Browsing by Subject "Spondylosis"
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Item Open Access Anterior versus posterior surgical approaches to treat cervical spondylotic myelopathy: outcomes of the prospective multicenter AOSpine North America CSM study in 264 patients.(Spine, 2013-12) Fehlings, Michael G; Barry, Sean; Kopjar, Branko; Yoon, Sangwook Tim; Arnold, Paul; Massicotte, Eric M; Vaccaro, Alexander; Brodke, Darrel S; Shaffrey, Christopher; Smith, Justin S; Woodard, Eric; Banco, Robert J; Chapman, Jens; Janssen, Michael; Bono, Christopher; Sasso, Rick; Dekutoski, Mark; Gokaslan, Ziya LStudy design
A prospective observational multicenter study.Objective
To help solve the debate regarding whether the anterior or posterior surgical approach is optimal for patients with cervical spondylotic myelopathy (CSM).Summary of background data
The optimal surgical approach to treat CSM remains debated with varying opinions favoring anterior versus posterior surgical approaches. We present an analysis of a prospective observational multicenter study examining outcomes of surgical treatment for CSM.Methods
A total of 278 subjects from 12 sites in North America received anterior/posterior or combined surgery at the discretion of the surgeon. This study focused on subjects who had either anterior or posterior surgery (n = 264, follow-up rate, 87%). Outcome measures included the modified Japanese Orthopedic Assessment scale, the Nurick scale, the Neck Disability Index, and the Short-Form 36 (SF-36) Health Survey version 2 Physical and Mental Component Scores.Results
One hundred and sixty-nine patients were treated anteriorly and 95 underwent posterior surgery. Anterior surgical cases were younger and had less severe myelopathy as assessed by mJOA and Nurick scores. There were no baseline differences in Neck Disability Index or SF-36 between the anterior and posterior cases. Improvement in the mJOA was significantly lower in the anterior group than posterior group (2.47 vs. 3.62, respectively, P < 0.01), although the groups started at different levels of baseline impairment. The extent of improvement in the Nurick Scale, Neck Disability Index, SF-36 version 2 Physical Component Score, and SF-36 version 2 Mental Component Score did not differ between the groups.Conclusion
Patients with CSM show significant improvements in several health-related outcome measures with either anterior or posterior surgery. Importantly, patients treated with anterior techniques were younger, with less severe impairment and more focal pathology. We demonstrate for the first time that, when patient and disease factors are controlled for, anterior and posterior surgical techniques have equivalent efficacy in the treatment of CSM.Level of evidence
3.Item Open Access Association of myelopathy scores with cervical sagittal balance and normalized spinal cord volume: analysis of 56 preoperative cases from the AOSpine North America Myelopathy study.(Spine, 2013-10) Smith, Justin S; Lafage, Virginie; Ryan, Devon J; Shaffrey, Christopher I; Schwab, Frank J; Patel, Alpesh A; Brodke, Darrel S; Arnold, Paul M; Riew, K Daniel; Traynelis, Vincent C; Radcliff, Kris; Vaccaro, Alexander R; Fehlings, Michael G; Ames, Christopher PStudy design
Post hoc analysis of prospectively collected data.Objective
Development of methods to determine in vivo spinal cord dimensions and application to correlate preoperative alignment, myelopathy, and health-related quality-of-life scores in patients with cervical spondylotic myelopathy (CSM).Summary of background data
CSM is the leading cause of spinal cord dysfunction. The association between cervical alignment, sagittal balance, and myelopathy has not been well characterized.Methods
This was a post hoc analysis of the prospective, multicenter AOSpine North America CSM study. Inclusion criteria for this study required preoperative cervical magnetic resonance imaging (MRI) and neutral sagittal cervical radiography. Techniques for MRI assessment of spinal cord dimensions were developed. Correlations between imaging and health-related quality-of-life scores were assessed.Results
Fifty-six patients met inclusion criteria (mean age = 55.4 yr). The modified Japanese Orthopedic Association (mJOA) scores correlated with C2-C7 sagittal vertical axis (SVA) (r = -0.282, P = 0.035). Spinal cord volume correlated with cord length (r = 0.472, P < 0.001) and cord average cross-sectional area (r = 0.957, P < 0.001). For all patients, no correlations were found between MRI measurements of spinal cord length, volume, mean cross-sectional area or surface area, and outcomes. For patients with cervical lordosis, mJOA scores correlated positively with cord volume (r = 0.366, P = 0.022), external cord area (r = 0.399, P = 0.012), and mean cross-sectional cord area (r = 0.345, P = 0.031). In contrast, for patients with cervical kyphosis, mJOA scores correlated negatively with cord volume (r = -0.496, P = 0.043) and mean cross-sectional cord area (r = -0.535, P = 0.027).Conclusion
