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A Clinical Prediction Rule to Determine Outcomes in Patients with Cervical Spondylotic Myelopathy Undergoing Surgical Treatment: Data from the Prospective, Multicenter AOSpine North America CSM Study
Proceedings of the NASS 28th Annual Meeting / The Spine Journal 13 (2013) 1S–168S
19S 6 1
Thursday, October 10, 2013 3:05 – 4:05 PM Concurrent Session: Myelopathy
Michael G. Fehlings, MD, PhD, FRCSC ; University Health Network, Toronto, ON, Canada; 2Mercer Island, WA, US; 3University of Kansas Medical Center, Department of Neurosurgery, Kansas City, KS, US; 4 Rothman Institute, Philadelphia, PA, US; 5University of Toronto, Toronto, ON, Canada; 6Toronto Western Hospital, Toronto, ON, Canada
35. Comparison of Outcomes Between Anterior and Posterior Cervical Procedures: Results from the AOSpine North America Cervical Spondylotic Myelopathy Study (CSM) Michael G. Fehlings, MD, PhD, FRCSC1, Nikhil A. Thakur, MD2, S. Tim Yoon, MD, PhD3, John M. Rhee, MD4, Alexander R. Vaccaro, MD, PhD5, Paul M. Arnold, MD6, Branko Kopjar, MD, PhD7, John G. Heller, MD3; 1Toronto Western Hospital, Toronto, ON, Canada; 2Rhode Island Hospital, Providence, RI, US; 3The Emory Spine Center, Atlanta, GA, US; 4 Emory University, Atlanta, GA, US; 5Rothman Institute, Philadelphia, PA, US; 6University of Kansas Medical Center, Department of Neurosurgery, Kansas City, KS, US; 7Mercer Island, WA, US
BACKGROUND CONTEXT: Cervical spondylotic myelopathy (CSM) is a degenerative spine disease and is the most common cause of spinal cord dysfunction worldwide. It is a progressive disease that can present with a wide range of symptoms from numb clumsy hands to impaired gait. Surgery is an effective and common treatment option for mild to severe CSM. PURPOSE: The objective of this study is to develop a clinical prediction rule relating a combination of clinical and imaging variables to surgical outcome in patients with cervical spondylotic myelopathy (CSM), based on data from a multicenter prospective study. STUDY DESIGN/SETTING: Prospective multicenter study. PATIENT SAMPLE: Two hundred and seventy-eight patients diagnosed with cervical myelopathy treated surgically were enrolled in the CSMNorth American multicenter study at 12 different sites. OUTCOME MEASURES: The dependent variable, modified Japanese Orthopaedic Association (mJOA) score at 1-year, was dichotomized for logistic regression: a "successful" outcome was defined as a final mJOA greater than or equal to sixteen and a "failed" outcome was a score less than sixteen. METHODS: Univariate analyses were performed to evaluate the relationship between outcome and various clinical and imaging predictors. A set of important variables for the final model was selected based on author consensus, literature support and statistical findings. Logistic regression was used to formulate the final model. RESULTS: Univariate analysis demonstrated that the odds of a successful outcome decreased with a longer duration of symptoms (OR: 0.80, 95% CI: 0.65-0.98, p50.030), a lower baseline mJOA score (OR: 0.74, 95% CI: 0.65-0.84, p!0.0001), the presence of psychological (OR: 0.51, 95% CI: 0.29-0.92, p50.024) or cardiovascular co-morbidities (OR: 0.62, 95% CI: 0.36-1.05, p50.076), smoking (OR: 0.53, 95% CI: 0.27-1.02, p50.057), the presence of broad-based, unstable gait (OR: 2.72, 95% CI: 1.47-5.07, p50.0018) or other gait impairment (OR: 3.55, 95% CI: 1.75-7.22, p50.0005), and older age (OR: 0.96, 95% CI: 0.93-0.98, p50.0004). The final model included age (OR: 0.96, 95% CI: 0.94-0.99, p50.0017), duration of symptoms (OR: 0.78, 95%CI:0.61-0.997, p50.048), smoking status (OR:0.46, 95%CI:0.21-0.98, p50.043), impairment of gait (OR:2.66, 95% CI: 1.17-6.06, p50.020), psychological comorbidities (OR:0.33, 95%CI:0.15-0.69, p50.0035) and baseline severity score (OR:1.22, 95%CI:1.05-1.41, p50.0084) and transverse area of the cord on MRI (OR: 1.02, 95%CI: 0.99-1.05, p50.19). The area under the receiver operator (ROC) curve was 0.79, indicating good model prediction. CONCLUSIONS: Based on this study, we have identified a list of the most important predictors of surgical outcome for CSM. