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11. Predicting disability and pain outcomes one year after elective surgery for degenerative cervical diseases: analysis from quality outcomes database
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Proceedings of the 34th Annual Meeting of the North American Spine Society / The Spine Journal 19 (2019) S1−S58
11. Predicting disability and pain outcomes one year after elective surgery for degenerative cervical diseases: analysis from quality outcomes database Inamullah Khan, MD1, Clinton J. Devin, MD1, Hui Nian, PhD2, Frank E. Harrell Jr., PhD1, Jacquelyn S. Pennings, PhD1, Mohamad Bydon, MD3, Ahilan Sivaganesan, MD1, Kristin R. Archer, PhD, DPT1; 1 Vanderbilt University Medical Center, Nashville, TN, US; 2 Nashville, TN, US; 3 Mayo Clinic, Rochester, MN, US BACKGROUND CONTEXT: In the current era of value-based health care reform, engaging patients in shared decision-making for treatment planning is imperative. Predictive models capable of providing individualized predictions of patient-reported outcomes (PROs) following cervical spine surgery have the potential to be valuable tools for a shared decisionmaking process. PURPOSE: The aim of the study is to develop and validate predictive models for 12-month postoperative disability, pain, and myelopathy outcomes in patients undergoing elective spine surgery for degenerative cervical diseases (radiculopathy and 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: Patients undergoing cervical spine surgery for the diagnosis of radiculopathy or myelopathy with degenerative etiologies are eligible for inclusion in the QOD registry. OUTCOME MEASURES: The outcomes of interest in this study were neck related disability (NDI), pain [NRS- neck pain (NP) and arm pain (AP)] and modified Japanese Orthopedic Association score for myelopathy (mJOA). METHODS: Two distinct sets of multivariable proportional odds ordinal regression models were developed with the outcomes of interest of disability (NDI), pain (NRS-NP and NRS-AP) and myelopathy (mJOA) score in the myelopathy cohort and disability (NDI) and pain (NRS-NP and NRSAP) in the radiculopathy cohort. Patient characteristics of age, gender, BMI, race, education level, smoking status, history of diabetes, anxiety and depression, symptom duration, motor deficit or numbness at presentation, preoperative imaging finding of listhesis, employment status, workers’ compensation, insurance status, and ambulatory ability, baseline PROs as well as surgery-specific variables of number of levels, arthrodesis, and surgical approach were included in the models. The models were internally validated using bootstrap resampling. RESULTS: A total of 5,076 patients who underwent surgery for cervical radiculopathy and 2717 patients who underwent surgery for cervical myelopathy were included in fitting the models for the distinct set of outcomes. There was a significant improvement in all PROs at 12 months after surgery (P<0.001). The most important predictors of the outcomes in both the models set were the respective baseline PROs scores. In addition, symptom duration, preoperative ambulatory status, patients’ employment status, patients’ education status, race and age of the patients had a statistically significant impact on the outcomes (p <0.001). Among the surgery-specific variables, surgical approach was the most important predictor for all outcomes across the models for radiculopathy and myelopathy (p<0.001). The models’ discriminative performance (measured by overfitting-corrected c-index) were: NDI=0.688, NRS-NP=0.668, NRS-AP=0.645 for the radiculopathy and NDI=0.696, NRS-NP=0.682, NRS-AP=0.670, mJOA=0.717 for the myelopathy patients. CONCLUSIONS: These predictive models can provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical diseases. Novel predictive models constructed with these data hold the potential to guide individualized patient discussions on postsurgical outcomes and expectations. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.024
12. Angiotensin-II type-1 receptor blockade decreased T2 signal intensity in spinal cord compression in symptomatic cervical spondylotic myelopathy Alexander Perdomo-Pantoja, MD1, Alejandro Chara, BS2, Joshua Casaos, BS2, Samuel Kalb, MD1, Corinna Zygourakis, MD3, Zach Pennington, BS2, Ethan Cottrill, MS2, Amir Manbachi, PhD4, Timothy F. Witham, MD, FACS1, Nicholas Theodore, MD2; 1 Johns Hopkins University School of Medicine, Baltimore, MD, US; 2 Baltimore, MD, US; 3 Stanford Department of Neurosurgery, Stanford, CA, US; 4 Johns Hopkins University Department of Biomedical Engineering, Baltimore, MD, US BACKGROUND CONTEXT: Cervical spondylosis may lead to spinal cord compression, poor vascular perfusion, and ultimately cervical myelopathy. The process whereby chronic compression may cause spinal cord damage has not been fully understood. However, multiple mechanisms such as inflammation, apoptosis, and vascular variations, are thought to be responsible for the neuronal loss, axonal degeneration, and myelin impairment seen in cervical spondylotic myelopathy (CSM). Studies reported a beneficial effect of renin-angiotensin system (RAS) blockers in the central nervous system, particularly in brain inflammation and stroke, but data on their influence on the spinal cord are limited. PURPOSE: We aimed to determine if RAS blockers are correlated with preoperative functional status and radiological markers of spinal cord damage secondary to compression in patients with CSM. