Arm Pain Versus Neck Pain: A Novel Ratio as a Predictor of Post-Operative Clinical Outcomes in Cervical Radiculopathy Patients

Long-Term (>24 Months) Duration of Symptoms Negatively Impacts Patient-Reported Outcomes Following Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the impact of long symptom duration (>24 mo) on patient self-reported outcomes for pain, function, and quality of life following anterior cervical discectomy and fusion (ACDF) for cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

ACDF is an effective treatment to relieve the symptoms of cervical radiculopathy. However, there is no consensus on whether prolonged preoperative length of symptoms negatively impacts postoperative outcomes.

METHODS

This study included consecutive patients who underwent ACDF for cervical radiculopathy from May 1, 2012 to Dec 1, 2019 by a single surgeon. Patients were stratified by short (<24 mo) and long (>24 mo) duration of symptoms. Outcomes including visual analog scale (VAS) neck and arm, neck disability index (NDI), EuroQol-5D (EQ-5D), and overall state of health (EQ-VAS) were compared between cohort both for absolute values and percentage of patients achieving minimal clinically important difference.

RESULTS

A total of 111 consecutive patients were included in our study, including 59 patients in the short symptom duration group and 52 patients in the long symptom duration group. The mean age of the patients was 51.4±9.4 and 41 (36.9%) were female. The baseline VAS neck and arm, NDI, EQ-5D, and EQ-VAS were similar between groups. Patients in both long and short symptom duration groups had clinical improvement following surgery. However, patients with short symptom duration had better VAS Neck and EQ-5D outcomes, and were more likely to meet minimal clinically important difference for NDI, EQ-5D, or any outcome. Multivariate analysis confirmed symptom duration <24 months as an independent predictor for better patient-reported outcomes.

CONCLUSION

We appreciated better clinical outcomes in patients with shorter symptom duration who received ACDF for cervical radiculopathy. On the basis of this data, we advocate for prompt treatment of cervical radiculopathy to avoid the potential for long-term impairment.

LEVEL OF EVIDENCE

Level 3.

Comparison of Cervical Biportal Endoscopic Spine Surgery and Anterior Cervical Discectomy and Fusion in Patients with Symptomatic Cervical Disc Herniation

Background: We aimed to analyze the clinical outcomes and effectiveness of cervical biportal endoscopic spine surgery (C-BESS) and anterior cervical discectomy and fusion (ACDF) in patients with symptomatic cervical disc herniation. Methods: This study was a retrospective chart review of four-year clinical data involving 318 cases of symptomatic cervical disc herniation, with 156 patients undergoing the ACDF and 162 patients receiving the C-BESS. Preoperative and postoperative one-year data were collected. Results: The numeric rating scale and neck disability index showed statistically significant improvement for both ACDF and C-BESS groups. While showing a longer operation time and more blood loss during surgery compared to the ACDF group, the C-BESS group demonstrated a learning effect as the surgeon's proficiency increased with more cases. There was no significant difference in the postoperative length of hospitalization between the two methods. The subgroup with predominant arm pain revealed the statistical difference in arm pain intensity changes between the two groups (p < 0.001). The rates of complication were 2.6% for the ACDF group and 1.9% for the C-BESS group. Conclusions: C-BESS and ACDF are effective surgical treatments for patients with symptomatic single-level cervical disc herniation in relieving relevant pain intensities and pain-related disabilities.

Differences in Time to Achieve Minimum Clinically Important Difference Between Patients Undergoing Anterior Cervical Discectomy and Fusion and Cervical Disc Replacement

OBJECTIVE

To compare patients undergoing anterior cervical discectomy and fusion (ACDF) versus cervical disc replacement (CDR) for time to minimum clinically important difference (MCID) achievement and predictors of delayed MCID achievement for the patient-reported outcomes (PROs), Patient-Reported Outcomes Measurement Information System Physical Function, Neck Disability Index, Visual Analog Scale (VAS) neck, and VAS arm.

METHODS

PROs of patients undergoing ACDF or CDR were collected preoperatively and postoperatively at 6-week/12-week/6-month/1-year/2-year periods. MCID achievement was calculated through comparison of changes in Patient-Reported Outcomes Measurement to previously established values in literature. Time to MCID achievement and predictors for delayed MCID achievement were determined through Kaplan-Meier survival analysis and multivariable Cox regression, respectively.

