Letter to the Editor on “Imaging and Electrophysiology for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 9]” by Allan R. Martin et al.

To the Editor,

I read with great interest the article by Martin, et al. titled “Imaging and Electrophysiology for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 9]”. ¹ The research conducted is commendable and provides crucial insights into the use of imaging and electrophysiology in assessing DCM.

While I appreciate the exhaustive exploration of imaging modalities, I write this letter to bring attention to an aspect that has not been adequately addressed in the study, as well as in previous related research. The potential influence of symptom duration on Diffusion Tensor Imaging (DTI) parameters, particularly Fractional Anisotropy (FA), in patients with DCM is a subject worth contemplating.

A wealth of studies indeed show a decrease in FA, signifying a loss of spinal cord integrity in DCM. However, earlier research has suggested that the initial stages of spinal cord compression were marked by a focal decrease in Apparent Diffusion Coefficient (ADC) and an increase in FA.^2,3 Furthermore, in cases of mild Traumatic Brain Injury (TBI) in the subacute phase, FA could rise, possibly due to cytotoxic edema. ⁴ These observations hint towards a potential fluctuation in DTI parameters, particularly FA, with the progression of disease symptoms.

Unfortunately, this study, like many others evaluating DTI parameters in DCM patients, seems to overlook the relationship between symptom duration and DTI parameters. The consideration of disease duration might offer a more nuanced understanding of the observed DTI changes and their implications for patient prognosis and treatment strategies.

As we strive to develop DTI as a prognostic tool and possibly as an aid to decide which mild DCM patients would benefit more from surgery - since the guideline for surgery in this population does not unequivocally suggest surgery as it does for moderate to severe myelopathy ⁵ - we must consider the possible impact of symptom and disease duration on DTI parameters. A comprehensive understanding of this relationship could assist us in tailoring more effective, individualized treatment plans, and further our understanding of the disease’s progression.

I thus urge researchers in the field to take into account symptom duration when assessing DTI parameters in future DCM studies. Such an approach will not only enhance our current understanding of DCM but also pave the way for better, more effective management of patients suffering from this condition.