Lightning Podiums: Cervical Degenerative - Room 802A

Presented by: J. Badhiwala

Author(s):

J. Badhiwala(1), C. Witiw(1), F. Nassiri(1), M. Akbar(1), A. Mansouri(1), J. Wilson(1), M. Fehlings(1)

(1) University of Toronto, Division of Neurosurgery, Department of Surgery, Toronto, ON, Canada

Abstract

Introduction: Controversy persists over the best treatment strategy for patients with mild degenerative cervical myelopathy (DCM). The most recent clinical guidelines suggest either surgery or non-operative treatment are reasonable initial approaches. We sought to evaluate the degree of impairment in baseline quality of life as compared to population norms, and functional, disability, and quality of life outcomes following surgery in a prospective cohort of mild DCM patients undergoing surgical decompression.

Methods: We captured patients with mild DCM, defined by a modified Japanese Orthopaedic Association (mJOA) score of 15, 16, or 17, enrolled in the AOSpine CSM-NA or CSM-I prospective, multi-center studies. All patients underwent spinal decompression by an anterior, posterior, or combined approach. Data relating to patient demographics, clinical presentation, surgical treatment, and clinical outcomes were extracted. Baseline quality of life (SF-36v2) was compared to Canadian population normative data by the standardized mean difference (SMD). Functional status (mJOA, Nurick grade), disability (Neck Disability Index [NDI]), and quality of life (SF-36v2) were evaluated pre-operatively and 6 months, 1 year, and 2 years after surgery. We performed pairwise comparison of means using the Tukey adjustment for multiple comparisons to study how the outcomes of mJOA score, Nurick grade, each of the eight domains and two composite scores of the SF-36v2, and NDI changed over time. Post-operative complications within 30 days of surgery were monitored.

Results: A total of 193 patients met eligibility criteria. Mean age was 52.4 years and there were 67 females (34.7%). Mean symptom duration was 26.7 months. The most common presenting complaint was numb hands (156; 80.8%) and the most common exam finding was hyperreflexia (135; 69.9%). Patients demonstrated significant impairment in every domain of the SF-36v2 compared to population norms, greatest for Social Functioning (SMD -2.33, 95% CI -2.48 to -2.18), Physical Functioning (SMD -2.31, 95% CI -2.46 to -2.16), and Mental Health (SMD -2.30, 95% CI -2.44 to -2.15). A statistically significant improvement in mean score from baseline to 2-year follow-up was observed for all major outcomes, including mJOA (0.87, 95% CI 0.42 to 1.33, P< 0.01), Nurick grade (-1.24, 95% CI -1.55 to -0.93, P< 0.01), NDI (-12.97, 95% CI -18.18 to -7.76, P< 0.01), and SF-36v2 PCS (5.75, 95% CI 3.08 to 8.41, P< 0.01) and MCS (6.93, 95% CI 3.41 to 10.45, P< 0.01). The most common complication was worsening of myelopathy in 13 patients (6.7%), followed by worsening of axial neck pain in 12 (6.2%), and dysphagia in 11 (5.7%). Six patients (3.1%) developed a superficial wound infection, 6 (3.1%) had a malpositioned screw, and 4 (2.1%) developed a post-operative kyphotic deformity.

Conclusion: Even minimally symptomatic DCM, technically classified as "mild", is associated with significant impairment in quality of life. Surgery provides significant gains in functional status, level of disability, and quality of life. Perhaps it is time we recalibrate the way we think of the goals of surgery in this population to extend beyond preventing neurological deterioration, to improving function and quality of life. Stability may not be a "good" or acceptable outcome to patients.