Browsing by Author "Skelly, Andrea C"

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    Frequency, timing, and predictors of neurological dysfunction in the nonmyelopathic patient with cervical spinal cord compression, canal stenosis, and/or ossification of the posterior longitudinal ligament.
    (Spine, 2013-10) Wilson, Jefferson R; Barry, Sean; Fischer, Dena J; Skelly, Andrea C; Arnold, Paul M; Riew, K Daniel; Shaffrey, Christopher I; Traynelis, Vincent C; Fehlings, Michael G

    Study design

    Systematic review and survey.

    Objective

    To perform an evidence synthesis of the literature and obtain information from the global spine care community assessing the frequency, timing, and predictors of symptom development in patients with radiographical evidence of cervical spinal cord compression, spinal canal narrowing, and/or ossification of posterior longitudinal ligament (OPLL) but no symptoms of myelopathy.

    Summary of background data

    Evidence for a marker to predict symptom development remains sparse, and there is controversy surrounding the management of asymptomatic patients.

    Methods

    We conducted a systematic review of the English language literature and an international survey of spine surgeons to answer the following key questions in patients with radiographical evidence of cervical spinal cord compression, spinal canal narrowing, and/or OPLL but no symptoms of myelopathy: (1) What are the frequency and timing of symptom development? (2) What are the clinical, radiographical, and electrophysiological predictors of symptom development? (3) What clinical and/or radiographical features influence treatment decisions based on an international survey of spine care professionals?

    Results

    The initial literature search yielded 388 citations. Applying the inclusion/exclusion criteria narrowed this to 5 articles. Two of these dealt with the same population. For patients with spinal cord compression secondary to spondylosis, one study reported the frequency of myelopathy development to be 22.6%. The presence of symptomatic radiculopathy, cervical cord hyperintensity on magnetic resonance imaging, and prolonged somatosensory- and motor-evoked potentials were reported in one study as significant independent predictors of myelopathy development. In contrast, the lack of magnetic resonance imaging hyperintensity was found to be a positive predictor of early myelopathy development (≤ 12-mo follow-up). For subjects with OPLL, frequency of myelopathy development was reported in 3 articles and ranged from 0.0% to 61.5% of subjects. One of these studies reported canal stenosis of 60% or more, lateral deviated OPLL, and increased cervical range of motion as significant predictors of myelopathy development. In a survey of 774 spine surgeons, the majority deemed the presence of clinically symptomatic radiculopathy to predict progression to myelopathy in nonmyelopathic patients with cervical stenosis. Survey responses pertaining to 3 patient case vignettes are also presented and discussed in the context of the current literature.

    Conclusion

    On the basis of these results, we provide a series of evidence-based recommendations related to the frequency, timing, and predictors of myelopathy development in asymptomatic patients with cervical stenosis secondary to spondylosis or OPLL. Future prospective studies are required to refine our understanding of this topic. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:

    Recommendation

    Patients with cervical canal stenosis and cord compression secondary to spondylosis, without clinical evidence of myelopathy, and who present with clinical or electrophysiological evidence of cervical radicular dysfunction or central conduction deficits seem to be at higher risk for developing myelopathy and should be counseled to consider surgical treatment.

    Overall strength of evidence

    Moderate.

    Strength of recommendation

    Strong. SUMMARY STATEMENTS: STATEMENT 1: On the basis of the current literature, for patients with cervical canal stenosis and cord compression secondary to spondylosis, without clinical evidence of myelopathy, approximately 8% at 1-year follow-up and 23% at a median of 44-months follow-up develop clinical evidence of myelopathy. STATEMENT 2: For patients with cervical canal stenosis and cord compression secondary to spondylosis, without clinical evidence of myelopathy, the absence of magnetic resonance imaging intramedullary T2 hyperintensity has been shown to predict early myelopathy development (<12-mo follow-up) and the presence of such signal has been shown to predict late myelopathy development (mean 44-mo follow-up). In light of this discrepancy, no definite recommendation can be made surrounding the utility of this finding in predicting myelopathy development. STATEMENT 3: For patients with OPLL but without myelopathy, no recommendation can be made regarding the incidence or predictors of progression to myelopathy.
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    Predictive factors affecting outcome after cervical laminoplasty.
    (Spine, 2013-10) Yoon, S Tim; Raich, Annie; Hashimoto, Robin E; Riew, K Daniel; Shaffrey, Christopher I; Rhee, John M; Tetreault, Lindsay A; Skelly, Andrea C; Fehlings, Michael G

    Study design

    Systematic review.

    Objective

    To determine whether various preoperative factors affect patient outcome after cervical laminoplasty for cervical spondylotic myelopathy (CSM) and/or ossification of posterior longitudinal ligament (OPLL).

