Surgery For Degenerative Cervical Myelopathy Research Articles

Functional and Quality of Life Outcomes of Surgery for Degenerative Cervical Myelopathy: a Quality Improvement Study

Background: This study aimed to determine the outcome of surgical treatments in patients with degenerative cervical myelopathy (DCM). During one-year follow-up period, we evaluated patient-reported functional and quality of life (QOL) measures. Methods: In a retrospective single-center study, we collected data of patients with DCM who underwent cervical fusion surgeries in Imam Khomeini Hospital, Tehran, Iran, from 2011 to 2015. Patients underwent single or multi-level anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), or posterior laminectomy and fusion. We utilized patient-reported assessments including Short Form 36 (SF-36), Visual Analogue Scale (VAS), Neck Disability Index (NDI), and Nurick grade. Follow-up was performed at 6 weeks, 3 months, 6 months, and 12 months post-operatively to assess the outcome of surgery. Results: Ninety patients (56 men, 34 women) with a mean age of 54.1 (27-87) years were included. Comparison of pre- and post-operative scores showed significant improvement in SF-36 parameters, VAS, NDI, and Nurick grade (P < 0.001). Also, women’s VAS scores improved more than men's VAS scores during the follow-up period (P < 0.050). Age and type of surgery did not significantly affect the SF-36 parameters, VAS, NDI, and Nurick grade (P > 0.05). Conclusions: Cervical surgeries in patients with different severity of DCM can improve different aspects of QOL during one-year after surgery

Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy

Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored. To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM. This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest. A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in their myelopathic symptoms, compared to patients with mild mJOA score in. Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.

How common is repeat surgery and multi-level treatment in Degenerative Cervical Myelopathy? Findings from a patient perspective survey

Degenerative Cervical Myelopathy (DCM) is a common condition which causes significant disability and reduces health-related quality of life. The only evidence-based treatment and current management guidance is surgery to decompress the spinal cord and stop further damage in moderate to severe cases. However, this guidance is mainly informed by studies that only include first time surgery and/or single level disease, but DCM can reoccur after primary surgery and affect multiple levels of the spine. It is unclear whether patients in these subgroups; repeat surgery and multi-level DCM, differ significantly in their baseline and disease characteristics from those with single-level, single-operation disease. To investigate this, we conducted an online survey of people with DCM looking at key demographic, disease (e.g. mJOA) and treatment characteristics. We received a total of 778 respondents, of which 159 (20%) had undergone surgery for DCM. Around 75% of these respondents had a single operation and 65% at a single level. We found no statistically significant difference in key participant and disease characteristics between respondents with single-level or single-operation and those with multi-level DCM or multiple operations. These data support generalisability of research to these subgroups but also warrants further investigations as these subgroups are underrepresented in current research.

Prevalence of anemia and its relationship with neurological status in patients undergoing surgery for degenerative cervical myelopathy and radiculopathy: A retrospective study of 2 spine centers

Both degenerative cervical myelopathy (DCM) and anemia are common among older patients, however insufficient data exists evaluating their co-occurrence and the influence of anemia on baseline neurological status. To address this, we examined a retrospective multicenter series of patients treated for DCM or radiculopathy. Myelopathy was graded using the Nurick scale. Established criteria for diagnosing abnormalities were used to identify blood abnormalities, including macrocytic and microcytic anemia. Multivariable regression was used to determine the impact of hematological anomalies on Nurick grades. In our analysis, we included 725 patients (age of 57.1 ± 11.7), of whom 398 presented with myelopathy and 327 presented with radiculopathy alone. Twenty six percent of all patients were anemic at baseline and the mean preoperative Nurick grade across all patients was 2.09 ± 1.29; mean Nurick grade amongst those with DCM was 2.98 ± 1.12. Compared to those with myelopathy, patients with radiculopathy were significantly younger (53.8 ± 11.0 vs 59.8 ± 11.6, p < 0.001) and less likely to be anemic (16.8% vs 33.7%, p < 0.0001). Nurick grading was significantly higher in myelopathy patients with anemia (3.13 ± 1.19 vs 2.91 ± 1.07, p = 0.05) and macrocytic anemia (4.00 ± 1.41 vs 2.97 ± 1.11, p = 0.04). Multivariate regression demonstrated that anemia (p < 0.001), age (p < 0.0001), and posterior surgical approach (p < 0.0001) were related to worse preoperative Nurick grade. In sum, these data suggest that anemia and degenerative cervical spine pathologies commonly co-occur. Anemia, and macrocytic anemia specifically, is associated with poorer neurological status in myelopathic patients. These data suggest anemia may influence baseline neurological status and impact surgical recovery in patients treated for DCM or radiculopathy.

