Loading [Contrib]/a11y/accessibility-menu.js
Skip to main content
null
J Orthopaedic Experience & Innovation
  • Menu
  • Articles
    • Brief Report
    • Case Report
    • Data Paper
    • Editorial
    • Hand
    • Meeting Reports/Abstracts
    • Methods Article
    • Product Review
    • Research Article
    • Review Article
    • Review Articles
    • Systematic Review
    • All
  • For Authors
  • Editorial Board
  • About
  • Issues
  • Blog
  • "Open Mic" Topic Sessions
  • Advertisers
  • Recorded Content
  • CME
  • JOEI KOL Connect
  • search

RSS Feed

Enter the URL below into your favorite RSS reader.

http://localhost:40118/feed
Research Article
Vol. 3, Issue 1, 2022May 07, 2022 EDT

Risk Factors for MCID Drop-Off in Patients Undergoing Anterior Cervical Discectomy and Fusion

Madhav R. Patel, BS, Kevin C. Jacob, BS, Alexander W. Parsons, MS, Nisheka N. Vanjani, BS, Elliot D.K. Cha, MS, Conor P. Lynch, MS, Michael C. Prabhu, BS, Hanna Pawlowski, BS, Kern Singh, MD,
anterior cervical discectomy and fusion = ACDFminimum clinically important difference = MCIDpatient reported outcomes = PRO
Copyright Logoccby-nc-nd-4.0
J Orthopaedic Experience & Innovation
Patel, Madhav R., Kevin C. Jacob, Alexander W. Parsons, Nisheka N. Vanjani, Elliot D.K. Cha, Conor P. Lynch, Michael C. Prabhu, Hanna Pawlowski, and Kern Singh. 2022. “Risk Factors for MCID Drop-Off in Patients Undergoing Anterior Cervical Discectomy and Fusion.” Journal of Orthopaedic Experience & Innovation 3 (1).
Save article as...▾

View more stats

Abstract

Background

Some patients may achieve a minimum clinically important difference (MCID) at an early postoperative time point, but these are not always retained long-term. We aim to characterize risk factors for regressing below a level of meaningful improvement in patients who had previously achieved an MCID following anterior cervical discectomy and fusion (ACDF).

Methods

A prospectively maintained surgical database was retrospectively reviewed for ACDF procedures. PROMs including visual analogue scale (VAS), Neck Disability Index (NDI), 12-Item Short Form Physical Component Summary (SF-12 PCS), Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF), and Patient Health Questionnaire-9 (PHQ-9) were administered at preoperative and postoperative time points. MCID achievement was assessed by comparing postoperative improvements in PROM scores from preoperative baseline to the previously established threshold values.

Results

A total of 351 ACDF patients were included: 204 patients underwent single level procedures and 147 underwent multi-level ACDF. The greatest proportions of patients achieved MCID for VAS neck at 6-months (56.3%), VAS arm at 6-months (38.5%), NDI at 6-months (68.1%), SF-12 PCS at 6-months (45.1%), and PROMIS-PF at 1-year (69.0%) Significant predictors for MCID drop-off were: Preoperative PHQ-9 (RR 1.1, p=0.011) , smoker status (RR 2.2, p=0.038) and preoperative VAS arm (RR 1.2, p=0.001) for VAS arm , none for NDI, and BMI (RR 1.1, p=0.006) for PROMIS PF.

Conclusion

Highest rates of MCID achievement were 6-months following ACDF. Higher BMI, greater preoperative arm pain, smoking, and depression identified as significant risk factors for MCID drop-off for various PROMs. Male sex and anterior cervical plating were factors against regression of previously attained MCID for SF-12 PCS and VAS neck, respectively. Understanding the relationship between preoperative risk-inducing and protective variables for MCID drop-off may allow for earlier management of modifiable risk factors to maintain long-term clinical benefits following ACDF. Discussing factors influencing MCID drop-off with patients may allow for better matching of expectations among provider and patient and ultimately lead to improved satisfaction.

Introduction

Anterior Cervical Discectomy and Fusion (ACDF) is the most common spine procedure used for the management of cervical spondylolysis, with approximately 132,000 ACDFs performed each year (Kamalapathy et al. 2021; Saifi et al. 2018). Throughout the years, the parameters clinicians use to assess surgical outcomes have changed from objective physical metrics to subjective outcome measures grounded on patient perception, as commonly assessed by Patient Reported Outcome Measures (PROMs) (Finkelstein and Schwartz 2019; Deshpande et al. 2011; Field, Holmes, and Newell 2019). Commonly used PROMs for cervical spinal fusion surgery include: Visual Analog Scale (VAS) neck and arm, Neck Disability Index (NDI), 12-Item Short Form Survey (SF-12) Physical Composite Score (PCS), and Patient-Reported Outcome Measures Information System physical function (PROMIS-PF) (Finkelstein and Schwartz 2019; Vaishnav et al. 2020; Boody et al. 2018; Haws et al. 2019).

