Myelomalacia severity on preoperative magnetic resonance imaging does not predict patient-reported outcomes after anterior cervical discectomy and fusion

Study Design/Setting: Retrospective cohort study. Background: Signal changes within the spinal cord on magnetic resonance imaging (MRI) or myelomalacia, are frequently seen in patients with cervical myelopathy. While often assumed to predict the outcomes, their prognostic value remains uncertain. Therefore, this study aimed to: (1) describe the clinical characteristics of patients with myelomalacia undergoing Anterior cervical discectomy and fusion (ACDF); (2) evaluate whether MRI findings correlate with patient-reported outcomes (PROMs); and (3) determine whether morphology predict recovery. Methods: A retrospective review at a single tertiary care center was performed (2014–2021). Patients were included if they underwent a primary elective ACDF with an available preoperative MRI. PROMs were collected preoperatively and postoperatively. Sagittal MRI assessment included Yukawa T2 hyperintensity grade, T1 signal change, morphology subtype, canal diameter, and K-line. Axial MRI was used to assess cord compression. Spearman correlation assessed the relationships between MRI measurements and PROMs. Results: Sixty-two patients were included. Bright T2 hyperintensity was observed in 61%, T1 hypointensity in 75%, and fusiform morphology in 53%; 79% were K-line positive. No consistent correlations were identified between MRI severity and PROMs. Yukawa T2 grading, T1 hypointensity, and morphology demonstrated negligible associations with postoperative outcomes. Weak associations were seen between K-line positivity and both 12-month SF-12 MCS (r = 0.34) and change in 6-month VAS neck (r = −0.39), but these were not clinically significant. Conclusion: Preoperative MRI severity and morphology of myelomalacia did not predict postoperative improvement after ACDF. These findings suggest that myelomalacia is best used as a diagnostic marker of spinal cord injury rather than a prognostic marker of recovery.