Comparison between recovery/progression rates in surgical and nonsurgical groups and comparison of actual mJOA. There was no significant clinical or functional improvement in the nonsurgical group when looking at overall mJOA and mMDI scores at months 3, 6, and 12. Furthermore, there was no improvement in upper limb function, lower limb function, sensitivity or of the sphincter in the non-surgical group, as assessed by
In the Neurosurgery and Neurology clinics, Mageshree and Margaret always allowed me to fit a patient in for follow-up when needed. Informed consent for surgery was obtained from everyone in the surgical group, explaining expected benefits, potential risks and possible alternative management, according to current standard of practice. Cervical osteophytes "Bone spurs" that form in the neck as a result of degeneration in the aging spine.
INTRODUCTION 1.1 Background
- The Natural History of CSM
- Surgical Techniques for the Treatment of CSM
- Assessing Clinical and Functional Outcomes
- Objectives Primary Objectives
It is therefore a difficult condition to handle. decompression is offered to patients with the aim of improving functional outcome. There are few studies that prospectively assess neurological recovery in patients with cervical spondylotic myelopathy. One such study by Cheung et al. 2008) excluded a subgroup of patients with more than two stenotic levels with loss of cervical lordosis as seen on MRI because this group of patients has a higher complication rate.
There are currently no published South African studies assessing neurological outcome in patients with CSM. Morgado & Welsh (2013) assessed the natural history of CSM and the role of surgery and concluded that conservative treatment of patients with mild CSM is an option, while patients with functional limitations are best treated. The Cochrane review by Matz et al. 2009) found that patients with mild CSM (mJOA ≥ 12) responded to surgical decompression or non-operative therapy in the short term (3 years), while more severe CSM responded to surgical decompression, where the benefits remained for a minimum of 5 years. years and up to 15 years after surgery.
In the latest prospective multicenter study on the efficacy and safety of surgery. decompression in patients with CSM, Fehlings et al. 2013) found that surgical decompression was associated with improved functional, disability-related, and quality-of-life outcomes at one-year follow-up for all disease severity categories. The MDI was developed as a functional assessment system for rheumatoid arthritis patients with cervical myelopathy and has also been validated by Holly et al.
METHODS
- Study Population
- Sampling Strategy
- Statistical Planning (Variables / Confounders)
- Sample Size
- Inclusion / Exclusion Criteria Inclusion Criteria
- Data Collection Methods and Tools
- Data Analysis Techniques
- Statistical Analysis
- Study Location
- Study Period
- Limitations of the Study
The participants in the surgical group formed the sample population used to assess the primary objective, i.e. the participants in the non-surgical group formed the sample population used to assess the secondary objective, i.e. = --- X 100 Full score – Preoperative mJOA score.
Post-op upper extremity mJOA – pre-op upper extremity mJOA Upper extremity recovery = --- X 100 Full upper extremity score – pre-op upper extremity score. Post-op Sensation mJOA – pre-op sensation mJOA Sensation recovery = --- X 100 Full sensation score – pre-op sensation score. Post-op lower limb mJOA – pre-op lower limb mJOA Lower limb recovery = --- X 100 Full lower limb score – pre-op lower limb score.
Postoperative sphincter mJOA – preoperative sphincter mJOA Sphincter recovery = --- X 100 Full sphincter score – Preoperative sphincter score. Post-operative mMDI functional score – Recovery rate of pre-operative mMDI score = --- X 100 Full score – Pre-operative mMDI score.
RESULTS
Demographics
- The effect of gender on recovery / progression rates as assessed by mJOA scores
One was a 72-year-old woman with stage 3 disease and a background of hypertension, diabetes and rheumatoid arthritis in poor clinical condition. It was felt that the benefit-risk ratio did not justify major surgery in any of these patients. Thus, in the surgical group of 27 patients, there were 16 with mild CSM and 11 with moderate-severe CSM.
In the nonsurgical group of 12 patients, 9 had mild CSM and 3 had moderate to severe CSM. When comparing the above demographics between the surgical and non-surgical groups, the only statistically significant difference was age, with a mean age of 54.7 years in the surgical group and 63.8 years in the non-surgical group ( p = 0.0127). Recovery/progression rates per mJOA at 3, 6, and 12 months in the surgical and nonsurgical groups.
Conclusion: Gender did not influence the outcome in the surgical or non-surgical groups at 3, 6 or 12 months.
Effect of smoking on recovery / progression rates
Effect of T2WI cord signal abnormality on MRI on the severity of CSM at presentation
- Effect of co-morbidities on clinical and functional outcomes as assessed by mJOA and mMDI scores respectively
- Effect of intra-op complications on clinical and functional outcomes in the surgical group as assessed by mJOA and mMDI score respectively (n=27)
- Overall recovery / progression rates as assessed by mJOA scores in the surgical and non-surgical groups
- Upper limb recovery / progression rates in the surgical and non- surgical groups
- Lower limb recovery / progression rates in the surgical and non-surgical groups
- Sensation recovery / progression rates in the surgical and non-surgical groups
- Sphincter recovery / progression rates in the surgical and non-surgical groups
- Functional recovery / progression rates as assessed by mMDI in the surgical and non-surgical groups
- Comparison between recovery / progression rates in the surgical and non-surgical groups
- Comparison of actual mJOA and mMDI scores
See Appendices ix-xii, xvi-xix, xx, and xxv for mJOA recovery/progression rates in surgical and nonsurgical groups. See Appendices ix-xii, xvi-xix, xxi, and xxvi for upper limb recovery/progression rates after mJOA in surgical and nonsurgical groups. In the non-surgical group, there was no improvement in upper limb progression rate at 3 compared with s.