    Summary of background data

    Cervical laminoplasty is a procedure designed to decompress the spinal cord by enlarging the spinal canal while preserving the lamina. Prior research has identified a variety of potential predictive factors that might affect outcomes after this procedure.

    Methods

    A systematic search of multiple major medical reference databases was conducted to identify studies explicitly designed to evaluate the effect of preoperative factors on patient outcome after cervical laminoplasty for CSM or OPLL. Studies specifically designed to evaluate potential predictive factors and their associations with outcome were included. Only cohort studies that used multivariate analysis, enrolled at least 20 patients, and adjusted for age as a potential confounding variable were included. JOA (Japanese Orthopaedic Association), modified JOA, and JOACMEQ-L (JOA Cervical Myelopathy Evaluation Questionnaire lower extremity function section) scores were the main outcome measures. Clinical recommendations and consensus statements were made through a modified Delphi approach by applying the GRADE (Grading of Recommendation Assessment, Development and Evaluation)/AHRQ (Agency for Healthcare Research and Quality) criteria.

    Results

    The search strategy yielded 433 citations, of which 1 prospective and 11 retrospective cohort studies met our inclusion criteria. Overall, the strength of evidence from the 12 studies is low or insufficient for most of the predictive factors. Increased age was not associated with poorer JOA outcomes for patients with CSM, but there is insufficient evidence to make a conclusion for patients with OPLL. Increased severity of disease and a longer duration of symptoms might be associated with JOA outcomes for patients with CSM. Hill-shaped lesions might be associated with poorer JOA outcomes for patients with OPLL. There is insufficient evidence to permit conclusions regarding other predictive factors.

    Conclusion

    Overall, the strength of evidence for all of the predictive factors was insufficient or low. Given that cervical myelopathy due to CSM tends to be progressive and that increased severity of myelopathy and duration of symptoms might be associated with poorer outcomes after cervical laminoplasty for CSM, it is preferable to perform laminoplasty in patients with CSM earlier rather than waiting for symptoms to get worse. Further research is needed to more clearly identify predictive factors that affect outcomes after cervical laminoplasty because there were relatively few studies identified that used multivariate analyses to control for confounding factors and many of these studies did not provide a detailed description of the multivariate analyses or the magnitude of effect estimates. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:

    Recommendation 1

    For patients with CSM, increased age is not a strong predictor of clinical neurological outcomes after laminoplasty; therefore, age by itself should not preclude cervical laminoplasty for CSM.

    Overall strength of evidence

    Low.

    Strength of recommendation

    Strong.

    Recommendation 2

    For patients with CSM, increased severity of disease and a longer duration of symptoms might be associated with poorer clinical neurological outcomes after laminoplasty; therefore, we recommend that patients be informed about this.

    Overall strength of evidence

    Low.

    Strength of recommendation

    Strong. SUMMARY STATEMENTS: For patients with OPLL, hill-shaped lesions might be associated with poorer clinical neurological outcomes after laminoplasty; therefore, surgeons might consider potential benefits and risks of alternative or additional surgery.
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    Proximal junctional kyphosis as a distinct form of adjacent segment pathology after spinal deformity surgery: a systematic review.
    (Spine, 2012-10) Kim, Han Jo; Lenke, Lawrence G; Shaffrey, Christopher I; Van Alstyne, Ellen M; Skelly, Andrea C

    Study design

    Systematic review.

    Objective

    To review the literature on proximal junctional kyphosis (PJK) as a specific form for proximal adjacent segment pathology and report on the incidence, timing, risk factors, and effect on health-related quality of life (HRQOL) outcomes reported for PJK.

    Summary of background data

    PJK is a complication of spinal deformity surgery that can compromise outcomes and necessitate revision surgery. Multiple risk factors have been associated with PJK, making the etiology multifactorial. Knowledge of the risk factors is important for minimizing the occurrence of PJK and to allow surgeons to take measures for its prevention when possible.

    Methods

    A systematic search of PubMed, CINAHL, EMBASE, the Cochrane Library, and Google Scholar through February 15, 2012, was performed. The focus was on studies designed to evaluate PJK in patients who had surgery for scoliosis and/or kyphosis. Adjusted effect sizes and significance based on adjusting for confounders were reported if available, otherwise, crude risk ratios and 95% confidence intervals were calculated.

    Results

    The search yielded 85 citations and 8 met the criteria for inclusion. The incidence of PJK ranged from 17% to 39% and the majority seemed to occur within 2 years of surgery. The most common patient demographic associated with a higher PJK risk was increased age. Surgery-related risk factors were fusions to the sacrum, combined anterior/posterior surgery, thoracoplasty, and upper instrumented vertebra at T1-T3. Postoperative hypokyphosis or hyperkyphosis was associated with an increased risk of PJK. Despite the presence of PJK, health-related quality of life outcomes were not affected.

