Minimum clinically important difference in outcome scores among patients undergoing cervical laminoplasty

Who Gets Better After Surgery for Degenerative Cervical Myelopathy? A Responder Analysis from the Multicenter Canadian Spine Outcomes and Research Network

BACKGROUND CONTEXT

Degenerative cervical myelopathy (DCM) is the most common cause of acquired non-traumatic spinal cord injury worldwide. Surgery is a common treatment for DCM; however, outcomes often vary across patients.

PURPOSE

To inform preoperative education and counseling, we performed a responder analysis to identify factors associated with treatment response.

STUDY DESIGN/SETTING

An observational cohort study was conducted utilizing prospectively collected data from the Canadian Spine Outcomes Research Network (CSORN) registry collected between 2015-2022.

PATIENT SAMPLE

We included all surgically treated DCM patients with complete 12-month follow-up and patient-reported outcomes (PROs) available at 1-year.

OUTCOME MEASURES

Treatment response was measured using the minimal clinically important difference (MCID) in PROs including the Neck Disability Index (NDI) and EuroQol-5D (EQ-5D) at 12 months post-surgery.

METHODS

A Least Absolute Shrinkage and Selection Operator (LASSO) machine learning model was used to identify significant associations between 14 pre-operative patient factors and likelihood of treatment response measured by achievement of the MCID in NDI, and EQ-5D. Variable importance was measured using standardized coefficients. To test robustness of findings we trained a separate XGBOOST model, with variable importance measured using SHAP values.

RESULTS

Among the 554 DCM patients included, 229 (41.3%) and 330 (59.6%) patients responded to treatment by meeting or surpassing MCID thresholds for NDI and EQ-5D at 1-year, respectively. LASSO regression for likelihood of treatment response measured through NDI found the variable importance rank order to be baseline NDI (OR 1.06 per 1 point increase; 95% CI 1.04 - 1.07), then symptom duration (OR 0.65; 95% CI 0.44-0.97). For EQ-5D, the variable importance rank order was baseline EQ-5D (OR 0.16 per 0.1-point increase; 95% CI 0.03 - 0.78), living independently (OR 2.17; 95% CI 1.22 - 3.85), symptom duration (OR 0.62; 95% CI 0.40 - 0.97), then number of levels affected (OR 0.80 per additional level; 95% CI 0.67 - 0.96). A separate XGBoost model of treatment response measured through NDI, corroborated findings that patients with higher baseline NDI, and shorter symptom duration were more likely to respond to treatment, and additionally found older patients, and those with kyphosis on baseline upright x-ray were less likely to respond. Similarly, an XGBoost model for treatment response measured through EQ-5D corroborated findings that patients with higher baseline EQ-5D, shorter symptom duration, living independently, with fewer affected levels were more likely to respond to treatment, and additionally found older patients were less likely to respond.

CONCLUSIONS

Our findings suggest patients with shorter symptom duration, higher baseline patient NDI, lower EQ-5D, younger age, living independently, without kyphosis on pre-operative x-ray, and fewer affected levels are more likely to respond to treatment. Timing of surgery with respect to patient symptoms is underscored as a crucial and modifiable patient factor associated with improved surgical outcomes in DCM.

Systematic review reveals that EQ-5D minimally important differences vary with treatment type and may decrease with increasing baseline score

OBJECTIVES

To provide an updated summary of published anchor-based Minimally Important Difference (MID) estimates for the EQ-5D index and EQ visual analog scale (EQ VAS) scores and identify factors influencing those estimates.

STUDY DESIGN AND SETTING

We systematically searched eight electronic databases from January 1990 to March 2023. We examined the association of baseline score, type of score change (improvement/worsening), data source, value set, disease/condition, treatment type (surgical/non-surgical), and type of anchor (clinical vs. self-rated) with MID estimates for the EQ-5D-3L and EQ-5D-5L indices, and EQ VAS. Significant variables were used to develop prediction formulas for MID by testing both linear and nonlinear regression models.

RESULTS

Of 6786 records reviewed, 47 articles were included for analysis. MID ranges for improved scores were -0.13 to 0.68 (EQ-5D-3L), 0.01-0.41 (EQ-5D-5L), and 0.42-23.0 (EQ VAS). Surgical intervention and lower baseline scores were associated with higher MIDs for both the EQ indices but not for EQ VAS. The nonlinear polynomial model outperformed the linear model in predicting the MIDs. MIDs based on deteriorated scores were insufficient for quantitative synthesis (mean: -0.02 for EQ-5D-3L; -0.04 for EQ-5D-5L; and -6.5 for EQ VAS).

CONCLUSION

This review revealed that the MID of EQ-5D index scores varies with baseline score and treatment type, indicating that use of a uniform MID may not be appropriate. We recommend using baseline score-adjusted and treatment type-specific EQ-5D MIDs, and call for more MID research, particularly in the context of assessing deterioration in health using this widely used generic health-status instrument.

Impact of incidental dural tears on postoperative outcomes in patients undergoing cervical spine surgery: a multicenter retrospective cohort study

BACKGROUND CONTEXT

Incidental dural tear (DT) during cervical spine surgery is a feared complication. However, its impact on patient-reported outcomes (PROs) remains unclear.

PURPOSE

To determine the influence of DTs on PROs 1 year after cervical spine surgery.

STUDY DESIGN

Retrospective cohort.

PATIENT SAMPLE

Patients undergoing elective cervical spine surgery for cervical spondylosis, ossification of the posterior longitudinal ligament (OPLL), and cervical disc herniation.

OUTCOME MEASURES

Analysis included patients' characteristics, perioperative complications, and PROs both preoperatively and at 1 year postoperatively.

METHODS

This study enrolled consecutive patients who underwent elective cervical spine surgery at 13 high-volume spine centers. All patients were required to complete questionnaires both preoperatively and 1 year postoperatively, which included PROs such as numerical rating scales of pain or dysesthesia for each part of the body, Neck Disability Index NDI, and Core Outcome Measures Index. Patients were divided into 2 groups based on the presence (DT+) or absence (DT-) of dural injury. Comparisons were made regarding patient background, perioperative complications, and pre and postoperative PROs. Propensity score matching was also utilized to adjust for patient background, and further comparisons were made regarding complication rates and PROs.

RESULTS

Out of 2,704 patients, dural tears were identified in 97 (3.6%) cases. The DT+ group had a significantly higher proportion of fixation surgeries, upper cervical surgeries, OPLL, and revision surgeries. Perioperative complications were significantly higher in the DT+ group, including intraoperative nerve damage, postoperative paralysis, surgical site infections (SSI), and cerebrovascular complications. Outcomes collected from 2,163 patients (79.9%) revealed significantly more severe neck and upper limb pain in the DT+ group. After propensity score matching, significant differences persisted in postoperative paralysis and SSI in the DT+ group, but no significant differences were observed in PROs.

CONCLUSIONS

Patients with dural tears showed nearly equivalent postoperative outcomes at 1 year following cervical spine surgery compared to those without dural tears. However, the incidence of perioperative complications was higher, emphasizing the need for careful management.

