by M. Stewart
One of the most unusual things about CSM is what we call the “clinical radiological mismatch”. This means that there is no clear link between the clinical picture (the pain and disability that you feel, and the abnormal neurological signs we see in the clinic) and the radiological picture (what we see when we take images of your spine using X-rays and MRI). Some people can have very little abnormality on imaging, but have disability indicating severe myelopathy. Others can have major changes in their spine on imaging, which we might expect to give myelopathy, but have few or no symptoms.
It’s easiest to understand why mismatch is a problem using the example of a simpler condition. Imagine you have fallen onto an outstretched hand and come into A&E. We can examine you and establish that your wrist is painful and difficult to move. We take an X-ray and see clearly that you have fractured one of the bones in your wrist. This allows us to:
Here, there’s no mismatch – what we see on the images (normally) links directly to what we see at the bedside. Compare this to CSM. There’s nothing as simple and easy as a broken bone to look for, with numerous changes on imaging being potentially associated with myelopathy. Cervical spinal cord compression (seen on MRI scans) was thought to be one of the key imaging changes seen in myelopathy. However, just last month we talked about how most older people have spinal cord compression, but only one or two in a hundred have actual myelopathy (i.e. are ‘symptomatic’). As we have no definite way of spotting it on imaging, it can be difficult to diagnose myelopathy, decide when to offer surgery for it, determine how well our surgery worked or judge how the disease might progress. This is especially problematic as effective surgery depends on early diagnosis, offered too late and spinal cord damage may be permanent. With this in mind, it could be extremely useful if we could find imaging changes that only occur in people who actually have myelopathy (the ‘symptomatic’ group).
Fascinatingly, a group in Hebei Medical University China seem to have done just this. They have discovered several imaging changes that may distinguish symptomatic patients and could even predict the likelihood of myelopathy .
What did this experiment involve?
68 patients with cervical spinal cord compression were examined and divided into two groups. 30 had no signs or symptoms of myelopathy (the ‘asymptomatic’ group) and 38 were symptomatic for myelopathy (nerve damage, changes in reflexes, muscle spasms etc). The researchers then looked at the patients’ X-rays, CTs and MRI scans and tried to identify any differences in imaging between the two groups.
What were the results?
Three types of imaging change were found to be significantly more common in the symptomatic group.
What might this mean?
This could be a chance to overcome the clinical-radiological mismatch in CSM. Looking out for these three imaging changes could help us identify those patients who actually have myelopathy and are in need of surgery from those who don’t, making sure we operate in time. Furthermore, they could help us confirm when asymptomatic patients have progressed to a symptomatic stage. Potentially, they could even help us see how well our operations have worked, by seeing if the changes are reversed after the procedure!!
What were the weaknesses of this study? What could be next?
The main weakness here was the small number of patients used. The next step is to continue it in other hospitals, to see if the results are supported or if other important imaging changes can be found. However all of this seems extremely promising for the future of CSM, especially in terms of early diagnosis and choice of treatment!!
Join us next week for our Christmas Special article (exciting!!!) as well as to vote in our very own Christmas Poll. Merry Christmas to everybody!!!
by B. Davies
Cerebrolysin® is a mixture of amino acids (think of these as essential ingredients for all human processes) and small proteins, thought to stimulate neural growth. The compound is marketed by Ever Pharma  and has a reasonable safety profile and has been tried in a range of neurological conditions including Stroke and Alzheimer’s Dementia, as well as our very own CSM!
Where's the proof?
So, experimental proof lies in research conducted in Egypt , where the scientists took patients with mild CSM and at random, gave half of the patients Cerebrolysin® and half a placebo, and followed the patients over 6 months . No patients in this series received surgery. They found that patients taking Cerebrolysin® were more likely to show improvement in their CSM after 6 months, and more likely to show a greater amount of improvement.
What's the catch?
There are a number of cautions that must be attached to these results:
However, these results are interesting. Cerebrolysin ® has shown promise in animal studies and some human studies; and just because clear efficacy has not yet been shown in humans yet, does not mean it isn’t of benefit.
