Early surgery compared to nonoperative management for mild degenerative cervical myelopathy: a cost-utility analysis

Wearable sensors: a valid tool for quantifying cervical spondylotic myelopathy (CSM)

BACKGROUND CONTEXT

Though nearly ubiquitous in testing for cervical spondylotic myelopathy (CSM), the conventional Romberg test is constrained by its binary nature. Differentiating which patients have mild cases from those who require surgery more urgently is challenging without objective metrics. The recent advance of performing a Romberg test on a force plate enables a more granular measure of imbalance in patients with CSM. Nonetheless, the use of force plates limits the amount of patient data that can be collected and the setting in which they can be collected. The advent of wearable sensors offers the opportunity to measure imbalance in patients when they are away from the clinical setting.

PURPOSE

To determine if wearable sensors provide quantitative Romberg test data comparable to that of using a force plate.

STUDY DESIGN

Prospective longitudinal cohort.

PATIENT SAMPLE

Subjects with CSM scheduled for surgery.

OUTCOME MEASURE

Quantitative Romberg test.

METHODS

Patients scheduled for surgical treatment of CSM underwent Romberg testing on a force plate with wearable sensors placed at the C7 level. Data on force plate displacement (measured in mm of displacement) was compared to motion data from the wearable sensor (measured in degrees of angular displacement).

RESULTS

Data was collected on 48 patients, mean age of 57.77 years, mean BMI of 31.69 kg/m2, with 23 (48%) females. There were strong statistically significant correlations between data from the force plate and from the wearable sensor with eyes closed for total lateral motion (r=0.766, p<.001), total path travelled (r=0.658, p<.001) and maximum lateral sway (r=0.800, p<.001) CONCLUSION: Wearable sensors present a growing subset of remote digital health technology to gather biomechanical gait and stance data. The results of this study suggest the feasibility of using sensors to quantify CSM severity. These data can elucidate the disease course and manifestations of conditions like CSM and may drive diagnostic and therapeutic decisions in the future.

Severe neck pain among patients with degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network

BACKGROUND CONTEXT

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. While surgical intervention is widely recognized as the primary treatment to halt disease progression and improve neurological function, its effectiveness in alleviating neck pain remains poorly understood.

PURPOSE

The aims of this study were to identify DCM patients that presented with severe neck pain and to compare their baseline characteristics and surgical outcomes to those who presented with less severe neck pain.

STUDY DESIGN/SETTING

This is a prospective, multicenter observational cohort study of the Canadian Spine Outcomes and Research Network (CSORN).

SAMPLE

Patients surgically treated for DCM between 2015 and 2022 were enrolled.

OUTCOME MEASURE

Baseline demographics, clinical/surgical details, PROs and mJOA were assessed.

METHODS

Baseline demographics, clinical/ surgical details, preoperative PROs and mJOA were compared between the patients with severe patient-rated neck pain (NP, defined as NRS-NP ≥ 8), and those with less severe NP. Between group improvements at 12 months were assessed using ANCOVA to adjust for any baseline significant differences between groups.

RESULTS

We included data from 725 DCM patients, 31.7 % (n=230) of whom presented with severe NP. Patients with severe NP were significantly more likely to be younger, smokers, unemployed, working rather than retired, unmarried, using pain medication, have a history of depression, have more comorbidities, and be physically less active (all p<.05). Baseline PROs (NRS AP and NP, NDI, SF-12 MCS and PCS and EQ5D) were significantly worse (p<.01), but mJOA scores were similar to those without severe NP. Among patients with severe NP, mean NRS-NP improved from 8.6 (SD 0.8) to 3.9 (SD 2.9, p<.01) at 12 months after surgery. Patients with severe NP were more likely to achieve MCID for neck pain in comparison to those without severe NP (74% vs. 33%, p<.01), but mean NRS-NP remained worse in this subgroup (3.9 vs. 2.6, p<.01) at 1 year after surgery. When adjusted for baseline characteristics, there were no differences between the 2 groups for the following PROs at 12 months postoperatively: NRS arm pain, NDI, SF-12 PCS, EQ5D. SF-12 MCS remained significantly worse among patients who presented with severe NP (p<.05). There was no significant difference in mJOA scores (report data) at 1 year after surgery.