    Conclusion

    Patients at higher risk for PJK are those who are of older age, who had fusions to the sacrum, combined anterior/posterior surgery, thoracoplasty, and an upper instrumented vertebra at T1-T3. Despite the presence of PJK, no differences were noted in health-related quality of life outcomes.

    Consensus statement

    1. The risk of developing PJK above a spinal deformity fusion is 17% to 39%, with most noted by 2 years postoperative.

    Level of evidence

    Moderate. Strength of Statement: Strong. 2. The risk factors of PJK development include increased age, fusion to sacrum, combined ASF/PSF, thoracoplasty, UIV at T1–T3, and nonanatomic restoration of thoracic kyphosis.

    Level of evidence

    Low. Strength of Statement: Weak. 3. The development of PJK does not seem to have a detrimental effect on HRQOL outcomes, at least in milder/nonrevision forms.

    Level of evidence

    Moderate. Strength of Statement: Weak.
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    Terminology.
    (Spine, 2012-10) Anderson, Paul A; Andersson, Gunnar BJ; Arnold, Paul M; Brodke, Darrel S; Brodt, Erika D; Chapman, Jens R; Chou, Dean; Dekutoski, Mark; Dettori, Joseph R; DeVine, John G; Ely, Claire G; Fehlings, Michael G; Fischer, Dena J; Fourney, Daryl R; Hansen, Mitchell A; Harrod, Christopher Chambliss; Hashimoto, Robin; Hermsmeyer, Jeffrey T; Hilibrand, Alan S; Kasliwal, Manish K; Kelly, Michael P; Kim, Han Jo; Kraemer, Paul; Lawrence, Brandon D; Lee, Michael J; Lenke, Lawrence G; Norvell, Daniel C; Raich, Annie; Riew, K Daniel; Shaffrey, Christopher I; Skelly, Andrea C; Smith, Justin S; Standaert, Christopher J; Van Alstyne, Ellen M; Wang, Jeffrey C
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    Timing of Decompression in Patients With Acute Spinal Cord Injury: A Systematic Review.
    (Global spine journal, 2017-09-05) Wilson, Jefferson R; Tetreault, Lindsay A; Kwon, Brian K; Arnold, Paul M; Mroz, Thomas E; Shaffrey, Christopher; Harrop, James S; Chapman, Jens R; Casha, Steve; Skelly, Andrea C; Holmer, Haley K; Brodt, Erika D; Fehlings, Michael G
    Systematic review.To conduct a systematic review and synthesis of the literature to assess the comparative effectiveness, safety, and cost-effectiveness of early (≤24 hours) versus late decompression (>24 hours) in adults with acute spinal cord injury (SCI).A systematic search was conducted of Medline, EMBASE, the Cochrane Collaboration Library, and Google Scholar to identify studies published through November 6, 2014. Studies published in any language, in humans, and with an abstract were considered for inclusion. Included studies were critically appraised and the overall strength of evidence was determined using methods proposed by the Grading of Recommendation Assessment, Development and Evaluation working group.The search yielded 449 potentially relevant citations. Sixteen additional primary studies were identified through other sources. Six studies met inclusion criteria. All but 2 studies were considered to have moderately high risk of bias. Across studies and injury levels, the impact of early surgical decompression (≤24 hours) on clinically important improvement in neurological status was variable. Isolated studies reported statistically significant and clinically important improvements at 6 months (cervical injury, low strength of evidence) and following discharge from inpatient rehabilitation (all levels, very low strength of evidence) but not at other time points; another study observed a statistically significant 6 point improvement in ASIA Impairment Scale (AIS) among patients with AIS B, C, or D, but not for those with AIS A (very low strength of evidence). In one study of acute central cord syndrome without instability, a clinically and statistically meaningful improvement in total motor scores was reported at 6 and 12 months in patients treated early (versus late). There were, however, no significant differences in AIS improvement between early and late surgical groups at 6- or 12-months (very low strength of evidence). One of 3 studies found a shorter length of hospital stay associated with early surgical decompression. Of 3 studies reporting on safety, no significant differences in rates of complications (including mortality, neurologic deterioration, pneumonia or pressure ulcers) were noted between early and late decompression groups.Results surrounding the efficacy of early versus late decompressive surgery, as well as the quality of evidence available, were variable depending on the level of SCI, timing of follow-up, and specific outcome considered. Existing evidence supports improved neurological recovery among cervical SCI patients undergoing early surgery; however, evidence regarding remaining SCI populations and clinical outcomes was inconsistent.