Safety and feasibility of an early telephone-supported home exercise program after anterior cervical discectomy and fusion: a case series

Comparison of Flexion Relaxation Phenomenon After Single-Level and Multi-Level Anterior Cervical Discectomy and Fusion

BACKGROUND

This prospective cohort study aimed to assess the influence of the number of fused segments in cervical paravertebral muscles by comparing the changes of the cervical flexion relaxation phenomenon (FRP) after single-level versus multilevel anterior cervical discectomy and fusion (ACDF).

METHODS

A total of 115 patients who had undergone ACDF were retrospectively recruited and divided into a 1-level group (n = 44), a 2-level group (n = 40) and a 3- to 4-level group (n = 31). The flexion relaxation experiment was carried out 3 days preoperatively and 12 months postoperatively by surface electromyography (SEMG). Patients were examined using the neck visual analog scale, cervical Japanese Orthopedic Association score, Neck Disability Index, and C2-C7 range of motion (ROM).

RESULTS

There was a significant difference in the time-related changes in flexion relaxation ratio (FRR) among the 3 study groups before and after surgery (F = 85.701; P < .001). Thirty-five patients (79.55%) with 1-level ACDF and 11 patients (27.5%) with 2-level ACDF had FRP were restored to normal at 12 months postoperatively; however, only 1 patient (3.33%) had normalized FRP after 3- to 4-level ACDF. There were significant differences in the time-related changes of the normalized SEMG root mean square values in each phase before and after surgery (P = .018, <.001, <.001, and <.001). A significant correlation was found between the changes in C2-C7 ROM and FRR in the 3 study groups (P = .007 for 1 level, P = .003 for 2 levels, and P = .036 for 3-4 levels).

CONCLUSIONS

Single-level ACDF contributes to normalizing the FRP of cervical paravertebral muscles, which is not ideally recovered by 2-level ACDF. In contrast, 3- or 4-level ACDF could not normalize the cervical FRP. Our research supports the passive structure hypothesis.

Postoperative Rehabilitation to Improve Outcomes After Cervical Spine Fusion for Degenerative Cervical Spondylosis: A Systematic Review

Postoperative rehabilitation has recently been identified as a high-priority research topic for improving surgical outcomes for degenerative cervical spondylosis (DCS). However, there remains no consensus on specific rehabilitation strategies. Thus, the objective of this study was to evaluate the effectiveness of postoperative rehabilitation strategies for short-term and long-term outcomes after cervical spine fusion for DCS. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines using the PubMed, Scopus, and Ovid Medline databases. All level I-IV therapeutic studies in the English language investigating the outcomes of postoperative rehabilitation strategies after cervical spine fusion for DCS were included. Nine studies with 895 patients with DCS (747 anterior-only fusion, 55 patients with posterior-only fusion, 93 patients with physiotherapy alone) were included in this analysis, with 446 (49.8%) patients receiving physiotherapy alone or standard postoperative therapy and 449 (50.2%) patients receiving standard postoperative therapy with additional intervention or augmentation. These interventions included pulsed electromagnetic field (PEMF) stimulation, telephone-supported home exercise program (HEP), early cervical spine stabilizer training, structured postoperative therapy, and a postoperative cervical collar. One level II study demonstrated that PEMF led to increased fusion rates at six months postoperatively compared to standard therapy alone, one level II study demonstrated that postoperative cervical therapy in addition to standard therapy was better than standard therapy alone in the improvement of neck pain intensity, one level IV study demonstrated home exercise therapy led to an improvement in neck pain, arm pain, and disability, and six level II studies reported no difference in clinical outcome measures between augmented or targeted therapy and standard postoperative therapy for DCS. In conclusion, there is moderate evidence to suggest that there is no significant difference in clinical and surgical outcomes between standard postoperative therapy and augmented or targeted postoperative therapy for cervical fusion in the setting of cervical spondylosis. However, there is some evidence to support that certain therapeutic modalities, such as PEMF stimulation, may lead to improved fusion rates, clinical outcomes, and patient satisfaction when compared to standard postoperative therapy protocols. There is no evidence to support a difference in effectiveness with different types of postoperative rehabilitation strategies between anterior and posterior fusions for DCS.

Patient and healthcare provider experience and perceptions of a preoperative rehabilitation class for lumbar discectomy: A qualitative study

BACKGROUND

Lumbar disc disease is a leading cause of low back pain. Lumbar discectomy (LD) may be indicated if symptoms are not managed conservatively. Rehabilitation has traditionally been delivered postoperatively; however, there is increasing delivery preoperatively. There are few data concerning perceptions and experiences of preoperative rehabilitation. Exploring experiences of preoperative rehabilitation may help in the development and delivery of effective care for patients.

OBJECTIVES

To develop an understanding of patient and healthcare provider (HCP) experiences, perspectives and preferences of preoperative LD rehabilitation, including why patients do not attend.