This study is the first to correlate cervical sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment. It is interesting to note that sagittal balance but not kyphosis is tied to myelopathy score. Future work will correlate alignment changes to cord morphology changes and myelopathy outcomes. SUMMARY STATEMENTS: This is the first study to correlate sagittal balance (C2-C7 SVA) to myelopathy severity. We found a moderate negative correlation in kyphotic patients of cord volume and cross-sectional area to mJOA scores. The opposite (positive correlation) was found for lordotic patients, suggesting a relationship of cord volume to myelopathy that differs on the basis of sagittal alignment.Item Open Access Cervical spondylotic myelopathy with severe axial neck pain: is anterior or posterior approach better?(Journal of neurosurgery. Spine, 2023-01) Chan, Andrew K; Shaffrey, Christopher I; Gottfried, Oren N; Park, Christine; Than, Khoi D; Bisson, Erica F; Bydon, Mohamad; Asher, Anthony L; Coric, Domagoj; Potts, Eric A; Foley, Kevin T; Wang, Michael Y; Fu, Kai-Ming; Virk, Michael S; Knightly, John J; Meyer, Scott; Park, Paul; Upadhyaya, Cheerag; Shaffrey, Mark E; Buchholz, Avery L; Tumialán, Luis M; Turner, Jay D; Michalopoulos, Giorgos D; Sherrod, Brandon A; Agarwal, Nitin; Chou, Dean; Haid, Regis W; Mummaneni, Praveen VObjective
The aim of this study was to determine whether multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical laminectomy and fusion (PCLF) is superior for patients with cervical spondylotic myelopathy (CSM) and high preoperative neck pain.Methods
This was a retrospective study of prospectively collected data using the Quality Outcomes Database (QOD) CSM module. Patients who received a subaxial fusion of 3 or 4 segments and had a visual analog scale (VAS) neck pain score of 7 or greater at baseline were included. The 3-, 12-, and 24-month outcomes were compared for patients undergoing ACDF with those undergoing PCLF.Results
Overall, 1141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score > 6). After applying inclusion and exclusion criteria, we compared 65 patients (54.6%) undergoing 3- and 4-level ACDF and 54 patients (45.4%) undergoing 3- and 4-level PCLF. Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs 45.9 ± 16.8, p = 0.03) but similar neck pain (p > 0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively). At the 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p < 0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p > 0.05). However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (β = 1.5 [95% CI 0.5-2.6], adjusted p = 0.01), higher EQ-5D score (β = 0.1 [95% CI 0.01-0.2], adjusted p = 0.04), and higher likelihood for return to baseline activities (OR 1.2 [95% CI 1.1-1.4], adjusted p = 0.002).Conclusions
Severe neck pain is prevalent among patients undergoing surgery for CSM, affecting more than 40% of patients. Both ACDF and PCLF achieved comparable postoperative neck pain improvement 3, 12, and 24 months following 3- or 4-segment surgery for patients with CSM and severe neck pain. However, multilevel ACDF was associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.Item Open Access Comparing Quality of Life in Cervical Spondylotic Myelopathy with Other Chronic Debilitating Diseases Using the Short Form Survey 36-Health Survey.(World neurosurgery, 2017-10) Oh, Taemin; Lafage, Renaud; Lafage, Virginie; Protopsaltis, Themistocles; Challier, Vincent; Shaffrey, Christopher; Kim, Han Jo; Arnold, Paul; Chapman, Jens; Schwab, Frank; Massicotte, Eric; Yoon, Tim; Bess, Shay; Fehlings, Michael; Smith, Justin; Ames, ChristopherBackground
Although cervical spondylotic myelopathy (CSM) can be devastating, its relative impact on general health remains unclear. Patient responses to the Short Form Survey 36-Health Survey (SF-36) Physical Component Summary (PCS)/Mental Component Summary (MCS) were compared between CSM and other diseases to evaluate their respective impacts on quality of life. The objective of this study was to compare SF-36 PCS/MCS scores in CSM with population and disease-specific norms.Methods
Retrospective analysis of a prospective, multicenter AOSpine North American CSM Study database. Inclusion criteria were symptomatic disease, age older than 18 years, cord compression on magnetic resonance imaging or computed tomography myelography, and baseline SF-36 values. SF-36 PCS/MCS scores in CSM were compared with national normative values and disease-specific norms using Student t test. Analysis of variance was used to assess differences across age groups and offsets from age-matched controls. Threshold for significance was P < 0.05.Results
There were 285 patients who met the inclusion criteria. The mean age was 56.6 ± 12.0 years, with male predominance (60%). SF-36 scores revealed significant baseline disability (PCS: 34.5 ± 9.8; MCS: 41.5 ± 14.4). Although there were no differences across age groups, when compared with age-matched normative data, younger patients had a larger PCS offset than older patients. CSM caused worse physical disability than most diseases except heart failure. Only back pain/sciatica induced worse mental disability.Conclusions
CSM affects quality of life to an extent greater than diabetes or cancer. Although mean impact of CSM does not vary with age, younger patients suffer from greater differences in baseline function. This study highlights the impact of myelopathy on patient function, particularly among younger age groups, and suggests that CSM merits a similar caliber of healthy policy attention as more well-studied diseases.Item Open Access Differences in Patient-Reported Outcomes Between Anterior and Posterior Approaches for Treatment of Cervical Spondylotic Myelopathy: A Quality Outcomes Database Analysis.(World neurosurgery, 2022-04) Wilkerson, Christopher G; Sherrod, Brandon A; Alvi, Mohammed Ali; Asher, Anthony L; Coric, Domagoj; Virk, Michael S; Fu, Kai-Ming; Foley, Kevin T; Park, Paul; Upadhyaya, Cheerag D; Knightly, John J; Shaffrey, Mark E; Potts, Eric A; Shaffrey, Christopher; Wang, Michael Y; Mummaneni, Praveen V; Chan, Andrew K; Bydon, Mohamad; Tumialán, Luis M; Bisson, Erica FObjective
