Day: October 6, 2026

Neurosurgery 99:928–937, 2026

Planning decompression for degenerative cervical myelopathy requires identifying not only the severity of spinal cord compression but also its distribution across levels and its response to movement. Neutral-position MRI may not fully represent this positional component. In a randomized single-center study, Ajem and colleagues examined whether additional flexion-extension MRI could refine operative planning and improve early neurological recovery. Dynamic imaging frequently changed the intended operation, and reported functional outcomes favored its use at three months. These findings are clinically relevant, but short follow-up and inconsistencies in outcome reporting temper the strength of the conclusions.

Objective

To determine whether adding dynamic MRI to conventional imaging changes surgical planning and improves three-month functional recovery in adults undergoing surgery for degenerative cervical myelopathy.

Methods

The trial was conducted at a single institution between February 2023 and December 2024. Seventy-four patients were randomized in equal groups after an initial surgical plan had been documented using static MRI. The control group proceeded according to that plan; the dynamic group underwent additional imaging that could change the approach, decompression levels or procedure. Eligibility excluded minors, previous spine surgery, spinal trauma or congenital anomalies, and concomitant lumbar stenosis. Most participants had severe myelopathy.

Dynamic imaging used sagittal T2-weighted sequences in flexion and extension on a 3-T scanner. Positioning was individualized and limited by tolerance without provoking neurological symptoms. The operating surgeon and a senior radiologist reviewed the findings, with additional adjudication when necessary. Five experienced surgeons performed the procedures, retaining discretion over the final operation.

The primary outcome was recovery rate derived from modified Japanese Orthopaedic Association (mJOA) scores at three months. Secondary assessments included mJOA scores, Nurick grades, changes in surgical planning and complications. Randomization concerned the imaging strategy, not the surgical approach.

Main results

Dynamic MRI changed the plan in 22/37 patients (59.5%): 12 anterior-to-posterior conversions, one posterior-to-anterior conversion, six increases in decompression levels and three changes from discectomy to corpectomy. Table 4 reports recovery of at least 50% in 34/37 dynamic-imaging patients versus 22/37 controls. Mean recovery rates were 55.42% and 46.76%, respectively; postoperative mJOA scores were 15.47 and 13.77. The reported between-group Nurick difference was not significant. One patient in each imaging group died after posterior surgery. These results require interpretation alongside the reporting limitations below.

Interpretation

The practical contribution is the opportunity to reconsider a documented operation when positional imaging reveals a different distribution of compression. The predominance of anterior-to-posterior conversions shows that dynamic information affected corridor selection as well as decompression extent. However, imaging-driven changes do not establish that every additional compressed level requires surgery. Clinical concordance and individualized review remain essential, and this study does not provide a validated rule for extending decompression. Nor does it isolate which particular change produced better recovery. Its findings support further evaluation of dynamic imaging as a planning adjunct, rather than automatic escalation of surgery.

Limitations

This small, single-center trial provides only three-month follow-up and does not establish durable neurological benefit, improved quality of life or reduced reoperation. Although described as single-blinded, the report does not clearly identify the blinded party or explain allocation concealment. Surgeons necessarily knew the additional imaging findings, and procedure selection was not standardized. Motion artifacts and discomfort may also limit the examination.

Numerical inconsistencies deserve particular attention. The reported P value of .044 for mean recovery rate is not readily reconciled with the sample sizes, means and standard deviations under the independent-samples t-test described in the methods. Recovery-category counts are also difficult to reconcile fully with the reported means and variability. The direction of the findings is therefore more credible as a preliminary signal than the precise magnitude or statistical certainty of benefit.

The anterior-versus-posterior comparison was not randomized: posterior patients had worse baseline mJOA scores and more levels decompressed. It cannot establish that one approach is inherently safer or more effective. Complication percentages in Table 5 do not correspond to the stated approach-group denominators, further limiting quantitative safety comparisons. The two deaths warrant acknowledgment but cannot support an approach-specific risk estimate in this sample.

Clinical takeaway

Dynamic MRI may help refine the choice of approach and decompression extent when positional findings materially change the assessment of cervical cord compression. This trial offers a useful planning signal, not definitive evidence for routine imaging in every patient or decompression of every dynamically narrowed level. Confirmation in larger trials with transparent outcome reporting and longer follow-up is needed.