Purpose
To conduct a systematic review of the literature to determine important clinical predictors of surgical outcome in patients with cervical spondylotic myelopathy (CSM).
Methods
A literature ...search was performed using MEDLINE, MEDLINE in Process, EMBASE and Cochrane Database of Systematic Reviews. Selected articles were evaluated using a 14-point modified SIGN scale and classified as either poor (<7), good (7–9) or excellent (10–14) quality of evidence. For each study, the association between various clinical factors and surgical outcome, evaluated by the (modified) Japanese Orthopaedic Association scale (mJOA/JOA), Nurick score or other measures, was defined. The results from the EXCELLENT studies were compared to the combined results from the EXCELLENT and GOOD studies which were compared to the results from all the studies.
Results
The initial search yielded 1,677 citations. Ninety-one of these articles, including three translated from Japanese, met the inclusion and exclusion criteria and were graded. Of these, 16 were excellent, 38 were good and 37 were poor quality. Based on the excellent studies alone, a longer duration of symptoms was associated with a poorer outcome evaluated on both the mJOA/JOA scale and Nurick score. A more severe baseline score was related with a worse outcome only on the mJOA/JOA scale. Based on the GOOD and EXCELLENT studies, duration of symptoms and baseline severity score were consistent predictors of mJOA/JOA, but not Nurick. Age was an insignificant predictor of outcome on any of the functional outcomes considered.
Conclusion
The most important predictors of outcome were preoperative severity and duration of symptoms. This review also identified many other valuable predictors including signs, symptoms, comorbidities and smoking status.
Abstract
BACKGROUND: Traumatic spinal cord injuries (SCI) have devastating consequences for the physical, financial, and psychosocial well-being of patients and their caregivers. Expediently ...delivering interventions during the early postinjury period can have a tremendous impact on long-term functional recovery.
PATHOPHYSIOLOGY: This is largely due to the unique pathophysiology of SCI where the initial traumatic insult (primary injury) is followed by a progressive secondary injury cascade characterized by ischemia, proapoptotic signaling, and peripheral inflammatory cell infiltration. Over the subsequent hours, release of proinflammatory cytokines and cytotoxic debris (DNA, ATP, reactive oxygen species) cyclically adds to the harsh postinjury microenvironment. As the lesions mature into the chronic phase, regeneration is severely impeded by the development of an astroglial-fibrous scar surrounding coalesced cystic cavities. Addressing these challenges forms the basis of current and upcoming treatments for SCI.
MANAGEMENT: This paper discusses the evidence-based management of a patient with SCI while emphasizing the importance of early definitive care. Key neuroprotective therapies are summarized including surgical decompression, methylprednisolone, and blood pressure augmentation. We then review exciting neuroprotective interventions on the cusp of translation such as Riluzole, Minocycline, magnesium, therapeutic hypothermia, and CSF drainage. We also explore the most promising neuroregenerative strategies in trial today including Cethrin™, anti-NOGO antibody, cell-based approaches, and bioengineered biomaterials. Each section provides a working knowledge of the key preclinical and patient trials relevant to clinicians while highlighting the pathophysiologic rationale for the therapies.
CONCLUSION: We conclude with our perspectives on the future of treatment and research in this rapidly evolving field.
STUDY DESIGN.Narrative overview of the focus issue on cervical spondylotic myelopathy (CSM).
OBJECTIVE.To provide an introduction to this special focus issue of Spine journal that deals with CSM.
...SUMMARY OF BACKGROUND DATA.CSM is a progressive spine disease and the leading cause of spinal cord dysfunction worldwide. The shift in population demographics in many parts of the world has motivated the development of this focus issue. With the overall aging of the population, we can predict that global health care systems will be confronted with an increase in patients presenting with degenerative spine changes and various stages of cervical myelopathy.
METHODS.The articles in this issue vary in their methods—there are systematic reviews, narrative reviews, a study protocol, and 2 primary research articles.
RESULTS.A summary of the findings of each article is provided as a table within this introduction.
CONCLUSION.By way of this issue, we have summarized current knowledge gaps and limitations in the evidence to provide direction for future research and investigation. These include the need for a unified nomenclature for referring to CSM, the need to specify the incidence of myelopathy and the prevalence of ossification of the posterior longitudinal ligament, and the need to explore both the safety and efficacy of neuroprotective and neuroreparative pharmacological strategies. Further work is also required to optimize the management of patients with minimal symptoms.
Degenerative cervical myelopathy DCM is a disabling and increasingly prevalent group of diseases. Heterogeneous reporting of trial outcomes limits effective inter-study comparison and optimisation of ...treatment. This is recognised in many fields of healthcare research. The present study aims to assess the heterogeneity of outcome reporting in DCM as the premise for the development of a standardised reporting set.
