Elsevier

World Neurosurgery

Volume 81, Issues 3–4, March–April 2014, Pages 623-633
World Neurosurgery

Peer-Review Report
Predictors of Outcome in Patients with Cervical Spondylotic Myelopathy Undergoing Surgical Treatment: A Survey of Members from AOSpine International

https://doi.org/10.1016/j.wneu.2013.09.023Get rights and content

Objectives

To conduct a survey of the AOSpine community to determine international perceptions of key predictors of outcome in patients with cervical spondylotic myelopathy. This knowledge will guide the development of clinical prediction models and allow the alignment of clinical perceptions with evidence-based reality.

Methods

A request to participate in a survey was distributed to members of AOSpine International. The primary question asked surgeons to rank eight clinical factors according to their ability to predict surgical outcome: age, preoperative severity, sex, duration of symptoms, smoking status, signs, and symptoms. Three questions were also included to address the importance of magnetic resonance imaging as a prognostic tool.

Results

Six hundred and eighty-nine international spine professionals completed the survey, most of whom were spine surgeons. Duration of symptoms and baseline severity score were ranked as the top two predictors of outcome from all geographic locations, with the exception of Europe, which rated the presence of myelopathic symptoms more important than preoperative severity. There was international agreement that 65 years and a modified Japanese Orthopaedic Association score of 12 were the threshold age and preoperative severity above/below which there becomes a negative impact on outcome. Surgeons most frequently selected diabetes (n = 538) as the comorbidity having the most significant impact on surgical results, followed by neuromuscular disorders (n = 360). Finally, there was international consensus that magnetic resonance imaging is a valuable prognostic tool and that signal changes on T2- and T1/T2-weighted images are the most important parameters in outcome prediction.

Conclusion

This survey summarizes surgeons' perceptions of the most important predictors of outcome and provides insight into how surgeons undertake decision making.

Introduction

Cervical spondylotic myelopathy (CSM) is a progressive spine disease and the leading cause of spinal cord dysfunction worldwide. In patients with CSM, the degeneration of various components of the vertebra and corresponding anatomical changes to the spine can result in canal stenosis and subsequent compression of the neural elements 2, 31. Surgery traditionally has been performed to arrest the progression of CSM but more recently has also been shown to improve functional status (35). Prediction of outcome in a surgical setting is a valuable tool to provide decision support to the surgeon, to appropriately manage patient expectations, and to counsel patients and their families as to potential treatment options (11).

Two extensive systematic reviews have been undertaken to determine the most important clinical predictors of surgical outcome 15, 30. Holly et al. (15) summarized the findings from 14 studies and concluded that there is low quality class III evidence suggesting that age and duration of symptoms carry prognostic value. The second and more recent systematic review by Tetreault et al. (30) included a larger subset of the literature with more high-quality prospective studies in which the authors used validated outcome measures. Synthesizing the results from 91 studies, Tetreault et al. (30) determined that duration of symptoms and baseline severity score were essential predictors and that age was a potential predictor when exploring only high-quality studies (n = 16). Other factors, including sex, smoking status, neurologic signs, and symptoms were also considered, but definite conclusions on their predictive value could not be drawn because of insufficient evidence.

In an attempt to clear up this existing controversy and to bridge the gap between research and clinical practice, we have conducted a survey of AOSpine International members to investigate professional opinion on the most important clinical and imaging predictors of outcome. This information will be valuable in guiding the construction of valid clinical prediction rules, allowing the alignment of clinical perceptions with evidence-based reality. A second objective is to assess differences in perceptions across six international regions, specifically North America, Asia Pacific, Europe, Africa, the Middle East, and Latin America. These results will be useful in interpreting findings from geographic validation studies used to assess the ability of clinical prediction models to predict outcome across regions.

Section snippets

Materials and Methods

An English language 11-question survey was created to determine important clinical and imaging predictors of surgical outcome in patients with CSM. An e-mail request to participate in this online survey was distributed to members of AOSpine International, with an attached link to Survey Monkey. The link to the survey was available electronically for 35 days, with three reminders sent out during this period. Table 1 displays the questions from this survey.

The results from the ranking questions

Results

Six hundred and eighty-nine members of AOSpine International completed the survey, representing a response rate of 11.6% (689/5934). The majority of participants were either neurosurgeons (n = 219), orthopaedic surgeons (n = 215), or spine surgeons (n = 171). Eighteen residents responded, along with two operating room nurses, two researchers, one neurologist, one pain management specialist, one radiologist, and one rheumatologist. Geographically, the greatest number of participants were from

Discussion

On the basis of the opinions of spine care professionals, it is evident that baseline severity score and duration of symptoms are the most important predictors of surgical outcome in CSM patients. The rationale behind these two findings is that both severe and chronic, longstanding compression of the spinal cord may lead to irreversible damage due to myelomalacia, spongiform changes, microcavitation and necrosis of the grey matter (6). These findings are consistent with the literature.

Given

Conclusions

This survey aimed to summarize global perceptions of key imaging and clinical predictors of surgical outcome in patients with cervical spondylotic myelopathy. The results from this survey can be used to guide the construction of valid clinical prediction models, enabling a clinician to quantify a patient's likely outcome and correctly manage expectations. The results from questions 2, 3, and 5 may provide guidelines on how to appropriately dichotomize or group continuous variables for

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    Conflict of interest: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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