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PRIMARY RESEARCH

Relationship Between Signal Changes on T2-weighted


Magnetic Resonance Images and Cervical Dynamics
in Cervical Spondylotic Myelopathy
Lipeng Yu, MD, PhD, Zitao Zhang, PhD, Qingfeng Ding, MD, Yiming Li, MD,
Yuwen Liu, MD, and Guoyong Yin, MD, PhD

Study Design: Technical note.


Objective: To determine the correlation between the highintensity lesions observed on T2-weighted magnetic resonance
images (T2W MRI) and the cervical dynamic characteristics of
patients with cervical spondylotic myelopathy (CSM).
Summary of Background Data: Intramedullary high signal intensity is frequently observed on T2W MRI of CSM patients
and represents pathologic changes in the spinal cord. However,
few studies have attempted to identify the eects on cervical
dynamics associated with such changes in MRI signals.
Methods: This study included 71 CSM patients who were admitted to our hospital between May, 2009 and May, 2012 (44
men, 27 women; average age, 52.5 11.7 y). They were divided
into 3 groups depending on T2W MRI data: group 1, no hyperintensity; group 2, slight hyperintensity; and group 3, bright
hyperintensity. The Cobb angle on cervical flexion-extension
radiographs was measured as a parameter of cervical spine
dynamics.
Results: Total hyperflexion, hyperextension curvature, range of
movement (ROM), and segmental hyperflexion curvature did
not dier among the groups (P > 0.05). Segmental hyperextension curvature and ROM were greater in groups 2 and 3
than in group 1 (P < 0.05) but did not dier significantly
between groups 2 and 3 (P > 0.05).
Conclusions: Increased segmental hyperextension curvature
(Z10 degrees) and ROM are risk factors for high-intensity
lesions on T2W MRI in CSM patients.
Key Words: cervical spondylotic myelopathy, curvature, hyperflexion, hyperextension, T2-weighted MRI, signal intensity
(J Spinal Disord Tech 2015;28:E365E367)
Received for publication August 14, 2012; accepted April 21, 2013.
From the Department of Spine Surgery, The First Aliated Hospital of
Nanjing Medical University, Nanjing, P.R. China.
L.Y. and Z.Z. contributed equally.
Supported by National Natural Science Foundation of China
(No. 81071481).
The authors declare no conflict of interest.
Reprints: Guoyong Yin, MD, PhD, Department of Spine Surgery, The
First Aliated Hospital of Nanjing Medical University, Nanjing
210029, P.R. China (e-mail: guoyong_yin2005nanjing@yahoo.com).
Copyright r 2013 Wolters Kluwer Health, Inc. All rights reserved.

J Spinal Disord Tech

ervical spondylotic myelopathy (CSM) is the most


severe type of cervical spondylosis and causes severe
neurological dysfunction such as spastic paralysis.1 Intramedullary high signal intensity is frequently observed
on T2-weighted magnetic resonance imaging (T2W MRI)
of CSM patients and often indicates a poor prognosis.2
Dynamic mechanical forces during abnormal movements
of the cervical vertebrae may lead to repetitive injury to
the spinal cord and may be a pathogenic factor in CSM.3
The present study used MRI and flexion-extension plain
radiographs to determine whether cervical curvature and
range of movement (ROM) are risk factors for cervical
intramedullary signal changes on T2W MRI.

MATERIALS AND METHODS


We recruited patients who were admitted to our
hospital for the treatment of CSM between May 2009 and
May 2012. The inclusion criteria were as follows: CSM at
admission; chronic shoulder and cervical pain, stiness,
limb pain/numbness/debilitation/muscular atrophy, and
other typical clinical manifestations of CSM; vertebral
hyperostosis, vertebral instability, disc herniation, and
other typical imaging characteristics of cervical syndrome; and availability of complete clinical, preoperative
flexion-extension plain radiography and MRI data. The
exclusion criteria were traumatic cervical disk herniation,
amyotrophic lateral sclerosis of the spinal cord, spinal
cord tumor, syringomyelia, spinal cord injuries, spinal
cord tuberculosis, basilar impression, secondary adhesive
arachnitis, peripheral polyneuritis, peripheral chronic injuries (such as carpal tunnel syndrome), and other diseases. Seventy-one patients met the inclusion criteria,
including 44 men and 27 women, with an average age of
52.5 11.7 years. The severity of CSM was evaluated
according to Japanese Orthopaedic Association scores.