A systematic review of MEDLINE and EMBASE databases, registered with PROSPERO (CRD42015025497) was conducted in accordance with PRISMA guidelines. Full text articles in English, with >50 patients (prospective) or >200 patients (retrospective), reporting outcomes of DCM were eligible.
108 studies, assessing 23,876 patients, conducted world-wide, were identified. Reported outcome themes included function (reported by 97, 90% of studies), complications (reported by 56, 52% of studies), quality of life (reported by 31, 29% of studies), pain (reported by 29, 27% of studies) and imaging (reported by 59, 55% of studies). Only 7 (6%) studies considered all of domains in a single publication. All domains showed variability in reporting.
Significant heterogeneity exists in the reporting of outcomes in DCM. The development of a consensus minimum dataset will facilitate future research synthesis.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction that confronts clinicians on a daily basis. Research performed over the past few decades has provided ...improved insight into the diagnosis, evaluation, and treatment of this disorder. We aim to provide clinicians with an update regarding the state of the art in DCM, focusing on more recent research pertaining to pathophysiology, natural history, treatment, consideration of the minimally symptomatic patient, surgical outcome prediction, and outcome measurement. Current concepts of pathophysiology focus on the combination of static and dynamic elements leading to breakdown of the blood–spinal cord barrier at the site of compression resulting in local inflammation, cellular dysfunction, and apoptosis. With respect to treatment, although there is a dearth of high-quality studies comparing surgical to nonoperative treatment, several large prospective studies have recently associated surgical management with clinically and statistically significant improvement in functional, disability, and quality of life outcome at long-term follow-up. When selecting the specific surgical intervention for a patient with DCM, anterior (discectomy, corpectomy, hybrid discectomy/corpectomy), posterior (laminectomy and fusion, laminoplasty), and combined approaches may be considered as options depending on the specifics of the patient in question; evidence supporting each of these approaches is reviewed in detail. Recently developed clinical prediction models allow for accurate forecasting of postoperative outcomes, permitting enhanced communication and management of patient expectations in the preoperative setting. Finally, an overview of outcome measures recommended for use in the assessment of DCM patients is provided.
Abstract Background Context Degenerative Cervical Myelopathy (DCM) represents the most common cause of non-traumatic spinal cord impairment in adults. Surgery has been shown to improve neurological ...symptoms and functional status, but it is costly. As sustainability concerns in the field of healthcare rise, the value of care has come to the forefront of policy decision-making. Evidence for both health related quality of life outcomes and financial expenditures are needed to inform resource allocation decisions. Purpose To estimate the lifetime incremental cost utility of surgical treatment for DCM. Design/Setting Prospective observational cohort study at a Canadian tertiary care facility. Patient Sample All patients undergoing surgery for DCM at a single center between 2005 and 2011 that were enrolled in either the AOSpine CSM-North America or CSM-International studies. Outcome Measures Health utility was measured at baseline and then 6, 12 and 24-months following surgery using the Short Form-6D (SF-6D) health utility score. Resource expenditures were calculated on an individual level, from the hospital payer perspective over the 24-month follow-up period. All costs were obtained from a micro-cost database, maintained by the institutional finance department and reported in Canadian dollars; inflated to January 2015 values. Methods Quality adjusted life year (QALY) gains for the study period were determined using an area under the curve calculation with a linear interpolation estimate. Lifetime incremental cost utility ratios (ICUR) for surgery were estimated using a Markov state transition model. Structural uncertainty arising from lifetime extrapolation and the single arm cohort design of the study were accounted for by constructing two models. The first included a highly conservative assumption that individuals undergoing non-operative management would not experience any lifetime neurological decline. This constraint was relaxed in the second model to permit more general parameters based upon the established natural history. Deterministic and probabilistic sensitivity analyses were employed to account for parameter uncertainty. All QALY gains and costs were discounted at a base of 3% per annum. Statistical significance was set at the 0.05 level. Results The analysis included 171 patients; follow-up was 96.5%. Mean age was 58.2 ± 12.0 years and baseline health utility was 0.56 ± 0.14. Mean QALY gained over the 24-month study period was 0.139 (95% CI: 0.109-0.170, p < 0.001) and the mean 2-year cost of treatment was $19,217.82 ± 12,404.23. Cost associated with the operation comprised 65.7% of the total. The remainder was apportioned over pre-surgical preparation and post-surgical recovery. Three patients required a re-operation over the 2-year follow-up period. The costs of revision surgery represented 1.85% of the total costs. Using the conservative model structure, the estimated lifetime ICUR of surgical intervention was $20,547.84/QALY gained, with 94.7% of estimates falling within the World Health Organization definition of ‘very cost effective’ ($54,000 CAD). Using the more general model structure, the estimated lifetime ICUR of surgical intervention was $11,496.02/QALY gained, with 97.9% of estimates meeting the criteria to be considered ‘very cost effective’. Conclusions Surgery for DCM is associated with a significant quality of life improvement. The intervention is cost effective and, from the perspective of the hospital payer, should be supported.
