Is surgery beneficial for patients with concurrent multiple sclerosis and degenerative cervical myelopathy? A review of literature

Concomitant multiple sclerosis and cervical myelopathy: A propensity-matched QOD analysis of patient-reported outcomes and return to work after cervical spine surgery

OBJECTIVE

The diagnosis of degenerative cervical myelopathy (CM) in multiple sclerosis (MS) patients is challenging due to overlapping symptomatology and radiological findings. Minimal literature reports patient reported outcomes measures (PROMs) for MS patients undergoing surgery for CM. Given the diagnostic difficulty, we aimed to determine if patients with MS have worse outcomes after elective cervical spine surgery.

METHODS

126 patients who underwent surgery for CM were retrospectively obtained from the Quality Outcomes Database (QOD). 63 MS patients were age and gender matched to 63 without MS. Postoperative PROMs including Visual Analogue Scale for neck/arm pain (VAS), Neck Disability Index (NDI), and satisfaction were compared at 3 and 12 months. Postoperative complications and return to work were studied as secondary outcomes.

RESULTS

The average age of both cohorts was 57.9 years, and 63.5 % were female. Baseline functional status and symptomatology were similar, although fewer MS patients could independently ambulate (p = .014). The operative time and length of stay were similar. MS patients had a greater average ASA grade (p = 0.018), however there were no significant differences in VAS, NDI, or satisfaction. MS patients had a higher 3-month readmission rate (p = .044), however returned to work at a similar rate greater than 70 %.

CONCLUSION

PROMs do not significantly differ for CM patients with concomitant MS. Patients with MS had a higher 3-month complication rate, although readmissions were largely unrelated to the procedure. Thus, despite the diagnostic challenge of CM in MS patients, the surgical outcomes are comparable to those without MS.

Evaluating the impact of multiple sclerosis on 2 year postoperative outcomes following long fusion for adult spinal deformity: a propensity score-matched analysis

STUDY DESIGN

Retrospective cohort study.

PURPOSE

The impact of neuromuscular disorders such as multiple sclerosis (MS) on outcomes following long segment fusion is underreported. This study evaluates the impact of MS on two-year (2Y) postoperative complications and revisions following ≥ 4-level fusion for adult spinal deformity (ASD).

METHODS

Patients undergoing ≥ 4-level fusion for ASD were identified from a statewide database. Patients with a baseline diagnosis of MS were also identified. Patients with infectious/traumatic/neoplastic indications were excluded. Subjects were 1:1 propensity score-matched (MS to no-MS) based on age, sex and race and compared for rates of 2Y postoperative complications and reoperations. Logistic regression models were utilized to determine risk factors for adverse outcomes at 2Y.

RESULTS

86 patients were included overall (n = 43 per group). Age, sex, and race were comparable between groups (p > 0.05). MS patients incurred higher charges for their surgical visit ($125,906 vs. $84,006, p = 0.007) with similar LOS (8.1 vs. 5.3 days, p > 0.05). MS patients experienced comparable rates of overall medical complications (30.1% vs. 25.6%) and surgical complications (34.9% vs. 30.2%); p > 0.05. MS patients had similar rates of 2Y revisions (16.3% vs. 9.3%, p = 0.333). MS was not associated with medical, surgical, or overall complications or revisions at minimum 2Y follow-up.

CONCLUSION

Patients with MS experienced similar postoperative course compared to those without MS following ≥ 4-level fusion for ASD. This data supports the findings of multiple previously published case series' that long segment fusions for ASD can be performed relatively safely in patients with MS.

Neuromyelitis Optica Spectrum Disorders (NMOSDs) Diagnosed After Surgery for the Ossification of the Posterior Longitudinal Ligament of the Cervical and Thoracic Spine: A Case Report

Complications of compressive spinal cord myelopathy and demyelinating disease can be difficult to diagnose. A 65-year-old woman gradually lost the ability to walk. Her imaging findings showed multiple spinal canal stenosis and ossification of the posterior longitudinal ligament in the cervical and thoracic spine. Some intramedullary signal changes were seen at sites distant from the spinal cord compression site. Although she underwent cervical and thoracic decompression and fusion surgery relatively early, her lower-extremity strength decreased after surgery. Her aquaporin 4 (AQP4)-antibody was found to be positive postoperatively, and she was diagnosed with NMOSD. Medical treatment for NMOSD improved her walking ability, and she finally became able to walk with a cane. In cases where there is a discrepancy between the site of strong stenosis and intramedullary signal changes, it is necessary to consider an anti-AQP4 antibody test and consultation with a neurologist.