Degenerative Cervical Myelopathy in Higher-Aged Patients: How Do They Benefit from Surgery?

Background: Degenerative cervical myelopathy (DCM) is the most common reason for spinal cord disease in elderly patients. This study analyzes the preoperative status and postoperative outcome of higher-aged patients in comparison to young and elderly patients in order to determine the benefit to those patients from DCM surgery. Methods: A retrospective analysis of the clinical data, radiological findings, and operative reports of 411 patients treated surgically between 2007 and 2016 suffering from DCM was performed. The preoperative and postoperative neurological functions were evaluated using the modified Japanese Orthopedic Association Score (mJOA Score), the postoperative mJOA Score improvement, the neurological recovery rate (NRR) of the mJOA Score, and the minimum clinically important difference (MCID). The Charlson Comorbidity Index (CCI) was used to evaluate the impact of comorbidities on the preoperative and postoperative mJOA Score. The comparisons were performed between the following age groups: G1: ≤50 years, G2: 51–70 years, and G3: >70 years. Results: The preoperative and postoperative mJOA Score was significantly lower in G3 than in G2 and G1 (p < 0.0001). However, the mean mJOA Score’s improvement did not differ significantly (p = 0.81) between those groups six months after surgery (G1: 1.99 ± 1.04, G2: 2.01 ± 1.04, G: 2.00 ± 0.91). Furthermore, the MCID showed a significant improvement in every age-group. The CCI was evaluated for each age-group, showing a statistically significant group effect (p < 0.0001). Analysis of variance revealed a significant group effect on the delay (weeks) between symptom onset and surgery (p = 0.003). The duration of the stay at the hospital did differ significantly between the age groups (p < 0.0001). Conclusion: Preoperative and postoperative mJOA Scores, but not the extent of postoperative improvement, are affected by the patients’ age. Therefore, patients should be considered for DCM surgery regardless of their age.

Effectiveness of Surgical Treatment for Degenerative Cervical Myelopathy in Preventing Falls and Fall-related Neurological Deterioration: A Prospective Multi-institutional Study.

Prospective multi-center study. The aim of this study was to evaluate the effectiveness of surgical treatment in reducing falls and fall-related neurological deterioration in a prospective cohort of patients undergoing surgery for degenerative cervical myelopathy (DCM). Current evidence is limited for the effectiveness of surgical interventions for DCM in reducing the risk of fall-related neurological deterioration. Patients with DCM scheduled for surgical treatment were enrolled prospectively at eight participating institutes. At the time of enrollment, participants were given diaries to record details of their falls, to be returned at the 1-year postoperative follow-up. In the fall diary, patients were asked whether they had experienced any deterioration in neurological symptoms at each fall episode. Deterioration of neurological symptoms was categorized as follows: only deterioration of sensory function in the limbs; or deterioration of motor deficits. The incidence rate of falls was calculated separately for the preoperative and postoperative periods, as the total number of falls divided by the time over which falls were monitored (100 person-years). Functional outcome was assessed with the Japanese Orthopaedic Association (JOA) score and Neck Disability Index. Of the initial 168 participants, 159 completed the 1-year follow-up, and 132 fall diaries were retrieved and analyzed. Of these 132 patients, 65 (49%) reported at least one fall during the survey period. The incidence rate of falls decreased significantly from 497.4 to 90.3 falls per 100 person-years after surgery. The incidence of motor deterioration per fall decreased significantly from 34% to 8% after surgery. Patients who experienced preoperative fall-related motor deterioration had a significantly lower JOA score compared with patients without fall-related motor deterioration at 1-year follow-up. Surgical intervention for DCM is effective not only in reducing the frequency of falls, but also in reducing the risk of fall-related deterioration of motor deficits. 2.

The Impact of Older Age on Functional Recovery and Quality of Life Outcomes after Surgical Decompression for Degenerative Cervical Myelopathy: Results from an Ambispective, Propensity-Matched Analysis from the CSM-NA and CSM-I International, Multi-Center Studies.