Radiography and Cervical MRI


Neutral lateral radiographs were taken with the
patient in a natural posture. Flexion-extension radiographs were taken by asking each patient to achieve his or
her maximum flexion and extension. All radiographs were
reviewed by a consensus of 2 spinal surgeons. Digital
radiograph measurements were made using Image-Pro
Plus 6.0 (Media Cybernetics, Rockville, MD).

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Yu et al

J Spinal Disord Tech

Volume 28, Number 6, July 2015

FIGURE 1. Grading of signals on T2-weighted magnetic resonance images of the cervical spine. A, Group 1 (no hyperintensity).
B, Group 2 (slight hyperintensity). The signal intensity is higher than that of normal spinal cord but lower than that of normal
cerebrospinal fluid. C, Group 3 (bright hyperintensity). The signal intensity is similar to that of normal cerebrospinal fluid.

All patients underwent high resolution 1.5 T MRI


(Symphony; Siemens, Erlangen, Germany). The method
reported by Yukawa et al4 for classifying signal intensity
on T2W MRI in cervical syndrome patients was used to
divide the subjects into 3 groups: group 1, no hyperintensity; group 2, slight hyperintensity, defined as signal
intensity higher than that of normal spinal cord but lower
than that of normal cerebrospinal fluid; and group 3,
bright hyperintensity, defined as signal intensity similar to
that of normal cerebrospinal fluid (Fig. 1).

Dynamic Measurements of Cervical Vertebrae


Cervical total curvature and ROM were determined
using the above dynamic radiographs; the angle between
lines extended from the inferior margins of the C2 and C7
vertebral bodies was taken as a measure of the curvature
of the cervical spine. Cervical segmental curvatures and
ROM were determined by measuring the angle between
lines drawn from the superior margin of the upper vertebral body and the inferior margin of the lower vertebral
body. For this purpose, 2 vertebrae adjacent to the level
of the highest intramedullary signal intensity on T2W
MRI or the most obvious cervical disk herniation

or cervical canal narrowing (in patients with normal


signal intensity) were selected. Hyperextension curvatures
were recorded as positive values and hyperflexion curvatures were recorded as negative values. The dierence
between those 2 curvatures was considered as the cervical
ROM.

Statistical Analysis
SPSS 16.0 was used for statistical analysis of the
data. Analysis of variance and the Student-NewmanKeuls and w2 tests were used to determine whether differences among the groups were statistically significant, as
indicated by a P value of <0.05.

RESULTS
Total hyperflexion, hyperextension curvature, ROM,
and segmental hyperflexion curvature did not dier
significantly between the groups (P > 0.05). However,
segmental hyperextension curvature diered significantly
(4.4 3.6 degrees; 7.3 4.2 degrees; and 8.3 3.7 degrees;
P = 0.011), as did segmental ROM (11.1 5.6 degrees;
16.0 8.8 degrees; and 17.7 3.7 degrees; P = 0.007)
(Table 1).

TABLE 1. Comparison of the Clinical Backgrounds of the 3 Patient Groups


Characteristic
Age (y)
Sex (male/female)
Duration of symptoms (mo)
Preoperative JOA score
Total hyperflexion curvature (deg.)
Total hyperextension curvature (deg.)
Total ROM (deg.)
Segmental hyperflexion curvature (deg.)
Segmental hyperextension curvature (deg.)
Segmental ROM (deg.)

Group 1 (n = 32)

Group 2 (n = 22)

Group 3 (n = 17)

52.6 9.8
18/14
18.6 27.5
12.0 3.0
" 16.0 8.9
22.3 12.7
38.3 14.0
" 6.7 4.7
4.4 3.6
11.1 5.6

49.4 12.8
14/8
12.0 12.0
11.7 2.5
" 18.2 8.0
27.7 11.4
45.9 10.1
" 8.7 6.3
7.3 4.2
16.0 8.8

56.4 13.1
12/5
9.1 8.7
10.2 2.7
"18.4 9.2
24.7 12.7
43.2 15.7
"9.1 3.2
8.6 3.7
17.7 3.7

1.005
1.335
1.457
2.394
0.597
1.280
2.171
1.661
7.857
7.024

0.371
0.605
0.240
0.099
0.553
0.285
0.122
0.198
0.001
0.002

a = 0.05.
JOA indicates Japanese Orthopedic Association; ROM, range of motion.

