Lindsay Tetreault - Academia.edu (original) (raw)
Papers by Lindsay Tetreault
Science translational medicine, Jan 2, 2015
Although surgical decompression is considered the gold standard treatment for cervical spondyloti... more Although surgical decompression is considered the gold standard treatment for cervical spondylotic myelopathy (CSM), a proportion of cases show postoperative decline or continue to exhibit substantial neurological dysfunction. To investigate this further, we first examined data from the prospective multicenter AOSpine North America CSM study, finding that 9.3% of patients exhibited postoperative functional decline (ΔmJOA, ≤-1) and that 44% of patients were left with substantial neurological impairment 6 months postoperatively. Notably, 4% of patients experienced perioperative neurological complications within 20 days after surgery in otherwise uneventful surgeries. To shed light on the mechanisms underlying this phenomenon and to test a combination therapeutic strategy for CSM, we performed surgical decompression in a rat model of CSM, randomizing some animals to also receive the U.S. Food and Drug Administration-approved drug riluzole. Spinal cord blood flow measurements increased ...
Spine, Oct 22, 2014
Prospective study. This study aims to determine the psychometric properties of the modified Japan... more Prospective study. This study aims to determine the psychometric properties of the modified Japanese Orthopaedic Association (mJOA) scale. Several outcome measures assess functional impairment and quality of life in patients with cervical myelopathy. However, a "gold standard" has not been established. One of the most widely accepted tools for assessing functional status is the mJOA scale. Two hundred and seventy-seven surgical patients with cervical spondylotic myelopathy were enrolled in the prospective cervical spondylotic myelopathy-North America study. Functional status was evaluated at baseline and at 6, 12, and 24 months postoperatively. The internal consistency of the mJOA was assessed by computing a Cronbach α for the total score and after removing 1 item at a time. Convergent validity and divergent validity were measured by correlating the mJOA with other assessment tools. The responsiveness of the scale was determined by comparing mJOA scores at baseline and 12 months after surgery and computing a Cohen effect size. The internal consistency of the scale was moderate with a Cronbach α of 0.63. Sphincter dysfunction measured a different dimension than the other 3 scale components. The mJOA was correlated with the Nurick score (r =-0.625) but was not associated with subscales of the Short-Form 36 that measure different constructs. These findings suggest convergent and divergent validity. The mJOA was responsive to change as reflected by a Cohen effect size of 1. The mJOA is a useful tool in the assessment of cervical spondylotic myelopathy and it should be adopted as the standard for evaluating functional status in this population.
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 23, 2015
Although surgery is used increasingly as a strategy to complement treatment with radiation and ch... more Although surgery is used increasingly as a strategy to complement treatment with radiation and chemotherapy in patients with metastatic epidural spinal cord compression (MESCC), the impact of surgery on health-related quality of life (HRQoL) is not well established. We aimed to prospectively evaluate survival, neurologic, functional, and HRQoL outcomes in patients with MESCC who underwent surgical management. One hundred forty-two patients with a single symptomatic MESCC lesion who were treated surgically were enrolled onto a prospective North American multicenter study and were observed at least up to 12 months. Clinical data, including Brief Pain Inventory, ASIA (American Spinal Injury Association) impairment scale, SF-36 Short Form Health Survey, Oswestry Disability Index, and EuroQol 5 dimensions (EQ-5D) scores, were obtained preoperatively, and at 6 weeks and 3, 6, 9, and 12 months postoperatively. Median survival time was 7.7 months. The 30-day and 12-month mortality rates wer...
Neurosurgery, 2015
: Cervical spinal cord dysfunction can result from either traumatic or nontraumatic causes, inclu... more : Cervical spinal cord dysfunction can result from either traumatic or nontraumatic causes, including tumors, infections, and degenerative changes. In this article, we review the range of degenerative spinal disorders resulting in progressive cervical spinal cord compression and propose the adoption of a new term, degenerative cervical myelopathy (DCM). DCM comprises both osteoarthritic changes to the spine, including spondylosis, disk herniation, and facet arthropathy (collectively referred to as cervical spondylotic myelopathy), and ligamentous aberrations such as ossification of the posterior longitudinal ligament and hypertrophy of the ligamentum flavum. This review summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood-spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies. CSM, cervical spondylotic myelopathyDCM, degenerative cervical myelopathyJOA, Japanese Orthopaedic AssociationmJOA, modified Japanese Orthopaedic AssociationOPLL, ossification of the posterior longitudinal ligamentSCI, spinal cord injury.