Surgery for cervical spondylotic myelopathy (CSM) may use anterior or posterior approaches. Our objective was to compare baseline differences and validated postoperative patient-reported outcome measures between anterior and posterior approaches.Methods
The NeuroPoint Quality Outcomes Database was queried retrospectively to identify patients with symptomatic CSM treated at 14 high-volume sites. Demographic, comorbidity, socioeconomic, and outcome measures were compared between treatment groups at baseline and 3 and 12 months postoperatively.Results
Of the 1151 patients with CSM in the cervical registry, 791 (68.7%) underwent anterior surgery and 360 (31.3%) underwent posterior surgery. Significant baseline differences were observed in age, comorbidities, myelopathy severity, unemployment, and length of hospital stay. After adjusting for these differences, anterior surgery patients had significantly lower Neck Disability Index score (NDI) and a higher proportion reaching a minimal clinically important difference (MCID) in NDI (P = 0.005 at 3 months; P = 0.003 at 12 months). Although modified Japanese Orthopaedic Association scores were lower in anterior surgery patients at 3 and 12 months (P < 0.001 and P = 0.022, respectively), no differences were seen in MCID or change from baseline. Greater EuroQol-5D improvement at 3 months after anterior versus posterior surgery (P = 0.024) was not sustained at 12 months and was insignificant on multivariate analysis.Conclusions
In the largest analysis to date of CSM surgery data, significant baseline differences existed for patients undergoing anterior versus posterior surgery for CSM. After adjusting for these differences, patients undergoing anterior surgery were more likely to achieve clinically significant improvement in NDI at short- and long-term follow-up.Item Open Access Does vertebral level of pedicle subtraction osteotomy correlate with degree of spinopelvic parameter correction?(Journal of neurosurgery. Spine, 2011-02) Lafage, Virginie; Schwab, Frank; Vira, Shaleen; Hart, Robert; Burton, Douglas; Smith, Justin S; Boachie-Adjei, Oheneba; Shelokov, Alexis; Hostin, Richard; Shaffrey, Christopher I; Gupta, Munish; Akbarnia, Behrooz A; Bess, Shay; Farcy, Jean-PierreObject
Pedicle subtraction osteotomy (PSO) is a spinal realignment technique that may be used to correct sagittal spinal imbalance. Theoretically, the level and degree of resection via a PSO should impact the degree of sagittal plane correction in the setting of deformity. However, the quantitative effect of PSO level and focal angular change on postoperative spinopelvic parameters has not been well described. The purpose of this study is to analyze the relationship between the level/degree of PSO and changes in global sagittal balance and spinopelvic parameters.Methods
In this multicenter retrospective study, 70 patients (54 women and 16 men) underwent lumbar PSO surgery for spinal imbalance. Preoperative and postoperative free-standing sagittal radiographs were obtained and analyzed by regional curves (lumbar, thoracic, and thoracolumbar), pelvic parameters (pelvic incidence and pelvic tilt [PT]) and global balance (sagittal vertical axis [SVA] and T-1 spinopelvic inclination). Correlations between PSO parameters (level and degree of change in angle between the 2 adjacent vertebrae) and spinopelvic measurements were analyzed.Results
Pedicle subtraction osteotomy distribution by level and degree of correction was as follows: L-1 (6 patients, 24°), L-2 (15 patients, 24°), L-3 (29 patients, 25°), and L-4 (20 patients, 22°). There was no significant difference in the focal correction achieved by PSO by level. All patients demonstrated changes in preoperative to postoperative parameters including increased lumbar lordosis (from 20° to 49°, p < 0.001), increased thoracic kyphosis (from 30° to 38°, p < 0.001), decreased SVA and T-1 spinopelvic inclination (from 122 to 34 mm, p < 0.001 and from +3° to -4°, p < 0.001, respectively), and decreased PT (from 31° to 23°, p < 0.001). More caudal PSO was correlated with greater PT reduction (r = -0.410, p < 0.05). No correlation was found between SVA correction and PSO location. The PSO degree was correlated with change in thoracic kyphosis (r = -0.474, p < 0.001), lumbar lordosis (r = 0.667, p < 0.001), sacral slope (r = 0.426, p < 0.001), and PT (r = -0.358, p < 0.005).Conclusions
The degree of PSO resection correlates more with spinopelvic parameters (lumbar lordosis, thoracic kyphosis, PT, and sacral slope) than PSO level. More importantly, PSO level impacts postoperative PT correction but not SVA.Item Open Access 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 GStudy 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.Item Open Access Impact of dynamic alignment, motion, and center of rotation on myelopathy grade and regional disability in cervical spondylotic myelopathy.(Journal of neurosurgery. Spine, 2015-12) Liu, Shian; Lafage, Renaud; Smith, Justin S; Protopsaltis, Themistocles S; Lafage, Virginie C; Challier, Vincent; Shaffrey, Christopher I; Radcliff, Kris; Arnold, Paul M; Chapman, Jens R; Schwab, Frank J; Massicotte, Eric M; Yoon, S Tim; Fehlings, Michael G; Ames, Christopher PObject