Background: The effect on functional and quality of life (QOL) outcomes of surgery in elderly degenerative cervical myelopathy (DCM) patients has not been definitively established. Objective: To evaluate the effect of older age on the functional and QOL outcomes after surgery in an international, multi-center cohort of patients with DCM. Methods: 107 patients aged over 70 years old (mean 75.6 ± 4.4 years) were enrolled in the AOSpine CSM-North America and International studies. A propensity-matched cohort of 107 patients was generated from the remaining 650 adults aged <70 years old (mean 56.3 ± 9.6 years), matched to gender, complexity of surgery, co-morbidities, and baseline functional impairment (modified Japanese Orthopedic Association scale (mJOA). Functional, disability, and QOL outcomes were compared at baseline and at two years post-operatively, along with peri-operative adverse events. Results: Both cohorts were equivalently matched. At two years, both cohorts showed significant functional improvement from the baseline but the magnitude was greater in the younger cohort (mJOA 3.8 (3.2–4.4) vs. 2.6 (2.0–3.3); p = 0.007). This difference between groups was also observed in the SF-36 physical component summary (PCS) and mental component summary (MCS) outcomes (p = <0.001, p = 0.007), but not present in the neck disability index (NDI) scores (p = 0.094). Adverse events were non-significantly higher in the elderly cohort (22.4% vs. 15%; p = 0.161). Conclusions: Elderly patients showed an improvement in functional and QOL outcomes after surgery for DCM, but the magnitude of improvement was less when compared to the matched younger adult cohort. An age over 70 was not associated with an increased risk of adverse events.

45. Trajectory of change in mJOA score within one year following surgery for degenerative cervical myelopathy

BACKGROUND CONTEXT Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The majority of these patients require surgical decompression to halt disease progression and improve functionality. The modified Japanese Orthopedic Association (mJOA) is a patient-reported questionnaire commonly used to grade symptoms and is a validated tool for assessment of postoperative improvement in the surgical management of cervical myelopathy. However, literature describing the natural history of recovery following surgical decompression is limited, especially in the postsurgical period of 3 to 12 months. PURPOSE The aim of the study is to assess the trajectory of mJOA improvement in the postsurgical period of 3 to 12 months in patients who underwent surgery for cervical myelopathy. STUDY DESIGN/SETTING This study is a retrospective analysis of prospectively collected data from the cervical module of a national spine registry, the Quality Outcomes Database (QOD). PATIENT SAMPLE A total of 2,156 patients who underwent elective surgery for DCM and had complete 3- and 12-month follow-up data in the QOD registry were included in the study. OUTCOME MEASURES The mJOA score was used to define severity of myelopathic symptoms in patients who underwent surgery for cervical myelopathy. METHODS Patients were divided into mild (≥14), moderate (9-13), or severe ( RESULTS Patients improved significantly from baseline to 3 months on their mJOA scores, regardless of their baseline mJOA severity. Four hundred five (18.8%) showed improvement during the time period of 3- to 12-month postsurgical follow-up. After adjusting for the relevant baseline patient and surgery specific characteristics, the baseline mJOA categories had significant impact on whether a patient improves by 2 points in mJOA score from 3- to 12-month postsurgery (75.49% of the total Wald X2, p CONCLUSIONS In the surgical management of cervical myelopathy, most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep improving until after a longer follow-up. Preoperative identification of such patients helps the clinician with setting realistic expectations for each follow-up time point. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

278. The impact of older age on functional recovery after surgical decompression for degenerative cervical myelopathy: results from an international, multicentre, prospective dataset in 757 patients