RESULTS

One hundred ninety-seven patients were identified, with 118 and 79 undergoing ACDF and CDR, respectively. Kaplan-Meier survival analysis demonstrated faster time to achieve MCID for CDR patients in Patient-Reported Outcomes Measurement Information System Physical Function (P = 0.006). Early predictors of MCID achievement through Cox regression were CDR procedure, Asian ethnicity, elevated preoperative PROs of VAS neck and VAS arm (hazard ratio, 1.16-7.28). Workers' compensation was a late predictor of MCID achievement (hazard ratio, 0.15).

CONCLUSIONS

Most patients achieved MCID in physical function, disability, and back pain outcomes within 2 years of surgery. Patients undergoing CDR achieved MCID faster in physical function. Early predictors of MCID achievement were CDR procedure, Asian ethnicity, and elevated preoperative PROs of pain outcomes. Workers' compensation was a late predictor. These findings may be helpful in managing patient expectations.

Does Baseline Severity of Arm Pain Influence Outcomes Following Single-Level Anterior Cervical Discectomy and Fusion?

STUDY DESIGN

Retrospective cohort.

PURPOSE

To assess preoperative arm pain severity influence on postoperative patient-reported outcomes measures (PROMs) and minimal clinically important difference (MCID) achievement following single-level anterior cervical discectomy and fusion (ACDF).

OVERVIEW OF LITERATURE

There is evidence that preoperative symptom severity can affect postoperative outcomes. Few have evaluated this association between preoperative arm pain severity and postoperative PROMs and MCID achievement following ACDF.

METHODS

Individuals undergoing single-level ACDF were identified. Patients were grouped by preoperative Visual Analog Scale (VAS) arm ≤8 vs. >8. PROMs collected preoperatively and postoperatively included VAS-arm/VAS-neck/Neck Disability Index (NDI)/12-item Short Form (SF-12) Physical Composite Score (PCS)/SF-12 mental composite score (MCS)/Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF). Demographics, PROMs, and MCID rates were compared between cohorts.

RESULTS

A total of 128 patients were included. The VAS arm ≤8 cohort significantly improved for all PROMs excepting VAS arm at 1-year/2-years, SF-12 MCS at 12-weeks/1-year/2-years, and SF-12 PCS/PROMIS-PF at 6-weeks, only (p ≤0.021, all). The VAS arm >8 cohort significantly improved for VAS neck at all timepoints, VAS arm from 6-weeks to 1-year, NDI from 6-weeks to 6-months, and SF-12 MCS/PROMIS-PF at 6-months (p ≤0.038, all). Postoperatively, the VAS arm >8 cohort had higher VAS-neck (6 weeks/6 months), VAS-arm (12 weeks/6 months), NDI (6 weeks/6 months), lower SF-12 MCS (6 weeks/6 months), SF-12 PCS (6 months), and PROMISPF (12 weeks/6 months) (p ≤0.038, all). MCID achievement rates were higher among the VAS arm >8 cohort for the VAS-arm at 6-weeks/12-weeks/1-year/overall and NDI at 2 years (p ≤0.038, all).

CONCLUSIONS

Significance in PROM score differences between VAS arm ≤8 vs. >8 generally dissipated at the 1-year and 2-year timepoint, although higher preoperative arm pain patients suffered from worse pain, disability, and mental/physical function scores. Furthermore, clinically meaningful rates of improvement were similar throughout the vast majority of timepoints for all PROMs studied.

Influence of Predominant Neck versus Arm Pain on Clinical Outcomes in Cervical Disc Replacement

OBJECTIVE

We aim to compare the postoperative clinical outcomes, through patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID), in patients undergoing cervical disc replacement (CDR) with preoperative predominant neck pain (pNP) or arm pain (pAP).

METHODS

Patients undergoing primary CDR were separated into pNP or pAP cohorts. Demographic, perioperative characteristics, PROMs at preoperative and postoperative time points, and MCID were compared using inferential statistics. Assessed PROMs included Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF), 12-Item Short Form Physical/Mental Component Score (SF-12 PCS/MCS), visual analog scale (VAS) neck, VAS arm, and Neck Disability Index.

RESULTS

There were a total of 84 patients, with 54 patients in the pNP cohort. The pNP cohort showed significant postoperative improvement in all PROMs, except for 6-week and 1-year SF-12 PCS, 1-year SF-12 MCS, and 6-month VAS arm score (P ≤ 0.023, all). The pAP cohort showed significant postoperative improvement in all PROMs, apart from 6-month to 1-year SF-12 PCS, and all SF-12 MCS (P ≤ 0.041, all). Greater MCID achievement rates were found in the pNP cohort for SF-12 MCS (P = 0.030). The pAP cohort had higher MCID achievement rates in VAS arm score and Neck Disability Index (P ≤ 0.046, all).

