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Analysis of recovery trajectories in degenerative cervical myelopathy to facilitate improved patient counseling and individualized treatment recommendations

Blessing N. R. Jaja, Christopher D. Witiw, Erin M. Harrington, Yingshi He, Ali Moghaddamjou, Michael G. Fehlings, and Jefferson R. Wilson

OBJECTIVE

There is a need to better understand and predict postsurgical outcomes for degenerative cervical myelopathy (DCM) patients, particularly to support treatment decisions for patients with mild DCM. The goal of this study was to identify and predict outcome trajectories for DCM patients up to 2 years postsurgery.

METHODS

The authors analyzed two North American multicenter prospective DCM studies (n = 757). Functional recovery and physical health component quality of life were assessed in DCM patients at baseline, 6 months, and 1 and 2 years postoperatively using the modified Japanese Orthopaedic Association (mJOA) score and Physical Component Summary (PCS) of the SF-36, respectively. Group-based trajectory modeling was used to identify recovery trajectories for mild, moderate, and severe DCM. Prediction models for recovery trajectories were developed and validated in bootstrap resamples.

RESULTS

Two recovery trajectories were identified for the functional and physical components of quality of life: good recovery and marginal recovery. Depending on outcome and myelopathy severity, one-half to three-fourths of the study patients followed the good recovery trajectory characterized by improvement in mJOA and PCS scores over time. The remaining one-half to one-fourth of patients followed the marginal recovery trajectory, experiencing little improvement and, in certain cases, worsening postoperatively. The prediction model for mild DCM had an area under the curve of 0.72 (95% CI 0.65–0.80), with preoperative neck pain, smoking, and posterior surgical approach noted as dominant predictors of marginal recovery.

CONCLUSIONS

Surgically treated DCM patients follow distinct recovery trajectories in the first 2 years postoperatively. While most patients experience substantial improvement, a significant minority experience little improvement or worsening. The ability to predict DCM patient recovery trajectories in the preoperative setting facilitates the formulation of individualized treatment recommendations for patients with mild symptoms.

In Journal of Neurosurgery: Spine Volume 38: Issue 6 (Jun 2023)

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Editorial. Topical epidural steroids after lumbar spine surgery: do the benefits observed after microdiscectomy extend to lumbar fusion?

Armaan K. Malhotra and Jefferson R. Wilson

In Journal of Neurosurgery: Spine Volume 37: Issue 4 (Oct 2022)

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Clinical outcomes of nonoperatively managed degenerative cervical myelopathy: an ambispective longitudinal cohort study in 117 patients

Allan R. Martin, Sukhvinder Kalsi-Ryan, Muhammad A. Akbar, Anna C. Rienmueller, Jetan H. Badhiwala, Jefferson R. Wilson, Lindsay A. Tetreault, Aria Nouri, Eric M. Massicotte, and Michael G. Fehlings

OBJECTIVE

Degenerative cervical myelopathy (DCM) is among the most common pathologies affecting the spinal cord but its natural history is poorly characterized. The purpose of this study was to investigate functional outcomes in patients with DCM who were managed nonoperatively as well as the utility of quantitative clinical measures and MRI to detect deterioration.

METHODS

Patients with newly diagnosed DCM or recurrent myelopathic symptoms after previous surgery who were initially managed nonoperatively were included. Retrospective chart reviews were performed to analyze clinical outcomes and anatomical MRI scans for worsening compression or increased signal change. Quantitative neurological assessments were collected prospectively, including modified Japanese Orthopaedic Association (mJOA) score; Quick-DASH; graded redefined assessment of strength, sensation, and prehension–myelopathy version (GRASSP–M: motor, sensory, and dexterity); grip dynamometer; Berg balance scale score; gait stability ratio; and gait variability index. A deterioration of 10% was considered significant (e.g., a 2-point decrease in mJOA score).