Spine, 2015
Analysis of the prospective AOSpine CSM-International and North America datasets and survey of AO... more Analysis of the prospective AOSpine CSM-International and North America datasets and survey of AO Spine International. This study aims to define the minimum clinically important difference (MCID) of the modified Japanese Orthopaedic Association (mJOA) in patients with degenerative cervical myelopathy (DCM). The mJOA is the most frequently used clinician-administered tool to assess functional status in patients with DCM. By defining its MCID, clinicians can better evaluate treatment outcomes for this condition. Three methods were used to determine the MCID of the mJOA: (1) distribution-based, (2) anchor-based and receiver operating characteristic (ROC) analysis, and (3) professional opinion. Distribution-based methods were used to estimate the MCID by computing the half standard deviation and standard error of measurement. Using anchor-based methods, mJOA at 12 months after surgery was compared between patients who were "slightly improved" on the Neck Disability Index (NDI)...
The spine journal : official journal of the North American Spine Society, 2015
Journal of neurosurgery. Spine, Jan 25, 2015
OBJECT Although generally safe and effective, surgery for the treatment of cervical spondylotic m... more OBJECT Although generally safe and effective, surgery for the treatment of cervical spondylotic myelopathy (CSM) is associated with complications in 11%-38% of patients. Several predictors of postoperative complications have been proposed but few are used to detect high-risk patients. A standard approach to identifying "at-risk" patients would improve surgeons' ability to prevent and manage these complications. The authors aimed to compare the complication rates between various surgical procedures used to treat CSM and to identify patient-specific, clinical, imaging, and surgical predictors of complications. METHODS The authors conducted a systematic review of the literature and searched MEDLINE, MEDLINE in Process, EMBASE, and Cochrane Central Register of Controlled Trials from 1948 to September 2013. Cohort studies designed to evaluate predictors of complications and intervention studies conducted to compare different surgical approaches were included. Each article w...
The Spine Journal, 2015
Surgery for cervical spondylotic myelopathy (CSM) is generally safe and effective. Nonetheless, c... more Surgery for cervical spondylotic myelopathy (CSM) is generally safe and effective. Nonetheless, complications occur in 11% to 38% of patients. Knowledge of important complication predictors will help clinicians identify high-risk patients and institute prevention and management strategies. To identify clinical and surgical predictors of perioperative complications in CSM patients. Four hundred seventy-nine surgical CSM patients were enrolled in the prospective CSM-International study at 16 sites. A panel of physicians reviewed all adverse events and classified each as related or unrelated to surgery. Univariate analyses were performed to determine differences between patients who experienced a perioperative complication and those who did not. A complication prediction rule was developed by using multiple logistic regression. Seventy-eight patients experienced 89 perioperative complications (16.25%). On univariate analysis, the major clinical risk factors were ossification of the posterior longitudinal ligament (OPLL) (P = .055), number of comorbidities (P = .002), comorbidity score (P = .006), diabetes mellitus (P = .001), and coexisting gastrointestinal (P = .039) and cardiovascular (P = .046) disorders. Patients undergoing a 2-stage surgery (P = .002) and those with a longer operative duration (P = .001) were at greater risk of perioperative complications. A final prediction model consisted of diabetes mellitus (odds ratio [OR] = 1.96, P = .060), number of comorbidities (OR = 1.20, P = .069), operative duration (OR = 1.07, P = .002), and OPLL (OR = 1.75, P = .040). Surgical CSM patients have a higher risk of perioperative complications if they have a greater number of comorbidities, coexisting diabetes mellitus, OPLL, and longer operative duration. Surgeons can use this information to discuss the risks and benefits of surgery with patients, to plan case-specific preventive strategies, and to ensure appropriate management in the perioperative period. BMI, body mass indexCSM, cervical spondylotic myelopathymJOA, modified Japanese Orthopaedic AssociationOPLL, ossification of the posterior longitudinal ligament.
Journal of neurology, neurosurgery, and psychiatry, Jan 29, 2015
In general, older patients with degenerative cervical myelopathy (DCM) are felt to have lower rec... more In general, older patients with degenerative cervical myelopathy (DCM) are felt to have lower recovery potential following surgery due to increased degenerative pathology, comorbidities, reduced physiological reserves and age-related changes to the spinal cord. This study aims to determine whether age truly is an independent predictor of surgical outcome and to provide evidence to guide practice and decision-making. A total of 479 patients with DCM were prospectively enrolled in the CSM-International study at 16 centres. Our sample was divided into a younger group (<65 years) and an elderly (≥65 years) group. A mixed model analytic approach was used to evaluate differences in the modified Japanese Orthopaedic Association (mJOA), Nurick, Short Form-36 (SF-36) and Neck Disability Index (NDI) scores between groups. We first created an unadjusted model between age and surgical outcome and then developed two adjusted models that accounted for variations in (1) baseline characteristics...