Rehabilitation to Improve Outcomes after Cervical Spine Surgery: Narrative Review

PURPOSE

The increasing elderly patient population is contributing to the rising worldwide load of cervical spinal disorders, which is expected to result in a global increase in the number of surgical procedures in the foreseeable future. Cervical rehabilitation plays a crucial role in optimal recovery after cervical spine surgeries. Nevertheless, there is no agreement in the existing research regarding the most suitable postsurgical rehabilitation program. Consequently, this review assesses the ideal rehabilitation approach for adult patients following cervical spine operations.

MATERIALS AND METHODS

This review covers activities of daily living and encompasses diverse treatment methods, including physiotherapy, specialized tools, and guidance for everyday activities. The review is organized under three headings: (1) historical perspectives, (2) patient-reported functional outcomes, and (3) general and disease-specific rehabilitation.

RESULTS

Rehabilitation programs are determined on the basis of patient-reported outcomes, performance tests, and disease prognosis. CSM requires strengthening of the neck and shoulder muscles that have been surgically invaded. In contrast, the CCI requires mobility according to the severity of the spinal cord injury and functional prognosis. The goal of rehabilitation for CCTs, as for CCIs, is to achieve ambulation, but the prognosis and impact of cancer treatment must be considered.

CONCLUSIONS

Rehabilitation of the cervical spine after surgery is essential for improving physical function and the ability to perform daily activities and enhancing overall quality of life. The rehabilitation process should encompass general as well as disease-specific exercises. While current rehabilitation protocols heavily focus on strengthening muscles, they often neglect the crucial aspect of spinal balance. Therefore, giving equal attention to muscle reinforcement and the enhancement of spinal balance following surgery on the cervical spine is vital.

Does Ending a Posterior Construct Proximally at C2 Versus C3 Impact Patient Reported Outcomes in Degenerative Cervical Myelopathy Patients up to 24 months After the Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The primary objective was to evaluate the impact of the upper instrumented level (UIV) being at C2 vs C3 in posterior cervical construct on patient reported outcomes (PROs) up to 24 months after surgery for cervical degenerative myelopathy (DCM). Secondary objectives were to compare operative time, intra-operative blood loss (IOBL), length of stay (LOS), adverse events (AEs) and re-operation.

METHODS

Patients who underwent a posterior cervical instrumented fusion (3 and + levels) with a C2 or C3 UIV, with 24 months follow-up were analyzed. PROs (NDI, EQ5D, SF-12 PCS/MCS, NRS arm/neck pain) were compared using ANCOVA. Operative duration, IOBL, AEs, and re-operation were compared. Subgroup analysis was performed on patient presenting with pre-operative malalignment (cervical sagittal vertical axis ≥40 mm and/or T1slope- cervical lordosis >15°).

RESULTS

173 patients were included, of which 41 (24%) had a C2 UIV and 132 (76%) a C3 UIV. There was no statistically significant difference between the groups for the changes in PROs up to 24 months. Subgroup analysis of patients with pre-operative malalignment showed a trend towards greater improvement in the NDI at 12 months with a C2 UIV (P = .054). Operative time, IOBL and peri-operative AEs were more in C2 group (P < .05). There was no significant difference in LOS and re-operation (P > .05).

CONCLUSION

In this observational study, up to 24 months after surgery for posterior cervical fusion in DCM greater than 3 levels, PROs appear to evolve similarly.

Radiographic characterization of OPLL progression in patients receiving laminoplasty with a minimum of two-years follow-up

Ossification of the posterior longitudinal ligament (OPLL) is a common cause of degenerative cervical myelopathy (DCM) in Asian populations. Characterization of OPLL progression following laminoplasty remains limited in the literature. 29 patients with OPLL received cervical laminoplasty and a minimum of 2-years follow-up. Clinical and radiological surveillance occurred at 3-months, 6-months, 12-months post-op and then at yearly intervals. Transverse (anteroposterior) diameter and sagittal length of OPLL in relation to their cervical vertebral level of localisation was assessed upon immediate post-op radiographs compared to those obtained at subsequent follow-up. OPLL progression was defined as an increase in transverse dimensions and/or length by ≥ 2 mm. The average period of clinical follow-up was 6.7 ± 3.3 years. Upon latest follow-up, 79% of patients demonstrated at least 2 mm of transverse or longitudinal progression of OPLL. This corresponded to 2-years and 5-year progression rates of 54% and 71% respectively. OPLL located over C5 demonstrated the greatest transverse progression rate at (0.24 ± 0.34 mm / year). The mean overall longitudinal progression rate was 1.61 ± 2.06 mm / year. No patients experienced neurological decline resulting from OPLL progression requiring revision decompression during the period of post-operative observation. Characterizing transverse and longitudinal progression by cervical level via radiographs has implications in surgical planning for OPLL and should be consolidated upon post-operative CT/MRI scans as well as larger sample sizes.

The Effects of Peri-Operative Adverse Events on Clinical and Patient-Reported Outcomes After Surgery for Degenerative Cervical Myelopathy: An Observational Cohort Study from the Canadian Spine Outcomes and Research Network

BACKGROUND AND OBJECTIVES

There is a lack of data examining the effects of perioperative adverse events (AEs) on long-term outcomes for patients undergoing surgery for degenerative cervical myelopathy. We aimed to investigate associations between the occurrence of perioperative AEs and coprimary outcomes: (1) modified Japanese Orthopaedic Association (mJOA) score and (2) Neck Disability Index (NDI) score.

METHODS

We analyzed data from 800 patients prospectively enrolled in the Canadian Spine Outcomes and Research Network multicenter observational study. The Spine AEs Severity system was used to collect intraoperative and postoperative AEs. Patients were assessed at up to 2 years after surgery using the NDI and the mJOA scale. We used a linear mixed-effect regression to assess the influence of AEs on longitudinal outcome measures as well as multivariable logistic regression to assess factors associated with meeting minimal clinically important difference (MCID) thresholds at 1 year.

RESULTS

There were 167 (20.9%) patients with minor AEs and 36 (4.5%) patients with major AEs. The occurrence of major AEs was associated with an average increase in NDI of 6.8 points (95% CI: 1.1-12.4, P = .019) and reduction of 1.5 points for mJOA scores (95% CI: -2.3 to -0.8, P < .001) up to 2 years after surgery. Occurrence of major AEs reduced the odds of patients achieving MCID targets at 1 year after surgery for mJOA (odds ratio 0.23, 95% CI: 0.086-0.53, P = .001) and for NDI (odds ratio 0.34, 95% CI: 0.11-0.84, P = .032).

CONCLUSION

Major AEs were associated with reduced functional gains and worse recovery trajectories for patients undergoing surgery for degenerative cervical myelopathy. Occurrence of major AEs reduced the probability of achieving mJOA and NDI MCID thresholds at 1 year. Both minor and major AEs significantly increased health resource utilization by reducing the proportion of discharges home and increasing length of stay.

Relationship between frailty and locomotive syndrome in older patients with degenerative cervical myelopathy: A retrospective longitudinal study

BACKGROUND

The management of degenerative cervical myelopathy (DCM), which often impairs lower extremity function and increases the risk of falls, is gaining recognition for its importance in an aging society. Despite the significant overlap between frailty and locomotive syndrome (LS) in older adults, their interaction in older DCM patients remains unclear. We aimed to determine the characteristics of older DCM patients with frailty, focusing on the association between frailty and LS.