Cervical stenosis is a defining feature of cervical spondylotic myelopathy (CSM). Matsunaga et al. proposed that elements of stenosis are both static and dynamic, where the dynamic elements magnify the canal deformation of the static state. For the current study, the authors hypothesized that dynamic changes may be associated with myelopathy severity and neck disability. This goal of this study was to present novel methods of dynamic motion analysis in CSM.Methods
A post hoc analysis was performed of a prospective, multicenter database of patients with CSM from the AOSpine North American study. One hundred ten patients (34%) met inclusion criteria, which were symptomatic CSM, age over 18 years, baseline flexion/extension radiographs, and health-related quality of life (HRQOL) questionnaires (modified Japanese Orthopaedic Association [mJOA] score, Neck Disability Index [NDI], the 36-Item Short Form Health Survey Physical Component Score [SF-36 PCS], and Nurick grade). The mean age was 56.9 ± 12 years, and 42% of patients were women (n = 46). Correlations with HRQOL measures were analyzed for regional (cervical lordosis and cervical sagittal vertical axis) and focal parameters (kyphosis and spondylolisthesis between adjacent vertebrae) in flexion and extension. Baseline dynamic parameters (flexion/extension cone relative to a fixed C-7, center of rotation [COR], and range of motion arc relative to the COR) were also analyzed for correlations with HRQOL measures.Results
At baseline, the mean HRQOL measures demonstrated disability and the mean radiographic parameters demonstrated sagittal malalignment. Among regional parameters, there was a significant correlation between decreased neck flexion (increased C2-7 angle in flexion) and worse Nurick grade (R = 0.189, p = 0.048), with no significant correlations in extension. Focal parameters, including increased C-7 sagittal translation overT-1 (slip), were significantly correlated with greater myelopathy severity (mJOA score, Flexion R = -0.377, p = 0.003; mJOA score, Extension R = -0.261, p = 0.027). Sagittal slip at C-2 and C-4 also correlated with worse HRQOL measures. Reduced flexion/extension motion cones, a more posterior COR, and smaller range of motion correlated with worse general health SF-36 PCS and Nurick grade.Conclusions
Dynamic motion analysis may play an important role in understanding CSM. Focal parameters demonstrated a significant correlation with worse HRQOL measures, especially increased C-7 sagittal slip in flexion and extension. Novel methods of motion analysis demonstrating reduced motion cones correlated with worse myelopathy grades. More posterior COR and smaller range of motion were both correlated with worse general health scores (SF-36 PCS and Nurick grade). To our knowledge, this is the first study to demonstrate correlation of dynamic motion and listhesis with disability and myelopathy in CSM.Item Open Access In response.(Spine, 2014-07) Fehlings, Michael G; Barry, Sean; Kopjar, Branko; Yoon, Sangwook Tim; Arnold, Paul; Massicotte, Eric M; Vaccaro, Alexander; Brodke, Darrel S; Shaffrey, Christopher; Smith, Justin S; Woodard, Eric; Banco, Robert J; Chapman, Jens; Janssen, Michael; Bono, Christopher; Sasso, Rick; Dekutoski, Mark; Gokaslan, Ziya LItem Open Access Is Upper Extremity or Lower Extremity Function More Important for Patient Satisfaction? An Analysis of 24-Month Outcomes from the QOD Cervical Spondylotic Myelopathy Cohort.(Clinical spine surgery, 2024-05) Yang, Eunice; Mummaneni, Praveen V; Chou, Dean; Izima, Chiemela; Fu, Kai-Ming; Bydon, Mohamad; Bisson, Erica F; Shaffrey, Christopher I; Gottfried, Oren N; Asher, Anthony L; Coric, Domagoj; Potts, Eric; Foley, Kevin T; Wang, Michael Y; Virk, Michael S; Knightly, John J; Meyer, Scott; Park, Paul; Upadhyaya, Cheerag; Shaffrey, Mark E; Uribe, Juan S; Tumialán, Luis M; Turner, Jay; Haid, Regis W; Chan, Andrew KStudy design
Retrospective analysis of a prospective, multicenter registry.Objective
To assess whether upper or lower limb mJOA improvement more strongly associates with patient satisfaction after surgery for cervical spondylotic myelopathy (CSM).Summary of background data
The modified Japanese Orthopaedic Association (mJOA) is commonly used to assess functional status in patients with CSM. Patients present with upper and/or lower extremity dysfunction, and it is unclear whether improvement in one and/or both symptoms drives postoperative patient satisfaction.Methods
This study utilizes the prospective Quality Outcomes Database (QOD) CSM data set. Clinical outcomes included mJOA and North American Spine Society (NASS) satisfaction. The upper limb mJOA score was defined as upper motor plus sensory mJOA, and the lower limb mJOA as lower motor plus sensory mJOA. Ordered logistic regression was used to determine whether upper or lower limb mJOA was more closely associated with NASS satisfaction, adjusting for other covariates.Results
