Cervical spondylotic myelopathy (CSM) is one of the most prevalent causes of spinal cord dysfunction in adults worldwide, particularly affecting the middle-aged and elderly population.[1] The underlying process involves degenerative changes in the cervical spine—commonly known as spondylosis—which can lead to progressive compression of the spinal cord.[2] This onset is typically insidious, manifesting initially with subtle symptoms such as numbness or clumsiness in the hands, gait disturbances, and limb weakness, and can eventually progress to significant neurological deficits.[3] The impact on quality of life and daily function can be profound, making CSM a topic of particular clinical importance.[4] The pathogenesis of CSM is multifactorial, including osteophyte formation, disc degeneration, and hypertrophy of ligaments, all contributing to reduced spinal canal diameter and compression of neural elements.[3] Clinically, patients may present with upper motor neuron findings, such as hyperreflexia, Babinski’s sign, and spasticity. Diagnostic evaluation relies heavily on clinical examination and advanced imaging, with magnetic resonance imaging (MRI) serving as the gold standard for identifying the extent of cord compression and intramedullary changes.[5] Imaging modalities such as X-rays, CT scans, and dynamic MRI further help delineate the anatomical aspects and dynamic nature of spinal cord impingement.[6] Neurophysiological studies, including somatosensory evoked potentials (SEPs) and motor-evoked potentials (MEPs), add valuable information regarding spinal cord functionality and prognosis when considering surgical intervention.[7] The decision to operate on CSM is a pivotal moment in patient management. While conservative strategies may suffice for minimal or slowly progressing symptoms, surgical decompression is widely recognized as the treatment of choice for patients with moderate to severe and progressive deficits. [8]The primary aim of surgery is to halt disease progression, relieve cord compression, and thereby improve or stabilize neurological function.[9] Approaches to decompression include anterior cervical discectomy and fusion (ACDF), corpectomy, laminectomy, laminoplasty, and posterior fusion, each tailored to individual radiological and clinical profiles. The choice between anterior and posterior surgical strategies hinges on factors such as the location and extent of compression, alignment of the cervical spine, presence of kyphosis, and comorbid conditions.[10] Posterior approaches such as laminectomy and laminoplasty remain robust, especially in multi-level disease, while anterior procedures might be preferable for localized, ventral compression or instability.[11,12] Outcomes after surgical intervention are influenced by a combination of patient age, duration and severity of symptoms prior to surgery, and radiological findings such as intramedullary signal changes on MRI and extent of cord compression.[13] Objective assessments such as the Japanese Orthopaedic Association (JOA) score and Nurick grading system, in conjunction with clinical and imaging parameters, provide quantifiable measures of pre- and postoperative function.[14-16] In summary, CSM due to spondylosis is a complex entity requiring a multifaceted diagnostic and therapeutic approach. Clinicoradiological assessment before and after surgical intervention remains critical for guiding management, predicting surgical outcomes, and optimizing patient recovery and quality of life. This review aims to elucidate the clinicoradiological parameters that impact functional outcomes in patients undergoing surgical decompression for CSM.[11,13]

Study Design This prospective observational study aims to analyze the clinical and radiological outcomes of patients with cervical spondylotic myelopathy (CSM) undergoing surgical decompression. The study will be conducted at the Department of Neurosurgery, J.A. Group of Hospitals, and G.R. Medical College, Gwalior, MP, over a two-year period from 2023 to 2025. Study Population The study will include 30 patients who are diagnosed with CSM based on radiological evidence, primarily through X-ray, CT, and MRI scans. These patients must meet the inclusion criteria for the study, which are: • Inclusion Criteria: Radiologically proven cases of CSM due to various pathologies such as spondylosis, degenerative changes, disc herniation, etc. • Exclusion Criteria: Neoplastic conditions, post-traumatic cases, systemic disorders such as rheumatoid arthritis, and conditions affecting the cervical vertebrae junction (CV Junction). Sample Size The sample size of 30 patients was determined based on the study by Jau-Ching Wu et al. (2013) and calculated using the formula for sample size estimation at a 5% level of significance and 18% absolute error. This provides adequate power for statistical analysis of the intervention's effects. Preoperative Assessment Before surgery, each patient will undergo: 1. Clinical Examination: A detailed clinical examination to assess the neurological status, including the Nurick Grade and modified Japanese Orthopaedic Association (mJOA) score for functional assessment. 