Spinal pathologies and management strategies associated with cervical angina (pseudoangina): a systematic review

Developing Mixed-effects Models to Optimize Prediction of Postoperative Outcomes in a Modern Sample of Over 450,000 Patients Undergoing Elective Cervical Spine Fusion Surgery

STUDY DESIGN

A retrospective cohort.

OBJECTIVE

We utilize big data and modeling techniques to create optimized comorbidity indices for predicting postoperative outcomes following cervical spine fusion surgery.

SUMMARY OF BACKGROUND DATA

Cervical spine decompression and fusion surgery are commonly used to treat degenerative cervical spine pathologies. However, there is a paucity of high-quality data defining the optimal comorbidity indices specifically in patients undergoing cervical spine fusion surgery.

METHODS

Using data from 2016 to 2019, we queried the Nationwide Readmissions Database (NRD) to identify individuals who had received cervical spine fusion surgery. The Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining indicator was used to assess frailty. To measure the level of comorbidity, Elixhauser Comorbidity Index (ECI) scores were queried. Receiver operating characteristic curves were developed utilizing comorbidity indices as predictor variables for pertinent complications such as mortality, nonroutine discharge, top-quartile cost, top-quartile length of stay, and 1-year readmission.

RESULTS

A total of 453,717 patients were eligible. Nonroutine discharges occurred in 93,961 (20.7%) patients. The mean adjusted all-payer cost for the procedure was $22,573.14±18,274.86 (top quartile: $26,775.80) and the mean length of stay was 2.7±4.4 days (top quartile: 4.7 d). There were 703 (0.15%) mortalities and 58,254 (12.8%) readmissions within 1 year postoperatively. Models using frailty+ECI as primary predictors consistently outperformed the ECI-only model with statistically significant P -values for most of the complications assessed. Cost and mortality were the only outcomes for which this was not the case, as frailty outperformed both ECI and frailty+ECI in cost ( P <0.0001 for all) and frailty+ECI performed as well as ECI alone in mortality ( P =0.10).

CONCLUSIONS

Our data suggest that frailty+ECI may most accurately predict clinical outcomes in patients receiving cervical spine fusion surgery. These models may be used to identify high-risk populations and patients who may necessitate greater resource utilization following elective cervical spinal fusion.

Cervical Radiculopathy as a Hidden Cause of Angina: Cervicogenic Angina

Patients presenting with chest pain to the emergency department constitute a diagnostic challenge as 77% of the patients' symptoms are not cardiac. Diagnostic uncertainty is a pervasive issue in primary care. A 56-year-old man presented with non-traumatic chest pain and chronic neck pain for 2 years, as well as numbness in his right third and fourth fingers for 6 months. It was not associated with palpitation, orthopnea or pedal edema. Except for hyperglycemia, no abnormal findings were found in diagnostic tests. At that time, he was being treated for type 2 diabetes using glucose-lowering drugs in order to lower his blood glucose and lessen his risk of heart disease. The cause of his chest pain remained unknown. Following a second opinion from an orthopedist, the patient was diagnosed with cervical radiculopathy and was treated with analgesics and physical therapy. Because the treatments had only provided temporary pain relief for the previous 6 months, he sought chiropractic care for pain relief. The patient's vital signs were stable and within normal limits during the assessment. A restricted neck movement, a positive Spurling test, and hypoesthesia in the right C7 dermatome were seen. Cervical radiographs revealed degenerative spondylosis with right C5/C6 neuroforaminal stenoses and bilateral C6/C7 neuroforaminal stenoses. A provisional diagnosis of cervical spondylotic radiculopathy associated with cervicogenic angina (CA) was made. Chiropractic procedures, including cervical manipulation, instrumented soft tissue mobilization, and motorized intermittent neck traction, were performed two to three times per week. After 3 months, the patient reported that the chest pain, neck pain, and radicular symptoms had completely resolved. Repeated radiographs taken during the 11th month follow-up revealed a comparable improvement in the increased spacing of the restricted neuroforamina, which could signify a beneficial alteration related to cervical function retrieval. CA is an angina-like chest pain caused by cervical spine disorders. This study adds to our understanding of the biomechanical impact of cervical radiculopathy on chest pain, which has largely been overlooked during diagnostic workups. Once cervical radiculopathy has been identified, CA symptoms can be eased by alleviating the noxious input stemming from the pinched nerve roots.