METHODS

We retrospectively examined the clinical records and imaging data of consecutive patients aged 65 years and above who underwent surgery for DCM at a single facility. Frailty and LS stage were diagnosed using the modified frailty index-11 and the 25-question Geriatric Locomotive Function Scale (GLFS-25), respectively.

RESULTS

A total of 114 subjects were analyzed, among whom approximately 30% were diagnosed with frailty. DCM patients with frailty had significantly worse Japanese Orthopaedic Association Cervical Myelopathy Assessment Questionnaire (JOACMEQ) and GLFS-25 scores at baseline than did those without frailty. Moreover, DCM patients with frailty had significantly more advanced LS stage at baseline than did those without frailty. Meanwhile, no significant difference in the improvement in JOACMEQ and GLFS-25 scores were observed between those with and without frailty after surgery. More precisely, DCM patients with frailty experienced better improvement in lower extremity function based on the JOACMEQ than did those without frailty.

CONCLUSIONS

Our results demonstrated that older DCM patients had favorable outcomes following surgery regardless of frailty. Despite the significant association between frailty and LS in DCM patients, frailty did not negatively impact the improvement in LS in older DCM patients. These findings provide valuable information for both older DCM patients and their attending physicians that would help guide decisions about cervical spine surgery for DCM.

Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial

BACKGROUND AND OBJECTIVES

Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW.

METHODS

In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model.

RESULTS

A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively.

CONCLUSION

Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

Influence of Body Mass Index on Surgical and Patient Outcomes for Cervical Spine Surgery

STUDY DESIGN

Secondary analysis of prospectively collected registry.

OBJECTIVE

We aim to investigate the effects of body mass index (BMI) on postsurgical cervical spine surgery outcomes and identify a potential substratification of obesity with worse outcomes.

SUMMARY OF BACKGROUND DATA

The impact of BMI on cervical spine surgery is unknown, with controversial outcomes for patients high and low BMI.

METHODS

The cervical spine Quality Outcomes Database was queried for a total of 10,381 patients who underwent single-stage cervical spine surgery. Patients were substratified into 6 groups based on BMI. Surgical outcomes, complications, hospitalization outcomes, and patient-reported outcomes for each cohort, including modified Japanese Orthopedic Association Score, Numeric Rating Scale arm pain, Numeric Rating Scale neck pain, Neck Disability Index, and EuroQol Health Survey, were assessed. Univariate analysis was performed for 3- and 12-month follow-up after surgical intervention.

RESULTS

Obese patients (class I, II, and III) requiring spine surgery were statistically younger than nonobese patients and had higher rates of diabetes compared with normal BMI patients. The surgical length was found to be longer for overweight and all classes of obese patients ( P < 0.01). Class III obese patients had higher odds of postoperative complications. Patients with class II and III obesity had lower odds of achieving optimal modified Japanese Orthopedic Association Score at 3 months [OR = 0.8 (0.67-0.94), P < 0.01, OR = 0.68 (0.56-0.82), P < 0.001, respectively] and 12 months [OR = 0.82 (0.68-0.98), P = 0.03, OR = 0.79 (0.64-0.98), P = 0.03, respectively].

CONCLUSIONS

This study investigates the relationship between substratified BMI and postoperative outcomes of cervical spine surgery. Class II and III obese patients have substantially greater risk factors and poor outcomes postoperatively. In addition, low BMI also presents unique challenges for patients. Further research is needed for comprehensive analysis on outcomes of cervical spine surgery after correcting BMI.

In the Treatment of Lateral Epicondylitis by Percutaneous Perforation, Injectables Have No Added Value

BACKGROUND

No single injection therapy has been proven to be superior in the treatment of lateral epicondylitis. In most studies, the injection technique is not standardized, which makes it challenging to compare outcomes.

QUESTIONS/PURPOSES

(1) Does injection with autologous blood, dextrose, or needle perforation only at the extensor carpi radialis brevis tendon origin produce better VAS pain scores during provocation testing at 5 months of follow-up? (2) Which percutaneous technique resulted in better secondary outcome measures: VAS during rest and activity, VAS during maximum grip, Oxford elbow score (OES), QuickDASH, Patient-related Tennis Elbow Evaluation (PRTEE), or EuroQol-5D (EQ-5D)?

METHODS

In this multicenter, randomized controlled trial performed from November 2015 to January 2020, 166 patients with lateral epicondylitis were included and assigned to one of the three treatment groups: autologous blood, dextrose, or perforation only. Complete follow-up data were available for the primary outcome measures at the 5-month follow-up interval for 77% (127 of 166) of patients. Injections of the extensor carpi radialis brevis tendon were conducted in an accurate and standardized way. The three groups did not differ in terms of key variables such as age, gender, duration of symptoms, smoking habits, pain medication, and physiotherapy use. Data were collected at baseline and 8 weeks, 5 months, and 1 year after treatment and compared among the groups. The primary endpoint was the VAS pain score with provocation at 5 months. Our secondary study outcomes were VAS pain scores during rest, after activity, and after maximum grip strength; functional recovery; and quality of life. Therefore, we report the VAS pain score (0 to 100, with higher scores representing more-severe pain, minimum clinically important difference [MCID] 10), OES (0 to 48, with higher scores representing more satisfactory joint function, MCID 10), QuickDASH (0 to 100, with higher scores representing more severe disability, MCID 5.3), PRTEE (0 to 100, with higher scores representing more pain or more disability, MCID 20), EQ-5D/QALY (EQ-5D sumscore 0 to 1, with the maximum score of 1 representing the best health state, MCID 0.04), and EQ-5D VAS (0 to 100, with higher scores representing the best health status, MCID 8). For analysis, one-way analysis of variance and a linear mixed-model analysis were used. The analyses were performed according to the intention-to-treat principle. Four patients from the perforation group opted to crossover to autologous blood after 5 months.

RESULTS

No injection therapy proved to be superior to any other in terms of VAS pain scores during the provocation test at 5 months of follow-up (VAS for perforation: 25 ± 31; autologous blood: 26 ± 27; dextrose: 29 ± 32; p = 0.35). For the secondary outcomes, only a clinically important difference was found for the QuickDASH score. Both the perforation-only group (-8 [98% CI -4 to -12]) and autologous blood (-7 points [98% CI -3 to -11]) had improved QuickDASH scores over time compared with the dextrose group (MCID 5.3; p < 0.01). For the other outcomes, no clinically important differences were found.

CONCLUSION

There is no benefit to injectable autologous blood and dextrose over perforation alone to treat lateral epicondylitis, and they are therefore not indicated for this condition.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Impact of the COVID-19 pandemic on surgical volume and outcomes in spine surgery: a multicentre retrospective study in Tokyo

OBJECTIVES

To investigate the effect of the COVID-19 pandemic on surgical volume and outcomes in spine surgery.

DESIGN

A retrospective cohort study using prospectively collected data.

SETTING AND PARTICIPANTS

A total of 9935 patients who underwent spine surgery between January 2019 and December 2021 at eight high-volume spine centres in the Greater Tokyo metropolitan area were included.