Overall, 1141 patients were enrolled in the QOD CSM cohort. In all, 780 had both preoperative and 24-month mJOA scores, met inclusion criteria, and were included for analysis. The baseline mJOA was 12.1±2.7, and postoperatively, 85.6% would undergo surgery again (NASS 1 or 2, satisfied). Patients exhibited mean improvement in both upper (baseline:3.9±1.4 vs. 24 mo:5.0±1.1, P<0.001) and lower limb mJOA (baseline:3.9±1.4 vs. 24 mon:4.5±1.5, P<0.001); however, the 24-month change in the upper limb mJOA was greater (upper:1.1±1.6 vs. lower:0.6±1.6, P<0.001). Across 24-month NASS satisfaction, the baseline upper and lower limb mJOA scores were similar (pupper=0.28, plower=0.092). However, as satisfaction decreased, the 24-month change in upper and lower limb mJOA decreased as well (pupper<0.001, plower<0.001). Patients with NASS scores of 4 (lowest satisfaction) did not demonstrate significant differences from baseline in upper or lower limb mJOA (P>0.05). In ordered logistic regression, NASS satisfaction was independently associated with upper limb mJOA improvement (OR=0.81; 95% CI: 0.68-0.97; P=0.019) but not lower limb mJOA improvement (OR=0.84; 95% CI: 0.70-1.0; P=0.054).Conclusions
As the magnitude of upper and lower mJOA improvement decreased postoperatively, so too did patient satisfaction with surgical intervention. Upper limb mJOA improvement was a significant independent predictor of patient satisfaction, whereas lower limb mJOA improvement was not. These findings may aid preoperative counseling, stratified by patients' upper and lower extremity treatment expectations.Level of evidence
Level-III.Item Open Access Mild diabetes is not a contraindication for surgical decompression in cervical spondylotic myelopathy: results of the AOSpine North America multicenter prospective study (CSM).(The spine journal : official journal of the North American Spine Society, 2014-01) Arnold, Paul M; Fehlings, Michael G; Kopjar, Branko; Yoon, Sangwook Tim; Massicotte, Eric M; Vaccaro, Alexander R; Brodke, Darrel S; Shaffrey, Christopher I; Smith, Justin S; Woodard, Eric J; Banco, Robert J; Chapman, Jens R; Janssen, Michael E; Bono, Christopher M; Sasso, Rick C; Dekutoski, Mark B; Gokaslan, Ziya LBackground context
Cervical spondylotic myelopathy (CSM) is a chronic spinal cord disease and can lead to progressive or stepwise neurologic decline. Several factors may influence this process, including extent of spinal cord compression, duration of symptoms, and medical comorbidities. Diabetes is a systemic disease that can impact multiple organ systems, including the central and peripheral nervous systems. There has been little information regarding the effect of diabetes on patients with coexistent CSM.Purpose
To provide empirical data regarding the effect of diabetes on treatment outcomes in patients who underwent surgical decompression for coexistent CSM.Study design/setting
Large prospective multicenter cohort study of patients with and without diabetes who underwent decompressive surgery for CSM.Patient sample
Two hundred thirty-six patients without and 42 patients with diabetes were enrolled. Of these, 37 were mild cases and five were moderate cases. Four required insulin. There were no severe cases associated with end-organ damage.Outcome measures
Self-report measures include Neck Disability Index and version 2 of 36-Item Short Form Health Survey (SF-36v2), and functional measures include modified Japanese Orthopedic Association (mJOA) score and Nurick grade.Methods
We compared presurgery symptoms and treatment outcomes between patients with and without diabetes using univariate and multivariate models, adjusting for demographics and comorbidities.Results
Diabetic patients were older, less likely to smoke, and more likely to be on social security disability insurance. Patients with diabetes presented with a worse Nurick grade, but there were no differences in mJOA and SF-36v2 at presentation. Overall, there was a significant improvement in all outcome parameters at 12 and 24 months. There was no difference in the level of improvement between the patients with and without diabetes, except in the SF-36v2 Physical Functioning, in which diabetic patients experienced significantly less improvement. There were no differences in surgical complication rates between diabetic patients and nondiabetic patients.Conclusions
Except for a worse Nurick grade, diabetes does not seem to affect severity of symptoms at presentation for surgery. More importantly, with the exception of the SF-36v2 Physical Functioning scores, outcomes of surgical treatment are similar in patients with diabetes and without diabetes. Surgical decompression is effective and should be offered to patients with diabetes who have symptomatic CSM and are appropriate surgical candidates.Item Open Access Novel Method Using Baseline Normalization and Area Under the Curve to Evaluate Differences in Outcome Between Treatment Groups and Application to Patients With Cervical Spondylotic Myelopathy Undergoing Anterior Versus Posterior Surgery.