CONCLUSIONS

Independent of predominant pain location, patients reported improved physical function, pain, and disability outcomes. Patients with pNP had higher MCID achievement rates in mental function. Patients with pAP had higher rates of MCID achievement in arm pain and disability outcomes. Considering the predominant location of preoperative pain may be helpful in managing expectations for patients undergoing CDR.

Anterior surgical treatment for cervical degenerative radiculopathy: a prediction model for non-success

PURPOSE

By using data from the Norwegian Registry for Spine Surgery, we wanted to develop and validate prediction models for non-success in patients operated with anterior surgical techniques for cervical degenerative radiculopathy (CDR).

METHODS

This is a multicentre longitudinal study of 2022 patients undergoing CDR surgery and followed for 12 months to find prognostic models for non-success in neck disability and arm pain using multivariable logistic regression analysis. Model performance was evaluated by area under the receiver operating characteristic curve (AUC) and a calibration test. Internal validation by bootstrapping re-sampling with 1000 repetitions was applied to correct for over-optimism. The clinical usefulness of the neck disability model was explored by developing a risk matrix for individual case examples.

RESULTS

Thirty-eight percent of patients experienced non-success in neck disability and 35% in arm pain. Loss to follow-up was 35% for both groups. Predictors for non-success in neck disability were high physical demands in work, low level of education, pending litigation, previous neck surgery, long duration of arm pain, medium-to-high baseline disability score and presence of anxiety/depression. AUC was 0.78 (95% CI, 0.75, 0.82). For the arm pain model, all predictors for non-success in neck disability, except for anxiety/depression, were found to be significant in addition to foreign mother tongue, smoking and medium-to-high baseline arm pain. AUC was 0.68 (95% CI, 0.64, 0.72).

CONCLUSION

The neck disability model showed high discriminative performance, whereas the arm pain model was shown to be acceptable. Based upon the models, individualized risk estimates can be made and applied in shared decision-making with patients referred for surgical assessment.

Does Age and Medicare Status Affect Clinical Outcomes in Patients Undergoing Anterior Cervical Discectomy and Fusion?

OBJECTIVE

The objective of this study was to determine if Medicare status and age affect clinical outcomes following anterior cervical discectomy and fusion.

METHODS

Patients who underwent cervical discectomy and fusion between 2014 and 2020 with complete preoperative and 1-year postoperative patient-reported outcome measures (PROMs) were grouped based on Medicare status and age: no Medicare under 65 years (NM < 65), Medicare under 65 years (M < 65), no Medicare 65 years or older (NM ≥ 65), and Medicare 65 years or older (M ≥ 65). Multivariate regression for ΔPROMs (Δ: postoperative minus preoperative) controlled for confounding differences between groups. Significant was set at P < 0.05.

RESULTS

A total of 1288 patients were included, with each group improving in the visual analog score (VAS) Neck (all, P < 0.001), VAS Arm (M < 65: P = 0.003; remaining groups: P < 0.001), and Neck Disability Index (M < 65: P = 0.009; remaining groups: P < 0.001) following surgery. Only M < 65 did not significantly improve in the Physical Component Score (PCS-12) and modified Japanese Orthopaedic Association (mJOA) score (P = 0.256 and P = 0.092, respectively). When comparing patients under 65 years, non-Medicare patients had better preoperative PCS-12 (P < 0.001), Neck Disability Index (P < 0.001), and modified Japanese Orthopaedic Association (P < 0.001), as well as better postoperative values for all PROMs (P < 0.001), but there were no differences in ΔPROMs. Multivariate analysis identified M < 65 to be an independent predictor of decreased improvement in ΔPCS-12 (β = -4.07, P = 0.015), ΔVAS Neck (β = 1.17, P = 0.010), and ΔVAS Arm (β = 1.15, P = 0.025) compared to NM < 65.

CONCLUSIONS

Regardless of age and Medicare status, all patients undergoing cervical discectomy and fusion had significant clinical improvement postoperatively. However, Medicare patients under age 65 have a smaller magnitude of improvement in PROMs.

Influence of Preoperative Severity on Postoperative Improvement Among Patients With Myeloradiculopathy Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

The aim was to determine how neck pain and disability improve following anterior cervical discectomy and fusion among patients with myeloradiculopathy.