OUTCOME MEASURES

The primary outcome measures were the number of surgical cases, perioperative complications and patient-reported outcomes, including numerical rating scales for each body part, Euro quality of life 5-dimension (EQ5D), Neck Disability Index and Oswestry Disability Index (ODI).

RESULTS

The total number of surgeries in 2020 and 2021 remained lower than that of 2019, with respective percentages of 93.1% and 95.7% compared with the prepandemic period, with a marked reduction observed in May 2020 compared with the same period in 2019 (56.1% decrease). There were no significant differences between the prepandemic and postpandemic groups in the incidence of perioperative complications, although the frequency of reoperation tended to be higher in the postpandemic group (3.04% vs 3.76%, p=0.05). Subgroup analysis focusing on cervical spine surgery revealed significantly worse preoperative EQ5D scores in the postpandemic group (0.57 vs 0.54, p=0.004). Similarly, in lumbar spine surgery, the postpandemic group showed higher levels of leg pain (5.7 vs 6.1 to 0.002) and worse ODI scores (46.2 vs 47.7 to 0.02). However, postoperative outcomes were not different between pre and post-pandemic groups.

CONCLUSIONS

The COVID-19 pandemic has significantly impacted spinal surgeries in Japan, leading to a decrease in surgical volumes and changes in patient characteristics and surgical procedures. However, surgical outcomes remained comparable between the pre and postpandemic periods, indicating the resilience and adaptability of healthcare systems.

Impact of C3 laminectomy on cervical sagittal alignment in cervical laminoplasty: a prospective, randomized controlled trial comparing clinical and radiological outcomes between C3 laminectomy with C4-C6 laminoplasty and C3-C6 laminoplasty

BACKGROUND CONTEXT

C3 laminectomy in cervical laminoplasty is a modified laminoplasty technique that can preserve the semispinalis cervicis muscle attached to the C2 spinous process. Several previous studies have shown that this technique can lead to better outcomes of postoperative axial neck pain and C2-C3 range of motion (ROM) than conventional cervical laminoplasty. However, there is still a lack of understanding of total and proportional postoperative cervical sagittal alignment outcomes.

PURPOSE

To assess the effects of C3 laminectomy in cervical laminoplasty on postoperative cervical alignment and clinical outcomes.

DESIGN

A single-center, patient-blinded, randomized controlled trial.

PATIENT SAMPLE

We included consecutive 126 patients diagnosed with cervical spondylotic myelopathy (CSM) or ossification of posterior longitudinal ligament (OPLL) who were scheduled for cervical laminoplasty from March 2017 to January 2020.

OUTCOME MEASURES

The primary outcome measures were C2-C7 Cobb angle (CA) and neck disability index (NDI). Secondary outcomes measures included other clinical outcomes and radiographic parameters including segmental Cobb angle and presence of C2-C3 interlaminar fusion.

METHODS

Patients were randomly allocated to either the C3 laminectomy with C4-C6 laminoplasty group (LN group) or the C3-C6 laminoplasty group (LP group) at a 1:1 ratio. Laminoplasty was performed using a unilateral open-door technique and stabilized with titanium mini plates. A linear mixed model analysis was employed to examine the longitudinal data from postoperative 1-year through 3-year. Additional analysis between three types of cervical sagittal alignment morphology was done.

RESULTS

Among 122 patients who were randomly allocated to one of two groups (LN group, n=61; LP group, n=61), modified intent-to-treat analysis was done for 109 patients (LN group, n=51, LP group, n=58) who had available at least a year of postoperative data. Postoperative C2-C7 CA was not significantly different between the two groups. However, NDI was significantly different between the two groups (12.8±1.0 in the LN group vs 8.6±1.0 in LP group, p=.005), which exceeded the minimum clinically important difference (MCID). The postoperative C2-C3 CA was significantly greater in the LN group (7.1±0.5° in LN group vs 3.2±0.5° in LP group, p<.001) while C4-C7 CA was significantly smaller in the LN group (3.9±0.8° in LN group vs 7.7±0.7° in LP group, p<.001) with greater cSVA in the LN group (31.6±1.4 mm in LN group vs 25.5±1.3 mm in LP group at postoperative 3-year, p=.002). Postoperative Euro-Quality of Life-5 Dimension (EQ-5D), numerical rating scores for neck pain (NRS-N) were significantly better in the LP group than in the LN group (all p<.05) and only EQ-5D surpassed the MCID. The C2-C3 fusion rate was significantly different between the LN group (9.8%) and the LP group (44.8%) (p<.001). The LN group showed a higher prevalence of a specific cervical alignment morphology characterized by a sigmoid shape with proximal lordosis and distal kyphosis (S curve). This S curve demonstrated significantly unfavorable outcomes across multiple outcome variables.

CONCLUSION

The impact of C3 laminectomy in cervical laminoplasty on postoperative kyphosis among patients with CSM or OPLL did not significantly differ from that of C3-C6 laminoplasty. However, C3 laminectomy in cervical laminoplasty might result in an unfavorable clinical outcome with an unbalanced cervical sagittal alignment characterized by a sigmoid shape with proximal lordosis and distal kyphosis.

Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state

PURPOSE

While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs.

METHODS

We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations.

RESULTS

Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22.

CONCLUSION

While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures.

LEVEL OF EVIDENCE

III.

Predictive Value of Preoperative Short Form-36 Survey Scale for Postoperative Axial Neck Pain in Patients With Degenerative Cervical Myelopathy

STUDY DESIGN

Prospective observational study.

OBJECTIVE

To evaluate the predictive value of the preoperative Short Form-36 survey (SF-36) scale for postoperative axial neck pain (ANP) in patients with degenerative cervical myelopathy (DCM) who underwent anterior cervical decompression and fusion (ACDF) surgery.

METHODS

This study enrolled patients with DCM who underwent ACDF surgery at author's Hospital between May 2010 and June 2016.

RESULTS

Out of 126 eligible patients, 122 completed the 3-month follow-up and 117 completed the 1-year follow-up. The results showed that the preoperative social functioning (SF) subscale score of the SF-36 scale was significantly lower in patients with moderate-to-severe postoperative ANP than in those with no or mild postoperative ANP at both follow-up timepoints (P < .05). ACDF at C4-5 level resulted in a higher ANP rate than ACDF at C5-6 or C6-7 level, both at 3-month (P = .019) and 1-year (P = .004) follow-up. Multivariate logistic regression analysis confirmed that the preoperative social functioning subscale score was an independent risk factor for moderate-to-severe postoperative ANP at 3 months and 1 year after surgery, and preoperative NRS was an independent risk factor at 1-year follow-up. No other demographic, clinical, or radiographic factors were found to be associated with postoperative ANP severity (P < .05).

CONCLUSIONS

Preoperative social functioning subscale score of SF-36 scale might be a favorable predictive tool for postoperative ANP in DCM patients who underwent ACDF surgery.

The anchor design of anchor-based method to determine the minimal clinically important difference: a systematic review

BACKGROUND

Positive results for clinical outcomes should be not only statistically significant, but also clinically significant. The minimum clinically important difference (MCID) is used to define the minimum threshold of clinical significance. The anchor-based method is a classical method for ascertaining MCID. This study aimed to summarise the design of the anchors of the anchor-based method by reviewing the existing research and providing references and suggestions.