Global Spine Journal, 2015
Spine, Jan 27, 2015
Prospective, multicenter international cohort. To evaluate the outcome of surgical decompression ... more Prospective, multicenter international cohort. To evaluate the outcome of surgical decompression for CSM at a global level. Cervical spondylotic myelopathy (CSM) is a degenerative spine disease and the most common cause of spinal cord dysfunction worldwide. Surgery is increasingly recommended as the preferred treatment strategy for CSM to improve neurological and functional status and quality of life. The outcomes of surgical intervention for CSM have never been evaluated at an international level. Between October 2007 and January 2011, 479 symptomatic patients with image-evidence of CSM were enrolled in the prospective, multicenter AOSpine CSM-International study from sixteen global sites. Preoperative and postoperative clinical status, functional impairment and quality of life were evaluated using the modified Japanese Orthopaedic Assessment Scale (mJOA), Nurick Scale, Neck Disability Index (NDI) and Short-Form-36v2. Preoperative and 12- and 24-months postoperative outcomes were c...
Spine, 2015
Prospective cohort studyObjective. To determine whether MRI parameters improve the predictive per... more Prospective cohort studyObjective. To determine whether MRI parameters improve the predictive performance of a validated clinical prediction rule used to assess functional outcomes in surgical DCM patients. Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in the elderly worldwide. A clinical prediction rule was developed to discriminate between patients with mild myelopathy postoperatively (mJOA≥16) and those with substantial residual neurological impairment (mJOA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;16). Recently, a separate MRI-based prediction model was also created. However, a model exploring the combined predictive value of imaging and clinical variables does not exist. One hundred and fourteen patients with MRIs were examined from a cohort of 278 patients enrolled in the AOSpine CSM-North America Study. Ninety-nine patients had complete preoperative imaging and postoperative outcome data. MRIs were evaluated for presence/absence of signal change on T2- and T1-weighted images. Quantitative analysis of the T2 signal change was conducted and maximum canal compromise (MCC) and cord compression (MSCC) were calculated. The added predictive performance of each MRI parameter to the clinical model was evaluated using receiver operator characteristic (ROC) curves. The model developed on our subsample yielded an area under the receiver operating curve (AUC) of 0.811 (95%C.I.: 0.726-0.896). The addition of imaging variables did not significantly improve the predictive performance. Small improvements in prediction were obtained when sagittal extent of T2 hyperintensity (AUC: 0.826, 95%C.I.: 0.743-0.908, 1.35% increase) or Wang&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s ratio (AUC: 0.823, 95%C.I.: 0.739-0.907, 1.21%) were added. Anatomic characteristics, such as MSCC and MCC, did not improve the discriminative ability of the clinical prediction model. In our sample of surgical patients, with clinical and image-evidence of DCM, MRI parameters do not significantly add to the predictive performance of a previously published clinical prediction rule. It remains plausible that combinations of the strongest clinical and MRI predictors may yield a similar or superior prediction model.
Global Spine Journal, 2015
Objective To evaluate the prevalence of Klippel-Feil syndrome (KFS) in a prospective data set of ... more Objective To evaluate the prevalence of Klippel-Feil syndrome (KFS) in a prospective data set of patients undergoing surgical treatment for cervical spondylotic myelopathy (CSM) and to evaluate if magnetic resonance imaging (MRI) features in patients with KFS are more pronounced than those of non-KFS patients with CSM. Methods A retrospective analysis of baseline MRI data from the AOSpine prospective and multicenter CSM-North American study was conducted. All the patients presented with at least one clinical sign of myelopathy and underwent decompression surgery. The MRIs and radiographs were reviewed by three investigators. The clinical and imaging findings were compared with patients without KFS but with CSM. Results Imaging analysis discovered 5 of 131 patients with CSM ($3.82%) had singlelevel congenital fusion of the cervical spine. The site of fusion differed for all the patients. One patient underwent posterior surgery and four patients received anterior surgery. Postoperative follow-up was available for four of the five patients with KFS and indicated stable or improved functional status. All five patients demonstrated pathologic changes of adjacent segments and hyperintensity signal changes in the spinal cord on T2-weighted MRI. Multiple MRI features, most notably maximum canal compromise (p ¼ 0.05) and T2 signal hyperintensity area (p ¼ 0.05), were worse in patients with CSM and KFS. Conclusions The high prevalence of KFS in our surgical series of patients with CSM may serve as an indication that these patients are prone to increased biomechanical use of segments adjacent to fused vertebra. This supposition is supported by a tendency of patients with KFS to present with more extensive MRI evidence of degeneration than non-KFS patients with CSM.
