Determining the time frame of maximum clinical improvement in surgical decompression for cervical spondylotic myelopathy when stratified by preoperative myelopathy severity: a cervical Quality Outcomes Database study

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  • 1 Department of Neurosurgery, University of Virginia, Charlottesville, Virginia;
  • | 2 Department of Neurological Surgery, University of California, San Francisco, California;
  • | 3 Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona;
  • | 4 Department of Neurological Surgery, University of Miami, Miami, Florida;
  • | 5 Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan;
  • | 6 Department of Neurosurgery, University of Utah, Salt Lake City, Utah;
  • | 7 Department of Neurosurgery, Division of Spine, Duke University Medical Center, Durham, North Carolina;
  • | 8 Department of Neurological Surgery, Weill Cornell Medicine, New York City, New York;
  • | 9 Department of Neurosurgery, University of Tennessee, Memphis, Tennessee;
  • | 10 Department of Neurosurgery, Mayo Clinic Neuro-Informatics Lab, Mayo Clinic, Rochester, Minnesota;
  • | 11 Marion Bloch Neuroscience Institute’s Spine Program, Saint Luke Health System, Kansas City, Missouri;
  • | 12 Carolina Neurosurgery & Spine Associates, Carolinas Medical Center, Charlotte, North Carolina;
  • | 13 Goodman Campbell Brain and Spine, Indianapolis, Indiana; and
  • | 14 Atlantic Neurosurgical Specialists, Altair Health Spine & Wellness Center, Morristown, New Jersey
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OBJECTIVE

While surgical decompression is an important treatment modality for cervical spondylotic myelopathy (CSM), it remains unclear if the severity of preoperative myelopathy status affects potential benefit from surgical intervention and when maximum postoperative improvement is expected. This investigation sought to determine if retrospective analysis of prospectively collected patient-reported outcomes (PROs) following surgery for CSM differed when stratified by preoperative myelopathy status. Secondary objectives included assessment of the minimal clinically important difference (MCID).

METHODS

A total of 1151 patients with CSM were prospectively enrolled from the Quality Outcomes Database at 14 US hospitals. Baseline demographics and PROs at baseline and 3 and 12 months were measured. These included the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), quality-adjusted life-years (QALYs) from the EQ-5D, and visual analog scale from the EQ-5D (EQ-VAS). Patients were stratified by preoperative myelopathy severity using criteria established by the AO Spine study group: mild (mJOA score 15–17), moderate (mJOA score 12–14), or severe (mJOA score < 12). Univariate analysis was used to identify demographic variables that significantly varied between myelopathy groups. Then, multivariate linear regression and linear mixed regression were used to model the effect of severity and time on PROs, respectively.

RESULTS

For NDI, EQ-VAS, and QALY, patients in all myelopathy cohorts achieved significant, maximal improvement at 3 months without further improvement at 12 months. For mJOA, moderate and severe myelopathy groups demonstrated significant, maximal improvement at 3 months, without further improvement at 12 months. The mild myelopathy group did not demonstrate significant change in mJOA score but did maintain and achieve higher PRO scores overall when compared with more advanced myelopathy cohorts. The MCID threshold was reached in all myelopathy cohorts at 3 months for mJOA, NDI, EQ-VAS, and QALY, with the only exception being mild myelopathy QALY at 3 months.

CONCLUSIONS

As assessed by statistical regression and MCID analysis, patients with cervical myelopathy experience maximal improvement in their quality of life, neck disability, myelopathy score, and overall health by 3 months after surgical decompression, regardless of their baseline myelopathy severity. An exception was seen for the mJOA score in the mild myelopathy cohort, improvement of which may have been limited by ceiling effect. The data presented here will aid surgeons in patient selection, preoperative counseling, and expected postoperative time courses.

ABBREVIATIONS

ASA = American Society of Anesthesiologists; CSM = cervical spondylotic myelopathy; EQ-VAS = EQ-5D visual analog scale; MCID = minimal clinically important difference; mJOA = modified Japanese Orthopaedic Association; NASS = North American Spine Society; NDI = Neck Disability Index; PRO = patient-reported outcome; QALY = quality-adjusted life-year; QOD = Quality Outcomes Database.

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