2. Radiological Assessment: Digital X-ray, CT, and MRI scans of the cervical spine will be performed to evaluate the severity of degenerative changes, canal diameter (CD), and cross-sectional area (CSA) of the spinal cord. 3. Demographic Data: The age, sex, medical history, and occupation of patients will be recorded. Surgical Intervention • Approach Selection: The type of surgical approach (anterior or posterior) will be based on factors such as the number of cervical levels involved, the patient’s age, general condition, comorbidities, and radiological findings. The posterior approach will be preferred for multi-level involvement (≥3 levels), while the anterior approach will be used for single or two-level involvement. • Surgical Techniques: The surgical procedures may include: o Decompression and Fusion o Decompression and Corpectomy o Decompression and Laminoplasty o Decompression and Laminectomy • Intraoperative Data Collection: During surgery, data on surgery time, blood loss, and any immediate complications will be documented. Postoperative Assessment 1. Neurological Status: Postoperative neurological assessments will be conducted at 48 hours, 1 month, 3 months, 6 months, and annually thereafter. Functional outcomes will be assessed using the Nurick Grade and mJOA score. 2. Radiological Follow-up: Postoperative CT and MRI scans will be conducted to assess the improvements in canal diameter (CD) and cross-sectional area (CSA). Imaging will be done within 2 weeks for CT and 3-4 months for MRI unless clinically indicated earlier. 3. Complications: Patients will be monitored for complications such as infection, bleeding, CSF leak, meningitis, vascular injury, and neural injury. 4. Pain Management: Postoperative pain will be managed, and any need for further interventions will be recorded. Follow-up Patients will be followed up annually after surgery to assess: • The long-term outcomes of surgery, including improvements in motor and sensory function, recurrence of symptoms, and any new neurological deficits. • The long-term complications of the surgery, including the need for reoperation, and changes in the patient’s radiological status. • The patient’s quality of life through follow-up surveys and interviews. Data Collection and Analysis • Quantitative Data: This will include the patient demographics (age, sex, medical history), preoperative and postoperative Nurick grades, mJOA scores, and radiological parameters (CSA, CD). • Qualitative Data: Patient satisfaction will be assessed through surveys to evaluate pain management, functional recovery, and overall quality of life after surgery. • Statistical Analysis: Data will be analyzed using appropriate statistical methods. The paired t-test or Wilcoxon signed-rank test will be used to analyze changes in neurological status and radiological parameters pre- and postoperatively. A p-value of < 0.05 will be considered statistically significant. Descriptive statistics (mean, standard deviation) will be used to summarize demographic data and outcomes. Expected Outcomes • Symptom Improvement: The primary expected outcome is an improvement in the neurological status of patients, including better motor and sensory function, especially in upper and lower limbs. This should lead to reduced spasticity, gait disturbances, and overall functional recovery. • Long-Term Benefits: It is anticipated that decompression surgery will result in significant long-term benefits, including a reduction in symptoms such as numbness and weakness. Radiological improvement in canal diameter and cross-sectional area of the spinal cord will correlate with better functional recovery. • Reduced Risk of Complications: Proper surgical intervention is expected to reduce the risks of severe complications, such as infection and reoperation, thereby enhancing the overall outcomes and quality of life of the patients.