BACKGROUND CONTEXT Surgical decompression has been shown to improve long-term function, disability and quality of life (QOL) in degenerative cervical myelopathy (DCM); however, the role of surgery, and the effect on functional and QOL outcomes, in elderly patients with DCM is controversial. PURPOSE To investigate the effect of older age (over 70) on the functional and QOL impairment and outcomes after DCM surgery compared to younger adults. STUDY DESIGN/SETTING Prospective, multicentre observational studies on the outcomes of surgery for DCM; the AO Spine CSM-North America and the CSM-International studies. PATIENT SAMPLE A harmonized, combined dataset of 757 patients enrolled from both studies. OUTCOME MEASURES Functional assessment was performed with the modified Japanese Orthopedic Association score (mJOA). QOL outcomes were measured by the SF-36 physical and mental component scores. METHODS Of 757 patients enrolled in both studies, 107 patients were identified as elderly (70 years or older) at the time of surgery. Outcomes and functional status were assessed at 6-, 12- and 24-month intervals. In addition to unadjusted univariate analyses, multiple linear regression was used to evaluate the effect of age ≥70 on change in outcome scores adjusting for diabetes, cardiac comorbidities, cigarette smoking, psychiatric disorders, number of operated levels, surgical approach and baseline mJOA. RESULTS The baseline mJOA in the elderly group was significantly lower than the younger group (11.0 [95% CI 10.4-11.5] vs 12.9 [12.7-13.1]; p= CONCLUSIONS In this combined dataset from 2 large prospectively collected multicentre studies on DCM surgery, the group aged 70 or greater demonstrated significantly worse functional and QOL recovery when compared to the younger cohort after adjusting for the effect of comorbidities, number of operated levels, surgical approach and baseline mJOA. Elderly patients undergoing surgery for DCM should therefore be counseled appropriately regarding expectations of surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Does the Neurological Examination Correlate with Patient-Perceived Outcomes in Degenerative Cervical Myelopathy?

In patients with neurological disorders, a divergence can exist between patients' perceptions regarding the outcomes and the objective neurological findings. Degenerative cervical myelopathy (DCM), a prevalent condition characterized by progressive compression of the cervical spinal cord, can produce debilitating symptoms and profound neurological findings. The purpose of the present study was to determine whether the physician-derived neurological examination findings, as recorded by American Spine Injury Association (ASIA) summary score, correlated with the patient-derived outcome measures for DCM. A total of 78 patients underwent surgical management of DCM with completion of preoperative and 6-month follow-up assessments. Surgical management consisted of either anterior or posterior cervical decompression. All patients underwent a neurological evaluation, including an ASIA assessment before surgery and 6 months after surgery, and completed the modified Japanese Orthopaedic Association (mJOA), neck disability index (NDI), and Short-Form 36-item (SF-36) scales pre- and postoperatively to measure both disease-specific and general perceived outcomes. The objective physician-derived neurological testing (ASIA) did not correlate with the patient-derived scales (mJOA, NDI, and SF-36) pre- or postoperatively. Patients reported significant improvements (P <0.001) at 6 months postoperatively in extremity functioning (mJOA), neck pain (NDI), overall physical health (SF-36), and objective strength and sensory functioning (ASIA). All patient-perceived outcome measures correlated with each other pre- and postoperatively (P < 0.01). Objective scoring of postoperative neurological function did not correlate with patient-perceived outcomes before and after surgery for DCM. Traditional testing of motor and sensory function as part of the neurological assessment may not be sensitive enough to assess the scope of neurological changes experienced by patients with DCM.

The discrepancy between functional outcome and self-reported health status after surgery for degenerative cervical myelopathy

INTRODUCTIONSurgery for degenerative cervical myelopathy has shown not only to halt neurologic deterioration, but also to improve functional impairments. Despite these improvements, some patients may be dissatisfied with their outcomes. This study aims to (1) investigate discrepancies between postoperative clinical measures and self-reported health status, and (2) identify important predictors of such discrepancies. METHODSFour hundred and seventy-nine surgical patients were prospectively enrolled in the CSM-International study at 16 global sites. At 1-year post-op, patients rated their general health status compared with their immediate preoperative status (much better, somewhat better, the same, somewhat worse, much worse). Descriptive analyses were conducted to evaluate the agreement between achieving a clinically important improvement (MCID) in function (modified Japanese Orthopedic Association [mJOA] scale) and self-reported health status. Agreement was defined as achieving the MCID on the mJOA and reporting general health as somewhat better or much better, whereas disagreement was defined as achieving MCID on the mJOA and reporting general health as the same, somewhat worse or much worse. Logistic regression analysis was used to determine factors that influence agreement between self-report of health status and functional outcomes. RESULTSA total of 395 patients had complete follow-up data at 1-year and were included in this analysis. Based on patient self-reports, 56 (14.2%) were somewhat or much worse than a year ago, 80 (20.2%) patients were the same and 259 (65.6%) patients were somewhat or much better. Thirty percent of patients who reported being somewhat or much worse were found to achieve the MCID on the mJOA; 57.5% of patients who indicated their health status were the same as before surgery also exhibited clinically meaningful improvements in functional impairment. Based on multivariate analysis, there was an increased odds of observing an agreement between self-reports of health status and functional outcomes if the patient exhibited greater improvement in mJOA upper extremity motor function at 1-year (odds ratio [OR]: 1.41, 95% confidence interval [CI] 1.03–1.93, p=.033) and reduced odds of agreement with increased age (OR for every decade: 0.66, 95% CI 0.50–0.87, p=.0035) and increased bodily pain at 1-year (OR: 0.62, 95% CI 0.49–078, p<.0001). CONCLUSIONSThere was a discrepancy between changes in mJOA and self-reports of health status in patients undergoing surgery for degenerative cervical myelopathy. Increased bodily pain at 1-year, smaller improvements in postoperative upper extremity score and increased age were associated with worsened or unchanged general health status, despite clinically significant improvements in overall postoperative function.