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT: The relative merits of anterior versus posterior cervical surgery for the treatment of multilevel cervical stenosis causing myelopathy are uncertain. Previous studies were limited because one- or two-level anterior surgeries have been compared to multilevel posterior cases. PURPOSE: To compare patient outcomes and complications of anterior and posterior multilevel cervical procedures. STUDY DESIGN/SETTING: A multicenter prospective cohort study. PATIENT SAMPLE: Patients with confirmed CSM undergoing surgery on 4 or 5 vertebral levels. OUTCOME MEASURES: Modified Japanese Orthopaedic Association scores (mJOA), Neck Disability Index (NDI), SF36v2 and Nurick grades. METHODS: Outcomes data, including adverse events, were collected at baseline, 12 and 24 months. The degree of change in outcomes was compared between the groups. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days and more) were compared between the groups. RESULTS: 49 patients had anterior (ACS) and 64 patients posterior procedure (PCS: 45 laminectomy þ fusion, 19 laminoplasty). ACS patients were younger (53.8 and 62.3 years, respectively, P!.05) and had fewer cardiovascular comorbidities (43% and 64%, respectively, P!.05). ACS patients were more likely to have disc disease as a source of stenosis (80% and 50%, respectively, P!.05) and PCS hypertrophied ligamentum flavum (31% and 6%, respectively, P! .05). Preoperative mJOA, SF36v2 and NDI scores showed no differences. However, Nurick grade was higher in PCS group (3.3 and 2.8, respectively, P!.05). Outcome scores: mJOA, NDI, SF36v2 and Nurick scores improved at 12 and 24 months after surgery in both groups. There were no statistically significant differences between the groups in amount of improvement between the groups for any of the outcomes. This finding remained after adjustment for differences in baseline characteristics. CONCLUSIONS: Both anterior and posterior surgical decompression improve outcomes in patients with multilevel CSM. We found no evidence of difference in outcomes and complication rates in relation to type of surgical approach. Decision-making related to approach and technique should be based on surgeon judgment and experience with these procedures. The limitations of this study include a nonrandomized study design and the grouping together of different subtypes of anterior and posterior procedures. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2013.07.076
36. A Clinical Prediction Rule to Determine Outcomes in Patients with Cervical Spondylotic Myelopathy Undergoing Surgical Treatment: Data from the Prospective, Multicenter AOSpine North America CSM Study Lindsay Tetreault1, Branko Kopjar, MD, PhD2, Paul M. Arnold, MD3, Alexander R. Vaccaro, MD, PhD4, Eric M. Massicotte, MD, FRCSC5,
http://dx.doi.org/10.1016/j.spinee.2013.07.077
37. Lateral Mass Screw Fixation in the Cervical Spine: A Systematic Review Jeffrey D. Coe, MD1, Alexander R. Vaccaro, MD, PhD2, Andrew T. Dailey, MD3, Richard L. Skolasky, Jr., ScD4, Rick C. Sasso, MD5, Steven C. Ludwig, MD6, Erika D. Brodt, BS7, Joseph R. Dettori, MPH, PhD7; 1 Silicon Valley Spine Institute, Campbell, CA, US; 2Rothman Institute, Philadelphia, PA, US; 3University of Utah Hospital Department of Neurosurgery, Salt Lake City, UT, US; 4Johns Hopkins University, Baltimore, MD, US; 5Indiana Spine Group, Carmel, IN, US; 6Timonium, MD, US; 7Spectrum Research, Tacoma, WA, US BACKGROUND CONTEXT: The use of lateral mass screw fixation (LMSF) with plates or rods in the subaxial cervical spine has become
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosures and FDA device/drug status at time of abstract submission.
