Conventional JOA score for cervical myelopathy has a rater's bias -In comparison with JOACMEQ.

Abstract

The JOA (Japan Orthopaedic Association) score has been a standard outcome measure to evaluate cervical myelopathy in Japan. Despite its reliability and convenience, there can be a rating bias in the JOA score. The current study was conducted to delineate the rater's bias of the JOA score by comparing it with a new objective outcome measure. Two hundred and thirty four operative candidates with cervical myelopathy were included in the study. The patients were divided into four groups according to the surgeon (92 patients in group A, 60 patients in group B, 38 patients in group C and 44 patients in group D). Each patient's preoperative JOA score was exclusively recorded by the surgeon himself, while JOACMEQ (Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire) was recorded by each patient. Disease severity, the most important prognostic factor, was equalized between patient groups by a special statistical method called inverse-probability weighting (IPW). To define similarity of the two groups, Cohen's d was used. After the adjustment, the differences of the JOA score were only 0.1 between groups A and D and 0 between groups B and C. The values of Cohen's d were also very small both between groups A and D (3%), and between groups B and C (0.3%). The averaged JOA scores of groups A and D were higher by 0.4-0.8 than those of groups B and C, while the averaged JOA scores were almost the same both between groups A and D, and between groups B and C. Surgeons A and D had the same tendency to give higher JOA scores than surgeons B and C did. The current study confirmed there is a definite rater's bias in the JOA score. JOACMEQ is to be applied as a more reliable outcome measure to evaluate myelopathy patients.