(Spine, 2015-12) Liu, Shian; Tetreault, Lindsay; Fehlings, Michael G; Challier, Vincent; Smith, Justin S; Shaffrey, Christopher I; Arnold, Paul M; Scheer, Justin K; Chapman, Jens R; Kopjar, Branko; Protopsaltis, Themistocles S; Lafage, Virginie; Schwab, Frank; Massicotte, Eric M; Yoon, Sangwook T; Ames, Christopher PRetrospective review of a prospective database.To describe a novel method that uses baseline normalization and area under the curve (AUC) to compare surgical outcomes between patients surgically treated anteriorly versus posteriorly for cervical spondylotic myelopathy (CSM).It is important to control for baseline characteristics, especially disease severity, when evaluating differences in outcomes between 2 treatment groups. However, current methods of reporting outcomes are limited perhaps diminish the health impact of the entire postoperative recovery experience.In the prospective, multicenter AO Spine North America CSM database, 147 patients had complete modified Japanese Orthopaedic Association (mJOA) data at baseline and at 6-, 12-, and 24-months postoperatively and were either treated anteriorly (n = 94) or posteriorly (n = 53). Each patient's follow-up mJOA scores were normalized by dividing them by the patient's baseline value. A graph was then plotted with the time point on the x-axis and the normalized score or "recovery index" on the y-axis. The AUC was calculated and then compared between the anterior and posterior surgical approach groups.The non-normalized recovery profile of the anterior group was better than that of the posterior group, as the patients treated anteriorly had less functional impairment at baseline. After normalization, patients in the anterior and posterior group had similar recovery indices and AUCs at 6-months following surgery. At 24-months, patients treated posteriorly had a significantly higher recovery index (1.32) and a larger AUC (16.3) than those treated anteriorly (1.11, 14.5, P = 0.004 and P = 0.006, respectively).This is the first study to apply AUC analysis to patients with CSM. In surgical patients with CSM, those treated anteriorly achieved a higher mJOA score at all time points than those treated posteriorly. The recovery indices, however, were not significantly different between approach groups at 6 months.3.Item Open Access Outcomes after laminoplasty compared with laminectomy and fusion in patients with cervical myelopathy: a systematic review.(Spine, 2013-10) Yoon, S Tim; Hashimoto, Robin E; Raich, Annie; Shaffrey, Christopher I; Rhee, John M; Riew, K DanielStudy design
Systematic review.Objective
To determine the effectiveness and safety of cervical laminoplasty versus laminectomy and fusion for the treatment of cervical myelopathy, and to identify any patient subgroups for whom one treatment may result in better outcomes than the other.Summary of background data
Cervical laminoplasty and cervical laminectomy plus fusion are both procedures that treat cervical stenosis induced myelopathy by expanding the space available for the spinal cord. Although there are strong proponents of each procedure, the effectiveness, safety, and differential effectiveness and safety of laminoplasty versus laminectomy and fusion remains unclear.Methods
A systematic search of multiple major medical reference databases was conducted to identify studies that compared laminoplasty with laminectomy and fusion. Studies could include either or both cervical myelopathic spondylosis (CSM) and ossification of the posterior longitudinal ligament. Randomized controlled trials and cohort studies were included. Case reports and studies with less than 10 patients in the comparative group were excluded. Japanese Orthopaedic Association, modified Japanese Orthopaedic Association, and Nurick scores were the primary outcomes measuring myelopathy effectiveness. Reoperation and complication rates were evaluated for safety. Clinical recommendations were made through a modified Delphi approach by applying the Grading of Recommendations Assessment, Development and Evaluation/Agency for Healthcare Research and Quality criteria.Results
The search strategy yielded 305 citations, and 4 retrospective cohort studies ultimately met our inclusion criteria. For patients with CSM, data from 3 class of evidence III retrospective cohort studies suggest that there is no difference between treatment groups in severity of myelopathy or pain: 2 studies reported no significant difference between treatment groups in severity of myelopathy, and 3 studies found no significant difference in pain outcomes between treatment groups. For patients with ossification of the posterior longitudinal ligament, one small class of evidence III retrospective cohort study reported significant improvements in myelopathy severity after laminectomy and fusion compared with laminoplasty, but no differences in long-term pain between treatment groups. The overall evidence on the comparative safety of laminoplasty compared with laminectomy and fusion is inconsistent. Reoperation rates were lower after laminoplasty in 2 of 3 studies reporting. However, the incidence of debilitating neck pain was higher after laminoplasty as reported by one study; results on neurological complications were inconclusive, with 2 studies reporting. Results on kyphotic deformity were inconsistent, with opposite results in the 2 studies reporting. After laminectomy and fusion, 1% to 38% of patients had pseudarthrosis. Infection rates were slightly lower after laminoplasty, but the results are not likely to be statistically significant.Conclusion