Real-world challenges in the diagnosis of primary progressive multiple sclerosis

BACKGROUND AND PURPOSE

Despite the 2017 revisions to the McDonald criteria, diagnosing primary progressive multiple sclerosis (PPMS) remains challenging. To improve clinical practice, the aim was to identify frequent diagnostic challenges in a real-world setting and associate these with the performance of the 2010 and 2017 PPMS diagnostic McDonald criteria.

METHODS

Clinical, radiological and laboratory characteristics at the time of diagnosis were retrospectively recorded from designated PPMS patient files. Possible complicating factors were recorded such as confounding comorbidity, signs indicative of alternative diagnoses, possible earlier relapses and/or incomplete diagnostic work-up (no cerebrospinal fluid examination and/or magnetic resonance imaging brain and spinal cord). The percentages of patients fulfilling the 2010 and 2017 McDonald criteria were calculated after censoring patients with these complicating factors.

RESULTS

A total of 322 designated PPMS patients were included. Of all participants, it was found that n = 28/322 had confounding comorbidity and/or signs indicative of alternative diagnoses, n = 103/294 had possible initial relapsing and/or uncertainly progressive phenotypes and n = 73/191 received an incomplete diagnostic work-up. When applying the 2010 and 2017 diagnostic PPMS McDonald criteria on n = 118 cases with a full diagnostic work-up and a primary progressive disease course without a better alternative explanation, these were met by 104/118 (88.1%) and 98/118 remaining patients (83.1%), respectively (p = 0.15).

CONCLUSION

Accurate interpretation of the initial clinical course, consideration of alternative diagnoses and a full diagnostic work-up are the cornerstones of a PPMS diagnosis. When these conditions are met, the 2010 and 2017 McDonald criteria for PPMS perform similarly, emphasizing the importance of their appropriate application in clinical practice.

A Comparison of Corpectomy ACDF Hybrid Procedures with Nano-Hydroxyapatite/Polyamide 66 Cage and Titanium Mesh Cage for Multi-level Degenerative Cervical Myelopathy: A Stepwise Propensity Score Matching Analysis

OBJECTIVE

Previous studies have found satisfactory clinical results with the nano-hydroxyapatite/polyamide 66 (n-HA/PA66) cage to reconstruct the stability of anterior cervical column. However, studies evaluating the long-term outcomes of the n-HA/PA66 cage in multi-level degenerative cervical myelopathy (MDCM) have not been reported. This study aims to compare the outcomes of corpectomy anterior cervical discectomy and fusion (ACDF) hybrid procedures between the n-HA/PA66 cage and titanium mesh cage (TMC) to treat MDCM.

METHODS

After the screening for eligibility, this retrospective study involved 90 patients who underwent corpectomy ACDF hybrid (CACDFH) procedure from June 2013 to June 2018. The CACDFH procedure is the combination of ACDF and anterior cervical corpectomy and fusion (ACCF). According to the cage utilized, we categorized patients into a n-HA/PA66 cage group and a TMC group. Then, stepwise propensity score matching (PSM) was performed to maintain comparable clinical data between groups. All the patients were followed up ≥4 years and the longest follow-up time was 65.43 (±11.49) months. Cage subsidence, adjacent segment degeneration (ASD), segmental height (SH), segmental angle (SA), cervical lordosis (CL), and clinical data (visual analogue scale [VAS] and Japanese Orthopaedic Association [JOA] score) was evaluated preoperatively, at 1 week, and at the final surgery follow-up. The independent student's t test and chi-square test were applied to compare the differences between groups.

RESULTS

Through PSM analysis, 25 patients from the n-HA/PA66 group were matched to 25 patients in the TMC group. The occurrence of ASD was 16.0% (4/25) in the n-HA/PA 66 group, which was significantly less than in the TMC group at 44.0% (11/25) (p = 0.031). Moreover, the cage subsidence rate was significantly higher in the TMC group as compared to the n-HA/PA 66 group (40.0% vs. 12.0%, p = 0.024). But there was no significant difference in SH, SA, and CL at any time after surgery as determined through follow-up. The VAS and JOA scores significantly improved in both groups at 3 months postoperative and at final follow-up. However, there were no significant differences in the VAS and JOA score at any time between the two groups in preoperative (p > 0.05).

CONCLUSION

The n-HA/PA66 cage is associated with lower rate of cage subsidence and ASD than the TMC in the treatment of MDCM. The n-HA/PA66 cage could be superior to the TMC in corpectomy ACDF hybrid procedures.