SUMMARY OF BACKGROUND DATA

Neck pain and disability have traditionally been assessed using the neck disability index (NDI) and visual analog scale (VAS). Few studies have investigated how neck pain/disability improve differently among patients with symptoms of both myelopathy and radiculopathy.

METHODS

Patients were identified through retrospective review of a prospective surgical database from 2013 to 2020. Patient-reported outcome measures (PROMs) collected included VAS neck and arm, NDI, 12-Item Short Form physical composite score (SF-12 PCS), Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF), and Patient Health Questionnaire 9 (PHQ-9). PROMs were collected preoperatively and up to 1-year postoperatively. Patients were categorized by preoperative symptom severity: high VAS arm (>7); high NDI (>55); high VAS arm and NDI; and moderate symptoms. Linear and logistic regression evaluated the impact of preoperative symptom severity on PROM scores and achievement of minimum clinically important difference (MCID), respectively.

RESULTS

A total of 187 patients were included, 98 with neither high VAS arm nor NDI (moderate group), 14 with high NDI, 46 with high VAS arm, and 29 with high NDI and VAS arm. Postoperatively, greater symptom severity was a significant predictor of VAS neck (all timepoints; P ≤0.002, all), VAS arm (6 weeks; P =0.007), NDI (6 weeks to 6 months; P <0.001, all), SF-12 PCS (6 months; P =0.004), P ROMIS PF (6 weeks; P =0.007), and PHQ-9 (6 weeks to 6 months; P <0.001, all). Mean postoperative improvement was different among the four severity groups for VAS arm, NDI, and VAS neck (except for 1-year) ( P ≤0.002, all). Overall MCID achievement rates were significantly greater among higher symptom severity groups across VAS arm and NDI ( P ≤0.003, both).

CONCLUSION

PROM improvement and MCID achievement for NDI, VAS neck, and VAS arm differed based on symptom severity.

Evaluation of Dynamic Foraminal Stenosis with Positional MRI in Patients with C6 Radiculopathy-Mimicking Pain: A Prospective Radiologic Cohort Study

Objective

Patients with a C6 radiculopathy-mimicking complaint are always in the gray zone if the diagnosis is not clear. The aim of the study is to make the diagnosis clear if the neck and shoulder pain is caused by a dynamic stenosis of the neural foramen at the C5-C6 level.

Methods

Patients with a C6 radiculopathy-mimicking complaint were included in the study. Patients had a cervical spine magnetic resonance imaging (MRI) at the normal limits, or a minimal protrusion at the C5-C6 level underwent a dynamic MRI procedure. We measured the foraminal area and spinal cord diameter (SCD) at the C5-C6 level by using the PACS system ROI irregular are determination integral embedded to PACS. Inter- and intraobserver reliability of measurements was evaluated. Results were analyzed statistically, and a p value< 0.05 was accepted as statistically meaningful.

Results

A total of 23 patients between January 2019 and June 2019 were included in the study. There were 10 men and 13 women, and the mean age was 41.3 (range 33-53). Foraminal area decrease at C5-C6 in extension and increase in flexion when compared with the neutral position was statistically significant (p < 0.001). Foraminal area changes between the complaint side and the opposite side was not statistically different (p > 0.05). Interobserver and intraobserver reliability of measurements were classified as in almost perfect agreement.

Conclusions

Our present work presented dynamic and positional foraminal changes in MRI with radiculopathy-mimicking patients. Soever, we did not find a difference between the clinical complaint side and the opposite side in radiculopathy-mimicking patients. Cervical radiculopathy pain should not be attributed only to foraminal sizes. PACS embedded irregular area measurement integral allows the easy measure of a big number of patients without additional set-up and digital work requirements.

Clinical outcomes and revision rates following four-level anterior cervical discectomy and fusion

Studies on outcomes after four-level anterior cervical discectomy and fusion (ACDF) are limited in the literature. The purpose of this study was to report on clinical outcomes and revision rates following four-level ACDF. Patients operated with four-level ACDF were identified in a prospectively accrued single institution database. Outcome scores included the Neck Disability Index (NDI) and Visual Analogue Scale (VAS) for neck and arm pain. Reoperation rates were determined. Any complications were identified from a review of the medical records. Twenty-eight patients with a minimum of 12 months follow up were included in the analysis. The mean age at surgery was 58.5 years. The median radiographic follow up time was 23 (IQR = 16–31.25) months. Cervical lordosis was significantly improved postoperatively (− 1 to − 13, p < 0.001). At the median 24 (IQR = 17.75–39.50) months clinical follow up time, there was a significant improvement in the NDI (38 to 28, p = 0.046) and VAS for neck pain scores (5.1 to 3, p = 0.012). The most common perioperative complication was transient dysphagia (32%) followed by hoarseness (14%). Four (14%) patients required revision surgery at a median 11.5 (IQR = 2–51) months postoperatively. The results of this study indicate that patients who undergo four-level ACDF have a significant improvement in clinical outcomes at median 24 months follow up. Stand-alone four-level ACDF is a valid option for the management of complex cervical degenerative conditions.

