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.


Study design

Retrospective analysis of a prospective, multicenter registry.


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.


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.


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).


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






Published Version (Please cite this version)


Publication Info

Yang, Eunice, Praveen V Mummaneni, Dean Chou, Chiemela Izima, Kai-Ming Fu, Mohamad Bydon, Erica F Bisson, Christopher I Shaffrey, et al. (2024). 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, 37(4). pp. 188–197. 10.1097/bsd.0000000000001613 Retrieved from

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Christopher Ignatius Shaffrey

Professor of Orthopaedic Surgery

I have more than 25 years of experience treating patients of all ages with spinal disorders. I have had an interest in the management of spinal disorders since starting my medical education. I performed residencies in both orthopaedic surgery and neurosurgery to gain a comprehensive understanding of the entire range of spinal disorders. My goal has been to find innovative ways to manage the range of spinal conditions, straightforward to complex. I have a focus on managing patients with complex spinal disorders. My patient evaluation and management philosophy is to provide engaged, compassionate care that focuses on providing the simplest and least aggressive treatment option for a particular condition. In many cases, non-operative treatment options exist to improve a patient’s symptoms. I have been actively engaged in clinical research to find the best ways to manage spinal disorders in order to achieve better results with fewer complications.


Oren N Gottfried

Professor of Neurosurgery

I specialize in the surgical management of all complex cervical, thoracic, lumbar, or sacral spinal diseases by using minimally invasive as well as standard approaches for arthritis or degenerative disease, deformity, tumors, and trauma. I have a special interest in the treatment of thoracolumbar deformities, occipital-cervical problems, and in helping patients with complex spinal issues from previously unsuccessful surgery or recurrent disease.I listen to my patients to understand their symptoms and experiences so I can provide them with the information and education they need to manage their disease. I make sure my patients understand their treatment options, and what will work best for their individual condition. I treat all my patients with care and concern – just as I would treat my family. I am available to address my patients' concerns before and after surgery.  I aim to improve surgical outcomes for my patients and care of all spine patients with active research evaluating clinical and radiological results after spine surgery with multiple prospective databases. I am particularly interested in prevention of spinal deformity, infections, complications, and recurrent spinal disease. Also, I study whether patient specific variables including pelvic/sacral anatomy and sagittal spinal balance predict complications from spine surgery.

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