A drawback of PROM questionnaires is that they lack clinically significant meaning on their own (Parker et al. 2011; Mouelhi et al. 2020). To overcome this limitation, the concept of minimum clinically important difference (MCID) was developed (Parker et al. 2011; Mouelhi et al. 2020; Sedaghat 2019). MCID is defined as the minimum change in a patient reported outcome measure that is clinically significant and can justify implementation into medical practice (Parker et al. 2011; Paul et al. 2017). MCID values are unique to each individual PROM and spinal pathology (Parker et al. 2012).

Prior literature has demonstrated that the following preoperative risk factors can lead to poorer postoperative PROMs following ACDF: higher or lower age, increased duration of symptoms, depression, and comorbidity burden (determined by the Charlson Comorbidity Index (CCI) (Narain et al. 2019; Li et al. 2019; Rahman, Ibaseta, Reidler, et al. 2020; Omidi-Kashani, Ghayem Hasankhani, and Ghandehari 2014). While most patients achieve MCID for NDI and VAS neck following ACDF, a smaller subset of patients reach MCID for arm pain (Narain et al. 2019; Goldberg et al. 2002). Narain et al., one of few studies assessing the impact of preoperative variables on achievement of MCID, determined an association of increased CCI with failure to reach MCID for NDI (Narain et al. 2019). To better understand the long-term success of favorable postoperative outcomes, it is important to study how preoperative characteristics influence postoperative maintenance of previously attained MCID. The present study aims to identify risk factors for regressing below a level of meaningful clinical improvement for patients who already achieved MCID at an earlier time point following anterior cervical discectomy and fusion.

Methods

Patient Population

Informed patient consent and Institutional Review Board approval (ORA #14051301) were obtained prior to study onset. A prospectively maintained surgical registry was retrospectively reviewed to identify patients who received ACDF surgery between April 2008 and October 2020. All procedures were performed by a single attending spine surgeon at a single academic institution. Inclusion criteria were patients who underwent primary, elective, single- or multi-level ACDF. The following exclusion criteria were implemented: patients who did not complete preoperative PROM surveys or underwent surgery due to trauma, infection, or malignancy.

Data Collection

Patient demographics including age, gender, body mass index (BMI), smoking status, diabetic status, American Society of Anesthesiologists (ASA) score, Ageless Charlson Comorbidity Index (CCI), American Society of Anesthesiologists physical status classification (ASA), and insurance (workers compensation or non-workers compensation) were collected. PROM scores were collected preoperatively and at 6-week, 12-week, 6-month, 1-year, and 2-year postoperative time points for VAS neck, VAS arm, NDI, SF-12 PCS, and PROMIS-PF. Perioperative characteristics, including mean operative duration, mean estimated blood loss (EBL), mean hospital length of stay (LOS), and utilization of a stand-alone cage vs. additional anterior cervical plating were recorded for both single- and multi-level patient cohorts. Preoperative spinal pathologies of patients were recorded and included herniated nucleus pulposus, central stenosis, and myeloradiculopathy.

Statistical Analysis

Data analysis was conducted with Stata 16.0 (StataCorp LP, College Station, TX). Mean PROM values were calculated, after which delta PROMs were computed as the improvement in PROMs from preoperative to each postoperative time point. Delta PROMs were used to calculate the proportion of patients achieving MCID by comparison to previously established threshold values: 2.6 for VAS neck (Parker et al. 2013), 4.1 for VAS arm (Parker et al. 2013), 8.5 for NDI (Parker et al. 2013), 8.1 for SF-12 PCS (Parker et al. 2013), and 4.5 for PROMIS PF (Steinhaus et al. 2019). MCID “drop-off” for each PROM was calculated as the proportion of patients who achieved MCID postoperatively but then failed to maintain clinical improvement at any subsequent time point till 2-years. Poisson regression with robust error variance was employed to evaluate the relative risk of each collected demographic and perioperative variable for all PROMs. A p-value ≤ 0.05 was used as a marker for statistical significance in all analyses performed.

