C-Spine Outcome

c-spine outcome
Title: Outcome in Patients with Cervical Radiculopathy: Prospective, Multicentre Study With Independent Clinical Review

Reference: Spine, Volume 24, Number 6, pg 591-197, 1999
Sampath, Bendebba, Drucker, Dept of Neurosurgery, John Hopkins, Baltimore

Main Message

Surgically treated patients had a significant improvement in pain, neurologic symptoms, functional status, and ability to perform activities of daily living, but a significant number of those who underwent surgery reported persistent excruciating or horrible pain. Also, medically treated patients ALSO had significant improvement in pain and overall functional status.

Points of Interest

Why did they do this study?

Cervical spondylotic or degenerative radiculopathy is common, and has a number of etiologies (disc herniation, disc degeneration, anterior cervical osteophytes, poterolatera/uncal osteophytes, facet hypertrophy). Radicular symptoms tend to resolve in time with minimal or no treatment. Surgical intervention is reserved for patients “with unremitting and progressive symptoms in whom medical treatment has failed,” but these criteria remain vague and nebulous. Detailed, prospective blinded outcome assessments have not been done.

The study was set up as a multicenter, nonrandomized blinded outcome assessment using patients from 41 surgeons. The outcome measures were: average and worst pain severity, overall patient satisfaction, neurologic parameters, functional status measurements, and ADLs. These were assessed rather grossly, using telephone survey. The inclusion criteria were pretty standard, but two weird things stuck out – patients who had one surgery prior were NOT excluded (8% had already undergone one operation), and there was no mention of WBC/ICBC type claims.

249 patients were enrolled. 160 (65%) had medical treatment recommended, 86 (35%) had surgery recommended. The reasons for surgical treatment were not described, and would vary amongst the 41 surgeons. In general, the surgical group had higher pain scores, higher opiate use, and higher restriction of their ADL’s. 155 (63%) returned for followup and completed the questionnaire – 67% had medical treatment, 33% had surgery.

Pain: Both groups had statistically significant improvements in pain, with more improvement in the surgical group.

Patient Satisfaction: the surgical group had a higher satisfaction rating – bias?

Neurologic Outcome: both groups had improvements in neurologic symptoms; the improvement was only statistically significant in the surgical group.

Functional Status: both groups had statistically significant improvements in overall function, with more improvement in the surgical group.

ADL’s: the surgical group had a statistically significant improvement (but started out worse than the medical group).

Thoughts….

Interesting paper, with some major flaws:

– there was no randomization, so comparing the two groups directly is technically not possible – YET, the authors DID compare the two groups despite saying that this comparison could not be performed. Weird. The blatant fact (which the authors point out) is that the groups were DIFFERENT before they started – there are significant differences in pain, ADL’s, functional status, between the two groups before the treatment was initiated!

– there was a fairly high drop out rate (37%)

– there was no indication of what the indications for surgery were. Amongst 41 surgeons, it is hard to imagine that everyone’s surgical indications were the same.

The most interesting observation, is that “even in the (surgical group), 26% of patients still described their worst pain to be horrible or excruciating, and 31% reported their average pain to be distressing or discomforting. Therefore, it would appear that, at best, only 75% of patients were “cured” of their pain after surgical treatment. This is somewhat surprising, given that most outcome studies of cervical radiculopathy report higher rate or excellent outcomes than were