Toci Gregory R, Lambrechts Mark J, Karamian Brian A, Canseco Jose A, Hilibrand Alan S, Kepler Christopher K, Vaccaro Alexander R, Schroeder Gregory D
Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA.
Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA.
Spine J. 2023 Feb;23(2):238-246. doi: 10.1016/j.spinee.2022.10.005. Epub 2022 Oct 17.
BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is commonly performed in patients with radiculopathy and myelopathy. Although the goal of surgery in patients with radiculopathy is to improve function and reduce pain, patients with myelopathy undergo surgery to halt disease progression. Although the expectations between these preoperative diagnoses are generally understood to be disparate by spine surgeons, there is limited literature demonstrating their discordant outcomes. PURPOSE: To compare improvements in patient reported outcome measures (PROMs) for patients undergoing ACDF for myelopathy or radiculopathy. Secondarily, we analyzed the proportion of patients who attain the minimum clinically important difference (MCID) postoperatively using thresholds derived from radiculopathy, myelopathy, and mixed cohort studies. STUDY DESIGN/SETTING: Single institution retrospective cohort study PATIENT SAMPLE: Patients undergoing primary, elective ACDF with a preoperative diagnosis of radiculopathy or myelopathy and a complete set of preoperative and one-year postoperative PROMs. OUTCOME MEASURES: Outcome measures included the following PROMs: Short-Form 12 Physical Component (PCS-12) and Mental Component (MCS-12) scores, the Visual Analog Scale (VAS) Arm score, and the Neck Disability Index (NDI). Hospital readmissions and revision surgery were also collected and evaluated. METHODS: Patients undergoing an ACDF from 2014 to 2020 were identified and grouped based on preoperative diagnosis (radiculopathy or myelopathy). We utilized "general MCID" thresholds from a cohort of patients with degenerative spine conditions, and "specific MCID" thresholds generated from cohorts of patients with myelopathy or radiculopathy, respectively. Multivariate linear regressions were performed for delta (∆) PROMs and multivariate logistic regressions were performed for both general and specific MCID improvements. RESULTS: A total of 798 patients met inclusion criteria. Patients with myelopathy had better baseline function and arm pain (MCS-12: 49.6 vs 47.6, p=.018; VAS Arm: 3.94 vs 6.02, p<.001; and NDI: 34.1 vs 41.9, p<.001), were older (p<.001), had more comorbidities (p=.014), more levels fused (p<.001), and had decreased improvement in PROMs following surgery compared to patients with radiculopathy (∆PCS-12: 4.76 vs 7.21, p=.006; ∆VAS Arm: -1.69 vs -3.70, p<.001; and ∆NDI: -11.94 vs -18.61, p<.001). On multivariate analysis, radiculopathy was an independent predictor of increased improvement in PCS-12 (β=2.10, p=.019), ∆NDI (β=-5.36, p<.001), and ∆VAS Arm (β=-1.93, p<.001). Radiculopathy patients were more likely to achieve general MCID improvements following surgery (NDI: Odds ratio (OR): 1.42, p=.035 and VAS Arm: OR: 2.98, p<.001), but there was no difference between patients with radiculopathy or myelopathy when using radiculopathy and myelopathy specific MCID thresholds (MCS-12: p=.113, PCS-12: p=.675, NDI: p=.108, and VAS Arm: p=.314). CONCLUSIONS: Patients undergoing ACDF with myelopathy or radiculopathy represent two distinct patient populations with differing treatment indications and clinical outcomes. Compared to radiculopathy, patients with myelopathy have better baseline function, decreased improvement in PROMs, and are less likely to reach MCID using general threshold values, but there is no difference in the proportion reaching MCID when using specific threshold values. LEVEL OF EVIDENCE: IRB.
背景：颈椎前路椎间盘切除融合术（ACDF）常用于神经根型颈椎病和脊髓型颈椎病患者。虽然神经根型颈椎病患者手术的目标是改善功能和减轻疼痛，但脊髓型颈椎病患者手术是为了阻止疾病进展。尽管脊柱外科医生普遍认为这两种术前诊断的预期不同，但证明其结果不一致的文献有限。 目的：比较接受ACDF治疗的脊髓型颈椎病或神经根型颈椎病患者报告的结局指标（PROMs）的改善情况。其次，我们分析了术后达到最小临床重要差异（MCID）的患者比例，该阈值来自神经根型颈椎病、脊髓型颈椎病和混合队列研究。 研究设计/设置：单机构回顾性队列研究 患者样本：接受初次择期ACDF且术前诊断为神经根型颈椎病或脊髓型颈椎病，并拥有完整术前和术后一年PROMs的患者。 结局指标：结局指标包括以下PROMs：简明健康调查12项身体成分（PCS - 12）和精神成分（MCS - 12）评分、视觉模拟量表（VAS）手臂评分以及颈部功能障碍指数（NDI）。还收集并评估了医院再入院情况和翻修手术。 方法：确定2014年至2020年接受ACDF的患者，并根据术前诊断（神经根型颈椎病或脊髓型颈椎病）进行分组。我们使用了来自退行性脊柱疾病患者队列的“一般MCID”阈值，以及分别来自脊髓型颈椎病或神经根型颈椎病患者队列的“特定MCID”阈值。对PROMs的变化量（∆）进行多变量线性回归，并对一般和特定MCID的改善情况进行多变量逻辑回归。 结果：共有798例患者符合纳入标准。脊髓型颈椎病患者具有更好的基线功能和手臂疼痛情况（MCS - 12：49.6对47.6，p = 0.018；VAS手臂：3.94对6.02，p < 0.001；NDI：34.1对41.9，p < 0.001），年龄更大（p < 0.001），合并症更多（p = 0.014），融合节段更多（p < 0.001），与神经根型颈椎病患者相比，术后PROMs改善程度降低（∆PCS - 12：4.76对7.21，p = 0.006；∆VAS手臂： - 1.69对 - 3.70，p < 0.001；∆NDI： - 11.94对 - 18.61，p < 0.001）。多变量分析显示，神经根型颈椎病是PCS - 12改善增加（β = 2.10，p = 0.019）、∆NDI（β = - 5.36，p < 0.001）和∆VAS手臂（β = - 1.93，p < 0.001）的独立预测因素。神经根型颈椎病患者术后更有可能实现一般MCID改善（NDI：优势比（OR）：1.42，p = 0.035；VAS手臂：OR：2.98，p < 0.001），但使用神经根型颈椎病和脊髓型颈椎病特定MCID阈值时，神经根型颈椎病或脊髓型颈椎病患者之间没有差异（MCS - 12：p = 0.113，PCS - 12：p = 0.675，NDI：p = 0.108，VAS手臂：p = 0.314）。 结论：接受ACDF治疗的脊髓型颈椎病或神经根型颈椎病患者代表两个不同的患者群体，具有不同的治疗指征和临床结局。与神经根型颈椎病相比，脊髓型颈椎病患者具有更好的基线功能，PROMs改善程度降低，使用一般阈值时达到MCID的可能性较小，但使用特定阈值时达到MCID的比例没有差异。 证据水平：机构审查委员会（IRB）
Int J Spine Surg. 2024-11-4
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