DESIGN

A qualitative interpretive approach using focus groups and individual interviews.

METHODS

Data were collected from; a) patients listed for surgery and attended the preoperative rehabilitation (October 2019 to March 2020), b) patients listed for surgery but did not attend rehabilitation, and c) HCPs involved in the delivery of rehabilitation. Data were transcribed verbatim and analysed using thematic analysis.

RESULTS/FINDINGS

Twenty participants were included, twelve patients and eight HCPs. The preoperative class was a valuable service for both patients and HCPs. It provided a solution to staffing and time pressures. It provided the required education and exercise content helping the patients along their surgery pathway. Travel distance, transportation links, parking difficulty and cost, lack of knowledge about the class aims, and previous negative experiences were barriers to patient attendance.

CONCLUSIONS

For most patients and HCPs, the preoperative class was valuable. Addressing the challenges and barriers could improve attendance. Future research should focus on management of patient expectations and preferences preoperatively.

The Effect of Preoperative Mental Health Status on Outcomes After Anterior Cervical Discectomy and Fusion

BACKGROUND

The effect of preoperative mental health on outcomes after anterior cervical discectomy and fusion (ACDF) is of increasing interest. The purpose of this study was to utilize patient-reported outcome measures (PROMs) to compare outcomes after ACDF in patients with and without poor mental health. We hypothesized that patients with worse baseline mental health would report worse outcomes after surgery.

METHODS

Patients undergoing ACDF for degenerative cervical spondylosis with at least 12 months of follow-up were included. Outcomes collected before and after surgery included the RAND-36, Neck Disability Index (NDI), EuroQol 5-dimension (EQ-5D), and Single Assessment Numeric Evaluation (SANE) score.

RESULTS

Seventy-one patients were included and assigned to the depression or nondepression group based on baseline mental health. The depression group had worse baseline preoperative scores across all PROMs: NDI (44.2 vs 36.8, P = 0.05), RAND (1511.4 vs 2198.18, P < 0.001), EQ-5D (12.55 vs 10.14, P < 0.001), and SANE (56.3 vs 72.9, P < 0.001). Postoperatively, the depression group had worse scores at the final follow-up for RAND (2242.8 vs 2662.2, P = 0.03) and SANE (71.5 vs 80.8, P = 0.02). Both groups experienced improvements with ACDF across all PROMs. The changes in each PROM were not statistically significant between groups. There were no statistically significant differences in the percentage of patients achieving the minimal clinically important difference across PROMs.

CONCLUSION

This study is the first to utilize the RAND-36, EQ-5D, NDI, and SANE scores to assess preoperative mental health and its effect on postoperative outcomes after ACDF. While poor preoperative mental health status yielded significantly worse baseline and postoperative outcomes scores, patients experienced significant improvement in symptoms after ACDF.

LEVEL OF EVIDENCE: 2

CLINICAL RELEVANCE

Clinicians should be aware of the effects of poor mental health status on clinical outcomes in patients undergoing anterior cervical fusion, but can still expect significant clinical improvements after surgery.

Effect of posterior cervical expansive open-door laminoplasty on cervical sagittal balance

PURPOSE

Posterior cervical expansive open-door laminoplasty (LAMP) is a mature surgical procedure for the treatment of cervical spondylotic myelopathy (CSM), but there are few studies on the changes in cervical sagittal balance. This study aimed to analyze the imaging and clinical data of patients who underwent LAMP and to explore the effect of this procedure on the cervical sagittal balance.

METHODS

This was a retrospective study of the patients who underwent LAMP between 01/2014 and 12/2017. The C0-C2 Cobb angle, sagittal vertical angle (SVA), C2-C7 Cobb angle, and T1-slope were measured. The Japanese Orthopaedic Association (JOA) score, neck disability index (NDI), and visual analog scale (VAS) were used.

RESULTS

There were 69 males and 39 females. The mean age was 61.3 ± 5.3 years. The C0-C2 Cobb angle increased from 11.3 ± 5.5° to 26.8 ± 4.8° (P = 0.186). The C2-C7 Cobb angle decreased from 13.9 ± 8.6° to 10.65 ± 10.7° P = 0.016). SVA increased from 21.0 ± 5.8 mm to 25.4 ± 11.5 mm (P = 0.001). The preoperative average JOA score was 11.1 ± 2.2 points, and the postoperative score was 14.0 ± 2.1 points, with an average improvement rate of JOA of 46.5 ± 3.8%. The NDI score decreased from preoperative 15.6 ± 5.4 points to 11.3 ± 7.9 points, and the VAS score was decreased from 4.6 ± 1.8 points to 3.3 ± 1.6 points (all P < 0.05).

CONCLUSION

LAMP improved the neurological function and quality of life of patients with CSM. The cervical vertebrae show a tendency of tilting forward, suggesting that overextension of the upper cervical vertebra might be used to maintain the center of gravity of the skull and horizontal vision.