Table 1: Age Group Distribution Age Group Count 40-50 8 51-60 8 61-70 7 71-80 5 Table 1 categorizes the patients based on their age. It shows that the majority of patients are evenly distributed between the 40-50 and 51-60 age groups (8 patients each). The 61-70 age group has 7 patients, and the 71-80 group has 5 patients, indicating that CSM affects a wide age range but is more prevalent in middle-aged individuals. Table 2: Gender Distribution Gender Count Female 17 Male 13 Table 2 shows a slightly higher prevalence of CSM in females, with 17 female patients compared to 13 male patients. This suggests a gender-based trend, though further research is needed to explore this more deeply. Table 3: Surgical Approach Distribution Surgical Approach Anterior (22) Posterior (08) ACDF ACD Laminectomy Laminoplasty 15 07 05 03 Table 3 indicates that a greater number of patients 22 had anterior surgical approach out of which 15 underwent ACDF & rest 07 underwent ACD and08had posterior surgical approach out which 05 underwent Laminectomy and rest 03 underwent Laminoplast. The choice of approach may depend on the number of cervical levels involved and the clinical condition of the patient. Table 4: Chief Complaint Distribution Chief Complaint Count Paraparesis/Paraplegia 11 Limb Weakness 11 Gait Disturbances 5 Numbness 3 Table 4 presents the most common symptoms experienced by the patients. Paraparesis/Paraplegia and Limb Weakness are the most frequent complaints, each reported by 11 patients. Gait disturbances and numbness are less common, with 5 and 3 patients respectively. Table 5: Duration of Symptoms before Surgery Duration of Symptoms (Months) Count 0-6 6 7-12 8 13-24 7 >24 9 Table 5 shows the duration of symptoms before surgery. A majority of patients (9) experienced symptoms for more than two years before seeking surgical intervention, indicating delayed presentation in some cases. Table 6: Radiological Findings Radiological Finding Count Cervical Spondylosis 18 Disc Protrusion/Extrusion 15 Spinal Canal Stenosis 10 Foraminal Stenosis 02 Table 6 highlights the common radiological findings in patients diagnosed with CSM. The most common finding is cervical spondylosis, present in 18 patients. Disc protrusions/extrusions and spinal canal stenosis are also significant findings, affecting 15 and 10 patients, respectively. Table 7: Post-Surgical Outcome (Follow-up) Outcome Count Improved 26 Unchanged 04 Worsened 01 Table 7 shows the post-surgical outcomes. The majority of patients (26) experienced improvement after surgery. However, a smaller proportion showed unchanged (04) or worsened (01) conditions, suggesting variable outcomes depending on the severity of the pre-surgical condition. Table 8: Clinical and Radiological Correlation Radiological Finding Common Clinical Symptoms Count of Patients Cervical Spondylosis Paraparesis, Limb Weakness, Gait Disturbances 18 Disc Protrusion/Extrusion Limb Weakness, Paraparesis 15 Spinal Canal Stenosis Paraparesis, Limb Weakness, Numbness, Gait Disturbances 10 Foraminal Stenosis Limb Weakness 02 Table 8 correlates the most common radiological findings with clinical symptoms. Cervical spondylosis and spinal canal stenosis are linked to the most severe symptoms like paraparesis and gait disturbances. Disc protrusion/extrusion primarily correlates with limb weakness. Table 9: Complications Post-Surgery Complication Count Infection 1 Hematoma 2 Instrumentation Failure 0 CSF leak 1 Meningitis 0 Vascular injury 0 Neural injury 0 No Complication 26 Table 9 shows the postoperative complications encountered by patients. Only a small number of patients experienced complications (4 total), with the majority (26) having no postoperative issues. Table 10: Functional Improvement Approach scale Group Preop At 1 month At 6 months At 1 year Anterior Modified Nurick ACDF 2.1 1.6 1.4 1.1 ACD 2.7 2.0 1.7 1.3 Posterior Modified Nurick Laminectomy 3.0 2.4 2.1 1.6 Laminoplasty 2.9 2.2 1.9 1.5 Anterior mJOA ACDF 6.2 7.0 8.3 8.6 ACD 5.5 6.5 7.4 8.5 Posterior mJOA Laminectomy 6.0 7.0 8.0 10.0 Laminoplasty 6.0 7.0 8.0 9.0 Abbreviations: ACDF, anterior cervical discectomy and fusion; ACD, anterior cervical discectomy; mJOA, modified Japanese Orthopedic Association. Table 11: Radiological Improvement Types of surgery Characteristics Preop Postop ACDF CD 9.7 13.5 CSA 0.8 1.2 ACD CD 9.4 13.6 CSA 0.8 1.1 Laminectomy CD 8.6 14.2 CSA 0.9 1.2 Laminoplasty CD 8.9 13.9 CSA 0.8 1.1 Abbreviations: ACDF, anterior cervical discectomy and fusion; ACD, anterior cervical disectomy; CSA, cross-sectional area in cm2; CD, canal diameter in mm.

