Prediction of 2-year clinical outcome trajectories in patients undergoing anterior cervical discectomy and fusion for spondylotic radiculopathy

Abstract

OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes. METHODS In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models. RESULTS The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%–23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health–related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome. CONCLUSIONS Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%–23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.

Variations in 1-year Trajectories of Levels of Pain and Capability After Shoulder Arthroplasty Are Associated With Baseline Mental Health

“…The observation that worse mental health is associated with greater pain intensity and magnitude of incapability throughout the recovery course, independent of arthroplasty type, confirms that comfort and capability achieved by shoulder arthroplasty can be limited by modifiable mindset factors and supports the comprehensive, biopsychosocial treatment of musculoskeletal illness. This aligns with other studies of recovery trajectories after musculoskeletal surgery finding that unhealthier mindsets are associated with greater pain [11] and capability [14,15] at baseline and until 2 years after surgery, as well as less likelihood that a patient will gain substantial benefits from surgery [37]. Baseline pain intensity was worse on average for people requesting revision arthroplasty [12].…”

“…Variations in pain intensity and magnitude of incapability have a limited association with pathophysiologic severity and are accounted for largely by variation in unhelpful thoughts and distress about symptoms [11,13,14,24]. Recent evidence suggests that recovery of comfort and capability over the course of 2 years after injury and surgery is tied to baseline mental health status [11].…”

“…Variations in pain intensity and magnitude of incapability have a limited association with pathophysiologic severity and are accounted for largely by variation in unhelpful thoughts and distress about symptoms [11,13,14,24]. Recent evidence suggests that recovery of comfort and capability over the course of 2 years after injury and surgery is tied to baseline mental health status [11]. Our study of trajectories of pain intensity and magnitude of capability after shoulder arthroplasty based on quartiles of the MCS found that people with a less healthy mindset had worse baseline levels of pain and capability with no differences in rates of recovery, suggesting that outcomes are worse throughout the trajectory if mental health is not addressed.…”

Geospatial Evaluation of Disparities in Access to Cervical Spine Fusion in Metropolitan Areas Across the United States

“…The association between race and delays in treatment has been noted previously by Elsamadicy et al 24 , who found race to be a predictor of the temporal delay of cervical stenosis treatment. According to Hébert et al, these delays in treatment have been shown to worsen surgical outcomes across the board in those needing cervical spine fusions 25 . Many studies analyzing not only cervical spine fusion but also spine surgery in general have also identified racial disparities in both utilization and outcomes.…”

“…According to Hébert et al, these delays in treatment have been shown to worsen surgical outcomes across the board in those needing cervical spine fusions. 25 Many studies analyzing not only cervical spine fusion but also spine surgery in general have also identified racial disparities in both utilization and outcomes. Amen et al 26 found that white patients were nearly twice as likely as Black patients to utilize outpatient cervical spine procedures, while another study by Elsamadicy et al 27 found that Black patients had higher lengths of stay and complication rates in cervical spine fusions.…”