Acute spinal cord injury (SCI) is a traumatic event that results in disturbances to normal sensory, motor, or autonomic function and ultimately affects a patient’s physical, psychological, and social ...well-being. The management of patients with SCI has drastically evolved over the past century as a result of increasing knowledge on injury mechanisms, disease pathophysiology, and the role of surgery. There still, however, remain controversial areas surrounding available management strategies for the treatment of SCI, including the use of corticosteroids such as methylprednisolone sodium succinate, the optimal timing of surgical intervention, the type and timing of anticoagulation prophylaxis, the role of magnetic resonance imaging, and the type and timing of rehabilitation. This lack of consensus has prevented the standardization of care across treatment centers and among the various disciplines that encounter patients with SCI. The objective of this guideline is to form evidence-based recommendations for these areas of controversy and outline how to best manage patients with SCI. The ultimate goal of these guidelines is to improve outcomes and reduce morbidity in patients with SCI by promoting standardization of care and encouraging clinicians to make evidence-informed decisions.
BACKGROUND:Cervical spondylotic myelopathy is a progressive spine disease and the most common cause of spinal cord dysfunction worldwide. The objective of this study was to develop a prediction ...model, based on data from a prospective multi-center study, relating a combination of clinical and imaging variables to surgical outcome in patients with cervical spondylotic myelopathy.
METHODS:Two hundred and seventy-eight patients diagnosed with cervical spondylotic myelopathy treated surgically were enrolled at twelve different sites in the multi-center AOSpine North America study. Univariate analyses were performed to evaluate the relationship between outcome, assessed with the modified Japanese Orthopaedic Association (mJOA) score, and various clinical and imaging predictors. A set of important candidate variables for the final model was selected on the basis of author consensus, literature support, and statistical findings. Logistic regression was used to formulate the final model.
RESULTS:Univariate analyses demonstrated that the odds of a successful outcome decreased with a longer duration of symptoms (odds ratio OR = 0.80, 95% confidence interval CI = 0.65 to 0.98, p = 0.030); a lower baseline mJOA score (OR = 0.74, 95% CI = 0.65 to 0.84, p < 0.0001); the presence of psychological comorbidities (OR = 0.51, 95% CI = 0.29 to 0.92, p = 0.024); the presence of broad-based, unstable gait (OR = 2.72, 95% CI = 1.47 to 5.06, p = 0.0018) or other gait impairment (OR = 3.56, 95% CI = 1.75 to 7.22, p = 0.0005); and older age (OR = 0.96, 95% CI = 0.93 to 0.98, p = 0.0004). The dependent variable, the mJOA score at one year, was dichotomized for logistic regressiona “successful” outcome was defined as a final score of ≥16 and a “failed” outcome was a score of <16. The final model included age (OR = 0.97, 95% CI = 0.94 to 0.99, p = 0.0017), duration of symptoms (OR = 0.78, 95% CI = 0.61 to 0.997, p = 0.048), smoking status (OR = 0.46, 95% CI = 0.21 to 0.98, p = 0.043), impairment of gait (OR = 2.66, 95% CI = 1.17 to 6.06, p = 0.020), psychological comorbidities (OR = 0.33, 95% CI = 0.15 to 0.69, p = 0.0035), baseline mJOA score (OR = 1.22, 95% CI = 1.05 to 1.41, p = 0.0084), and baseline transverse area of the cord on magnetic resonance imaging (OR = 1.02, 95% CI = 0.99 to 1.05, p = 0.19). The area under the receiver operator characteristic curve was 0.79, indicating good model prediction.
CONCLUSIONS:On the basis of the results of the AOSpine North America study, we identified a list of the most important predictors of surgical outcome for cervical spondylotic myelopathy.