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Copyright

2013 Wolters Kluwer Health, Inc. All rights reserved.

Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

J Spinal Disord Tech

Volume 28, Number 6, July 2015

T2W MRI and Cervical Dynamics in CSM

TABLE 2. Clinical and Imaging Data Comparison Between 2 Groups


P

Group

Age

Duration of
Symptoms

Group 1/group 2
Group 2/group 3
Group 1/group 3

0.320
0.280
0.066

0.238
0.656
0.119

Preoperative
JOA

Total Hyperflexion
Curvature

Total Hyperextension
Curvature

Total
ROM

Segmental
Hyperflexion
Curvature

Segmental
Hyperextension
Curvature

Segmental
ROM

0.651
0.111
0.035

0.375
0.930
0.361

0.115
0.457
0.505

0.05
0.536
0.233

0.152
0.828
0.121

0.008
0.276
0.000

0.008
0.419
0.001

a = 0.05.
ROM indicates range of motion.

The Student-Newman-Keuls test showed that segmental hyperextension curvature and ROM diered significantly between groups 1 and 2 and between groups 1
and 3 (P < 0.05) but not between groups 2 and 3 (Table 2).
However, a tendency test indicated that the hyperintense
signals on T2W MRI tended to increase with increase in
segmental hyperextension curvature (P = 0) and segmental
ROM (P = 0.001) between groups 2 and 3. All subjects
were then divided into 2 groups according to their segmental hyperextension curvature. As shown in Table 3,
when the curvature was Z10 degrees, the incidence of
hyperintense signals on T2W MRI was higher (P = 0.007).

DISCUSSION
CSM is a common disorder that impairs the function
of the spinal cord. The present study found that segmental
hyperextension curvature and ROM were significantly associated with signal abnormalities in CSM patients. In people without CSM, physiological changes in the length and
cross-sectional area of the spinal cord during neck motion
may protect the cord from significant mechanical compression, and the spinal subarachnoid may have a buering
eect. However, this buering eect decreases with cataplastic changes such as disk herniation, ligamentum flavum
hypertrophy, stenosis and osteophyte formation, and this
decrease may easily lead to spinal compression.5 In flexion,
hyperplastic osteophytes on the posterior margin of the
vertebral body, protruded disks or a hypertrophic posterior
longitudinal ligament, may cause direct forward pressure
injury to the spinal cord. In extension, the decreased sagittal
TABLE 3. The Comparison of Subject Distributions According
to Segmental Extension Curvature
Group

Hyperintense Signal No Hyperintense Signal

< 10 degrees
Z10 degrees

25
14

30
2

P
0.007

a = 0.05.

Copyright

diameter of the canal and increased transverse diameter of


the spinal cord further decrease the eective space for the
cord.6 Cataplastic tissues in the anterior region of the spinal
cord and hypertrophic ligamenta flava in the posterior region
have a clamp-like eect on the spinal cord, leading to
considerable cord compression. In some cases, during cervical spine flexion, with a thinner spinal cord, a stretched
posterior longitudinal ligament may return a protruded disk
and invagination of the ligamenta flava may disappear, effectively increasing the relative spinal cord space. These may
be the reasons why segmental hyperflexion curvature has no
eect on cervical intramedullary lesions on MRI.
This study showed that segmental hyperextension
curvature and ROM are risk factors for the presence of hyperintense lesions on T2W MRI in patients with CSM. Such
patients may exhibit intramedullary signal changes when
their segmental hyperextension curvature is Z10 degrees.
However, the study was retrospective in nature and had a
small sample size; therefore, its conclusions should be confirmed in a large, multicenter, randomized controlled trial.
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2013 Wolters Kluwer Health, Inc. All rights reserved.


Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

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