See Appendices ix-xii, xvi-xix, xxii, and xxvii for lower extremity mJOA recovery/progression rates in the surgical and nonsurgical groups. In the non-surgical group, there was no improvement in lower limb progression rate at 3 versus. See Appendices ix-xii, xvi-xix, xxii and xxviii for sensation recovery/progression rates in mJOA in the surgical and non-surgical groups.
See Appendices ix-xii, xvi-xix, xxiii, and xxix for sphincter repair/progression rates by mJOA in the surgical and nonsurgical groups. See Appendices ix-xii, xvi-xix, xxiv and xxx for mMDI recovery/progression rates in the surgical and non-surgical groups. In the non-surgical group, there was no improvement in functional progression rates at 3 vs.
DISCUSSION
- Demographics .1 Age
- The effect of gender on outcome
- Effect of smoking on outcome
- Effect of T2WI cord signal abnormality on MRI on the severity of CSM at presentation, and
- Effect of T2WI cord signal abnormality on recovery rates in the surgical and non-surgical groups
- Effect of duration of symptoms on outcome
- Effect of severity of CSM at baseline on outcome in the surgical and non-surgical groups
- Effect of co-morbidities on clinical and functional outcomes as assessed by mJOA and mMDI scores respectively
- Effect of intra-operative complications on clinical and functional outcomes in the surgical group as assessed by mJOA and mMDI score
While this effect is seen after posterolateral transplantation of the lumbar spine, the same effect has not been conclusively demonstrated in the cervical spine. compelling evidence of smoking as an independent predictor of outcome. 2008) assessed the effect of diabetes and smoking on postoperative outcome and found that smoking did not influence outcome. When assessing the recovery rate at 3, 6 and 12 months, we found no difference between smokers and non-smokers in both the surgical and non-surgical groups. In the non-surgical group, the duration of symptoms does not influence the outcome/progression of the disease.
The outcome assessed using recovery or progression rates calculated using the mJOA score shows that in the surgical group there is no difference in the outcome in the mild vs. In the non-surgical group, the severity of CSM at baseline had no effect on outcome at 3, 6 or 12 months. In the surgical group, benefit from surgery is noted regardless of the severity of CSM (Figure 4).
This third patient manifested with worsening lower limb function in the immediate post-operative period. 4.9 – 4.14 Recovery/progression rates in the surgical and non-surgical groups as assessed by overall mJOA score, upper limb recovery rate, lower limb recovery rate, sensation recovery rate, sphincter recovery rate and functional recovery as assessed by mMDI scores. In the surgical group, there was statistically significant improvement in overall clinical and functional recovery as assessed by mJOA and mMDI scores.
No clinical or functional improvement as assessed by mJOA or mMDI scores was observed in the non-surgical group. Comparison between recovery/progression rates in surgical and non-surgical groups and comparison of actual mJOA and mMDI scores When the study was designed, we did not anticipate that a direct comparison between the surgical and non-surgical groups would be possible, as we expected that the two groups would not be comparable . The patients expected to form the non-surgical group would be those with mild CSM who refused surgery, or those who were severely debilitated in whom we felt that surgery would provide no benefit if compared with the associated risks.
However, when the data is analyzed, the only factor found to be statistically significant between the groups is older age in the non-surgical group. Except for a better recovery in the surgery group when assessing mJOA scores at 12 months (p = 0.0434) and a better recovery of the lower limb in the surgery group at 12 months (p = 0.0155), there were no statistically significant differences in the rates of recovery or progression between the two groups at 3, 6 and 12 months. For this reason, only 8 patients from the non-surgical group are included in the statistics.
CONCLUSIONS, LIMITATIONS AND RECOMMENDATIONS Conclusions
Clinical improvement assessed by mJOA normalizes at 12 months, but these patients are still functionally impaired as assessed by mMDI at 12 months. A number of potential patients are excluded from the study because preoperative mJOA and mMDI scores were not performed. While radiologists at IALCH, when evaluating cervical MRIs of patients with suspected CSM, always comment on T2WI marrow signal abnormality, T1-weighted imaging of spinal cord signal changes is not routinely commented.
It would have been interesting to study the effect of cord T1WI signal hypointensity on. Non-operative management is an option in patients with mild CSM, however close clinical follow-up is recommended to identify those showing early signs of deterioration. It seems reasonable to recommend non-operative treatment of patients with mild CSM and no T2 signal change on MRI.
Longer follow-up of this group would be useful to assess the time at which the benefits of surgery plateau, as well as to assess the long-term natural history in those patients in the nonsurgical group.
1996) Development of a functional assessment system for rheumatoid arthritis patients with cervical myelopathy. 2009) Long-term outcome of instrumented laminectomy and fusion for cervical ossification of the posterior longitudinal ligament. 2008). Natural history and results of surgical treatment of spinal cord disorder associated with cervical spondylosis. 2001) Long-term results of the anterior floating method for cervical myelopathy caused by ossification of the posterior longitudinal ligament.