For patients with CSM, there is low-quality evidence that suggests that laminoplasty and laminectomy and fusion procedures are similarly effective in treating CSM. For patients with ossification of the posterior longitudinal ligament, the evidence regarding the effectiveness of these procedures is insufficient. For both patient populations, the evidence as to whether one procedure is safer than the other is insufficient. Higher-quality research is necessary to more clearly delineate when one procedure is preferred compared with the other. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:Recommendation
For CSM, evidence suggests that laminoplasty and laminectomy-fusion procedures can be similarly effective. We suggest that surgeons consider each case individually and take into account their own familiarity and expertise with each procedure.Overall strength of evidence
Low.Strength of recommendation
Weak.Item Open Access Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study.(Journal of neurosurgery. Spine, 2012-05) Fehlings, Michael G; Smith, Justin S; Kopjar, Branko; Arnold, Paul M; Yoon, S Tim; Vaccaro, Alexander R; Brodke, Darrel S; Janssen, Michael E; Chapman, Jens R; Sasso, Rick C; Woodard, Eric J; Banco, Robert J; Massicotte, Eric M; Dekutoski, Mark B; Gokaslan, Ziya L; Bono, Christopher M; Shaffrey, Christopher IObject
Rates of complications associated with the surgical treatment of cervical spondylotic myelopathy (CSM) are not clear. Appreciating these risks is important for patient counseling and quality improvement. The authors sought to assess the rates of and risk factors associated with perioperative and delayed complications associated with the surgical treatment of CSM.Methods
Data from the AOSpine North America Cervical Spondylotic Myelopathy Study, a prospective, multicenter study, were analyzed. Outcomes data, including adverse events, were collected in a standardized manner and externally monitored. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days to 2 years following surgery) were tabulated and stratified based on clinical factors.Results
The study enrolled 302 patients (mean age 57 years, range 29-86) years. Of 332 reported adverse events, 73 were classified as perioperative complications (25 major and 48 minor) in 47 patients (overall perioperative complication rate of 15.6%). The most common perioperative complications included minor cardiopulmonary events (3.0%), dysphagia (3.0%), and superficial wound infection (2.3%). Perioperative worsening of myelopathy was reported in 4 patients (1.3%). Based on 275 patients who completed 2 years of follow-up, there were 14 delayed complications (8 minor, 6 major) in 12 patients, for an overall delayed complication rate of 4.4%. Of patients treated with anterior-only (n = 176), posterior-only (n = 107), and combined anterior-posterior (n = 19) procedures, 11%, 19%, and 37%, respectively, had 1 or more perioperative complications. Compared with anterior-only approaches, posterior-only approaches had a higher rate of wound infection (0.6% vs 4.7%, p = 0.030). Dysphagia was more common with combined anterior-posterior procedures (21.1%) compared with anterior-only procedures (2.3%) or posterior-only procedures (0.9%) (p < 0.001). The incidence of C-5 radiculopathy was not associated with the surgical approach (p = 0.8). The occurrence of perioperative complications was associated with increased age (p = 0.006), combined anterior-posterior procedures (p = 0.016), increased operative time (p = 0.009), and increased operative blood loss (p = 0.005), but it was not associated with comorbidity score, body mass index, modified Japanese Orthopaedic Association score, smoking status, anterior-only versus posterior-only approach, or specific procedures. Multivariate analysis of factors associated with minor or major complications identified age (OR 1.029, 95% CI 1.002-1.057, p = 0.035) and operative time (OR 1.005, 95% CI 1.002-1.008, p = 0.001). Multivariate analysis of factors associated with major complications identified age (OR 1.054, 95% CI 1.015-1.094, p = 0.006) and combined anterior-posterior procedures (OR 5.297, 95% CI 1.626-17.256, p = 0.006).Conclusions
For the surgical treatment of CSM, the vast majority of complications were treatable and without long-term impact. Multivariate factors associated with an increased risk of complications include greater age, increased operative time, and use of combined anterior-posterior procedures.Item Open Access 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 GStudy 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.Item Open Access Riluzole for Degenerative Cervical Myelopathy: A Secondary Analysis of the CSM-PROTECT Trial.(JAMA network open, 2024-06) Fehlings, Michael G; Pedro, Karlo M; Alvi, Mohammed Ali; Badhiwala, Jetan H; Ahn, Henry; Farhadi, H Francis; Shaffrey, Christopher I; Nassr, Ahmad; Mummaneni, Praveen; Arnold, Paul M; Jacobs, W Bradley; Riew, K Daniel; Kelly, Michael; Brodke, Darrel S; Vaccaro, Alexander R; Hilibrand, Alan S; Wilson, Jason; Harrop, James S; Yoon, S Tim; Kim, Kee D; Fourney, Daryl R; Santaguida, Carlo; Massicotte, Eric M; Huang, PengImportance
The modified Japanese Orthopaedic Association (mJOA) scale is the most common scale used to represent outcomes of degenerative cervical myelopathy (DCM); however, it lacks consideration for neck pain scores and neglects the multidimensional aspect of recovery after surgery.Objective