How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

BACKGROUND

The presence of predominant pain in the arm vs the neck as a predictor of postoperative outcomes after anterior cervical discectomy and fusion (ACDF) has been seldom reported; therefore, the purpose of this study was to determine whether patients with predominant neck pain improve after surgery compared to patients with predominant arm pain or those with mixed symptoms in patients undergoing ACDF for radiculopathy.

METHODS

A retrospective cohort study was conducted on patients who underwent ACDF at a single center from 2016 to 2018. Patients were split into groups based on preoperative neck and arm pain scores: neck (N) pain dominant group (visual analog scale [VAS] neck ≥ VAS arm by 1.0 point); neutral group (VAS neck < VAS arm by 1.0 point); or arm (A) pain dominant group (VAS arm ≥ VAS neck by 1.0 point), using a threshold difference of 1.0 point. Subsequently, individuals were substratified into 2 groups based on the arm to neck pain ratio (ANR): non-arm pain dominant defined as ANR ≤1.0 and arm pain dominant (APD) defined as ANR >1.0. Patient-reported outcome measurements including Neck Disability Index (NDI), Physical Component Score-12, and Mental Component Score (MCS-12) were compared between groups.

RESULTS

No significant differences between groups when stratifying patients using a threshold difference of 1.0 point. When stratifying patients using the ANR, those in the APD group had significantly higher postoperative MCS-12 (P = 0.008) and NDI (P = 0.011) scores. In addition, the APD group showed a greater magnitude of improvement for MCS-12 and NDI scores (P = 0.043 and P = 0.038, respectively). Multiple linear regression showed that the A and the APD groups were both independent predictors of improvement in NDI.

CONCLUSION

Patients with dominant arm pain showed significantly greater improvement in terms of MCS-12 and NDI scores compared to patients with dominant neck pain.

CLINICAL RELEVANCE

To compare the impact of ACDF on arm and neck pain in the context of cervical radiculopathy using patient-reported outcome measures as an objective measurement.

LEVEL OF EVIDENCE: 3

Influence of Predominant Neck vs Arm Pain on ACDF Outcomes: A Follow-Up Study

OBJECTIVE

To assess differences in postoperative PROMs and MCID attainment following single-level ACDF based on predominant preoperative pain symptom.

METHODS

Primary, single-level ACDFs were identified. PROMs included VAS arm and neck/SF-12 PCS/PROMIS-PF/NDI, collected preoperatively and at 6-week/12-week/6-month/1-year/2-year postoperative timepoints. Patients were grouped: pAP (preoperative VAS arm > preoperative VAS neck) vs pNP (preoperative VAS neck > preoperative VAS arm). Chi-square and Student's t-test compared demographic and perioperative characteristics. Student's t-test evaluated change from preoperative to postoperative PROM values, and compared PROMs between groups. MCID achievement was determined using established threshold values. MCID attainment rates were compared using chi-squared.

RESULTS

110 patients were assessed-52 pNP/58 pAP. Demographics did not differ between cohorts. Total 1-year arthrodesis rate was 95.7% and did not differ by grouping. pNP patients improved significantly from preoperative to postoperative at 12-weeks-1-year for PROMIS-PF, 6-months/1-year for SF-12 PCS, 6-weeks-1-year for VAS neck, 6-weeks-6-months for VAS arm, and 6-weeks through 2-years for NDI(p≤0.035, all). pAP patients improved significantly from preoperative to all postoperative timepoints for PROMIS-PF, 6-months-2-years for SF-12 PCS, 6-weeks-1-year for VAS neck, 6-weeks-1-year for VAS arm, and 6-weeks-6-months for NDI(p≤0.040, all). Mean PROMIS-PF was higher for pAP at 6-weeks, preoperative VAS neck lower for pAP, and preoperative VAS arm higher for pAP(p≤0.013, all). MCID attainment was significantly higher among pAP only for PROMIS-PF from 6-weeks-6-months, SF-12 PCS 6-weeks, and VAS arm 12-weeks.

