Clinical predictors of achieving the minimal clinically important difference after surgery for cervical spondylotic myelopathy: an external validation study from the Canadian Spine Outcomes and Research Network
Clinical predictors of achieving the minimal clinically important difference after surgery for cervical spondylotic myelopathy: an external validation study from the Canadian Spine Outcomes and Research Network
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DOI：
10.3171/2020.2.spine191495
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发表时间：
2020-08-01
影响因子：
2.8
通讯作者：
Jacobs, W. Bradley
中科院分区：
文献类型：
--
作者：
Evaniew, Nathan;Cadotte, David W.;Jacobs, W. Bradley
目的：最近确定的脊髓型颈椎病（CSM）手术患者的预后变量仅限于两个大型国际数据集。为了最佳地告知共享的临床决策，作者评价了哪些术前临床因素与术后12个月至少最小临床重要差异（MCID）的改良日本骨科协会（mJOA）量表的改善显著相关，来自加拿大脊柱结局和研究网络（CSORN）的患者中方法：作者进行了一项观察性队列研究，数据前瞻性收集自2015年至2017年7家中心的CSM患者。使用单变量和多项二项logistic回归对候选变量进行了检验，并进行了多项敏感性分析，以检验有关统计模型性质的假设。实施了经验证的mJOA MCID，其根据基线CSM严重程度而有所不同。结果在205名CSM患者中，有64名（31%）被归类为轻度，86名（42%）被归类为中度，55名（27%）被归类为重度。总体而言，52%的患者实现了MCID，术后12个月mJOA评分的平均变化为1.7 +/- 2.6分（p < 0.01），但轻度CSM患者亚组没有显著改善（平均变化0.1 +/- 1.9分，p = 0.8）。单变量分析未能确定MCID与性别、BMI、生活状况、教育、吸烟、残疾索赔或合并症数量之间的显著相关性。调整潜在混杂因素后，年龄越大（OR 0.7/10，95% CI 0.5-0.9，p < 0.01）和基线mJOA评分越高（OR 0.8/分，95% CI 0.7-0.9，p < 0.01），MCID的发生率显著降低。症状持续时间（OR 1.0每增加一个月，95%CI 0.9-1.0，p = 0.2）和吸烟（OR 0.4，95%CI 0.2-1.0，p = 0.06）的影响没有统计学意义。结论手术是有效的，在停止与CSM功能下降的进展，大约一半的患者实现MCID。来自CSORN的数据证实，年龄较大与预后较差独立相关，但新的发现包括轻度CSM患者没有出现有意义的改善，症状持续时间和吸烟并不重要。这些发现支持了一种细致入微的共同决策方法，即在权衡各种风险、获益和手术治疗替代方案时，承认存在一些预后不确定性。
OBJECTIVE Recently identified prognostic variables among patients undergoing surgery for cervical spondylotic myelopathy (CSM) are limited to two large international data sets. To optimally inform shared clinical decision-making, the authors evaluated which preoperative clinical factors are significantly associated with improvement on the modified Japanese Orthopaedic Association (mJOA) scale by at least the minimum clinically important difference (MCID) 12 months after surgery, among patients from the Canadian Spine Outcomes and Research Network (CSORN).METHODS The authors performed an observational cohort study with data that were prospectively collected from CSM patients at 7 centers between 2015 and 2017. Candidate variables were tested using univariable and multiple binomial logistic regression, and multiple sensitivity analyses were performed to test assumptions about the nature of the statistical models. Validated mJOA MCIDs were implemented that varied according to baseline CSM severity.RESULTS Among 205 patients with CSM, there were 64 (31%) classified as mild, 86 (42%) as moderate, and 55 (27%) as severe. Overall, 52% of patients achieved MCID and the mean change in mJOA score at 12 months after surgery was 1.7 +/- 2.6 points (p < 0.01), but the subgroup of patients with mild CSM did not significantly improve (mean change 0.1 +/- 1.9 points, p = 0.8). Univariate analyses failed to identify significant associations between achieving MCID and sex, BMI, living status, education, smoking, disability claims, or number of comorbidities. After adjustment for potential confounders, the odds of achieving MCID were significantly reduced with older age (OR 0.7 per decade, 95% CI 0.5-0.9, p < 0.01) and higher baseline mJOA score (OR 0.8 per point, 95% CI 0.7-0.9, p < 0.01). The effects of symptom duration (OR 1.0 per additional month, 95% CI 0.9-1.0, p = 0.2) and smoking (OR 0.4, 95% CI 0.2-1.0, p = 0.06) were not statistically significant.CONCLUSIONS Surgery is effective at halting the progression of functional decline with CSM, and approximately half of all patients achieve the MCID. Data from the CSORN confirmed that older age is independently associated with poorer outcomes, but novel findings include that patients with milder CSM did not experience meaningful improvement, and that symptom duration and smoking were not important. These findings support a nuanced approach to shared decision-making that acknowledges some prognostic uncertainty when weighing the various risks, benefits, and alternatives to surgical treatment.