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Symptomatic cervical spondylosis patients. OUTCOME MEASURES: Functional status (including modified Japanese Orthopedic Association [mJOA] and Nurick grading scales) and imaging characteristics (including % maximum canal compromise [MCC], % maximum spinal cord compromise [MSCC], increased signal intensity [ISI], signal intensity ration [SIR] and ISI surface area), all of which were evaluated on midsagittal T2-weighted MRIs. METHODS: Adults with symptomatic degenerative cervical stenosis patients were included. Demographic data, comorbidities, antihypertensive medications (particularly RAS blockers), and functional status were collected. We assessed % canal compromise, % cord compromise, surface area of T2 signal cord change, and pixel intensity of signal cord change compared to normal cord on T2-weighted MRI sequences. RESULTS: Of the 267 patients, 41.6% were female and 58.1% male; median age of 57.2 years; 20.6% smokers; 24.7% diabetics. One hundred forty-nine patients (55.8%) had hypertension, of which 142 (95.3%) were taking antihypertensive medications: 37 angiotensin-II receptor blockers [ARBs], 44 angiotensin-converting enzyme inhibitors [ACEIs], and 61 other medications). Patients treated with ARBs displayed a higher signal intensity ratio (lower signal intensity change in the compressed cord area) compared to those untreated non-hypertensive patients (p=.004). Hypertensive patients had worse preoperative mJOA and Nurick scores compared to non-hypertensive patients (p<.001). In the multivariate analysis, ARBs remained an independent beneficial factor for lower signal intensity change (p=.04), while hypertension remained a risk factor for worse preoperative neurological status (p<.01), after adjusting for covariables that were significant in the univariate analyses or were considered relevant. CONCLUSIONS: In cervical spinal cord compression patients, hypertensive subjects treated with RAS inhibitors were associated with less signal intensity change (higher SIR) than untreated non-hypertensive patients. Also, hypertensive subjects under any antihypertensive medication displayed worse mJOA and Nurick scores compared to untreated non-hypertensive individuals. Further studies are warranted to verify the effect of RAS inhibitors in spinal cord damage. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.025
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.
Proceedings of the 34th Annual Meeting of the North American Spine Society / The Spine Journal 19 (2019) S1−S58
11. Predicting disability and pain outcomes one year after elective surgery for degenerative cervical diseases: analysis from quality outcomes database Inamullah Khan, MD1, Clinton J. Devin, MD1, Hui Nian, PhD2, Frank E. Harrell Jr., PhD1, Jacquelyn S. Pennings, PhD1, Mohamad Bydon, MD3, Ahilan Sivaganesan, MD1, Kristin R. Archer, PhD, DPT1; 1 Vanderbilt University Medical Center, Nashville, TN, US; 2 Nashville, TN, US; 3 Mayo Clinic, Rochester, MN, US BACKGROUND CONTEXT: In the current era of value-based health care reform, engaging patients in shared decision-making for treatment planning is imperative. Predictive models capable of providing individualized predictions of patient-reported outcomes (PROs) following cervical spine surgery have the potential to be valuable tools for a shared decisionmaking process. PURPOSE: The aim of the study is to develop and validate predictive models for 12-month postoperative disability, pain, and myelopathy outcomes in patients undergoing elective spine surgery for degenerative cervical diseases (radiculopathy and 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: Patients undergoing cervical spine surgery for the diagnosis of radiculopathy or myelopathy with degenerative etiologies are eligible for inclusion in the QOD registry. OUTCOME MEASURES: The outcomes of interest in this study were neck related disability (NDI), pain [NRS- neck pain (NP) and arm pain (AP)] and modified Japanese Orthopedic Association score for myelopathy (mJOA). METHODS: Two distinct sets of multivariable proportional odds ordinal regression models were developed with the outcomes of interest of disability (NDI), pain (NRS-NP and NRS-AP) and myelopathy (mJOA) score in the myelopathy cohort and disability (NDI) and pain (NRS-NP and NRSAP) in the radiculopathy cohort. Patient characteristics of age, gender, BMI, race, education level, smoking status, history of diabetes, anxiety and depression, symptom duration, motor deficit or numbness at presentation, preoperative imaging finding of listhesis, employment status, workers’ compensation, insurance status, and ambulatory ability, baseline PROs as well as surgery-specific variables of number of levels, arthrodesis, and surgical approach were included in the models. The models were internally validated using bootstrap resampling. RESULTS: A total of 5,076 patients who underwent surgery for cervical radiculopathy and 2717 patients who underwent surgery for cervical myelopathy were included in fitting the models for the distinct set