RESULTS

A total of 117 patients were included (95 newly diagnosed, 22 recurrent myelopathy), including 74 mild, 28 moderate, and 15 severe cases. Over a mean follow-up of 2.5 years, 57% (95% CI 46%–67%) of newly diagnosed patients and 73% (95% CI 50%–88%) of patients with recurrent DCM deteriorated neurologically. Deterioration was best detected with grip strength (60%), GRASSP dexterity (60%), and gait stability ratio (50%), whereas the mJOA score had low sensitivity (33%) in 50 patients. A composite score had a sensitivity of 81% and a specificity of 82%. The sensitivity of anatomical MRI was 28% (83 patients).

CONCLUSIONS

DCM appears to have a poor natural history; however, prospective studies are needed for validation. Serial assessments should include mJOA score, grip strength, dexterity, balance, and gait analysis. The absence of worsening on anatomical MRI or in mJOA scores is not sufficient to determine clinical stability.

In Journal of Neurosurgery: Spine Volume 34: Issue 6 (Jun 2021)

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A comparison of the perioperative outcomes of anterior surgical techniques for the treatment of multilevel degenerative cervical myelopathy

Jetan H. Badhiwala, Sean N. Leung, Yosef Ellenbogen, Muhammad A. Akbar, Allan R. Martin, Fan Jiang, Jamie R. F. Wilson, Farshad Nassiri, Christopher D. Witiw, Jefferson R. Wilson, and Michael G. Fehlings

OBJECTIVE

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Multilevel ventral compressive pathology is routinely managed through anterior decompression and reconstruction, but there remains uncertainty regarding the relative safety and efficacy of multiple discectomies, multiple corpectomies, or hybrid corpectomy-discectomy. To that end, using a large national administrative healthcare data set, the authors sought to compare the perioperative outcomes of anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and hybrid corpectomy-discectomy for multilevel DCM.

METHODS

Patients with a primary diagnosis of DCM who underwent an elective anterior cervical decompression and reconstruction operation over 3 cervical spinal segments were identified from the 2012–2017 National Surgical Quality Improvement Program database. Patients were separated into those undergoing 3-level discectomy, 2-level corpectomy, or a hybrid procedure (single-level corpectomy plus additional single-level discectomy). Outcomes included 30-day mortality, major complication, reoperation, and readmission, as well as operative duration, length of stay (LOS), and routine discharge home. Outcomes were compared between treatment groups by multivariable regression, adjusting for age and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD) and associated 95% confidence interval.

RESULTS

The study cohort consisted of 1298 patients; of these, 713 underwent 3-level ACDF, 314 2-level ACCF, and 271 hybrid corpectomy-discectomy. There was no difference in 30-day mortality, reoperation, or readmission among the 3 procedures. However, on both univariate and adjusted analyses, compared to 3-level ACDF, 2-level ACCF was associated with significantly greater risk of major complication (aOR 2.82, p = 0.005), longer hospital LOS (aMD 0.8 days, p = 0.002), and less frequent discharge home (aOR 0.59, p = 0.046). In contrast, hybrid corpectomy-discectomy had comparable outcomes to 3-level ACDF but was associated with significantly shorter operative duration (aMD −16.9 minutes, p = 0.002).

CONCLUSIONS

The authors found multiple discectomies and hybrid corpectomy-discectomy to have a comparable safety profile in treating multilevel DCM. In contrast, multiple corpectomies were associated with a higher complication rate, longer hospital LOS, and lower likelihood of being discharged directly home from the hospital, and may therefore be a higher-risk operation.

In Journal of Neurosurgery: Spine Volume 33: Issue 4 (Oct 2020)

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Letter to the Editor. Intraoperative neurophysiological monitoring and ACDF

W. Bryan Wilent, John P. Ney, Jeffrey Balzer, Miriam L. Donohue, Jeffrey H. Gertsch, Robert Holdefer, Faisal R. Jahangiri, Kathryn Overzet, Jay Shils, and Richard Vogel

In Journal of Neurosurgery: Spine Volume 32: Issue 1 (Jan 2020)

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Investigating the utility of intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion: analysis of over 140,000 cases from the National (Nationwide) Inpatient Sample data set

Jetan H. Badhiwala, Farshad Nassiri, Christopher D. Witiw, Alireza Mansouri, Saleh A. Almenawer, Leodante da Costa, Michael G. Fehlings, and Jefferson R. Wilson

OBJECTIVE

Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF.

