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?

Raphaële Charest-MorinCombined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, British Columbia;

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Christopher S. BaileyDepartment of Orthopedics Surgery, London Health Science Centre, Western University, London, Ontario;

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Greg McIntoshCanadian Spine Outcomes and Research Network, Markdale, Ontario;

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Y. Raja RampersaudDivisions of Orthopaedic Surgery and Neurosurgery, University of Toronto, Ontario;

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W. Bradley JacobsCombined Neurosurgical and Orthopedic Spine Program, University of Calgary, Alberta;

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David W. CadotteCombined Neurosurgical and Orthopedic Spine Program, University of Calgary, Alberta;

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Jérome PaquetCentre de Recherche CHU de Quebec, CHU de Québec-Université Laval, Quebec City, Quebec;

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Hamilton HallDepartment of Surgery, University of Toronto, Ontario;

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Michael H. WeberDepartment of Orthopedics Surgery, McGill University Health Centre, Montreal, Quebec;

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Michael G. JohnsonDepartment of Surgery, Section of Orthopedics and Neurosurgery, University of Manitoba, Winnipeg, Manitoba;

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Andrew NatarajDivision of Neurosurgery, Department of Surgery, University of Alberta Hospital, Edmonton, Alberta;

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Najmedden AttabibCanada East Spine Centre, Division of Neurosurgery, Zone 2, Horizon Health Network, Saint John, New Brunswick;

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Neil MansonCanada East Spine Centre, Saint John Orthopedics, Dalhousie Medicine New Brunswick, Saint John Campus, Saint John, New Brunswick;

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Philippe PhanDepartment of Orthopedics Surgery, The Ottawa Hospital, Ottawa, Ontario; and

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Sean D. ChristieDivision of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada

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Kenneth C. ThomasCombined Neurosurgical and Orthopedic Spine Program, University of Calgary, Alberta;

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Charles G. FisherCombined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, British Columbia;

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Nicolas DeaCombined Neurosurgical and Orthopedic Spine Program, Department of Orthopedics Surgery, University of British Columbia, Vancouver, British Columbia;

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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.

ABBREVIATIONS

AE = adverse event; CSORN = Canadian Spine Outcomes and Research Network; cSVA = cervical sagittal vertical axis; CTJ = cervicothoracic junction; DCM = degenerative cervical myelopathy; MCID = minimal clinically important difference; MCS = mental component summary; mJOA = modified Japanese Orthopaedic Association; NDI = Neck Disability Index; NRS = numeric rating scale; PCS = physical component summary; PRO = patient-reported outcome.

Supplementary Materials

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Images from de Andrada Pereira et al. (pp 525–534).

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