The Spine Journal, 2014
ABSTRACT Symptomatic Metastatic Epidural Spinal Cord Compression (MESCC) afflicts up to 10% of al... more ABSTRACT Symptomatic Metastatic Epidural Spinal Cord Compression (MESCC) afflicts up to 10% of all cancer patients and is associated with shortened survival and worsened quality of life. This study aims to identify the key survival prognostic factors in MESCC patients who were surgically treated for a single symptomatic lesion. One hundred forty-two MESCC patients were enrolled in a prospective North American multicenter study and followed postoperatively for 12 months. With the use of univariate analyses, Kaplan-Meier methods, and log-rank tests, the prognostic value of various clinical predictors were assessed. Noncollinear predictors with P < .05 in univariate analyses were included in the final Cox proportional hazards model. The overall median survival was 7.7 months (range: 3 days-35.6 months); breast cancer had the longest median survival (12.1 months). Ten patients (7%), whose primary cancer was lung (3), kidney (3), sarcoma (2), prostate (1), and breast (1), died within 30 days postoperatively, and 88 had died at 12 months (62%). Univariate analyses yielded 8 significant predictors for survival: the growth of primary tumor (Tomita grade 1 vs grade 2 and 3), body mass index, sex, preoperative SF-36 physical component, EQ-5D, and Oswestry Disability Index (ODI) scores, as well as the presence of either visceral or extraspinal bony metastasis. The multiple regression analysis revealed that the Tomita grade (grade 1 vs grade 2 and 3; HR 2.81, P = .0007), the absence of visceral metastasis (HR 2.01; P = .0044), and higher score on SF-36 physical component (HR 0.945, P < .0001) were independent predictors for longer survival regardless of the selection method used (backward, forward, or stepwise). Slow-growing tumor (Tomita grade 1), absence of visceral metastasis, and lower degree of preoperative physical disability, as reflected by a higher score on the SF-36 physical component questionnaire, are good prognostic factors for survival in selected patients who underwent surgical treatment for a focal symptomatic MESCC lesion.
Spine, Jan 2, 2015
ReviewObjective. To formally introduce 'Degenerative Cervical Myelopathy' as the overarch... more ReviewObjective. To formally introduce 'Degenerative Cervical Myelopathy' as the overarching term to describe the various degenerative conditions of the cervical spine that cause myelopathy. Herein, the epidemiology, pathogenesis and genetics of conditions falling under this hypernym are carefully described. Non-traumatic, degenerative forms of cervical myelopathy represent the commonest cause of spinal cord impairment in adults and include Cervical Spondylotic Myelopathy (CSM), Ossification of the Posterior Longitudinal Ligament (OPLL), Ossification of the Ligamentum Flavum (OLF), and Degenerative Disc Disease (DDD). Unfortunately, there is neither a specific term nor specific diagnostic ICD-10 code to describe this collection of clinical entities. This has resulted in the inconsistent use of diagnostic terms when referring to patients with myelopathy due to degenerative disease of the cervical spine. Narrative review. The incidence and prevalence of myelopathy due to degen...
World Neurosurgery, 2015
Surgery for the treatment of cervical spondylotic myelopathy (CSM) is typically accompanied by co... more Surgery for the treatment of cervical spondylotic myelopathy (CSM) is typically accompanied by complication rates between 11% and 38%. By determining clinical and surgical predictors of complications, clinicians can identify high-risk patients and plan accordingly. This study aims to conduct a survey of the AOSpine community to identify key predictors of postoperative complications. Members of AOSpine International were invited participate. The survey was divided into three sections. The first and second sections focused on key clinical and imaging risk factors. The third section was designed to determine whether rates of complications differ depending on surgical approach, procedure, number of stages and use of fusion. Results from the entire sample and from each geographic region were analyzed. Nine-hundred and sixteen participants completed the survey. The presence of co-morbidities was ranked as the most important clinical predictor of complications. The majority of respondents believed that patients with diabetes are at a higher risk of cardiac complications (69.75%) and wound infections (95.0%) than non-diabetics. Regarding surgical technique, 40% of professionals reported higher complication rates in posterior compared to anterior surgery, while 30% believed there is no difference. The types of complications vary significantly between approaches. On the other hand, rates of dysphagia, wound infection, dural tear and C5 radiculopathy are similar between posterior techniques. This survey summarizes surgeons&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perceptions of the most important clinical, imaging and surgical risk factors for postoperative complications. Knowledge of these predictors will allow clinicians to identify high-risk patients and the institution of prevention plans.