METHOD

This study was mainly based on literature research. We performed a systematic search using Web of Science, PubMed, CNKI, Wanfang, and VIP databases. Two reviewers independently screened titles and abstracts to identify relevant articles. Data were extracted from eligible articles using a predefined data collection form. Discrepancies were resolved by discussion and the involvement of a third reviewer.

RESULT

Three hundred and forty articles were retained for final analysis. For the design of anchors, Subjective anchors (99.12%) were the most common type of anchor used, mainly the Patient's rating of change or patient satisfaction (66.47%) and related scale health status evaluation items or scores (39.41%). Almost half of the studies (48.53%) did not assess the correlation test between the anchor and the research indicator or scale. The cut-off values and grouping were usually based on the choice of the anchor types. In addition, due to the large number of included studies, this study selected the most calculated SF-36 (28 articles) for an in-depth analysis. The results showed that the overall design of the anchor and the cut-off value were the same as above. The statistical methods used were mostly traditional (mean change, ROC). The MCID thresholds of these studies had a wide range (SF-36 PCS: 2-17.4, SF-36 MCS: 1.46-10.28), and different anchors or statistical methods lead to different results.

CONCLUSION

It is of great importance to select several types of anchors and to use more reliable statistical methods to calculate the MCID. It is suggested that the order of selection of anchors should be: objective anchors > anchors with established MCID in subjective anchors (specific scale > generic scale) > ranked anchors in subjective anchors. The selection of internal anchors should be avoided, and anchors should be evaluated by a correlation test.

Are the results of patient reported outcome measures after spine surgery influenced by recall of preoperative scores? A randomized controlled trial

BACKGROUND CONTEXT

Patient reported outcome measures (PROMs) are of utmost importance to clinical practice as they permit a patient-focused evaluation of surgical outcomes. However, recall bias can limit an adequate interpretation of PROMs.

PURPOSE

To assess the impact of recall bias of preoperative status on postoperative PROMs of patients submitted to surgery due to degenerative spine disease.

STUDY DESIGN / SETTING

Randomized controlled trial in a tertiary care neurosurgical unit in Portugal PATIENT SAMPLE: All patients submitted to surgery at our institution from January 2019 to April 2020 due to degenerative lumbar or cervical spine disease with valid PROMs questionnaires were enrolled, and 2 computer generated randomized groups were created.

OUTCOME MEASURES

The study´s primary endpoint was the median postoperative Core Outcome Measure Index (COMI) score.

METHODS

The intervention group was sent postoperative questionnaires including preoperative answers, while patients in the control group were sent the same PROMs without the preoperative answers.

RESULTS

Randomization was applied to 236 patients (118 for each group) and valid results were obtained for 147 patients (81 lumbar, 44 from the intervention group; and 66 cervical, 29 from the intervention group), from which 88 (60%) were females, with a median age of 58 years. Both groups shared similar baseline clinical characteristics and preoperative scores. Median postoperative COMI scores and interquartile ranges (IQR) were 4.20 (IQR: 2.30-6.00) and 5.45 (IQR: 3.75-7.40) for the intervention and control groups, respectively (Wilcoxon, p=.02). This difference was reached mainly due to cervical spine patients as median postoperative COMI score was 3.95 (IQR: 2.20-5.32) in the intervention group and 5.1 (IQR: 4.0-8.4) in the control group (Wilcoxon, p=.01). No significant difference was reached for lumbar patients.

CONCLUSIONS

Better PROMs scores were obtained for degenerative cervical spine patients to whom the preoperative results were provided. Therefore, providing preoperative scores to patients upon postoperative PROMs fulfilment might influence postoperative results. Further research is necessary to increase the reliability of PROMs in clinical practice.

Determinants of quality of life in degenerative cervical myelopathy: a systematic review

BACKGROUND

Degenerative cervical myelopathy (DCM) is the most common cause of chronic, progressive spinal cord impairment worldwide. Patients experience substantial pain, functional neurological decline and disability. Health-related quality of life (HRQoL) appears to be particularly poor, even when compared to other chronic diseases. However, the determinants of HRQoL are poorly understood. The objective was to perform a systematic review of the determinants of quality of life of people with DCM.

METHODS

A systematic search was conducted in MEDLINE and Embase following PRISMA 2020 guidelines (PROSPERO CRD42018115675). Full-text papers in English, exclusively studying DCM, published before 26 March 2020 were eligible for inclusion and were assessed using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias 2 (RoB 2) tool. Study sample characteristics, patient demographics, cohort type, HRQoL instrument utilised, HRQoL score, and relationships of HRQoL with other variables were qualitatively synthesised.

RESULTS

A total of 1176 papers were identified; 77 papers and 13,572 patients were included in the final analysis. A total of 96% of papers studied surgical cohorts and 86% utilised the 36-Item Short Form Survey (SF-36) as a measure of HRQoL. HRQoL determinants were grouped into nine themes. The most common determinant to be assessed was surgical technique (38/77, 49%) and patient satisfaction and experience of pain (10/77, 13%). HRQoL appeared to improve after surgery. Pain was a negative predictor of HRQoL.

CONCLUSION

Current data on the determinants of HRQoL in DCM are limited, contradictory and heterogeneous. Limitations of this systematic review include lack of distinction between DCM subtypes and heterogenous findings amongst the papers in which HRQoL is measured postoperatively or post-diagnosis. This highlights the need for greater standardisation in DCM research to allow further synthesis. Studies of greater precision are necessary to account for HRQoL being complex, multi-factorial and both time and context dependent.

Minimal clinically important difference as a method for assessing the effectiveness of spinal surgery using scales and questionnaires: non-systematic literature review

Objective. To analyze the literature data and to present recommendations on the use of the minimum clinically important difference (MCID) in the practice of spinal surgeon-researcher.

Material and Methods. The article is a non-systematic review of the literature. A search was performed for sources, which describe the calculation and analysis of the MCID parameter on a cohort of patients with degenerative spinal diseases in the PubMed, Scopus and Web of Science databases. Further, the analysis of the literature was carried out on the application of MCID to assess the effectiveness of surgical treatment.

Results. The MCID parameter is illustrated for the most common clinical scales used to assess the effectiveness of treatment in spinal surgery, with their detailed description and discussion of their benefits and drawbacks. The specific MCID values for cervical and lumbar pathologies, first of all degenerative ones, and follow-up periods, which can be used in assessing the results of the treatment, as well as in planning prospective comparative studies are presented.

Conclusion. The MCID parameter is required for sample size calculation and for the analysis of treatment outcomes. The MCID reflects not just the change in the baseline indicator, but also the clinical significance for the patient.

