasticity, and clonus.

In group A, outcomes were excellent in 34 patients (76%) and good in 11 (24%). In group B, outcomes were excellent in nine patients (39%), good in 13 (56.5%), fair in one (4.3%), and poor in none. In group C, outcomes were excellent in none, good in two (25%), fair in four (50%), and poor in two (25%).

Of 23 patients in group B, 11 demonstrated reversal of abnormal T2 signal. None of them had clonus or leg spasticity.

The authors did not explain what percent of the remaining patients in this group had spasticity and clonus. Intramedullary cord signal was associated with a poor outcome by Odom’s criteria (P <0.0001), but this was not further clarified in the paper. Conclusions
In patients with CSM, normal T1/high T2 cord lesions predict better outcome than low T1/high T2 cord lesions. Patients with high T2 signal without clonus or spasticity may experience good surgical outcome. Predictors of poor outcome are low T1 cord signal, clonus, and spasticity.

Reviewer’s Comments
The presentation of data was incomplete and confusing. This is an excellent review explaining theories concerning myelopathic cord signal.

Author: Yaron Lebovitz, MD

Reference:
Alafifi T, Kern R, Fehlings M. Clinical and MRI Predictors of Outcome After Surgical Intervention for Cervical Spondylotic Myelopathy.
J Neuroimaging; 2007; 17 (October): 315-322

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