Science translational medicine, Jan 2, 2015
Although surgical decompression is considered the gold standard treatment for cervical spondyloti... more Although surgical decompression is considered the gold standard treatment for cervical spondylotic myelopathy (CSM), a proportion of cases show postoperative decline or continue to exhibit substantial neurological dysfunction. To investigate this further, we first examined data from the prospective multicenter AOSpine North America CSM study, finding that 9.3% of patients exhibited postoperative functional decline (ΔmJOA, ≤-1) and that 44% of patients were left with substantial neurological impairment 6 months postoperatively. Notably, 4% of patients experienced perioperative neurological complications within 20 days after surgery in otherwise uneventful surgeries. To shed light on the mechanisms underlying this phenomenon and to test a combination therapeutic strategy for CSM, we performed surgical decompression in a rat model of CSM, randomizing some animals to also receive the U.S. Food and Drug Administration-approved drug riluzole. Spinal cord blood flow measurements increased ...
Spine, Oct 22, 2014
Prospective study. This study aims to determine the psychometric properties of the modified Japan... more Prospective study. This study aims to determine the psychometric properties of the modified Japanese Orthopaedic Association (mJOA) scale. Several outcome measures assess functional impairment and quality of life in patients with cervical myelopathy. However, a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;gold standard&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; has not been established. One of the most widely accepted tools for assessing functional status is the mJOA scale. Two hundred and seventy-seven surgical patients with cervical spondylotic myelopathy were enrolled in the prospective cervical spondylotic myelopathy-North America study. Functional status was evaluated at baseline and at 6, 12, and 24 months postoperatively. The internal consistency of the mJOA was assessed by computing a Cronbach α for the total score and after removing 1 item at a time. Convergent validity and divergent validity were measured by correlating the mJOA with other assessment tools. The responsiveness of the scale was determined by comparing mJOA scores at baseline and 12 months after surgery and computing a Cohen effect size. The internal consistency of the scale was moderate with a Cronbach α of 0.63. Sphincter dysfunction measured a different dimension than the other 3 scale components. The mJOA was correlated with the Nurick score (r =-0.625) but was not associated with subscales of the Short-Form 36 that measure different constructs. These findings suggest convergent and divergent validity. The mJOA was responsive to change as reflected by a Cohen effect size of 1. The mJOA is a useful tool in the assessment of cervical spondylotic myelopathy and it should be adopted as the standard for evaluating functional status in this population.
Journal of clinical oncology : official journal of the American Society of Clinical Oncology, Jan 23, 2015
Although surgery is used increasingly as a strategy to complement treatment with radiation and ch... more Although surgery is used increasingly as a strategy to complement treatment with radiation and chemotherapy in patients with metastatic epidural spinal cord compression (MESCC), the impact of surgery on health-related quality of life (HRQoL) is not well established. We aimed to prospectively evaluate survival, neurologic, functional, and HRQoL outcomes in patients with MESCC who underwent surgical management. One hundred forty-two patients with a single symptomatic MESCC lesion who were treated surgically were enrolled onto a prospective North American multicenter study and were observed at least up to 12 months. Clinical data, including Brief Pain Inventory, ASIA (American Spinal Injury Association) impairment scale, SF-36 Short Form Health Survey, Oswestry Disability Index, and EuroQol 5 dimensions (EQ-5D) scores, were obtained preoperatively, and at 6 weeks and 3, 6, 9, and 12 months postoperatively. Median survival time was 7.7 months. The 30-day and 12-month mortality rates wer...
Neurosurgery, 2015
: Cervical spinal cord dysfunction can result from either traumatic or nontraumatic causes, inclu... more : Cervical spinal cord dysfunction can result from either traumatic or nontraumatic causes, including tumors, infections, and degenerative changes. In this article, we review the range of degenerative spinal disorders resulting in progressive cervical spinal cord compression and propose the adoption of a new term, degenerative cervical myelopathy (DCM). DCM comprises both osteoarthritic changes to the spine, including spondylosis, disk herniation, and facet arthropathy (collectively referred to as cervical spondylotic myelopathy), and ligamentous aberrations such as ossification of the posterior longitudinal ligament and hypertrophy of the ligamentum flavum. This review summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood-spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies. CSM, cervical spondylotic myelopathyDCM, degenerative cervical myelopathyJOA, Japanese Orthopaedic AssociationmJOA, modified Japanese Orthopaedic AssociationOPLL, ossification of the posterior longitudinal ligamentSCI, spinal cord injury.