CONCLUSION

Predominant pain symptom demonstrated little effect on perioperative characteristics and postoperative PROMs. ACDF candidates will likely experience similar clinically meaningful postoperative improvements in physical function/disability/pain.

Impact of predominant symptom location among patients undergoing cervical spine surgery on 12-month outcomes: an analysis from the Quality Outcomes Database

OBJECTIVE

The impact of the type of pain presentation on outcomes of spine surgery remains elusive. The aim of this study was to assess the impact of predominant symptom location (predominant arm pain vs predominant neck pain vs equal neck and arm pain) on postoperative improvement in patient-reported outcomes.

METHODS

The Quality Outcomes Database cervical spine module was queried for patients undergoing 1- or 2-level anterior cervical discectomy and fusion (ACDF) for degenerative spine disease.

RESULTS

A total of 9277 patients were included in the final analysis. Of these patients, 18.4% presented with predominant arm pain, 32.3% presented with predominant neck pain, and 49.3% presented with equal neck and arm pain. Patients with predominant neck pain were found to have higher (worse) 12-month Neck Disability Index (NDI) scores (coefficient 0.24, 95% CI 0.15-0.33; p < 0.0001). The three groups did not differ significantly in odds of return to work and achieving minimal clinically important difference in NDI score at the 12-month follow-up.

CONCLUSIONS

Analysis from a national spine registry showed significantly lower odds of patient satisfaction and worse NDI score at 1 year after surgery for patients with predominant neck pain when compared with patients with predominant arm pain and those with equal neck and arm pain after 1- or 2-level ACDF. With regard to return to work, all three groups (arm pain, neck pain, and equal arm and neck pain) were found to be similar after multivariable analysis. The authors' results suggest that predominant pain location, especially predominant neck pain, might be a significant determinant of improvement in functional outcomes and patient satisfaction after ACDF for degenerative spine disease. In addition to confirmation of the common experience that patients with predominant neck pain have worse outcomes, the authors' findings provide potential targets for improvement in patient management for these specific populations.

Cervical Total Disc Replacement: Indications and Technique

Cervical total disc replacement devices have been marketed in the United States (US) since 2007, with abundant level 1 evidence published on the treatment. Adherence to the strict inclusion/exclusion criteria and the surgical technique training of the US clinical trials remains the consistent and conservative approach to patient selection and implantation technique. However, patient selection and surgical technique remain debated among US surgeons as the published data and available cervical total disc replacements continue to grow.

Do Patients with Back Pain-Dominant Symptoms Improve After Lumbar Surgery for Radiculopathy or Claudication?

BACKGROUND

Currently, few studies have examined whether patients with back or leg pain-predominant symptoms fare better clinically after lumbar spine surgery; therefore, the purpose of this study was to determine whether patients with back pain-dominant symptoms improved to a similar degree as patients with mixed or leg pain-dominant symptoms after lumbar surgery.

METHODS

A retrospective cohort study was conducted at a single academic center, in which patients were stratified into three groups: (1) back pain-dominant group (B) (visual analog score [VAS] back - VAS leg ≥ 1.0 point), (2) neutral group (N) (VAS back - VAS leg < 1.0 point), or (3) leg pain-dominant group (L) (VAS leg - VAS back ≥ 1.0 point), using a VAS threshold difference of 1.0 point. As a secondary analysis, the VAS leg-to-back pain (LBR) ratio was used to further stratify patients: (1) nonleg pain-dominant (NLPD) group (LBR ≤ 1.0) or (2) leg pain-dominant (LPD) group (LBR > 1.0). Patient outcomes, including physical component score of the short form-12 survey (PCS-12), mental component score of the short form-12 survey (MCS-12), and Oswestry Disability Index (ODI), were identified and compared between groups using univariate and multivariate analysis.

RESULTS

There were no significant differences in preoperative, postoperative, or delta scores for PCS-12 or ODI scores between groups. In patients undergoing decompression surgery, those with back pain-dominant or mixed symptoms (B, N, or NLPD groups) did not improve with respect to MCS-12 scores after surgery (P > .05), and those with leg pain-dominant symptoms (LPD group) had greater delta MCS-12 scores (P = .046) and greater recovery rates (P = .035). Multiple linear regression did not find LPD to be an independent predictor of PCS-12 or ODI scores.

CONCLUSION

Patients undergoing lumbar decompression surgery and leg pain-dominant symptoms noted a greater improvement in MCS-12 scores; however, there were no differences in PCS-12 or ODI scores.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Patients undergoing lumbar decompression surgery demonstrate no major clinically significant differences when split up by pain-dominance groups.