Prospective Investigation of Surgical Outcomes after Anterior Decompression with Fusion and Laminoplasty for the Cervical Ossification of the Posterior Longitudinal Ligament: A Propensity Score Matching Analysis

The ideal surgical strategy for cervical ossification of the posterior longitudinal ligament (OPLL) remains controversial due to the lack of high-quality evidence. Herein, we prospectively investigated the surgical outcomes of anterior cervical decompression with fusion (ADF) and laminoplasty (LAMP) with cervical OPLL. Three hundred patients were included in this study (ADF: n = 89; LAMP: n = 211 patients), and propensity score matching yielded 67 pairs of patients with ADF and LAMP, in which clinical outcomes were compared. Crude analysis revealed that the ADF group showed greater neurological recovery in cervical Japanese Orthopedic Association scores at two years, compared with that in the LAMP group (53.1% vs. 44.3%, p = 0.037). The ratio of minimum clinically important difference (MCID) success was significantly greater in the ADF group (59.6% vs. 43.6%, p = 0.016). Multivariate analysis showed that the factors affecting MCID success were age, body mass index, duration of symptoms, and choice of ADF. In the 1:1 matched analysis, neurological improvement was more favorable in the ADF group (57.2%) compared to the LAMP group (46.8%) at two years (p = 0.049). However, perioperative complications, such as dysphagia and graft-related complications, were more common in the ADF group.

Does extending a posterior cervical fusion construct into the upper thoracic spine impact patient-reported outcomes as long as 2 years after surgery in patients with degenerative cervical myelopathy?

OBJECTIVE

In multilevel posterior cervical instrumented fusion, extension of fusion across the cervicothoracic junction (CTJ) at T1 or T2 has been associated with decreased rates of reoperation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient-reported outcomes (PROs) remains unclear. The primary objective was to determine whether extension of fusion through the CTJ influenced PROs at 3, 12, and 24 months after surgery. The secondary objective was to compare the number of patients who reached the minimal clinically important differences (MCIDs) for the PROs, modified Japanese Orthopaedic Association (mJOA) score, operative time, intraoperative blood loss, length of stay, discharge disposition, adverse events (AEs), reoperation within 24 months of surgery, and patient satisfaction.

METHODS

This was a retrospective observational cohort study of prospectively collected multicenter data of patients with degenerative cervical myelopathy. Patients who underwent posterior instrumented fusion of 4 levels or greater (between C2 and T2) between January 2015 and October 2020 and received 24 months of follow-up were included. PROs (scores on the Neck Disability Index [NDI], EQ-5D, physical component summary and mental component summary of SF-12, and numeric rating scale for arm and neck pain) and mJOA scores were compared using ANCOVA and adjusted for baseline differences. Patient demographic characteristics, comorbidities, and surgical details were abstracted. The proportions of patients who reached the MCIDs for these outcomes were compared with the chi-square test. Operative duration, intraoperative blood loss, AEs, reoperation, discharge disposition, length of stay, and satisfaction was compared by using the chi-square test for categorical variables and the independent-samples t-test for continuous variables.

RESULTS

A total of 198 patients were included in this study (101 patients with fusion not crossing the CTJ and 97 with fusion crossing the CTJ). Patients with a construct extending through the CTJ were more likely to be female and have worse baseline NDI scores (p > 0.05). When adjusted for baseline differences, there were no statistically significant differences between the two groups in terms of the PROs and mJOA scores at 3, 12, and 24 months. Surgical duration was longer (p < 0.001) and intraoperative blood loss was greater in the group with fusion extending to the upper thoracic spine (p = 0.013). There were no significant differences between groups in terms of AEs (p > 0.05). Fusion with a construct crossing the CTJ was associated with reoperation (p = 0.04). Satisfaction with surgery was not significantly different between groups. The proportions of patients who reached the MCIDs for the PROs were not statistically different at any time point.

CONCLUSIONS

There were no statistically significant differences in PROs between patients with a posterior construct extending to the upper thoracic spine and those without such extension for as long as 24 months after surgery. The AE profiles were not significantly different, but longer surgical time and increased blood loss were associated with constructs extending across the CTJ.

Differences in postoperative quality of life in young, early elderly, and late elderly patients undergoing surgical treatment for degenerative cervical myelopathy

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is a common progressive spine disorder affecting predominantly middle-aged and elderly populations. With increasing life expectancy, the incidence of CSM is expected to rise further. The outcomes of elderly patients undergoing CSM surgery and especially their quality of life (QOL) postoperatively remain undetermined. This study retrospectively reviewed patients to identify baseline differences and validated postoperative patient-reported outcome (PRO) measures in elderly patients undergoing CSM surgery.

METHODS

The multi-institutional, neurosurgery-specific NeuroPoint Quality Outcomes Database was queried to identify CSM patients treated surgically at the 14 highest-volume sites from January 2016 to December 2018. Patients were divided into three groups: young (< 65 years), early elderly (65-74 years), and late elderly (≥ 75 years). Demographic and PRO measures (Neck Disability Index [NDI] score, modified Japanese Orthopaedic Association [mJOA] score, EQ-5D score, EQ-5D visual analog scale [VAS] score, arm pain VAS, and neck pain VAS) were compared among the groups at baseline and 3 and 12 months postoperatively.

RESULTS

A total of 1151 patients were identified: 691 patients (60%) in the young, 331 patients (28.7%) in the early elderly, and 129 patients (11.2%) in the late elderly groups. At baseline, younger patients presented with worse NDI scores (p < 0.001) and lower EQ-5D VAS (p = 0.004) and EQ-5D (p < 0.001) scores compared with early and late elderly patients. No differences among age groups were found in the mJOA score. An improvement of all QOL scores was noted in all age groups. On unadjusted analysis at 3 months, younger patients had greater improvement in arm pain VAS, NDI, and EQ-5D VAS compared with early and late elderly patients. At 12 months, the same changes were seen, but on adjusted analysis, there were no differences in PROs between the age groups.

CONCLUSIONS

The authors' results indicate that elderly patients undergoing CSM surgery achieved QOL outcomes that were equivalent to those of younger patients at the 12-month follow-up.

Differences in Patient-Reported Outcomes Between Anterior and Posterior Approaches for Treatment of Cervical Spondylotic Myelopathy: A Quality Outcomes Database Analysis

OBJECTIVE

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.

Minimal clinically important difference in patients who underwent decompression alone for lumbar degenerative disease

BACKGROUND CONTEXT

The minimal clinically important difference (MCID) represents the smallest change in an outcome measure recognized as clinically meaningful to a patient after receiving a clinical intervention. Most studies that discussed the MCIDs for lumbar spinal stenosis (LSS) included mixed pathologies or procedures despite that the MCID value should be different depending on the intervention. Moreover, despite the efficacy of adopting percentage-change improvement for the MCID threshold, there are limited reports and discussions in the field of lumbar surgery.

PURPOSE

The aim of the present study was to elucidate the MCIDs for the Oswestry Disability Index (ODI), EuroQOL 5-dimension 3-level (EQ-5D-3L), physical component summary (PCS) of the Short Form of the Medical Outcomes Study, and Numeric Rating Scale (NRS) in patients with degenerative LSS treated with decompression surgery without fusion.

STUDY DESIGN/SETTING

A multicenter retrospective cohort study was performed.

PATIENT SAMPLE

A total of 422 patients who underwent decompression surgery for LSS and answered a complete set of questionnaires were included in the study. Patients who underwent endoscopic or revision surgery were excluded.

OUTCOME MEASURES

Preoperative and 1-year postoperative scores of each health-related quality of life questionnaires (HRQOLs) and patient satisfaction questionnaire response METHODS: The patient satisfaction question was used as an anchor, and the cutoff values were estimated based on absolute point improvement from baseline using a receiver-operating characteristic (ROC) curve analysis and the "mean change" method for MCIDs. The MCID values for percentage-change in HRQOLs were also calculated using ROC curve analysis. The three cutoff values for each HRQOL were validated using the Youden index for determining the most robust MCIDs.