Spine, 2015
Analysis of the prospective AOSpine CSM-International and North America datasets and survey of AO... more Analysis of the prospective AOSpine CSM-International and North America datasets and survey of AO Spine International. This study aims to define the minimum clinically important difference (MCID) of the modified Japanese Orthopaedic Association (mJOA) in patients with degenerative cervical myelopathy (DCM). The mJOA is the most frequently used clinician-administered tool to assess functional status in patients with DCM. By defining its MCID, clinicians can better evaluate treatment outcomes for this condition. Three methods were used to determine the MCID of the mJOA: (1) distribution-based, (2) anchor-based and receiver operating characteristic (ROC) analysis, and (3) professional opinion. Distribution-based methods were used to estimate the MCID by computing the half standard deviation and standard error of measurement. Using anchor-based methods, mJOA at 12 months after surgery was compared between patients who were "slightly improved" on the Neck Disability Index (NDI)...
The spine journal : official journal of the North American Spine Society, 2015
Journal of neurosurgery. Spine, Jan 25, 2015
OBJECT Although generally safe and effective, surgery for the treatment of cervical spondylotic m... more OBJECT Although generally safe and effective, surgery for the treatment of cervical spondylotic myelopathy (CSM) is associated with complications in 11%-38% of patients. Several predictors of postoperative complications have been proposed but few are used to detect high-risk patients. A standard approach to identifying "at-risk" patients would improve surgeons' ability to prevent and manage these complications. The authors aimed to compare the complication rates between various surgical procedures used to treat CSM and to identify patient-specific, clinical, imaging, and surgical predictors of complications. METHODS The authors conducted a systematic review of the literature and searched MEDLINE, MEDLINE in Process, EMBASE, and Cochrane Central Register of Controlled Trials from 1948 to September 2013. Cohort studies designed to evaluate predictors of complications and intervention studies conducted to compare different surgical approaches were included. Each article w...
The Spine Journal, 2015
Surgery for cervical spondylotic myelopathy (CSM) is generally safe and effective. Nonetheless, c... more Surgery for cervical spondylotic myelopathy (CSM) is generally safe and effective. Nonetheless, complications occur in 11% to 38% of patients. Knowledge of important complication predictors will help clinicians identify high-risk patients and institute prevention and management strategies. To identify clinical and surgical predictors of perioperative complications in CSM patients. Four hundred seventy-nine surgical CSM patients were enrolled in the prospective CSM-International study at 16 sites. A panel of physicians reviewed all adverse events and classified each as related or unrelated to surgery. Univariate analyses were performed to determine differences between patients who experienced a perioperative complication and those who did not. A complication prediction rule was developed by using multiple logistic regression. Seventy-eight patients experienced 89 perioperative complications (16.25%). On univariate analysis, the major clinical risk factors were ossification of the posterior longitudinal ligament (OPLL) (P = .055), number of comorbidities (P = .002), comorbidity score (P = .006), diabetes mellitus (P = .001), and coexisting gastrointestinal (P = .039) and cardiovascular (P = .046) disorders. Patients undergoing a 2-stage surgery (P = .002) and those with a longer operative duration (P = .001) were at greater risk of perioperative complications. A final prediction model consisted of diabetes mellitus (odds ratio [OR] = 1.96, P = .060), number of comorbidities (OR = 1.20, P = .069), operative duration (OR = 1.07, P = .002), and OPLL (OR = 1.75, P = .040). Surgical CSM patients have a higher risk of perioperative complications if they have a greater number of comorbidities, coexisting diabetes mellitus, OPLL, and longer operative duration. Surgeons can use this information to discuss the risks and benefits of surgery with patients, to plan case-specific preventive strategies, and to ensure appropriate management in the perioperative period. BMI, body mass indexCSM, cervical spondylotic myelopathymJOA, modified Japanese Orthopaedic AssociationOPLL, ossification of the posterior longitudinal ligament.
Journal of neurology, neurosurgery, and psychiatry, Jan 29, 2015
In general, older patients with degenerative cervical myelopathy (DCM) are felt to have lower rec... more In general, older patients with degenerative cervical myelopathy (DCM) are felt to have lower recovery potential following surgery due to increased degenerative pathology, comorbidities, reduced physiological reserves and age-related changes to the spinal cord. This study aims to determine whether age truly is an independent predictor of surgical outcome and to provide evidence to guide practice and decision-making. A total of 479 patients with DCM were prospectively enrolled in the CSM-International study at 16 centres. Our sample was divided into a younger group (<65 years) and an elderly (≥65 years) group. A mixed model analytic approach was used to evaluate differences in the modified Japanese Orthopaedic Association (mJOA), Nurick, Short Form-36 (SF-36) and Neck Disability Index (NDI) scores between groups. We first created an unadjusted model between age and surgical outcome and then developed two adjusted models that accounted for variations in (1) baseline characteristics...