Discrepancy between functional recovery and cutaneous silent period change in surgically treated degenerative cervical myelopathy: a prospective pilot study.

Exploratory research OBJECTIVES: Cutaneous silent periods (CSPs) that reflect the inhibitory spinal cord reflex, can sensitively detect spinal cord dysfunction, and contribute to the diagnosis of degenerative cervical myelopathy (DCM). However, CSP changes after DCM surgery related to functional improvement have not been reported. University hospital in Nankoku, Japan METHODS: CSP recorded at four time points-before surgery, 3, 6, 12 months after surgery-were investigated in 31 hands of 16 DCM patients. CSPs were categorized as follows: normal, delayed onset latency, shortened duration, onset delay with shortened duration, and absent CSP. Myelopathic symptoms were evaluated by the Japanese Orthopaedic Association score (JOA score). Normal CSPs were observed in five hands (16%) before surgery and six hands (19%) twelve months after surgery (P > 0.05). Either onset delay or shortened duration or both were observed in 18 hands (58%) before surgery and 16 hands (52%) twelve months after surgery (P > 0.05). Absent CSPs were observed in eight hands (26%) before surgery and nine hands (29%) twelve months after surgery (P > 0.05). Measured values of onset latency and duration also did not change throughout the study period (P > 0.05). On the other hand, JOA scores improved after surgery. (P = 0.003). CSP abnormalities persisted after surgery in most cases, indicating irreversible damage of the intramedullary reflex circuit. JOA score recovery without CSP recovery provides insight into postoperative neural recovery in DCM.

Effect of Modified Japanese Orthopedic Association Severity Classifications on Satisfaction With Outcomes 12 Months After Elective Surgery for Cervical Spine Myelopathy.

This study retrospectively analyzes prospectively collected data. Here, we aim to determine the influence of preoperative and 12-month modified Japanese Orthopedic Association (mJOA) on satisfaction and understand the change in mJOA severity classification after surgical management of degenerative cervical myelopathy (DCM). DCM is a progressive degenerative spine disease resulting from cervical cord compression. The natural progression of DCM is variable; some patients experience periods of stability, while others rapidly deteriorate following disease onset. The mJOA is commonly used to grade and categorize myelopathy symptoms, but its association with postoperative satisfaction has not been previously explored. The quality and outcomes database (QOD) was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9 to 13), or severe (<9) categories on the mJOA scores. A McNemar-Bowker test was used to assess whether a significant proportion of patients changed mJOA category between preoperative and 12 months postoperative. A multivariable proportional odds ordinal logistic regression model was fitted with 12-month satisfaction as the outcome of interest. We identified 1963 patients who underwent elective surgery for DCM and completed 12-months follow-ups. Comparing mJOA severity level preoperatively and at 12 months revealed that 55% remained in the same category, 37% improved, and 7% moved to a worse category. After adjusting for baseline and surgery-specific variables, the 12-month mJOA category had the highest impact on patient satisfaction (P < 0.001). Patient satisfaction is an indispensable tool for measuring quality of care after spine surgery. In this sample, 12-month mJOA category, regardless of preop mJOA, was significantly correlated with satisfaction. Given these findings, it is important to advise patients of the probability that surgery will change their mJOA severity classification and the changes required to achieve postoperative satisfaction. 3.

Using a machine learning approach to predict outcome after surgery for degenerative cervical myelopathy.