19S 6 1
Thursday, October 10, 2013 3:05 – 4:05 PM Concurrent Session: Myelopathy
Michael G. Fehlings, MD, PhD, FRCSC ; University Health Network, Toronto, ON, Canada; 2Mercer Island, WA, US; 3University of Kansas Medical Center, Department of Neurosurgery, Kansas City, KS, US; 4 Rothman Institute, Philadelphia, PA, US; 5University of Toronto, Toronto, ON, Canada; 6Toronto Western Hospital, Toronto, ON, Canada
35. Comparison of Outcomes Between Anterior and Posterior Cervical Procedures: Results from the AOSpine North America Cervical Spondylotic Myelopathy Study (CSM) Michael G. Fehlings, MD, PhD, FRCSC1, Nikhil A. Thakur, MD2, S. Tim Yoon, MD, PhD3, John M. Rhee, MD4, Alexander R. Vaccaro, MD, PhD5, Paul M. Arnold, MD6, Branko Kopjar, MD, PhD7, John G. Heller, MD3; 1Toronto Western Hospital, Toronto, ON, Canada; 2Rhode Island Hospital, Providence, RI, US; 3The Emory Spine Center, Atlanta, GA, US; 4 Emory University, Atlanta, GA, US; 5Rothman Institute, Philadelphia, PA, US; 6University of Kansas Medical Center, Department of Neurosurgery, Kansas City, KS, US; 7Mercer Island, WA, US
BACKGROUND CONTEXT: Cervical spondylotic myelopathy (CSM) is a degenerative spine disease and is the most common cause of spinal cord dysfunction worldwide. It is a progressive disease that can present with a wide range of symptoms from numb clumsy hands to impaired gait. Surgery is an effective and common treatment option for mild to severe CSM. PURPOSE: The objective of this study is to develop a clinical prediction rule relating a combination of clinical and imaging variables to surgical outcome in patients with cervical spondylotic myelopathy (CSM), based on data from a multicenter prospective study. STUDY DESIGN/SETTING: Prospective multicenter study. PATIENT SAMPLE: Two hundred and seventy-eight patients diagnosed with cervical myelopathy treated surgically were enrolled in the CSMNorth American multicenter study at 12 different sites. OUTCOME MEASURES: The dependent variable, modified Japanese Orthopaedic Association (mJOA) score at 1-year, was dichotomized for logistic regression: a "successful" outcome was defined as a final mJOA greater than or equal to sixteen and a "failed" outcome was a score less than sixteen. METHODS: Univariate analyses were performed to evaluate the relationship between outcome and various clinical and imaging predictors. A set of important variables for the final model was selected based on author consensus, literature support and statistical findings. Logistic regression was used to formulate the final model. RESULTS: Univariate analysis demonstrated that the odds of a successful outcome decreased with a longer duration of symptoms (OR: 0.80, 95% CI: 0.65-0.98, p50.030), a lower baseline mJOA score (OR: 0.74, 95% CI: 0.65-0.84, p!0.0001), the presence of psychological (OR: 0.51, 95% CI: 0.29-0.92, p50.024) or cardiovascular co-morbidities (OR: 0.62, 95% CI: 0.36-1.05, p50.076), smoking (OR: 0.53, 95% CI: 0.27-1.02, p50.057), the presence of broad-based, unstable gait (OR: 2.72, 95% CI: 1.47-5.07, p50.0018) or other gait impairment (OR: 3.55, 95% CI: 1.75-7.22, p50.0005), and older age (OR: 0.96, 95% CI: 0.93-0.98, p50.0004). The final model included age (OR: 0.96, 95% CI: 0.94-0.99, p50.0017), duration of symptoms (OR: 0.78, 95%CI:0.61-0.997, p50.048), smoking status (OR:0.46, 95%CI:0.21-0.98, p50.043), impairment of gait (OR:2.66, 95% CI: 1.17-6.06, p50.020), psychological comorbidities (OR:0.33, 95%CI:0.15-0.69, p50.0035) and baseline severity score (OR:1.22, 95%CI:1.05-1.41, p50.0084) and transverse area of the cord on MRI (OR: 1.02, 95%CI: 0.99-1.05, p50.19). The area under the receiver operator (ROC) curve was 0.79, indicating good model prediction. CONCLUSIONS: Based on this study, we have identified a list of the most important predictors of surgical outcome for CSM. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT: The relative merits of anterior versus posterior cervical surgery for the treatment of multilevel cervical stenosis causing myelopathy are uncertain. Previous studies were limited because one- or two-level anterior surgeries have been compared to multilevel posterior cases. PURPOSE: To compare patient outcomes and complications of anterior and posterior multilevel cervical procedures. STUDY DESIGN/SETTING: A multicenter prospective cohort study. PATIENT SAMPLE: Patients with confirmed CSM undergoing surgery on 4 or 5 vertebral levels. OUTCOME MEASURES: Modified Japanese Orthopaedic Association scores (mJOA), Neck Disability Index (NDI), SF36v2 and Nurick grades. METHODS: Outcomes data, including adverse events, were collected at baseline, 12 and 24 months. The degree of change in outcomes was compared between the groups. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days and more) were compared between the groups. RESULTS: 49 patients had anterior (ACS) and 64 patients posterior procedure (PCS: 45 laminectomy þ fusion, 19 laminoplasty). ACS patients were younger (53.8 and 62.3 years, respectively, P!.05) and had fewer cardiovascular comorbidities (43% and 64%, respectively, P!.05). ACS patients were more likely to have disc disease as a source of stenosis (80% and 50%, respectively, P!.05) and PCS hypertrophied ligamentum flavum (31% and 6%, respectively, P! .05). Preoperative mJOA, SF36v2 and NDI scores showed no differences. However, Nurick grade was higher in PCS group (3.3 and 2.8, respectively, P!.05). Outcome scores: mJOA, NDI, SF36v2 and Nurick scores improved at 12 and 24 months after surgery in both groups. There were no statistically significant differences between the groups in amount of improvement between the groups for any of the outcomes. This finding remained after adjustment for differences in baseline characteristics. CONCLUSIONS: Both anterior and posterior surgical decompression improve outcomes in patients with multilevel CSM. We found no evidence of difference in outcomes and complication rates in relation to type of surgical approach. Decision-making related to approach and technique should be based on surgeon judgment and experience with these procedures. The limitations of this study include a nonrandomized study design and the grouping together of different subtypes of anterior and posterior procedures. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. http://dx.doi.org/10.1016/j.spinee.2013.07.076
36. A Clinical Prediction Rule to Determine Outcomes in Patients with Cervical Spondylotic Myelopathy Undergoing Surgical Treatment: Data from the Prospective, Multicenter AOSpine North America CSM Study Lindsay Tetreault1, Branko Kopjar, MD, PhD2, Paul M. Arnold, MD3, Alexander R. Vaccaro, MD, PhD4, Eric M. Massicotte, MD, FRCSC5,
http://dx.doi.org/10.1016/j.spinee.2013.07.077
37. Lateral Mass Screw Fixation in the Cervical Spine: A Systematic Review Jeffrey D. Coe, MD1, Alexander R. Vaccaro, MD, PhD2, Andrew T. Dailey, MD3, Richard L. Skolasky, Jr., ScD4, Rick C. Sasso, MD5, Steven C. Ludwig, MD6, Erika D. Brodt, BS7, Joseph R. Dettori, MPH, PhD7; 1 Silicon Valley Spine Institute, Campbell, CA, US; 2Rothman Institute, Philadelphia, PA, US; 3University of Utah Hospital Department of Neurosurgery, Salt Lake City, UT, US; 4Johns Hopkins University, Baltimore, MD, US; 5Indiana Spine Group, Carmel, IN, US; 6Timonium, MD, US; 7Spectrum Research, Tacoma, WA, US BACKGROUND CONTEXT: The use of lateral mass screw fixation (LMSF) with plates or rods in the subaxial cervical spine has become
Refer to onsite Annual Meeting presentations and postmeeting proceedings for possible referenced figures and tables. Authors are responsible for accurately reporting disclosures and FDA device/drug status at time of abstract submission.