Global Spine Journal, 2015
Spine, Jan 27, 2015
Prospective, multicenter international cohort. To evaluate the outcome of surgical decompression ... more Prospective, multicenter international cohort. To evaluate the outcome of surgical decompression for CSM at a global level. Cervical spondylotic myelopathy (CSM) is a degenerative spine disease and the most common cause of spinal cord dysfunction worldwide. Surgery is increasingly recommended as the preferred treatment strategy for CSM to improve neurological and functional status and quality of life. The outcomes of surgical intervention for CSM have never been evaluated at an international level. Between October 2007 and January 2011, 479 symptomatic patients with image-evidence of CSM were enrolled in the prospective, multicenter AOSpine CSM-International study from sixteen global sites. Preoperative and postoperative clinical status, functional impairment and quality of life were evaluated using the modified Japanese Orthopaedic Assessment Scale (mJOA), Nurick Scale, Neck Disability Index (NDI) and Short-Form-36v2. Preoperative and 12- and 24-months postoperative outcomes were c...
Spine, 2015
Prospective cohort studyObjective. To determine whether MRI parameters improve the predictive per... more Prospective cohort studyObjective. To determine whether MRI parameters improve the predictive performance of a validated clinical prediction rule used to assess functional outcomes in surgical DCM patients. Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in the elderly worldwide. A clinical prediction rule was developed to discriminate between patients with mild myelopathy postoperatively (mJOA≥16) and those with substantial residual neurological impairment (mJOA&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;16). Recently, a separate MRI-based prediction model was also created. However, a model exploring the combined predictive value of imaging and clinical variables does not exist. One hundred and fourteen patients with MRIs were examined from a cohort of 278 patients enrolled in the AOSpine CSM-North America Study. Ninety-nine patients had complete preoperative imaging and postoperative outcome data. MRIs were evaluated for presence/absence of signal change on T2- and T1-weighted images. Quantitative analysis of the T2 signal change was conducted and maximum canal compromise (MCC) and cord compression (MSCC) were calculated. The added predictive performance of each MRI parameter to the clinical model was evaluated using receiver operator characteristic (ROC) curves. The model developed on our subsample yielded an area under the receiver operating curve (AUC) of 0.811 (95%C.I.: 0.726-0.896). The addition of imaging variables did not significantly improve the predictive performance. Small improvements in prediction were obtained when sagittal extent of T2 hyperintensity (AUC: 0.826, 95%C.I.: 0.743-0.908, 1.35% increase) or Wang&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s ratio (AUC: 0.823, 95%C.I.: 0.739-0.907, 1.21%) were added. Anatomic characteristics, such as MSCC and MCC, did not improve the discriminative ability of the clinical prediction model. In our sample of surgical patients, with clinical and image-evidence of DCM, MRI parameters do not significantly add to the predictive performance of a previously published clinical prediction rule. It remains plausible that combinations of the strongest clinical and MRI predictors may yield a similar or superior prediction model.
Global Spine Journal, 2015
Objective To evaluate the prevalence of Klippel-Feil syndrome (KFS) in a prospective data set of ... more Objective To evaluate the prevalence of Klippel-Feil syndrome (KFS) in a prospective data set of patients undergoing surgical treatment for cervical spondylotic myelopathy (CSM) and to evaluate if magnetic resonance imaging (MRI) features in patients with KFS are more pronounced than those of non-KFS patients with CSM. Methods A retrospective analysis of baseline MRI data from the AOSpine prospective and multicenter CSM-North American study was conducted. All the patients presented with at least one clinical sign of myelopathy and underwent decompression surgery. The MRIs and radiographs were reviewed by three investigators. The clinical and imaging findings were compared with patients without KFS but with CSM. Results Imaging analysis discovered 5 of 131 patients with CSM ($3.82%) had singlelevel congenital fusion of the cervical spine. The site of fusion differed for all the patients. One patient underwent posterior surgery and four patients received anterior surgery. Postoperative follow-up was available for four of the five patients with KFS and indicated stable or improved functional status. All five patients demonstrated pathologic changes of adjacent segments and hyperintensity signal changes in the spinal cord on T2-weighted MRI. Multiple MRI features, most notably maximum canal compromise (p ¼ 0.05) and T2 signal hyperintensity area (p ¼ 0.05), were worse in patients with CSM and KFS. Conclusions The high prevalence of KFS in our surgical series of patients with CSM may serve as an indication that these patients are prone to increased biomechanical use of segments adjacent to fused vertebra. This supposition is supported by a tendency of patients with KFS to present with more extensive MRI evidence of degeneration than non-KFS patients with CSM.