of outcomes. There was a significant improvement in all PROs at 12 months after surgery (P<0.001). The most important predictors of the outcomes in both the models set were the respective baseline PROs scores. In addition, symptom duration, preoperative ambulatory status, patients’ employment status, patients’ education status, race and age of the patients had a statistically significant impact on the outcomes (p <0.001). Among the surgery-specific variables, surgical approach was the most important predictor for all outcomes across the models for radiculopathy and myelopathy (p<0.001). The models’ discriminative performance (measured by overfitting-corrected c-index) were: NDI=0.688, NRS-NP=0.668, NRS-AP=0.645 for the radiculopathy and NDI=0.696, NRS-NP=0.682, NRS-AP=0.670, mJOA=0.717 for the myelopathy patients. CONCLUSIONS: These predictive models can provide individualized risk-adjusted estimates of 12-month disability, pain, and myelopathy outcomes for patients undergoing spine surgery for degenerative cervical diseases. Novel predictive models constructed with these data hold the potential to guide individualized patient discussions on postsurgical outcomes and expectations. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.024
12. Angiotensin-II type-1 receptor blockade decreased T2 signal intensity in spinal cord compression in symptomatic cervical spondylotic myelopathy Alexander Perdomo-Pantoja, MD1, Alejandro Chara, BS2, Joshua Casaos, BS2, Samuel Kalb, MD1, Corinna Zygourakis, MD3, Zach Pennington, BS2, Ethan Cottrill, MS2, Amir Manbachi, PhD4, Timothy F. Witham, MD, FACS1, Nicholas Theodore, MD2; 1 Johns Hopkins University School of Medicine, Baltimore, MD, US; 2 Baltimore, MD, US; 3 Stanford Department of Neurosurgery, Stanford, CA, US; 4 Johns Hopkins University Department of Biomedical Engineering, Baltimore, MD, US BACKGROUND CONTEXT: Cervical spondylosis may lead to spinal cord compression, poor vascular perfusion, and ultimately cervical myelopathy. The process whereby chronic compression may cause spinal cord damage has not been fully understood. However, multiple mechanisms such as inflammation, apoptosis, and vascular variations, are thought to be responsible for the neuronal loss, axonal degeneration, and myelin impairment seen in cervical spondylotic myelopathy (CSM). Studies reported a beneficial effect of renin-angiotensin system (RAS) blockers in the central nervous system, particularly in brain inflammation and stroke, but data on their influence on the spinal cord are limited. PURPOSE: We aimed to determine if RAS blockers are correlated with preoperative functional status and radiological markers of spinal cord damage secondary to compression in patients with CSM. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Symptomatic cervical spondylosis patients. OUTCOME MEASURES: Functional status (including modified Japanese Orthopedic Association [mJOA] and Nurick grading scales) and imaging characteristics (including % maximum canal compromise [MCC], % maximum spinal cord compromise [MSCC], increased signal intensity [ISI], signal intensity ration [SIR] and ISI surface area), all of which were evaluated on midsagittal T2-weighted MRIs. METHODS: Adults with symptomatic degenerative cervical stenosis patients were included. Demographic data, comorbidities, antihypertensive medications (particularly RAS blockers), and functional status were collected. We assessed % canal compromise, % cord compromise, surface area of T2 signal cord change, and pixel intensity of signal cord change compared to normal cord on T2-weighted MRI sequences. RESULTS: Of the 267 patients, 41.6% were female and 58.1% male; median age of 57.2 years; 20.6% smokers; 24.7% diabetics. One hundred forty-nine patients (55.8%) had hypertension, of which 142 (95.3%) were taking antihypertensive medications: 37 angiotensin-II receptor blockers [ARBs], 44 angiotensin-converting enzyme inhibitors [ACEIs], and 61 other medications). Patients treated with ARBs displayed a higher signal intensity ratio (lower signal intensity change in the compressed cord area) compared to those untreated non-hypertensive patients (p=.004). Hypertensive patients had worse preoperative mJOA and Nurick scores compared to non-hypertensive patients (p<.001). In the multivariate analysis, ARBs remained an independent beneficial factor for lower signal intensity change (p=.04), while hypertension remained a risk factor for worse preoperative neurological status (p<.01), after adjusting for covariables that were significant in the univariate analyses or were considered relevant. CONCLUSIONS: In cervical spinal cord compression patients, hypertensive subjects treated with RAS inhibitors were associated with less signal intensity change (higher SIR) than untreated non-hypertensive patients. Also, hypertensive subjects under any antihypertensive medication displayed worse mJOA and Nurick scores compared to untreated non-hypertensive individuals. Further studies are warranted to verify the effect of RAS inhibitors in spinal cord damage. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. https://doi.org/10.1016/j.spinee.2019.05.025
Refer to onsite annual meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosure and FDA device/drug status at time of abstract submission.