Degenerative cervical myelopathy (DCM) is a spinal cord condition that results in progressive non-traumatic compression of the cervical spinal cord. Spine surgeons must consider a large quantity of information relating to disease presentation, imaging features, and patient characteristics to determine if a patient will benefit from surgery for DCM. We applied a supervised machine learning approach to develop a classification model to predict individual patient outcome after surgery for DCM. Patients undergoing surgery for DCM as a part of the AOSpine CSM-NA or CSM-I prospective, multi-centre studies were included in the analysis. Out of 757 patients 605, 583, and 539 patients had complete follow-up information at 6, 12, and 24 months respectively and were included in the analysis. The primary outcome was improvement in the SF-6D quality of life indicator score by the minimum clinically important difference (MCID). The secondary outcome was improvement in the modified Japanese Orthopedic Association (mJOA) score by the MCID. Predictor variables reflected information about pre-operative disease severity, disease presentation, patient demographics, and comorbidities. A machine learning approach of feature engineering, data pre-processing, and model optimization was used to create the most accurate predictive model of outcome after surgery for DCM. Following data pre-processing 48, 108, and 101 features were chosen for model training at 6, 12, and 24 months respectively. The best performing predictive model used a random forest structure and had an average area under the curve (AUC) of 0.70, classification accuracy of 77%, and sensitivity of 78% when evaluated on a testing cohort that was not used for model training. Worse pre-operative disease severity, longer duration of DCM symptoms, older age, higher body weight, and current smoking status were associated with worse surgical outcomes. We developed a model that predicted positive surgical outcome for DCM with good accuracy at the individual patient level on an independent testing cohort. Our analysis demonstrates the applicability of machine-learning to predictive modeling in spine surgery.

P85 Waiting time for operative management of degenerative cervical myelopathy (DCM) and its impact on outcome

ObjectivesTo audit the waiting time for patients with degenerative cervical myelopathy (DCM ) and its impact on outcome in the Imperial College NHS Trust (ICNHST) against the latest AO standard.DesignRetrospective analysis.Subjects1. Waiting time for surgery and impact on outcome for DCM. 2. Operative approach.MethodsThe medical records of 107 patients who had undergone surgery for DCM at ICNHST in 2016 to 2017 was reviewed. Central tendency analysis of nominal and ordinal variables such as surgery waiting time and demographics were assessed using Microsoft excel.ResultsThe mean age reviewed was 58.2 years. Male to female ratio was 1:1. The mean wait time was 10.22 overall. However, 58% of cases were moderate with mean wait time in that stratum at 4 weeks. Most patients improved at 3–6 months by 2 points on the mJOA regardless of approach done although 63% of cases were anterior. The results were compatible with the latest AO recommendations except for mild patients where it seemed more efficient to converse about morbidity of surgery vs myelopathy in the first instance, since disease burden is tolerable and plated in most hence risk may outweigh benefit. The approach chosen should be individually chosen based on a gestalt of patient and disease factors since results are equivocal.ConclusionsThe approach to the cervical myelopathy must be taken at the merit of each patient based on a gestalt of the individual clinical factors involved. However, default approach to limiting wait to under 4 weeks is reasonable.

172 Role of the Sodium/Glutamate Blocker Riluzole in Enhancing Functional Outcomes in Patient Undergoing Surgery for Degenerative Cervical Myelopathy

172 Role of the Sodium/Glutamate Blocker Riluzole in Enhancing Functional Outcomes in Patient Undergoing Surgery for Degenerative Cervical Myelopathy

Friday, September 28, 2018 4:05 PM–5:05 PM abstracts: cervical myelopathy and deformity: 253. Degenerative cervical myelopathy in the United States, 2002-2014: a silent epidemic