The Spine Journal, 2014
ABSTRACT Symptomatic Metastatic Epidural Spinal Cord Compression (MESCC) afflicts up to 10% of al... more ABSTRACT Symptomatic Metastatic Epidural Spinal Cord Compression (MESCC) afflicts up to 10% of all cancer patients and is associated with shortened survival and worsened quality of life. This study aims to identify the key survival prognostic factors in MESCC patients who were surgically treated for a single symptomatic lesion. One hundred forty-two MESCC patients were enrolled in a prospective North American multicenter study and followed postoperatively for 12 months. With the use of univariate analyses, Kaplan-Meier methods, and log-rank tests, the prognostic value of various clinical predictors were assessed. Noncollinear predictors with P < .05 in univariate analyses were included in the final Cox proportional hazards model. The overall median survival was 7.7 months (range: 3 days-35.6 months); breast cancer had the longest median survival (12.1 months). Ten patients (7%), whose primary cancer was lung (3), kidney (3), sarcoma (2), prostate (1), and breast (1), died within 30 days postoperatively, and 88 had died at 12 months (62%). Univariate analyses yielded 8 significant predictors for survival: the growth of primary tumor (Tomita grade 1 vs grade 2 and 3), body mass index, sex, preoperative SF-36 physical component, EQ-5D, and Oswestry Disability Index (ODI) scores, as well as the presence of either visceral or extraspinal bony metastasis. The multiple regression analysis revealed that the Tomita grade (grade 1 vs grade 2 and 3; HR 2.81, P = .0007), the absence of visceral metastasis (HR 2.01; P = .0044), and higher score on SF-36 physical component (HR 0.945, P < .0001) were independent predictors for longer survival regardless of the selection method used (backward, forward, or stepwise). Slow-growing tumor (Tomita grade 1), absence of visceral metastasis, and lower degree of preoperative physical disability, as reflected by a higher score on the SF-36 physical component questionnaire, are good prognostic factors for survival in selected patients who underwent surgical treatment for a focal symptomatic MESCC lesion.
Spine, Jan 2, 2015
ReviewObjective. To formally introduce 'Degenerative Cervical Myelopathy' as the overarch... more ReviewObjective. To formally introduce 'Degenerative Cervical Myelopathy' as the overarching term to describe the various degenerative conditions of the cervical spine that cause myelopathy. Herein, the epidemiology, pathogenesis and genetics of conditions falling under this hypernym are carefully described. Non-traumatic, degenerative forms of cervical myelopathy represent the commonest cause of spinal cord impairment in adults and include Cervical Spondylotic Myelopathy (CSM), Ossification of the Posterior Longitudinal Ligament (OPLL), Ossification of the Ligamentum Flavum (OLF), and Degenerative Disc Disease (DDD). Unfortunately, there is neither a specific term nor specific diagnostic ICD-10 code to describe this collection of clinical entities. This has resulted in the inconsistent use of diagnostic terms when referring to patients with myelopathy due to degenerative disease of the cervical spine. Narrative review. The incidence and prevalence of myelopathy due to degen...
World Neurosurgery, 2015
Surgery for the treatment of cervical spondylotic myelopathy (CSM) is typically accompanied by co... more Surgery for the treatment of cervical spondylotic myelopathy (CSM) is typically accompanied by complication rates between 11% and 38%. By determining clinical and surgical predictors of complications, clinicians can identify high-risk patients and plan accordingly. This study aims to conduct a survey of the AOSpine community to identify key predictors of postoperative complications. Members of AOSpine International were invited participate. The survey was divided into three sections. The first and second sections focused on key clinical and imaging risk factors. The third section was designed to determine whether rates of complications differ depending on surgical approach, procedure, number of stages and use of fusion. Results from the entire sample and from each geographic region were analyzed. Nine-hundred and sixteen participants completed the survey. The presence of co-morbidities was ranked as the most important clinical predictor of complications. The majority of respondents believed that patients with diabetes are at a higher risk of cardiac complications (69.75%) and wound infections (95.0%) than non-diabetics. Regarding surgical technique, 40% of professionals reported higher complication rates in posterior compared to anterior surgery, while 30% believed there is no difference. The types of complications vary significantly between approaches. On the other hand, rates of dysphagia, wound infection, dural tear and C5 radiculopathy are similar between posterior techniques. This survey summarizes surgeons&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perceptions of the most important clinical, imaging and surgical risk factors for postoperative complications. Knowledge of these predictors will allow clinicians to identify high-risk patients and the institution of prevention plans.