To use a global statistical approach that incorporates assessments of multiple outcomes to reassess the efficacy of riluzole in patients undergoing spinal surgery for DCM.Design, setting, and participants
This was a secondary analysis of prespecified secondary end points within the Efficacy of Riluzole in Surgical Treatment for Cervical Spondylotic Myelopathy (CSM-PROTECT) trial, a multicenter, double-blind, phase 3 randomized clinical trial conducted from January 2012 to May 2017. Adult surgical patients with DCM with moderate to severe myelopathy (mJOA scale score of 8-14) were randomized to receive either riluzole or placebo. The present study was conducted from July to December 2023.Intervention
Riluzole (50 mg twice daily) or placebo for a total of 6 weeks, including 2 weeks prior to surgery and 4 weeks following surgery.Main outcomes and measures
The primary outcome measure was a difference in clinical improvement from baseline to 1-year follow-up, assessed using a global statistical test (GST). The 36-Item Short Form Health Survey Physical Component Score (SF-36 PCS), arm and neck pain numeric rating scale (NRS) scores, American Spinal Injury Association (ASIA) motor score, and Nurick grade were combined into a single summary statistic known as the global treatment effect (GTE).Results
Overall, 290 patients (riluzole group, 141; placebo group, 149; mean [SD] age, 59 [10.1] years; 161 [56%] male) were included. Riluzole showed a significantly higher probability of global improvement compared with placebo at 1-year follow-up (GTE, 0.08; 95% CI, 0.00-0.16; P = .02). A similar favorable global response was seen at 35 days and 6 months (GTE for both, 0.07; 95% CI, -0.01 to 0.15; P = .04), although the results were not statistically significant. Riluzole-treated patients had at least a 54% likelihood of achieving better outcomes at 1 year compared with the placebo group. The ASIA motor score and neck and arm pain NRS combination at 1 year provided the best-fit parsimonious model for detecting a benefit of riluzole (GTE, 0.11; 95% CI, 0.02-0.16; P = .007).Conclusions and relevance
In this secondary analysis of the CSM-PROTECT trial using a global outcome technique, riluzole was associated with improved clinical outcomes in patients with DCM. The GST offered probability-based results capable of representing diverse outcome scales and should be considered in future studies assessing spine surgery outcomes.Item Open Access Sleep Disturbances in Cervical Spondylotic Myelopathy: Prevalence and Postoperative Outcomes-an Analysis From the Quality Outcomes Database.(Clinical spine surgery, 2023-04) Bisson, Erica F; Mummaneni, Praveen V; Michalopoulos, Giorgos D; El Sammak, Sally; Chan, Andrew K; Agarwal, Nitin; Wang, Michael Y; Knightly, John J; Sherrod, Brandon A; Gottfried, Oren N; Than, Khoi D; Shaffrey, Christopher I; Goldberg, Jacob L; Virk, Michael S; Hussain, Ibrahim; Shabani, Saman; Glassman, Steven D; Tumialan, Louis M; Turner, Jay D; Uribe, Juan S; Meyer, Scott A; Lu, Daniel C; Buchholz, Avery L; Upadhyaya, Cheerag; Shaffrey, Mark E; Park, Paul; Foley, Kevin T; Coric, Domagoj; Slotkin, Jonathan R; Potts, Eric A; Stroink, Ann R; Chou, Dean; Fu, Kai-Ming G; Haid, Regis W; Asher, Anthony L; Bydon, MohamadStudy design
Prospective observational study, level of evidence 1 for prognostic investigations.Objectives
To evaluate the prevalence of sleep impairment and predictors of improved sleep quality 24 months postoperatively in cervical spondylotic myelopathy (CSM) using the quality outcomes database.Summary of background data
Sleep disturbances are a common yet understudied symptom in CSM.Materials and methods
The quality outcomes database was queried for patients with CSM, and sleep quality was assessed through the neck disability index sleep component at baseline and 24 months postoperatively. Multivariable logistic regressions were performed to identify risk factors of failure to improve sleep impairment and symptoms causing lingering sleep dysfunction 24 months after surgery.Results
Among 1135 patients with CSM, 904 (79.5%) had some degree of sleep dysfunction at baseline. At 24 months postoperatively, 72.8% of the patients with baseline sleep symptoms experienced improvement, with 42.5% reporting complete resolution. Patients who did not improve were more like to be smokers [adjusted odds ratio (aOR): 1.85], have osteoarthritis (aOR: 1.72), report baseline radicular paresthesia (aOR: 1.51), and have neck pain of ≥4/10 on a numeric rating scale. Patients with improved sleep noted higher satisfaction with surgery (88.8% vs 72.9%, aOR: 1.66) independent of improvement in other functional areas. In a multivariable analysis including pain scores and several myelopathy-related symptoms, lingering sleep dysfunction at 24 months was associated with neck pain (aOR: 1.47) and upper (aOR: 1.45) and lower (aOR: 1.52) extremity paresthesias.Conclusion
The majority of patients presenting with CSM have associated sleep disturbances. Most patients experience sustained improvement after surgery, with almost half reporting complete resolution. Smoking, osteoarthritis, radicular paresthesia, and neck pain ≥4/10 numeric rating scale score are baseline risk factors of failure to improve sleep dysfunction. Improvement in sleep symptoms is a major driver of patient-reported satisfaction. Incomplete resolution of sleep impairment is likely due to neck pain and extremity paresthesia.