BACKGROUND CONTEXT Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord injury and a major source of disability globally; however, data on the national trends of DCM incidence are limited. PURPOSE To evaluate contemporary trends in DCM incidence and healthcare resource utilization in the United States. STUDY DESIGN/SETTING Determination of epidemiological estimates of DCM using population-based survey data from the United States AHRQ HCUP National Inpatient Sample (NIS) for years 2002 through 2014. PATIENT SAMPLE A total of 618,323 patients who underwent surgery for DCM in the United States between 2002 and 2014. OUTCOME MEASURES Overall and age- and sex-stratified incidences of surgically-treated DCM; surgical techniques utilized, hospitalization charges and costs, and inpatient complications and mortality for treatment of DCM. METHODS Patients who underwent surgery for DCM were identified from the NIS using ICD-9-CM codes based on a diagnosis code for cervical spondylosis and/or OPLL plus cervical myelopathy, plus a procedure code for anterior or posterior decompression plus or minus fusion, or disc replacement. Data pertaining to patient-, treatment-, admission-, and hospital-related factors and outcomes were collected. Patient-specific discharge weights were used to obtain national estimates. We calculated standard errors and 95% confidence intervals (CIs) using strata and cluster variables to account for hospital-level clustering of patients and the sampling design. We calculated overall and age- and sex-stratified incidences of surgically-treated DCM per 100,000 persons for each year using population estimates from the U.S. Census Bureau. These were compared to incidences of acute traumatic SCI and three very common neurosurgical procedures: (1) evacuation of subdural hematoma (SDH) (including acute, subacute, and chronic); (2) craniotomy for tumor (including primary and metastatic); and (3) clipping or endovascular coiling of cerebral aneurysm. Hospitalization charges and costs were indexed to year 2008 to adjust for inflation using Consumer Price Index (CPI) data from the U.S. Bureau of Labor Statistics. Trends were analyzed by joinpoint regression analysis for incidences to determine the average annual percent change (AAPC), the Cochrane–Armitage trend test for categorical variables, and linear regression for continuous variables. RESULTS The overall incidence of surgical DCM rose from 10.3 per 100,000 persons in 2002 to 21.1 per 100,000 persons in 2014, representing an AAPC of 5.9% (95% CI 5.5%–6.3%). The highest incidence (61.1/100,000) and growth rate (AAPC 7.4%) were seen in the 65 to 84-year-old age group. Age-adjusted incidence and annual growth rates for DCM exceeded those of acute traumatic SCI (5.0/100,000; −0.5%), evacuation of SDH (8.2/100,000; 0.4%), craniotomy for brain tumor (14.2/100,000; 1.1%), and clipping or coiling of cerebral aneurysm (7.2/100,000; 2.4%). Cumulative hospital charges and costs for DCM rose from $0.99 billion and $0.29 billion in 2002 to $5.13 billion and $1.32 billion in 2014, respectively. The proportion of cases for which Medicare was the primary payer increased from 30.5% in 2002 to 43.6% in 2014. CONCLUSIONS DCM is the leading indication for operation on the central nervous system. The incidence of, and healthcare dollars spent on, surgery for DCM has steadily risen over the past decade likely owing both to an aging population and increasing recognition of the role of surgical management in these patients.

The Role of Vitamin B12 in the Management and Optimization of Treatment in Patients With Degenerative Cervical Myelopathy.

Study Design:Narrative review.Objectives:To discuss the relationship between degenerative cervical myelopathy (DCM) and vitamin B12 deficiency. Specifically, it is the aim to outline the rational for future research into assessment and therapeutic optimization of vitamin B12 in the treatment of DCM.Methods:Literature review.Results:DCM is the commonest cause of spinal cord impairment, with an average age of presentation in the sixth decade. Patients at this age have also been reported to have a high prevalence of vitamin B12 deficiency, with estimates of up to 20% in the elderly. Vitamin B12 deficiency can result in subacute combined degeneration of the spinal cord (SACD), and several case reports have pointed to patients with both DCM and SACD. Both SACD and reversible compressive injury due to DCM necessitate remyelination in the spinal cord, a process that requires adequate vitamin B12 levels. Basic science research on nerve crush injuries have shown that vitamin B12 levels are altered after nerve injury and that vitamin B12 along with dexamethasone or nonsteroidal anti-inflammatory drugs can reduce Wallerian degeneration. Furthermore, it has been suggested that a combination of B-vitamins can reduce glutamate-induced neurotoxicity.Conclusions:Given the high prevalence of clinical and subclinical vitamin B12 deficiency in the elderly, the role of vitamin B12 in myelination, and vitamin B12 deficiency as a differential diagnosis of DCM, it is important to investigate what role vitamin B12 levels play in patients with DCM in terms of baseline neurological function and whether optimization of vitamin B12 levels can improve surgical outcome. Furthermore, the routine assessment of vitamin B12 levels in patients considered for DCM surgery should be considered.

