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• W3138291609 abstract "Where Are We Now? Spine surgeons generally treat symptomatic cervical spine conditions like radiculopathy and myelopathy with anterior cervical discectomy and fusion (ACDF). Approximately 150,000 ACDF procedures are performed annually, and that number is expected to increase during the next two decades [6]. ACDF candidates typically present with numerous MRI findings, including intervertebral disc degeneration, disc space narrowing, disc protrusion/herniations, endplate abnormalities, and osteophytes. I wonder whether just focusing on the elements that might cause nerve root or cord compression misses an important part of the larger picture. What about the cervical spine muscles? After all, surgeons use minimally invasive procedures to minimize their disruption. Surgeons should consider the cervical spine musculature because paraspinal muscles provide active capacity to control and stabilize the head and neck, and their compromise has been linked with worsening cervical deformity [7] and reduce functional scores [4]. This becomes increasingly important when treating patients with sarcopenia because the loss of muscle mass and function is linked to increased likelihood of adverse outcomes including falls, fractures, physical disability, and mortality [2]. Specific to cervical spine patients, sarcopenia has been associated with poor postoperative cervical alignment and reduced function [5], which suggests measures of muscle mass may be useful in risk stratification of patients undergoing spinal surgery. Two commonly reported measures used to quantify skeletal muscle changes in sarcopenia are muscle cross-sectional area and composition, where cross-sectional area provides information regarding size (asymmetry, atrophy, or hypertrophy) and muscle composition offers additional insight into the tissues (fatty infiltration, fibrosus) that constitute a given cross-sectional area. However, our current understanding of how both cervical spine muscle size and composition present in the ACDF patient population is limited. In the current study, Pinter et al. [8] pose an interesting question: Do patients undergoing ACDF with increasing paraspinal fatty degeneration on advanced imaging also demonstrate decreased cervical paraspinal cross-sectional area? Based on their interpretation of the results, the short answer to this question (as indicated in the title) is: not entirely. That is, when Pinter et al. [8] used axial MRI to categorize (using the modified Goutallier classification) patients who underwent ACDF into normal, moderate, or severe fatty infiltration groups, there were no between-group differences in cross-sectional area for the obliquus capitis inferior, multifidus, or sternocleidomastoid muscles at two spinal levels measured (C2-C3 and C5-C6 interspace). However, moderate and severe fatty infiltration groups had larger longus coli cross-sectional area than those classified as normal. Pinter et al. [8] further explain that based on the preoperative findings in patients who underwent ACDF, physicians should not assume cervical paraspinal muscle quantity and muscle quality go hand in hand. This is a key concept to understand since reductions in muscle function/strength have been shown to be greater than the reductions in muscle cross-sectional area [3], which speaks to the importance of muscle quality. In a separate study, Pinter and colleagues [9] found that patients with ACDF who were classified with more cervical muscle fatty infiltration may have more symptom relief following ACDF than those patients with better muscle quality. Based on these discoveries, surgeons should appreciate the amount of fatty infiltration present in the cervical musculature on axial images, as this may be a sign of sarcopenia, impaired function, and a possible indicator of postsurgical alignment and recovery following spine surgery. Where Do We Need To Go? We still have a lot to learn about how MRI measurements of cervical spine muscle characteristics may serve as diagnostic and prognostic biomarkers in patients with cervical spine conditions. Which measurements or which muscles are most meaningful when assessing paraspinal muscle cross-sectional area and fatty infiltration on medical imaging? Does increased cervical muscle fatty infiltration/poor muscle quality imply progressive disease state or predict treatment outcomes? Are the changes observed modifiable or reversable with intervention, and if so, do improvements in muscle quality correlate with improved clinical outcomes? What mechanisms are responsible for cervical muscle fatty infiltration? Answers to these questions are not yet available; the reasons for degenerative changes in cervical musculature may be confounded by comorbidities, aging, and underlying diagnosis. The issue is further complicated in that cervical muscle characteristics have been shown to differ in patients diagnosed with chronic neck pain and those with whiplash-associated disorders [2]. All of these factors are pertinent to patients who undergo (or who are considering) ACDF. Pinter et al. [8] made precise measurements of the cross-sectional area and graded fatty infiltration semiqualitatively of select paraspinal muscles at two spinal levels. Alternative methods using precise volumetric measures of muscle quantity and composition across multiple spinal levels can also be used to quantify muscle quality; these quantitative techniques are laborious, time-consuming, and may require specialized analysis software. All of these methods are used to assess muscle quality, but when different methodologies are used, comparing studies can be challenging. Even with all the advancements in imaging and technology, it will be some time before thorough, quantitative descriptions of cervical paraspinal muscles will accompany every MRI study. In order to determine whether such descriptions are diagnostically or prognostically important, more research is necessary. How Do We Get There? Moving forward, consensus regarding the most reliable, valid, sensitive, time-efficient, and clinically relevant measures will allow for comparison of patient populations or treatment interventions between studies. In fact, efforts toward establishing such methodologies aimed at facilitating standardized and accurate quantification of the cervical spine musculature are underway [4]. As the methods used to quantify muscle quality become less time-consuming, more automated, and standardized [4], our ability to amass more data will improve, as will our ability to communicate and validate findings across studies. Further, experts in the field have discussed the potential value of combining quantitative imaging data (radiomics) with phenomics, genomics, and patient-reported outcome measures [1]. I think the next steps toward answering, “Which measurements or which muscles are most meaningful when assessing paraspinal muscle cross-sectional area and fatty infiltration on medical imaging?” will involve sophisticated analytical techniques, such as machine learning, which has been done recently in patients who have undergone ACDF [10]. In the era of precision medicine and increasing amounts of data being compiled, one could imagine how sophisticated analyses and algorithms, like machine learning, could be implemented into a digital health platform used to identify patients who are at high risk for adverse surgical outcomes or provide a prognosis for recovery. As evidence supports the notion that poor cervical muscle quality and function plays a role in worsening cervical spine deformity, postoperative alignment, and function, then we should understand how cervical spine surgery, like ACDF, affects cervical spine muscle quality. This would require longitudinal studies where patients undergoing ACDF surgery would undergo cervical spine MRI before surgery and are followed up with serial measures of muscle quality and patient-reported outcome measures over a longer period of time. For example, it would be interesting to follow the ACDF patients reported by Pinter et al. in both of their studies [8, 9] and measure cervical muscle quality and function postoperatively at 6, 12, and 24 months or even longer. There are clear costs associated with such follow-up (MRI, personnel, analysis), but if improvements in cervical muscle quality were to correlate with clinical outcomes, such findings would speak to the benefit of spine surgery and increase the motivation to pay closer attention to the cervical musculature on imaging studies. The importance of understanding the biological mechanisms responsible for reduced muscle quality in patients with cervical spine conditions cannot be overstated. Once such mechanisms are identified, interventions (biologics, injections, biomechanical) to improve cervical muscle quality may be prescribed in lieu of surgery or in conjunction with spine surgery to improve surgical outcomes." @default.
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• W3138291609 date "2021-03-11" @default.
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• W3138291609 title "CORR Insights®: Cervical Paraspinal Muscle Fatty Degeneration Is Not Associated with Muscle Cross-sectional Area: Qualitative Assessment Is Preferable for Cervical Sarcopenia" @default.
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