LEVEL OF EVIDENCE:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Abstract Background context Clinical prediction rules are valuable tools in a surgical setting but should not be used to guide clinical practice until validated in other populations. Purpose The ...objective of this study was to validate a clinical prediction rule developed to determine surgical outcome in patients with cervical spondylotic myelopathy (CSM). The study will also identify key clinical predictors of outcome at a global level. Study design/setting This is a prospective multicenter cohort study. Patient sample Two-hundred seventy-eight and 479 surgical CSM patients enrolled in the AOSpine CSM—North American (CSM-NA) and CSM—International (CSM-I) studies, respectively. Outcome measures The outcome measure was a Modified Japanese Orthopedic Association (mJOA) Scale. Methods A clinical prediction model was built using data from 272 patients enrolled in the CSM-NA study. Bootstrapping was used for internal validation. The original model was externally validated using data on 471 patients participating in the CSM-I study. The predictive performance of the model was evaluated, including its discrimination, measured by area under the receiver-operating curve (AUC), and calibration, assessed by calibration slope, observed:expected ratios, and Hosmer-Lemeshow goodness-of-fit test. Results The modified original model consisted of six covariates: age (odds ratio OR, 0.96), duration of symptoms (0.76), baseline severity score (1.21), psychiatric comorbidities (0.44), impairment of gait (2.48), and smoking status (0.50). The AUC for the original model was 0.77 (95% confidence interval CI: 0.71, 0.82) and across the bootstrap replicates was 0.77 (95% CI: 0.76, 0.77), reflecting good discrimination and internal validity. The model tested on the CSM-I dataset yielded an AUC of 0.74 (95% CI: 0.69, 0.79), a calibration slope of 0.75, and an insignificant Hosmer-Lemeshow test. The ORs generated for baseline mJOA (OR, 1.26), impairment of gait (2.67), age (0.97), and smoking (0.55) were very similar to the original values of 1.28, 2.39, and 0.97, respectively. Duration of symptoms (OR, 0.94) had a significantly different odds ratio than in the original model, but the direction of its relationship with outcome was the same. Psychiatric comorbidities was not a significant predictor at an international level, likely because of underreporting: only six patients outside of North American centers were diagnosed with depression or bipolar. Conclusions The parameter estimates generated from the original analysis were internally valid. The original model was also externally valid. The most significant global predictors of surgical outcome were baseline myelopathy severity, age, smoking status and impaired gait.
Abstract Background Context It remains unclear whether cervical laminoplasty (LP) offers advantages over cervical laminectomy and fusion (LF) in patients undergoing posterior decompression for ...degenerative cervical myelopathy (DCM). Purpose The objective of this study is to compare outcomes of LP and LF. Study Design/Setting This is a multicenter international prospective cohort study. Patient Sample A total of 266 surgically treated symptomatic DCM patients undergoing cervical decompression using LP (N=100) or LF (N=166) were included. Outcome Measures The outcome measures were the modified Japanese Orthopaedic Association score (mJOA), Nurick grade, Neck Disability Index (NDI), Short-Form 36v2 (SF36v2), length of hospital stay, length of stay in the intensive care unit, treatment complications, and reoperations. Methods Differences in outcomes between the LP and LF groups were analyzed by analysis of variance and analysis of covariance. The dependent variable in all analyses was the change score between baseline and 24-month follow-up, and the independent variable was surgical procedure (LP or LF). In the analysis of covariance, outcomes were compared between cohorts while adjusting for gender, age, smoking, number of operative levels, duration of symptoms, geographic region, and baseline scores. Results There were no differences in age, gender, smoking status, number of operated levels, and baseline Nurick, NDI, and SF36v2 scores between the LP and LF groups. Preoperative mJOA was lower in the LP compared with the LF group (11.52±2.77 and 12.30±2.85, respectively, p=.0297). Patients in both groups showed significant improvements in mJOA, Nurick grade, NDI, and SF36v2 physical and mental health component scores 24 months after surgery (p<.0001). At 24 months, mJOA scores improved by 3.49 (95% confidence interval CI: 2.84, 4.13) in the LP group compared with 2.39 (95% CI: 1.91, 2.86) in the LF group (p=.0069). Nurick grades improved by 1.57 (95% CI: 1.23, 1.90) in the LP group and 1.18 (95% CI: 0.92, 1.44) in the LF group (p=.0770). There were no differences between the groups with respect to NDI and SF36v2 outcomes. After adjustment for preoperative characteristics, surgical factors and geographic region, the differences in mJOA between surgical groups were no longer significant. The rate of treatment-related complications in the LF group was 28.31% compared with 21.00% in the LP group (p=.1079). Conclusions Both LP and LF are effective at improving clinical disease severity, functional status, and quality of life in patients with DCM. In an unadjusted analysis, patients treated with LP achieved greater improvements on the mJOA at 24-month follow-up than those who received LF; however, these differences were insignificant following adjustment for relevant confounders.
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