Cervical spondylotic myelopathy surgery outcome
Indications and optimal timing for surgical treatment of degenerative cervical myelopathy (DCM) remain unclear, and data from daily clinical practice are warranted.
Gulati et al. investigated clinical outcomes following decompressive surgery for DCM.
Data were obtained from the Norwegian Registry for Spine Surgery. The primary outcome was change in the neck disability index (NDI) 1 yr after surgery. Secondary endpoints were the European myelopathy score (EMS), quality of life (EuroQoL 5D [EQ-5D]), numeric rating scales (NRS) for headache, neck pain, and arm pain, complications, and perceived benefit of surgery assessed by the Global Perceived Effect scale.
They included 905 patients operated between January 2012 and June 2018. There were significant improvements in all Patient-reported outcome measures (PROMs) including NDI (mean -10.0, 95% CI -11.5 to -8.4, P < .001), EMS (mean 1.0, 95% CI 0.8-1.1, P < .001), EQ-5D index score (mean 0.16, 95% CI 0.13-0.19, P < .001), EQ-5D visual analogue scale (mean 13.8, 95% CI 11.7-15.9, P < .001), headache NRS (mean -1.1, 95% CI -1.4 to -0.8, P < .001), neck pain NRS (mean -1.8, 95% CI -2.0 to -1.5, P < .001), and arm pain NRS (mean -1.7, 95% CI -1.9 to -1.4, P < .001). According to GPE scale assessments, 229/513 patients (44.6%) experienced “complete recovery” or felt “much better” at 1 yr. There were significant improvements in all PROMs for both mild and moderate-to-severe DCM. A total of 251 patients (27.7%) experienced adverse effects within 3 mo.
Surgery for DCM is associated with significant and clinically meaningful improvement across a wide range of PROMs 1).
Objective scoring of the post-operative neurological function did not correlate with patient-perceived outcomes in Degenerative cervical myelopathy outcome (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 Degenerative cervical myelopathy patients 2).
Hamdan assessed the relation between MRI T2 Weighted images (T2WI) hyperintense cord signal and clinical outcome after anterior cervical discectomy in patients with degenerative cervical disc herniation.
This retrospective observational study was conducted on twenty-five patients with degenerative cervical disc prolapse associated with MRI T2WI hyperintense cord signal, at the Department of Neurosurgery, Qena University Hospital, South Valley University from August 2014 to December 2016. A complete clinical and radiological evaluation of the patients was done. Anterior cervical discectomy and fusion was done for all patients. Patients were clinically assessed preoperatively and postoperatively at 3, 6, and 12 months using Modified Japanese Orthopaedic Association scale (MJOA). Radiographic assessment was done by preoperative and postoperative T2WI MRI. The statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software (version 22.0).
There were 25 patients included in the study; 16 (64%) females and 9 (36%) males. The mean age was 46.89 ± 7.52 standard deviation (SD) years with range from 26 to 64 years, 3 (12%) patients had worsened in the form of postoperative motor power deterioration, and 14 (56%) patients has no improvement and remain as preoperative condition. The remaining 8 (32%) patients had a reported postoperative improvement of symptoms and signs according to MJOA score. The mean follow-up period (in months) was 11 ± 2.34 (SD). Conclusion:
The presence of T2W hyperintense signal on preoperative MRI predicts a poor surgical outcome in patients with cervical disc prolapse. The regression of T2W ISI postoperatively correlates with better functional outcomes 3).
Whilst decompressive surgery can halt disease progression, existing spinal cord damage is often permanent, leaving patients with lifelong disability.
Early surgery improves the likelihood of recovery, yet the average time from onset of symptoms to correct diagnosis is over 2 years. The majority of delays occur initially, before and within primary care, mainly due to a lack of recognition. Symptom checkers are widely used by patients before medical consultation and can be useful for preliminary triage and diagnosis. Lack of recognition of Degenerative Cervical Myelopathy (DCM) by symptom checkers may contribute to the delay in diagnosis.
The impact of the changes in myelopathic signs following cervical decompression surgery and their relationship to functional outcome measures remains unclear.
Surgery 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 4).
Surgical decompression for CSM is safe and results in improved functional status and quality of life in patients around the world, irrespective of differences in medical systems and socio-cultural determinants of health 5).
The successful management of CSM depends upon an early and accurate diagnosis, an objective assessment of impairment and disability, and an ability to predict outcome. In this field, quantitative measures are increasingly used by clinicians to grade functional and neurological status and to provide decision-making support 6).
In addition, objective assessment tools allow clinicians to quantify myelopathy severity, predict outcome, and evaluate surgical benefits by tracking improvements throughout follow-up 7) 8) 9).
Several outcome measures assess functional impairment and quality of life in patients with cervical myelopathy 10) 11) 12) 13) 14).
A validated “gold standard,” however, has not been established, preventing the development of quantitative guidelines for CSM management 15).
