European Spine Journal - 2026-05-04 - Journal Article
Preoperative carotid ultrasound in degenerative cervical myelopathy: from routine screening to selective use.
Lin T, Shangguan Z, Wu R, Du R, Lin H, Lin X, Qin C, Chen G, Liu W, Wang Z
Topics
Key Takeaway
Carotid atherosclerotic plaque was present in 58.8% of DCM surgical patients, and a four-variable nomogram (age, BMI, vertigo, cervical lordosis) predicted plaque with an AUC of 0.863 in development and 0.892 in temporal validation, supporting selective rather than universal preoperative carotid ultrasound screening.
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Summary
This single-center retrospective study asked whether a nomogram could replace routine preoperative carotid ultrasound in 160 consecutive DCM surgical patients by identifying those at highest risk for carotid plaque. Development (n=104) and internal-temporal validation (n=56) cohorts were analyzed; multivariable logistic regression identified age, BMI, vertigo, and C2-C7 Cobb angle as independent predictors. The resulting nomogram achieved AUC 0.863 (optimism-corrected 0.838) in development and 0.892 in validation, with decision curve analysis favoring selective over universal screening; patients with carotid plaque had a lower proportion of excellent/good modified Macnab outcomes.
Key Limitation
The association between carotid plaque and inferior modified Macnab outcomes is observational with no causal mechanism established, and no data on whether preoperative carotid intervention in screen-positive patients alters neurological recovery.
Original Abstract
PURPOSE
To determine the prevalence and clinical relevance of carotid atherosclerosis in patients undergoing surgery for degenerative cervical myelopathy (DCM). Specifically, to identify clinical and radiographic predictors of carotid plaque, to develop and internal-temporal validate a nomogram to guide selective preoperative carotid ultrasound screening, and to explore the association between carotid disease and both neurological recovery and global patient-reported outcome.
METHODS
We conducted a single-center retrospective prognostic cohort study of 160 consecutive patients who underwent cervical decompression for DCM between January 2017 and February 2023, all with ≥ 2 years of follow-up. Patients treated from 2017 to 2021 (n = 104) formed the development cohort, and those treated from 2021 to 2023 (n = 56) constituted a temporally distinct internal-temporal validation cohort from the same institution. Preoperative carotid ultrasonography classified patients by (1) presence of carotid plaque and (2) carotid stenosis severity (none/mild vs. moderate/severe, ≥ 50%). Clinical, biochemical, radiographic, and outcome measures-including mJOA recovery rate and modified Macnab criteria (excellent/good vs. fair/poor)-were compared between groups. In the development cohort, variables with p < 0.05 in univariable analyses entered multivariable logistic regression to identify independent predictors of carotid plaque and construct a nomogram. Model performance was assessed by the area under the receiver operating characteristic curve (AUC), calibration plots, and decision curve analysis (DCA) in both cohorts. Bootstrap-based internal validation with 1,000 resamples was additionally performed for the final prediction model in the development cohort.
RESULTS
Overall, 94 of 160 patients (58.8%) had carotid plaque and 39 (24.4%) had moderate/severe carotid stenosis. In the development cohort, the plaque group was older, had higher body mass index (BMI), more vertigo and hypertension, greater C2-C7 Cobb angle (CL), more moderate/severe stenosis, and a lower proportion of excellent/good outcomes by modified Macnab criteria than the normal group (p < 0.05). Multivariable analysis identified age, BMI, vertigo, and CL as independent predictors of carotid plaque; each 1-year increase in age increased the odds of plaque by 13.7% (odds ratio 1.137, p < 0.001). These four variables were incorporated into a nomogram. The model showed good discrimination in the development cohort (apparent AUC 0.863; optimism-corrected AUC 0.838) and internal-temporal validation cohort (AUC 0.892), with acceptable calibration. DCA in both cohorts demonstrated greater net benefit for nomogram-guided selective screening than for "screen-all" or "screen-none" strategies across a clinically relevant range of threshold probabilities.
CONCLUSION
Carotid atherosclerotic plaque is common in patients undergoing surgery for DCM and is independently associated with age, BMI, vertigo, and increased cervical lordosis. These findings do not support mandatory preoperative carotid ultrasound screening for all DCM patients. A nomogram-based selective screening strategy using these four readily available variables may provide a practical framework for risk stratification, but its clinical utility should be interpreted cautiously pending stronger outcome-based evidence and external validation.