Clinically Meaningful Improvement Following Cervical Spine Surgery: 30% Reduction Versus Absolute Point-change MCID Values

STUDY DESIGN

Retrospective analysis of prospectively collected registry data.

OBJECTIVE

The aim of this study was to compare the performance of 30% reduction to established absolute point-change values for measures of disability and pain in patients undergoing elective cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Recent studies recommend using a proportional change from baseline instead of an absolute point-change value to define minimum clinically important difference (MCID).

METHODS

Analyses included 13,179 patients who underwent cervical spine surgery for degenerative disease between April 2013 and February 2018. Participants completed a baseline and 12-month follow-up assessment that included questionnaires to assess disability (Neck Disability Index [NDI]), neck and arm pain (Numeric Rating Scale [NRS-NP/AP], and satisfaction [NASS scale]). Participants were classified as met or not met 30% reduction from baseline in each of the respective measures. The 30% reduction in scores at 12 months was compared to a wide range of established absolute point-change MCID values using receiver-operating characteristic curves, area under the receiver-operating characteristic curve (AUROC), and logistic regression analyses. These analyses were conducted for the entire patient cohort, as well as for subgroups based on baseline severity and surgical approach.

RESULTS

Thirty percent reduction in NDI and NRS-NP/AP scores predicted satisfaction with more accuracy than absolute point-change values for the total population and ACDF and posterior fusion procedures (P < 0.05). The largest AUROC differences, in favor of 30% reduction, were found for the lowest disability (ODI 0-20%: 16.8%) and bed-bound disability (ODI 81%-100%: 16.6%) categories. For pain, there was a 1.9% to 11% and 1.6% to 9.6% AUROC difference for no/mild neck and arm pain (NRS 0-4), respectively, in favor of a 30% reduction threshold.

CONCLUSION

A 30% reduction from baseline is a valid method for determining MCID in disability and pain for patients undergoing cervical spine surgery.Level of Evidence: 3.

Does the Predominant Pain Location Influence Functional Outcomes, Satisfaction and Return to Work After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

STUDY DESIGN

Retrospective review of prospectively-collected registry data.

OBJECTIVES

The aim of this study was to determine how different combinations of preoperative neck pain (NP) and arm pain (AP) influence functional outcomes, patient satisfaction, and return-to-work in patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical radiculopathy (DCR).

SUMMARY OF BACKGROUND DATA

Surgeons often base decisions on the traditional belief that the predominance of radicular upper extremity symptoms is a stronger indication for cervical spine surgery than axial pain. However, there is a paucity of literature supporting this notion.

METHODS

A prospectively maintained registry was reviewed for all patients who underwent primary ACDF for DCR. Patients were categorized into three groups depending on predominant pain location: AP predominant ([APP]; AP > NP), NP predominant ([NPP]; NP > AP), and equal pain predominance ([EPP]; NP = AP). Patients were prospectively followed for at least 2 years.

RESULTS

In total, 303 patients were included: 27.4% APP, 38.9% NPP, and 33.7% EPP cases. The APP group was significantly older (P = 0.030), although there were no other preoperative differences among the three groups. After adjusting for baseline differences, the SF-36 Physical Component Summary was significantly better in the APP group at 6 months (P = 0.048) and 2 years (P = 0.039). In addition, they showed a trend towards better 6-month Neck Disability Index (P = 0.077) and 2-year SF-36 Mental Component Summary (P = 0.059). However, an equal proportion of patients in each group achieved the Minimal Clinically Important Difference for each outcome, were satisfied, and returned to work 2 years after surgery.

CONCLUSION

Although patients with NPP had slightly poorer function and quality of life, all patients experienced a clinically meaningful improvement in patient-reported outcomes, regardless of the predominant pain location. High rates of satisfaction and return-to-work were also achieved. In the context of proper indications, these findings suggest that ACDF can be equally effective for DCR patients with varying combinations of NP or AP.Level of Evidence: 3.

Development and Validation of Cervical Prediction Models for Patient-Reported Outcomes at 1 Year After Cervical Spine Surgery for Radiculopathy and Myelopathy

STUDY DESIGN

Retrospective analysis of prospectively collected registry data.

OBJECTIVE

To develop and validate prediction models for 12-month patient-reported outcomes of disability, pain, and myelopathy in patients undergoing elective cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Predictive models have the potential to be utilized preoperatively to set expectations, adjust modifiable characteristics, and provide a patient-centered model of care.