So, a small study, with limitations, but of interest! We look forward to seeing further developments in this area; who knows, this could turn out to be a wonder drug! Comment down below if you wish to share your experience with this drug, or any others you've found helpful in dealing with CSM symptoms.
Next week, we're going to tell you more about what sort of factors doctors might look for in imaging studies to decide whether CSM is going to be symptomatic or not - stay tuned!!
by B. Davies
On the surface, this seems a totally impossible idea! But on the basis of promising evidence in animals a group of researchers from the United States has conducted the first ever trial in humans.
What was the experiment about?
Experiments  on spinal cord injury animal models has shown that if animals experience bouts of breathing low levels of oxygen, combined with rehabilitation, then they recover greater physical function. So, the group from America decided to put this into practice in patients with chronic spinal cord injury. In patients with chronic (i.e. a long time after their injury) spinal cord injury, the capacity for improvement is thought to have plateaued.
The group took 6 patients and randomly assigned 3 to perform hand exercises for 1.5minutes whilst breathing low level oxygen and the other 3 to perform hand exercises at normal oxygen levels.
Patients breathing low levels of oxygen had significantly greater hand function after treatment for 5 consecutive days, than those who did not. The group hypothesize that the low levels of oxygen stimulates the release of growth factors, that, when coupled with rehabilitation, drive spinal cord repair.
What do these results tell us?
These results are very exciting. However, there are a number of limitations with this study and further evaluation is still needed, especially since this is an idea in its early stages - so we are by no means advocating you stop breathing anytime soon!
 Trumbower, R., Hayes, H., Mitchell, G., Wolf, S., & Stahl, V. (2017, September 29). Effects of acute intermittent hypoxia on hand use after spinal cord trauma; a preliminary study. Neurology, 89(18), 1904-1907. Retrieved from pubmed.gov: https://www.ncbi.nlm.nih.gov/pubmed/28972191
by Colin Munro
Hello everyone! My name is Colin Munro and I am a medical student at the University of Cambridge, School of Clinical Medicine. I have been working with Ben, Mark and the Myelopathy.org team to see if we can better understand how DCM (Degenerative Cervical Myelopathy, an alternative name for CSM) affects you. In particular I am trying to work out what comes first (i.e. the degeneration or the myelopathy), with the hope that this might better allows us to catch the condition early, which is a real problem at the moment. We also want to discover which symptoms and effects on life are most important to patients, such that further efforts into research can be put in those areas.
The Project’s Background:
Our project had its beginnings all the way back in September 2016, just before I joined the team, with the Myelopathy Day at the University of Cambridge, where a small group of people described how DCM affected them. There were some fantastic insights obtained from that day, giving us a long list of symptoms and ways in which DCM can affect your life. This was eye opening, as some of the descriptions weren’t signposted in medical textbooks! We also agreed on a way to group these symptoms and effects together into categories. However, in order to ensure these results represented everyone with DCM, we needed to test the results in a larger group of people, to see if we had missed anything. To achieve this, I put together a survey that went live in January 2017. Since then over 300 people have taken part! A massive “thank you” to you all! We again managed to get some great results, especially regarding which categories patients find most important. I have been fortunate enough to present this work to both national and international audiences at Oxford and Magdeburg, Germany, respectively.
Where are we up to? How can you help?
Nevertheless, following this first survey, quite a few of you mentioned symptoms and effects on your lives that we hadn’t previously considered. This means we need to add these to our lists and then re-survey everyone, to see how common these symptoms are amongst all DCM patients, to ensure they are also fully representative (for anyone interested, we call this process a DELPHI study). If after completing the first survey you agreed to be contacted again, we will do so by email (and you won’t have to complete those tedious demographics questions again!). However, if you haven’t already taken part, there will be a version of the second-round survey for those who didn’t do the first one online at Myelopathy.org. The second-round survey will be much shorter to complete (fortunately), as we no longer need to ask about which categories are most important to patients.
Thank you all in advance for your help!
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