METHODS

This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score–matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars).

RESULTS

A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score–matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges.

CONCLUSIONS

The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).

In Journal of Neurosurgery: Spine Volume 31: Issue 1 (Jul 2019)

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Abstracts of the 2017 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves Las Vegas, Nevada • March 8–11, 2017

In Neurosurgical Focus Volume 42 (2017): Issue 3 (Mar 2017): Peripheral Nerve

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Predicting the minimum clinically important difference in patients undergoing surgery for the treatment of degenerative cervical myelopathy

Lindsay Tetreault, Jefferson R. Wilson, Mark R. N. Kotter, Aria Nouri, Pierre Côté, Branko Kopjar, Paul M. Arnold, and Michael G. Fehlings

OBJECTIVE

The minimum clinically important difference (MCID) is defined as the minimum change in a measurement that a patient would identify as beneficial. Before undergoing surgery, patients are likely to inquire about the ultimate goals of the operation and of their chances of experiencing meaningful improvements. The objective of this study was to define significant predictors of achieving an MCID on the modified Japanese Orthopaedic Association (mJOA) scale at 2 years following surgery for the treatment of degenerative cervical myelopathy (DCM).

METHODS

Seven hundred fifty-seven patients were prospectively enrolled in either the AOSpine North America or International study at 26 global sites. Fourteen patients had a perfect preoperative mJOA score of 18 and were excluded from this analysis (n = 743). Data were collected for each participating subject, including demographic information, symptomatology, medical history, causative pathology, and functional impairment. Univariate log-binominal regression analyses were conducted to evaluate the association between preoperative clinical factors and achieving an MCID on the mJOA scale. Modified Poisson regression using robust error variances was used to create the final multivariate model and compute the relative risk for each predictor.

RESULTS

The sample consisted of 463 men (62.31%) and 280 women (37.69%), with an average age of 56.48 ± 11.85 years. At 2 years following surgery, patients exhibited a mean change in functional status of 2.71 ± 2.89 points on the mJOA scale. Of the 687 patients with available follow-up data, 481 (70.01%) exhibited meaningful gains on the mJOA scale, whereas 206 (29.98%) failed to achieve an MCID. Based on univariate analysis, significant predictors of achieving the MCID on the mJOA scale were younger age; female sex; shorter duration of symptoms; nonsmoking status; a lower comorbidity score and absence of cardiovascular disease; and absence of upgoing plantar responses, lower-limb spasticity, and broad-based unstable gait. The final model included age (relative risk [RR] 0.924, p < 0.0001), smoking status (RR 0.837, p = 0.0043), broad-based unstable gait (RR 0.869, p = 0.0036), and duration of symptoms (RR 0.943, p = 0.0003).

CONCLUSIONS

In this large multinational prospective cohort, 70% of patients treated surgically for DCM exhibited a meaningful functional gain on the mJOA scale. The key predictors of achieving an MCID on the mJOA scale were younger age, shorter duration of symptoms, nonsmoking status, and lack of significant gait impairment.

In Neurosurgical Focus Volume 40 (2016): Issue 6 (Jun 2016): Cervical Spondylotic Myelopathy With and Without OPLL

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Clinical prediction model for acute inpatient complications after traumatic cervical spinal cord injury: a subanalysis from the Surgical Timing in Acute Spinal Cord Injury Study

Jefferson R. Wilson, Paul M. Arnold, Anoushka Singh, Sukhvinder Kalsi-Ryan, and Michael G. Fehlings

Object

While the majority of existing reports focus on complications sustained during the chronic stages after traumatic spinal cord injury (SCI), the objective in the current study was to characterize and quantify acute inpatient complications. In addition, the authors sought to create a prediction model using clinical variables documented at hospital admission to predict acute complication development.