Patient phenotypes associated with outcome following surgery for mild degenerative cervical myelopathy: a principal component regression analysis

Background ContextPredictors of outcome after surgery for degenerative cervical myelopathy (DCM) have been determined previously through hypothesis-driven multivariate statistical models that rely on a priori knowledge of potential confounders, exclude potentially important variables because of restrictions in model building, cannot include highly collinear variables in the same model, and ignore intrinsic correlations among variables. PurposeThe present study aimed to apply a data-driven approach to identify patient phenotypes that may predict outcomes after surgery for mild DCM. Study DesignThis is a principal component analysis of data from two related prospective, multicenter cohort studies. Patient SampleThe study included patients with mild DCM, defined by a modified Japanese Orthopaedic Association score of 15–17, undergoing surgical decompression as part of the AOSpine CSM-NA or CSM-I trials. Outcome MeasuresPatient outcomes were evaluated preoperatively at baseline and at 6 months, 1 year, and 2 years after surgery. Quality of life (QOL) was evaluated by the Neck Disability Index (NDI) and Short Form-36 version 2 (SF-36v2). These are both patient self-reported measures that evaluate health-related QOL, with NDI being specific to neck conditions and SF-36v2 being a generic instrument. Materials and MethodsThe analysis included 154 patients. A heterogeneous correlation matrix was created using a combination of Pearson, polyserial, and polychoric regressions among 67 variables, which then underwent eigen decomposition. Scores of significant principal components (PCs) (with eigenvalues>1) were included in multivariate logistic regression analyses for three dichotomous outcomes of interest: achievement of the minimum clinically important difference [MCID] in (1) NDI (≤−7.5), (2) SF-36v2 Physical Component Summary (PCS) score (≥5), and (3) SF-36v2 Mental Component Summary (MCS) score (≥5). ResultsTwenty-four significant PCs accounting for 75% of the variance in the data were identified. Two PCs were associated with achievement of the MCID in NDI. The first (PC 1) was dominated by variables related to surgical approach and number of operated levels; the second (PC 21) consisted of variables related to patient demographics, severity and etiology of DCM, comorbid status, and surgical approach. Both PC 1 and PC 21 also correlated with SF-36v2 PCS score, in addition to PC 4, which described patients' physical profile, including gender, height, and weight, as well as comorbid renal disease; PC 6, which received large loadings from variables related to cardiac disease, impaired mobility, and length of surgery and recovery; and PC 9, which harbored large contributions from features of upper limb dysfunction, cardiorespiratory disease, surgical approach, and region. In addition to PC 21, a component profiling patients' socioeconomic status and support systems and degree of physical disability (PC 24) was associated with achievement of the MCID in SF-36 MCS score. ConclusionsThrough a data-driven approach, we identified several phenotypes associated with disability and physical and mental health-related QOL. Such data reduction methods may separate patient-, disease-, and treatment-related variables more accurately into clinically meaningful phenotypes that may inform patient care and recruitment into clinical trials.

Impact of Cervical Spine Deformity on Preoperative Disease Severity and Postoperative Outcomes Following Fusion Surgery for Degenerative Cervical Myelopathy: Sub-analysis of AOSpine North America and International Studies.

Sub-analysis of the prospective AOSpine CSM North America and International studies. The aim of this study was to investigate the impact of cervical spine deformity on pre- and postoperative outcomes in fusion surgeries for degenerative cervical myelopathy. The associations between cervical alignment and patient outcomes have been reported but are not well established in a myelopathy cohort. The impact of deformity correction in this population also needs to be elucidated. A total of 757 patients were enrolled in two prospective international multicenter AOSpine studies. Among those who underwent anterior or posterior fusion surgeries, pre- and 1-year postoperative upright neutral lateral radiographs of cervical spine were investigated to measure C2-7 Cobb angle and C2-7 sagittal vertical axis (SVA). Patient outcome measures included the modified Japanese Orthopedic Association score for myelopathy severity, Neck Disability Index (NDI), and Short-form 36 (SF-36). These scores were compared between patients with and without cervical deformity, which was defined as C2-7 Cobb >10° kyphosis and/or SVA >40 mm. A total of 178 patients were included with complete pre- and postoperative radiographs. SVA significantly increased postoperatively (27.4 vs. 30.7 mm, P = 0.004). All outcome measurement showed significant improvements above minimal clinically important differences. 23.6% of the patients had cervical deformity preoperatively; preoperative deformity was associated with worse preoperative NDI scores (45.7 vs. 38.9, P = 0.04). Postoperatively, those with deformity exhibited significantly lower SF-36 physical component scores (37.2 vs. 41.4, P = 0.048). However, when focusing on the preoperatively deformed cohort, we did not find any significant differences in the postoperative outcome scores between those with and without residual deformity. There was a significant association between cervical deformity and both preoperative disease severity and postoperative outcomes; however, no impact of deformity correction was shown. 2.