In this field, one of the most widely accepted tool for assessing functional status is the modified Japanese Orthopaedic Association scale (mJOA).
Some studies have found that resolution of T2 hyperintensity in subjects with CSM who undergo ventral decompressive surgery correlates with improved functional outcomes. Other studies have found little correlation with postoperative outcome 16) 17).
Machine learning for degenerative cervical myelopathy
see Machine learning for degenerative cervical myelopathy.
References
1) Gulati S, Vangen-Lønne V, Nygaard ØP, Gulati AM, Hammer TA, Johansen TO, Peul WC, Salvesen ØO, Solberg TK. Surgery for Degenerative Cervical Myelopathy: A Nationwide Registry-Based Observational Study With Patient-Reported Outcomes. Neurosurgery. 2021 Jul 29:nyab259. doi: 10.1093/neuros/nyab259. Epub ahead of print. PMID: 34325471.2) McGregor SM, Detombe S, Goncalves S, Doyle-Pettypiece P, Bartha R, Duggal N. Does the Neurological Exam Correlate with Patient Perceived Outcomes in Degenerative Cervical Myelopathy? World Neurosurg. 2019 Aug 2. pii: S1878-8750(19)32111-4. doi: 10.1016/j.wneu.2019.07.195. [Epub ahead of print] PubMed PMID: 31382071.3) Hamdan ARK. The Relation between Cord Signal and Clinical Outcome after Anterior Cervical Discectomy in Patients with Degenerative Cervical Disc Herniation. Asian J Neurosurg. 2019 Jan-Mar;14(1):106-110. doi: 10.4103/ajns.AJNS_262_17. PubMed PMID: 30937019; PubMed Central PMCID: PMC6417293.4) Witiw CD, Tetreault LA, Smieliauskas F, Kopjar B, Massicotte EM, Fehlings MG. Surgery for degenerative cervical myelopathy: a patient centered quality of life and health economic evaluation. Spine J. 2016 Oct 25. pii: S1529-9430(16)31022-1. doi: 10.1016/j.spinee.2016.10.015. [Epub ahead of print] PubMed PMID: 27793760.5) Fehlings MG, Ibrahim A, Tetreault L, Albanese V, Alvarado M, Arnold P, Barbagallo G, Bartels R, Bolger C, Defino H, Kale S, Massicotte E, Moraes O, Scerrati M, Tan G, Tanaka M, Toyone T, Yukawa Y, Zhou Q, Zileli M, Kopjar B. A Global Perspective on the Outcomes of Surgical Decompression in Patients with Cervical Spondylotic Myelopathy: Results from the Prospective Multicenter AOSpine International Study on 479 patients. Spine (Phila Pa 1976). 2015 May 27. [Epub ahead of print] PubMed PMID: 26020847.6) , 15) Singh A, Tetreault L, Casey A, et al. A summary of assessment tools for patients suffering from cervical spondylotic myelopathy: a systematic review on validity, reliability, and responsiveness [published online ahead of print September 5, 2013]. Eur Spine J. doi:10.1007/s00586-013-2935-x.7) Laing RJ. Measuring outcome in neurosurgery. Br J Neurosurg 2000;14:181–4.8) Holly LT, Matz PG, Anderson PA, et al. Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy. J Neurosurg Spine 2009;11:112–8.9) Kalsi-Ryan S, Singh A, Massicotte EM, et al. Ancillary outcome measures for assessment of individuals with cervical spondylotic myelopathy. Spine (Phila Pa 1976) 2013;38:S111–22.10) Singh A, Crockard HA. Quantitative assessment of cervical spondylotic myelopathy by a simple walking test. Lancet 1999;354:370–3.11) Nurick S. The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain 1972;95:101–8.12) Olindo S, Signate A, Richech A, et al. Quantitative assessment of hand disability by the nine-hole-peg test (9-HPT) in cervical spondylotic myelopathy. J Neurol Neurosurg Psychiatry 2008;79:965–7.13) Hosono N, Sakaura H, Mukai Y, et al. A simple performance test for quantifying the severity of cervical myelopathy [erratum in: J Bone Joint Surg Br 2008;90:1534]. J Bone Joint Surg Br 2008;90:1210–3.14) Casey AT, Bland JM, Crockard HA. Development of a functional scoring system for rheumatoid arthritis patients with cervical myelopathy. Ann Rheum Dis 1996;55:901–6.16) Sarkar S, Turel MK, Jacob KS, Chacko AG. The evolution of T2-weighted intramedullary signal changes following ventral decompressive surgery for cervical spondylotic myelopathy. J Neurosurg Spine. 2014;21(4):538-546.17) Vedantam A, Rajshekhar V. Change in morphology of intramedullary T2- weighted increased signal intensity after anterior decompressive surgery for cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2014;39(18):1458-1462.