CONCLUSION

Severe neck pain affects about a third of the DCM population. Most patients who presented with severe neck pain experienced substantial improvement of their neck pain after surgery. Except for mental health scores which remained worse, patients with severe neck pain experienced similar improvements in other outcome measures such as neurological function and health-related quality of life when compared to those with less severe neck pain. These findings suggest that surgical treatment not only addresses the structural causes of DCM but also provides meaningful improvements across multiple domains, underscoring its value in managing both the physical and psychosocial burdens of the disease.

Spinal cord demyelination predicts neurological deterioration in patients with mild degenerative cervical myelopathy

Background

Degenerative cervical myelopathy (DCM) is the most common form of atraumatic spinal cord injury globally. Clinical guidelines regarding surgery for patients with mild DCM and minimal symptoms remain uncertain. This study aims to identify imaging and clinical predictors of neurological deterioration in mild DCM and explore pathophysiological correlates to guide clinical decision-making.

Methods

Patients with mild DCM underwent advanced MRI scans that included T2-weighted, diffusion tensor imaging and magnetisation transfer (MT) sequences, along with clinical outcome measures at baseline and 6-month intervals after enrolment. Quantitative MRI (qMRI) metrics were derived above and below maximally compressed cervical levels (MCCLs). Various machine learning (ML) models were trained to predict 6 month neurological deterioration, followed by global and local model interpretation to assess feature importance.

Results

A total of 49 patients were followed for a maximum of 2 years, contributing 110 6-month data entries. Neurological deterioration occurred in 38% of cases. The best-performing ML model, combining clinical and qMRI metrics, achieved a balanced accuracy of 83%, and an area under curve-receiver operating characteristic of 0.87. Key predictors included MT ratio (demyelination) above the MCCL in the dorsal and ventral funiculi and moderate tingling in the arm, shoulder or hand. qMRI metrics significantly improved predictive performance compared to models using only clinical (bal. acc=68.1%) or imaging data (bal. acc=57.4%).

Conclusions

Reduced myelin content in the dorsal and ventral funiculi above the site of compression, combined with sensory deficits in the hands and gait/balance disturbances, predicts 6-month neurological deterioration in mild DCM and may warrant early surgical intervention.

The Effects of Peri-Operative Adverse Events on Clinical and Patient-Reported Outcomes After Surgery for Degenerative Cervical Myelopathy: An Observational Cohort Study from the Canadian Spine Outcomes and Research Network

BACKGROUND AND OBJECTIVES

There is a lack of data examining the effects of perioperative adverse events (AEs) on long-term outcomes for patients undergoing surgery for degenerative cervical myelopathy. We aimed to investigate associations between the occurrence of perioperative AEs and coprimary outcomes: (1) modified Japanese Orthopaedic Association (mJOA) score and (2) Neck Disability Index (NDI) score.

METHODS

We analyzed data from 800 patients prospectively enrolled in the Canadian Spine Outcomes and Research Network multicenter observational study. The Spine AEs Severity system was used to collect intraoperative and postoperative AEs. Patients were assessed at up to 2 years after surgery using the NDI and the mJOA scale. We used a linear mixed-effect regression to assess the influence of AEs on longitudinal outcome measures as well as multivariable logistic regression to assess factors associated with meeting minimal clinically important difference (MCID) thresholds at 1 year.

RESULTS

There were 167 (20.9%) patients with minor AEs and 36 (4.5%) patients with major AEs. The occurrence of major AEs was associated with an average increase in NDI of 6.8 points (95% CI: 1.1-12.4, P = .019) and reduction of 1.5 points for mJOA scores (95% CI: -2.3 to -0.8, P < .001) up to 2 years after surgery. Occurrence of major AEs reduced the odds of patients achieving MCID targets at 1 year after surgery for mJOA (odds ratio 0.23, 95% CI: 0.086-0.53, P = .001) and for NDI (odds ratio 0.34, 95% CI: 0.11-0.84, P = .032).

CONCLUSION

Major AEs were associated with reduced functional gains and worse recovery trajectories for patients undergoing surgery for degenerative cervical myelopathy. Occurrence of major AEs reduced the probability of achieving mJOA and NDI MCID thresholds at 1 year. Both minor and major AEs significantly increased health resource utilization by reducing the proportion of discharges home and increasing length of stay.