Abstract
BACKGROUND: In patients with cervical spondylotic myelopathy caused by ossification of the posterior longitudinal ligament, high cord signal (HCS) is frequently observed. However, limited research has investigated the variations in HCS improvement resulting from different surgical approaches. This study aims to explore the potential relationship between the choice of surgical approach and the postoperative improvement of intramedullary high signal in ossification of the posterior longitudinal ligament (OPLL) patients. METHODS: We extensively reviewed the patients' medical records, based on which demographic information such as gender, age, and body mass index (BMI) were recorded, and assessed the severity of the patients' neurological status preoperatively and postoperatively by using the Japanese Orthopedic Association score (JOAs), focusing on consecutive preoperative and postoperative Magnetic resonance imaging (MRI) T2WI measurements, to study the statistical correlation between the improvement of HCS and the choice of surgical approach. RESULTS: There were no significant differences in demographic, imaging parameters, and clinical symptoms between patients undergoing anterior and posterior surgery (p > 0.05, Table 1). However, both improvement in JOAs (Recovery2) and improvement in HCS (CR2) were significantly better in the anterior surgery group two years after surgery (p < 0.05, Table 1). Multifactorial logistic regression analysis revealed that posterior surgery and higher preoperative signal change ratio (SCR) were identified as risk factors for poor HCS improvement at the two-year postoperative period (p < 0.05, Table 2). Table 1 Differences in demographic, imaging parameters, and clinical symptoms in patients with anterior and posterior approach Anterior approach Posterior approach P-Values Demographic data Sex (male/female) 10/12 6/17 0.175 Age 58.59 ± 5.68 61.43 ± 9.04 0.215 Hypertension 14/8 14/9 0.848 Diabetes 16/6 19/4 0.425 BMI 25.58 ± 4.72 26.95 ± 4.58 0.331 Smoking history 19/3 16/7 0.175 Preoperative measured imaging parameters Preoperative SCR 1.615 ± 0.369 1.668 ± 0.356 0.623 CR1 0.106 ± 0.125 0.011 ± 0.246 0.08 CNR 0.33 ± 0.073 0.368 ± 0.096 0.15 C2-7 Cobb angle 8.977 ± 10.818 13.862 ± 13.191 0.182 SVA 15.212 ± 8.024 17.46 ± 8.91 0.38 mK-line INT 3.694 ± 3.291 4.527 ± 2.227 0.323 Imaging follow-up 6 months postoperative SCR 1.45 ± 0.44 1.63 ± 0.397 0.149 2 years postoperative SCR 1.26 ± 0.19 1.65 ± 0.35 0.000** CR2 0.219 ± 0.14 - 0.012 ± 0.237 0.000** Clinical symptoms Preoperative JOAs 10.64 ± 1.59 10.83 ± 1.47 0.679 6 months postoperative JOAs 11.82 ± 1.37 11.65 ± 1.4 0.69 2 years postoperative JOAs 14.18 ± 1.01 12.52 ± 2.06 0.001** Recovery1 0.181 ± 0.109 0.128 ± 0.154 0.189 Recovery2 0.536 ± 0.178 0.278 ± 0.307 0.001** (*), statistical significance (p < 0.05). **, statistical significance (p < 0.01) BMI = body mass index. SCR = the signal change ratio between the localized high signal and normal spinal cord signal at the C7-T1 levels. CR1 = the regression of high cord signals at 6 months postoperatively (i.e., CR1 = (Preoperative SCR-SCR at 6 months postoperatively)/ Preoperative SCR). CR2 = the regression of high cord signal at 2 years postoperatively (i.e., CR2 = (Preoperative SCR-SCR at 2 years postoperatively)/ Preoperative SCR). CNR = canal narrowing ratio. SVA = sagittal vertical axis. mK-line INT = modified K-line interval. JOAs = Japanese Orthopedic Association score. Recovery1 = degree of JOAs recovery at 6 months postoperatively (i.e., Recover1 = (JOAs at 6 months postoperatively-Preoperative JOAs)/ (17- Preoperative JOAs)). Recovery2 = degree of JOAs recovery at 2 years postoperatively (i.e., Recover2 = (JOAs at 2 years postoperatively-Preoperative JOAs)/ (17-Preoperative JOAs)) Table 2 Linear regression analyses for lower CR2 values 95% CI P value Uni-variable analyses Demographic data Sex (male/female) - 0.01 0.221 0.924 Age - 0.015 0.003 0.195 Hypertension - 0.071 0.204 0.334 Diabetes - 0.195 0.135 0.716 BMI - 0.375 0.422 0.905 Smoking history - 0.249 0.077 0.295 Surgical approach - 0.349 - 0.113 0.000(#) Preoperative measured imaging parameters C2-7 Cobb angle - 0.009 0.002 0.185 SVA - 0.008 0.008 0.995 mK-line INT - 0.043 0.005 0.122 Preoperative SCR 0.092 0.445 0.004(#) CR1 0.156 0.784 0.004(#) CNR - 0.76 0.844 0.918 Multi-variable analyses Surgical approach - 0.321 - 0.118 0.000** Preoperative SCR 0.127 0.41 0.000** CR1 - 0.018 0.501 0.067 (#), variables that achieved a significance level of p < 0.1 in the univariate analysis *statistical significance (p < 0.05). **statistical significance (p < 0.01) BMI = body mass index. SCR = the signal change ratio between the localized high signal and normal spinal cord signal at the C7-T1 levels. CR1 = the regression of high cord signals at 6 months postoperatively (i.e., CR1 = (Preoperative SCR-SCR at 6 months postoperatively)/ Preoperative SCR). CR2 = the regression of high cord signal at 2 years postoperatively (i.e., CR2 = (Preoperative SCR-SCR at 2 years postoperatively)/ Preoperative SCR). CNR = canal narrowing ratio. SVA = sagittal vertical axis. mK-line INT = modified K-line interval CONCLUSIONS: For patients with OPLL-induced cervical spondylotic myelopathy and intramedullary high signal, anterior removal of the ossified posterior longitudinal ligament and direct decompression offer a greater potential for regression of intramedullary high signal. At the same time, this anterior surgical strategy improves clinical neurologic function better than indirect decompression in the posterior approach.