Methods

Analyses were based on data from the Surgical Timing in Acute Spinal Cord Injury Study (STASCIS) data registry, which contains prospective information on adult patients with cervical SCIs who were enrolled at 6 North American centers over a 7-year period. All patients who underwent a standardized American Spinal Injury Association (ASIA) neurological examination within 24 hours of injury and whose follow-up information was available at the acute hospital discharge were included in the study. For purposes of classification, complications were divided into 5 major categories: 1) cardiopulmonary, 2) surgical, 3) thrombotic, 4) infectious, and 5) decubitus ulcer development. Univariate statistical analyses were performed to determine the relationship between complication occurrence and individual demographic, injury, and treatment variables. Multivariate logistic regression was subsequently performed to create a complication prediction model. Model discrimination was judged according to the area under the receiver operating characteristic curve.

Results

Complete complication information was available for 411 patients at the acute care discharge. One hundred sixty patients (38.9%) experienced 240 complications. The mean age among those who experienced at least one complication was 45.9 years, as compared with 43.5 years among those who did not have a complication (p = 0.18). In the univariate analysis, patients with complications were less likely to receive steroids at admission (p = 0.01), had a greater severity of neurological injury as indicated by the ASIA Impairment Scale (AIS) grade at presentation (p < 0.01), and a higher frequency of significant comorbidity (p = 0.04). In a multivariate logistic regression model, a severe initial AIS grade (p < 0.01), a high-energy injury mechanism (p = 0.07), an older age (p = 0.05), the absence of steroid administration (p = 0.02), and the presence of comorbid illness (p = 0.02) were associated with a greater likelihood of complication development during the period of acute hospitalization. The area under the curve value for the full model was 0.75, indicating acceptable predictive discrimination.

Conclusions

These results will help clinicians to identify patients with cervical SCIs at greatest risk for complication development and thus allowing for the institution of aggressive complication prevention measures.

In Journal of Neurosurgery: Spine Volume 17 (2012): Issue Suppl1 (Sep 2012): NACTN/AOSNA Focus Issue on Spinal Cord Injury Pages 1-246

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Clinical predictors of neurological outcome, functional status, and survival after traumatic spinal cord injury: a systematic review

Jefferson R. Wilson, David W. Cadotte, and Michael G. Fehlings

Object

The object of this study was to identify, by means of a systematic review of the literature, the acute clinical predictors of neurological outcome, functional outcome, and survival after traumatic spinal cord injury (SCI).

Methods

A comprehensive computerized literature review search was performed, using MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews. Selected articles were classified according to their level of evidence. Articles were then stratified into one of 3 domains depending on whether the primary focus was clinical prediction of 1) neurological outcome, 2) functional status, or 3) survival. For each study selected, clinical predictors related to patient demographic characteristics, injury mechanism, or neurological examination findings were extracted, and the individual relationship to outcome was defined.

Results

The initial search resulted in 376 citations. After application of the inclusion and exclusion criteria and study review, 51 relevant articles were identified and graded. Of these, 25 provided predictors for neurological outcome, 22 for functional outcome, and 15 for survival, with several of the articles providing information on more than one type of outcome. All of the included studies were designated as providing Class I, II, or III levels of evidence. The severity of neurological injury (as measured by admission Americal Spinal Injury Association Impairment Scale grade, Frankel grade, or injury completeness), level of injury, and the presence of a zone of partial preservation were consistent predictors of neurological outcome. Severity of neurological injury, level of injury, reflex pattern, and age were consistent predictors of functional outcome. Finally, severity of neurological injury, level of injury, age, and the presence of multisystem trauma seen with higher-energy injury mechanisms were consistent predictors of survival.

Conclusions

On the basis on this review, the authors have identified a constellation of acute clinical features that may help to define an individual's profile for recovery and survival after SCI. This study will help to facilitate communication in the clinical realm and assist in classifying subsets of patients within future clinical studies.

In Journal of Neurosurgery: Spine Volume 17 (2012): Issue Suppl1 (Sep 2012): NACTN/AOSNA Focus Issue on Spinal Cord Injury Pages 1-246