METHODS

This study was conducted using data from the cervical module of the Quality Outcomes Database. The outcomes of interest were disability (Neck Disability Index:), pain (Numeric Rating Scale), and modified Japanese Orthopaedic Association score for myelopathy. Multivariable proportional odds ordinal regression models were developed for patients with cervical radiculopathy and myelopathy. Patient demographic, clinical, and surgical covariates as well as baseline patient-reported outcomes scores were included in all models. The models were internally validated using bootstrap resampling to estimate the likely performance on a new sample of patients.

RESULTS

Four thousand nine hundred eighty-eight patients underwent surgery for radiculopathy and 2641 patients for myelopathy. The most important predictor of poor postoperative outcomes at 12-months was the baseline Neck Disability Index score for patients with radiculopathy and modified Japanese Orthopaedic Association score for patients with myelopathy. In addition, symptom duration, workers' compensation, age, employment, and ambulatory and smoking status had a statistically significant impact on all outcomes (P < 0.001). Clinical and surgical variables contributed very little to predictive models, with posterior approach being associated with higher odds of having worse 12-month outcome scores in both the radiculopathy and myelopathy cohorts (P < 0.001). The full models overall discriminative performance ranged from 0.654 to 0.725.

CONCLUSIONS

These predictive models provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical disease. Predictive models have the potential to be used as a shared decision-making tool for evidence-based preoperative counselling.

LEVEL OF EVIDENCE

2.

The Outcomes of Patients With Neck Pain Following ACDF: A Comparison of Patients With Radiculopathy, Myelopathy, or Mixed Symptomatology

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy.

SUMMARY OF BACKGROUND DATA

Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF.

METHODS

Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain.

RESULTS

Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P < 0.001) reduction in VAS neck pain, (ΔVAS neck; R group: -2.9, M: -2.5, MR: -2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (P = 0.011), RR (P = 0.006), and % minimum clinically important difference (P = 0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (P = 0.025).

CONCLUSION

Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements.

LEVEL OF EVIDENCE

3.

Impact of Dominant Symptom on 12-Month Patient-Reported Outcomes for Patients Undergoing Lumbar Spine Surgery

BACKGROUND

The impact of symptom characteristics on outcomes of spine surgery remains elusive.

OBJECTIVE

To determine the impact of symptom location, severity, and duration on outcomes following lumbar spine surgery.

METHODS

We queried the Quality Outcomes Database (QOD) for patients undergoing elective lumbar spine surgery for lumbar degenerative spine disease. Multivariable regression was utilized to determine the impact of preoperative symptom characteristics (location, severity, and duration) on improvement in disability, quality of life, return to work, and patient satisfaction at 1 yr. Relative predictor importance was determined using an importance metric defined as Wald χ2 penalized by degrees of freedom.

RESULTS

A total of 22 022 subjects were analyzed. On adjusted analysis, we found patients with predominant leg pain were more likely to be satisfied (P < .0001), achieve minimum clinically important difference (MCID) in Oswestry Disability Index (ODI) (P = .002), and return to work (P = .03) at 1 yr following surgery without significant difference in Euro-QoL-5D (EQ-5D) (P = .09) [ref = predominant back pain]. Patients with equal leg and back pain were more likely to be satisfied (P < .0001), but showed no significant difference in achieving MCID (P = .22) or return to work (P = .07). Baseline numeric rating scale-leg pain and symptom duration were most important predictors of achieving MCID and change in EQ-5D. Predominant symptom was not found to be an important determinant of return to work. Worker's compensation was found to be most important determinant of satisfaction and return to work.

CONCLUSION

Predominant symptom location is a significant determinant of functional outcomes following spine surgery. However, pain severity and duration have higher predictive importance. Return to work is more dependent on sociodemographic features as compared to symptom characteristics.

Outcomes and value in elective cervical spine surgery: an introductory and practical narrative review

How we determine a successful clinical outcome and the value of a spine intervention are two major questions surrounding clinical spine research. Patient-reported outcomes (PROs), both LEGACY and Patient-Reported Outcomes Measurement Information System (PROMIS) measures, are becoming ubiquitous throughout the literature. Spine surgeons need a facile understanding of the financial landscape of their environment to influence change. In the current introductory, narrative review on outcomes and value in cervical spine surgery, we aim to: (I) define relevant outcome and cost terminology, (II) review recent cervical spine surgery literature, divided by specific pathology with a focus on LEGACY and PROMIS measures, and (III) discuss value and cost as they pertain to postoperative return to work and ambulatory surgery centers surgeries.