Kheram Najmeh, Pfender Nikolai, Boraschi Andrea, Farshad Mazda, Kurtcuoglu Vartan, Curt Armin, Schubert Martin, Zipser Carl M
Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.
University Spine Center, Balgrist University Hospital, Zurich, Switzerland.
Front Neurol. 2022 Aug 9;13:951018. doi: 10.3389/fneur.2022.951018. eCollection 2022.
Spinal canal narrowing with consecutive spinal cord compression is considered a key mechanism in degenerative cervical myelopathy (DCM). DCM is a common spine condition associated with progressive neurological disability, and timely decompressive surgery is recommended. However, the clinical and radiological diagnostic workup is often ambiguous, challenging confident proactive treatment recommendations. Cerebrospinal fluid pressure dynamics (CSFP) are altered by spinal canal narrowing. Therefore, we aim to explore the potential value of bedside CSFP assessments for qualitative and quantitative assessment of spinal canal narrowing in DCM. In this prospective case series, seven patients with DCM underwent bedside lumbar puncture with measurement of CSFP dynamics and routine CSF analysis (NCT02170155). The patients were enrolled when standard diagnostic algorithms did not permit a clear treatment decision. Measurements include baseline CSFP, cardiac-driven CSFP peak-to-trough amplitude (CSFPp), and the Queckenstedt's test (firm pressure on jugular veins) in neutral and reclined head position. From the Queckenstedt's test, proxies for craniospinal elastance (i.e., relative pulse pressure coefficient; RPPC-Q) were calculated analogously to infusion testing. CSFP metrics were deemed suspicious of canal narrowing when numbers were lower than the minimum value from a previously tested elderly spine-healthy cohort ( = 14). Mean age was 56 ± 13 years (range, 38-75; 2F); symptom severity was mostly mild to moderate (mean mJOA, 13.5 ± 2.6; range, 9-17). All the patients showed some extent of cervical stenosis in the MRI of unclear significance (5/7 following decompressive cervical spine surgery with an adjacent level or residual stenosis). Baseline CSFP was normal except for one patient (range, 4.7-17.4 mmHg). Normal values were found for CSFPp (0.4-1.3 mmHg) and the Queckenstedt's test in normal head positioning (9.-25.3 mmHg). During reclination, the Queckenstedt's test significantly decreased in one, and CSFPp in another case (>50% compared to normal position). RPPC-Q (0.07-0.19) aligned with lower values from spine-healthy (0.10-0.44). Routine CSF examinations showed mild total protein elevation (mean, 522 ± 108 mg/ml) without further evidence for the disturbed blood brain barrier. Intrathecal CSFP measurements allow discerning disturbed from normal CSFP dynamics in this population. Prospective longitudinal studies should further evaluate the diagnostic utility of CSFP assessments in DCM.
伴有连续性脊髓压迫的椎管狭窄被认为是退行性颈椎病（DCM）的关键机制。DCM是一种常见的脊柱疾病，与进行性神经功能障碍相关，建议及时进行减压手术。然而，临床和影像学诊断检查往往不明确，难以做出自信的积极治疗建议。椎管狭窄会改变脑脊液压力动力学（CSFP）。因此，我们旨在探讨床边CSFP评估对定性和定量评估DCM椎管狭窄的潜在价值。在这个前瞻性病例系列中，7例DCM患者接受了床边腰椎穿刺，测量CSFP动力学并进行常规脑脊液分析（NCT02170155）。当标准诊断算法无法做出明确的治疗决策时，纳入这些患者。测量包括基线CSFP、心脏驱动的CSFP峰谷振幅（CSFPp）以及中立位和头部后仰位的奎肯斯泰特试验（对颈静脉施加稳定压力）。根据奎肯斯泰特试验，类似于输液试验计算颅脊髓弹性指标（即相对脉压系数；RPPC-Q）。当数值低于先前测试的老年脊柱健康队列的最小值（=14）时，CSFP指标被认为可疑存在椎管狭窄。平均年龄为56±13岁（范围38-75岁；2名女性）；症状严重程度大多为轻度至中度（平均mJOA，13.5±2.6；范围9-17）。所有患者在MRI上均显示出一定程度的颈椎狭窄，但其意义不明确（7例中有5例在颈椎减压手术后出现相邻节段或残留狭窄）。除1例患者外，基线CSFP正常（范围4.7-17.4 mmHg）。CSFPp（0.4-1.3 mmHg）和中立位头部奎肯斯泰特试验（9.-25.3 mmHg）结果正常。在头部后仰过程中，1例患者的奎肯斯泰特试验显著降低，另1例患者的CSFPp降低（与正常位置相比>50%）。RPPC-Q（0.07-0.19）与脊柱健康者的较低值（0.10-0.44）一致。常规脑脊液检查显示总蛋白轻度升高（平均522±108 mg/ml），无血脑屏障受损的进一步证据。鞘内CSFP测量能够区分该人群中异常和正常的CSFP动力学。前瞻性纵向研究应进一步评估CSFP评估在DCM中的诊断效用。