Age-wise, CSM predominantly affects middle-aged individuals, primarily those aged between 40 and 60 years, as seen in our study population. This observation aligns with studies by Lebl et al.[17] and Wang et al.[18] who documented age-related degenerative changes peaking during the fourth to sixth decades of life. Similarly, the male to female ratio in our study showed a slightly higher prevalence in females, which requires further investigation. Contrarily, Kane et al.[19] reported a male predominance with a 3:1 ratio, indicating possible geographic or demographic variability in gender distribution. Clinically, the most common presentations involved motor deficits such as paraparesis, paraplegia, and limb weakness, with gait disturbances and sensory complaints occurring less frequently. These neurological impairments correspond well with the findings by Zhang et al.,[20] who emphasized the impact of spinal cord compression severity on lower limb motor function and gait abnormalities. The varied duration of symptoms before surgery in our cohort, often exceeding two years, echoes the delay in diagnosis or treatment-seeking behavior highlighted by Donnally et al.[21] Radiologically, cervical spondylosis with associated disc protrusion/extrusion and spinal canal stenosis were predominant, correlating with symptom severity and functional impairment. These imaging findings agree with observations by Wong et al.[22] and Ayub et al.,[23] confirming spinal canal narrowing and degenerative changes as key factors in myelopathy pathogenesis. The less frequent occurrence of foraminal stenosis in our series concurs with its lesser role in major neurological deficits in CSM patients. Surgically, anterior cervical discectomy and fusion (ACDF) was the preferred approach, consistent with reports by Qizhi et al.,[24] who noted high fusion rates and significant functional improvements with zero-profile ACDF devices. Huang et al.'[25] meta-analysis also underscores the efficacy and safety of anterior approaches compared to alternatives like cervical disc arthroplasty, lending further support to our surgical strategy. Postoperative outcomes were generally favorable, with most patients showing neurological improvement, consistent with findings from Furlan et al.[26] who observed significant functional recovery plateauing at six months post-surgery. Complication rates were low, with minor incidences of infection, hematoma, and cerebrospinal fluid leaks, corroborating Kim et al.'s [27]analysis which highlighted minimal severe complications in CSM surgery patients, although caution is warranted in special populations such as those with cerebral palsy. Functional and radiological improvements in spinal canal diameter and motor scores align with the conclusions of Wong et al.[22] and Zhang et al.,[20] indicating that surgical decompression effectively mitigates cord compression and facilitates recovery. These collective findings emphasize the importance of timely surgical intervention and individualized approach selection for optimal CSM management. Functional improvements observed included enhanced muscle strength, better coordination, and restoration of balance and gait, which translated into improved activities of daily living and quality of life. Neurological improvements manifested as increased motor power, reduced spasticity, improved sensation, and restoration of reflexes, all contributing to patient rehabilitation. Collectively, these findings underscore the critical importance of timely surgical intervention and individualized treatment planning to optimize outcomes in CSM management.

Cervical Spondylotic Myelopathy (CSM) primarily affects middle-aged individuals, with a slightly higher prevalence in females. Patients often present with severe neurological symptoms, such as paraparesis and limb weakness, and a significant number experience prolonged symptoms before seeking surgery. Surgical intervention, especially through anterior approaches like ACDF, shows positive outcomes, with most patients experiencing functional and radiological improvements. The low incidence of complications highlights the safety of these procedures, though the variability in outcomes stresses the need for individualized treatment. Early diagnosis and timely intervention are key to improving patient quality of life and mitigating the neurological impacts of CSM.

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