RESULTS

Of the patients, 356 (84.4%) were at least "somewhat satisfied" with the treatment results. The two cutoff values of absolute point-change in each HRQOL, which were estimated by two different anchor-based methods, were similar. The area under the curve of the ROC curve for percentage-change tended to be higher than that for absolute point-change. Moreover, the Youden index of the percentage-change in each HRQOL was higher than that of the absolute point-change calculated by either the "mean change" method or the ROC curve analysis. Based on these results, it was proposed that MCID was 42.4% for percentage-change in ODI, 22.0% for EQ-5D-3L, 13.7% for PCS, 25.0% for NRS (low back pain), 55.6% for NRS (leg pain), 22.2% for NRS (leg numbness).

CONCLUSIONS

The MCIDs of HRQOLs were calculated in patients with LSS treated with decompression surgery without concomitant fusion procedure. The MCID cutoffs based on percentage-change from baseline were more effective than those of absolute point-change.

Clinical improvement after surgery for degenerative cervical myelopathy; A comparison of Patient-Reported Outcome Measures during 12-month follow-up

OBJECT

Although many patients report clinical improvement after surgery due to degenerative cervical myelopathy, the aim of intervention is to stop progression of spinal cord dysfunction. We wanted to provide estimates and assess achievement rates of Minimal Clinically Important Difference (MCID) at 3- and 12-month follow-up for Neck Disability Index (NDI), Numeric Rating Scale for arm pain (NRS-AP) and neck pain (NRS-NP), Euro-Qol (EQ-5D-3L), and European Myelopathy Score (EMS).

METHODS

614 degenerative cervical myelopathy patients undergoing surgery responded to Patient-Reported Outcome Measures (PROMs) prior to, 3 and 12 months after surgery. External criterion was the Global Perceived Effect Scale (1-7), defining MCID as "slightly better", "much better" and "completely recovered". MCID estimates with highest sensitivity and specificity were calculated by Receiver Operating Curves for change and percentage change scores in the whole sample and in anterior and posterior procedural groups.

RESULTS

The NDI and NRS-NP percentage change scores were the most accurate PROMs with a MCID of 16%. The change score for NDI and percentage change scores for NDI, NRS-AP and NRS-NP were slightly higher in the anterior procedure group compared to the posterior procedure group, while remaining PROM estimates were similar across procedure type. The MCID achievement rates at 12-month follow-up ranged from 51% in EMS to 62% in NRS-NP.

CONCLUSION

The NDI and NRS-NP percentage change scores were the most accurate PROMs to measure clinical improvement after surgery for degenerative cervical myelopathy. We recommend using different cut-off estimates for anterior and posterior approach procedures. A MCID achievement rate of 60% or less must be interpreted in the perspective that the main goal of surgery for degenerative cervical myelopathy is to prevent worsening of the condition.

Effectiveness of Surgical Decompression in Patients With Degenerative Cervical Myelopathy: Results of the Canadian Prospective Multicenter Study

BACKGROUND

Conflicting evidence exists regarding the effectiveness of surgery for degenerative cervical myelopathy (DCM), particularly in mild DCM.

OBJECTIVE

To prospectively evaluate the impact of surgery on patient-reported outcomes in patients with mild (modified Japanese Orthopaedic Association [mJOA] ≥ 15), moderate (mJOA 12-14), and severe (mJOA < 12) DCM.

METHODS

Prospective, multicenter cohort study of patients with DCM who underwent surgery between 2015 and 2019 and completed 1-yr follow-up. Outcome measures (mJOA, Neck Disability Index [NDI], EuroQol-5D [EQ-5D], Short Form [SF-12] Physical Component Score [PCS]/Mental Component Score [MCS], numeric rating scale [NRS] neck, and arm pain) were assessed at 3 and 12 mo postoperatively and compared to baseline, stratified by DCM severity. Changes in outcome measures that were statistically significant (P < .05) and met their respective minimum clinically important differences (MCIDs) were deemed clinically meaningful. Responder analysis was performed to compare the proportion of patients between DCM severity groups who met the MCID for each outcome measure.

RESULTS

The cohort comprised 391 patients: 110 mild, 163 moderate, and 118 severe. At 12 mo after surgery, severe DCM patients experienced significant improvements in all outcome measures; moderate DCM patients improved in mJOA, NDI, EQ-5D, and PCS; mild DCM patients improved in EQ-5D and PCS. There was no significant difference between severity groups in the proportion of patients reaching MCID at 12 mo after surgery for any outcome measure, except NDI.

CONCLUSION

At 12 mo after surgery, patients with mild, moderate, and severe DCM all demonstrated improved outcomes. Severe DCM patients experienced the greatest breadth of improvement, but the proportion of patients in each severity group achieving clinically meaningful changes did not differ significantly across most outcome measures.

Minimum clinically important change for outcome scores among patients aged 75 or over undergoing lumbar spine surgery

PURPOSE

To elucidate the minimum clinically important change (MCIC) of the physical component summary (PCS) of the Short Form-12, Oswestry Disability Index (ODI), EuroQOL-5 dimensions (EQ-5D), and the Core Outcome Measures Index (COMI) in patients aged ≥ 75 years undergoing lumbar spine surgery.

METHODS

We retrospectively reviewed patients aged ≥ 75 years with degenerative lumbar spine disease who underwent lumbar spine decompression or fusion surgery within three levels between April 2017 and June 2018. We also evaluated patients aged < 75 years in the same period as reference. We evaluated the baseline and postoperative PCS, ODI, EQ-5D, and COMI scores. Patients were asked to answer an anchor question regarding health transition for MCICs using the anchor-based method.

RESULTS

A total of 247 patients aged ≥ 75 years and 398 patients aged < 75 years were included for analysis. Of patients aged ≥ 75 years, 83.4% showed at least "somewhat improved" outcomes, while 91.0% of patients aged < 75 years reported this outcome. PCS change score was not adequately correlated to health transition in patients aged ≥ 75 years. Receiver operating characteristic curve analyses revealed MCICs of 17.8 for ODI, 0.18 for EQ-5D, and 1.6 for COMI in patients aged ≥ 75 years, and 12.7 for ODI, 0.19 for EQ-5D, and 2.3 for COMI in patients aged < 75 years.

CONCLUSION

In patients aged ≥ 75 years, PCS may not be feasible for evaluation of health transition. The MCIC value for ODI score was higher and that for EQ-5D/COMI score was lower in patients aged ≥ 75 years, compared with those in patients aged < 75 years.

Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial

Importance

Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results.

Objective

To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year.

Design, Setting, and Participants

Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020.

Interventions

Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon's discretion.

Main Outcomes and Measures

The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score.

Results

Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, -2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%).

Conclusions and Relevance

Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach.

Trial Registration

ClinicalTrials.gov Identifier: NCT02076113.

Prediction of outcome following laminoplasty of cervical spondylotic myelopathy: Focus on the minimum clinically important difference

The minimum clinically important difference (MCID) of the Japanese Orthopaedic Association (JOA) score has been reported to be around 2.5 points in cervical myelopathy. This study sought to define significant predictive factors on achieving the MCID following laminoplasty in a large series of patients with cervical spondylotic myelopathy (CSM). A total of 485 consecutive patients with CSM (295 males and 190 females; mean age: 67.0 years; age range: 42-91 years) who underwent laminoplasty were prospectively enrolled. The average postoperative follow-up period was 26.6 months (range: 12-66 months). We calculated the achieved JOA score. The relationships between outcomes and various clinical and imaging predictors including comorbidity and quantitative performance tests were examined. Logistic regression analysis was conducted to identify the predictors correlated with a JOA score of 2.5 points or more. Clinically meaningful gains were exhibited in 299 patients (61.6%) with a JOA score of ≥2.5 points, whereas 186 patients (38.4%) achieved a JOA score of <2.5 points. Univariate logistic regression analysis showed the predictive factors with a shorter duration of CSM symptoms, lower preoperative JOA scores, absence of hypertension, no use of anticoagulant/antiplatelet agents, and nonsmoking status. Multivariate logistic regression analysis determined that the duration of CSM symptoms (odds ratio: 0.771, 95% confidence interval: 0.705-0.844; p < 0.01) was the only significant predictive factor for achieving JOA scores of ≥2.5 points. An important predictor of MCID achievement following laminoplasty was shorter duration of CSM symptoms.

Factors associated with postoperative axial symptom after expansive open-door laminoplasty: retrospective study using multivariable analysis

PURPOSE

The aim of the present study was to investigate the factors associated with axial symptom using multivariable analysis.

METHODS

The authors retrospectively assessed 249 patients treated by open-door laminoplasty. The patients were classified into two groups: axial symptom and no axial symptom group. The possible factors included demographic variables (age, sex, BMI, smoking, heart disease, diabetes, preoperative neck pain, preoperative JOA scores, preoperative NDI, course of disease and pathogenesis) and surgical and radiological variables [operation time, intraoperative blood loss, collar wear time, preoperative cervical curvature, postoperative cervical curvature, T1 slope, preoperative and postoperative C2 sagittal vertical axis (C2 SVA)].

RESULTS

The prevalence of axial symptom was 34.9% (89/249). The collar wear time, preoperative and postoperative C2 SVA were risk factors for axial symptom. A cutoff value of 22.6 mm for preoperative C2 SVA and 3.5 weeks for collar wear time predicted the development of axial symptom.

CONCLUSIONS

The longer collar wear time, larger preoperative and postoperative C2 SVA were positively correlated with the higher incidence of axial symptom.

Improvement in Patient Mental Well-being After Surgery for Cervical Spondylotic Myelopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to investigate changes in mental well-being after surgery for cervical spondylotic myelopathy (CSM) and identify factors associated with improvement.

SUMMARY OF BACKGROUND DATA

Posterior cervical surgery with laminoplasty significantly improves myelopathy and physical function in patients with CSM. However, its impact on mental well-being is unclear.

METHODS

Patients who underwent laminoplasty for CSM and had >2 years of follow-up were reviewed (n = 111). The mental component summary (MCS) score was used as a measure of mental well-being. The trend in MCS score change was evaluated using the Jonckheere-Terpstra trend test. Preoperative clinical scores were compared between patients with improvements greater and less than the minimal clinically important difference (MCID). Significant variables were included in a multinomial logistic regression analysis and further validated in a receiver-operating characteristic (ROC) curve analysis. Additionally, the results were confirmed in a long-term observation cohort of patients followed up for >5 years (n = 46).

RESULTS

The improvement in the average MCS score (5.6) was greater than the MCID (4.0). The trend of improvement was sustained for 2 years (P = 0.002), but not for 5 years (P = 0.130). In terms of individual cases, 56 patients (50.5%) achieved MCS score improvement greater than the MCID. These patients showed significantly lower preoperative MCS scores than those without meaningful improvement (P < 0.001). The preoperative "social functioning (SF)" score was independently associated with MCS score improvement (P = 0.001). ROC curve analysis validated the ability of preoperative SF to predict MCS score improvement at 2 and 5 years postoperatively (area under the curve: 0.744, 0.893, respectively).

CONCLUSION

Half of the patients achieved meaningful improvement in mental well-being. A lower preoperative SF score was independently associated with improvement. These results may help identify patients who could experience an improvement in mental well-being after surgery and develop novel approaches to achieve further improvement.

LEVEL OF EVIDENCE

3.

Treatment for ascites in adults with decompensated liver cirrhosis: a network meta-analysis

BACKGROUND

Approximately 20% of people with cirrhosis develop ascites. Several different treatments are available; including, among others, paracentesis plus fluid replacement, transjugular intrahepatic portosystemic shunts, aldosterone antagonists, and loop diuretics. However, there is uncertainty surrounding their relative efficacy.

OBJECTIVES

To compare the benefits and harms of different treatments for ascites in people with decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for ascites according to their safety and efficacy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until May 2019 to identify randomised clinical trials in people with cirrhosis and ascites.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and ascites. We excluded randomised clinical trials in which participants had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio (HR) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included a total of 49 randomised clinical trials (3521 participants) in the review. Forty-two trials (2870 participants) were included in one or more outcomes in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies, without other features of decompensation, having mainly grade 3 (severe), recurrent, or refractory ascites. The follow-up in the trials ranged from 0.1 to 84 months. All the trials were at high risk of bias, and the overall certainty of evidence was low or very low. Approximately 36.8% of participants who received paracentesis plus fluid replacement (reference group, the current standard treatment) died within 11 months. There was no evidence of differences in mortality, adverse events, or liver transplantation in people receiving different interventions compared to paracentesis plus fluid replacement (very low-certainty evidence). Resolution of ascites at maximal follow-up was higher with transjugular intrahepatic portosystemic shunt (HR 9.44; 95% CrI 1.93 to 62.68) and adding aldosterone antagonists to paracentesis plus fluid replacement (HR 30.63; 95% CrI 5.06 to 692.98) compared to paracentesis plus fluid replacement (very low-certainty evidence). Aldosterone antagonists plus loop diuretics had a higher rate of other decompensation events such as hepatic encephalopathy, hepatorenal syndrome, and variceal bleeding compared to paracentesis plus fluid replacement (rate ratio 2.04; 95% CrI 1.37 to 3.10) (very low-certainty evidence). None of the trials using paracentesis plus fluid replacement reported health-related quality of life or symptomatic recovery from ascites.

FUNDING

the source of funding for four trials were industries which would benefit from the results of the study; 24 trials received no additional funding or were funded by neutral organisations; and the source of funding for the remaining 21 trials was unclear.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence, there is considerable uncertainty about whether interventions for ascites in people with decompensated liver cirrhosis decrease mortality, adverse events, or liver transplantation compared to paracentesis plus fluid replacement in people with decompensated liver cirrhosis and ascites. Based on very low-certainty evidence, transjugular intrahepatic portosystemic shunt and adding aldosterone antagonists to paracentesis plus fluid replacement may increase the resolution of ascites compared to paracentesis plus fluid replacement. Based on very low-certainty evidence, aldosterone antagonists plus loop diuretics may increase the decompensation rate compared to paracentesis plus fluid replacement.