Results

Descriptive Analysis

351 patients who underwent either single-level or multi-level ACDF were studied (Table 1). Majority were male (57.3%), with an average age of 49.9 years and an average BMI of 29.3 kg/m2 (Table 1). Within the single-level ACDF cohort, the most commonly observed spinal pathology was herniated nucleus pulposus (92.2%), followed by myeloradiculopathy (73.5%) and central stenosis (29.4%). Of the patients undergoing multi-level fusion, spinal pathologies were seen more uniformly, with 71.4% of patients with herniated nucleus pulposus, 76.2% with myeloradiculopathy, and 71.4% with central stenosis (Table 2).

Table 1.Patient Baseline Characteristics
(n=351)
Age (mean±SD) 49.9 ± 10.1
Gender % (n)
Female 42.7% (150)
Male 57.3% (201)
Body mass index (BMI) 29.3 ± 5.8
Smoking Status
Non-Smoker 83.8% (294)
Smoker 16.2% (57)
Diabetes
Non-Diabetic 88.9% (312)
Diabetic 11.1% (39)
ASA score 1.9 ± 0.6
Ageless CCI 1.1 ± 1.1
Insurance
Non-WC 69.2% (243)
WC 30.8% (108)
Preoperative PROM Scores
VAS Neck 6.1 ± 2.5
VAS Arm 5.9 ± 2.7
NDI 40.0 ± 19.2
SF-12 PCS 37.4 ± 9.5
PROMIS PF 39.6 ± 7.0
PHQ-9 7.2 ± 6.4

ASA = American Society of Anesthesiologists; CCI = Charlson Comorbidity Index; NDI= Neck Disability Index; PROMIS PF = Patient Reported Outcomes Measurement Information System physical function; PHQ-9 = Patient Health Questionnaire-9; SF-12 PCS = 12 Item Short Form Physical Component Summary; VAS = Visual Analog Scale

Table 2.Perioperative Characteristic
Single Level (n=204) Multi-Level (n=147)
Spinal Pathology
Herniated Nucleus Pulposus 92.2% (188) 71.4% (105)
Central Stenosis 29.4% (60) 71.4% (105)
Myeloradiculopathy 73.5% (150) 76.2% (112)
Operative Duration (minutes) 55.4 ± 21.8 80.5 ± 23.8
EBL (mean ± SD; mL) 40.0 ± 36.3 43.9 ± 26.2
LOS (mean ± SD; hours) 18.5 ± 15.8 22.2 ± 15.8
Instrumentation
Stand-Alone Cage 47.1% (96) 5.4% (8)
Anterior Cervical Plate 52.9% (108) 94.6% (139)

EBL = Estimated Blood Loss; LOS = Postoperative Length of Stay

The mean operative duration for single-level ACDF was 55.4 minutes with an average estimated blood loss of 40.0 mL (Table 2). Multi-level fusions took approximately 80.5 minutes to perform with an average estimated blood loss of 43.9 mL. Patients with both single- and multi-level ACDF experienced a hospital stay of one day or less (Table 2).

In each ACDF procedure, either a conventional stand-alone cage or additional anterior cervical plate was used. Within single-level ACDF procedures, 96 patients received a stand-alone cage and 108 patients received the cage-plate. On the contrary, nearly all multi-level patients received the cage-plate (139), while only 8 patients received a stand-alone cage (Table 2).

Primary Outcome Measures

The proportion of patients achieving MCID across PROMs was highest for VAS neck at 12-weeks (56.5%), VAS arm at 6-months (38.5%), NDI at 6-months (68.1%), SF-12 PCS at 6-months (45.1%), and PROMIS-PF at 1-year (69.0%) (Table 3). MCID drop-off rates were highest for VAS arm (26.8%), followed by VAS neck (26.2%), SF-12 PCS (18.6%), NDI (17.0%), and PROMIS PF (16.3%) (Table 3).

Table 3.MCID Achievement
% (n)
VAS Neck
6-weeks 46.2% (104)
12-weeks 56.5% (117)
6-months 56.3% (103)
1-year 44.4% (44)
2-years 35.6% (16)
Drop-Off 26.2% (43)
VAS Arm
6-weeks 38.2% (78)
12-weeks 36.6% (68)
6-months 38.5% (65)
1-year 30.6% (30)
2-years 24.4% (10)
Drop-Off 26.8% (30)
NDI
6-weeks 43.8% (88)
12-weeks 58.2% (107)
6-months 68.1% (111)
1-year 58.5% (55)
2-years 57.1% (24)
Drop-Off 17.0% (27)
SF-12 PCS
6-weeks 22.0% (37)
12-weeks 38.1% (75)
6-months 45.1% (50)
1-year 43.8% (35)
2-years 40.4% (21)
Drop-Off 18.6% (24)
PROMIS PF
6-weeks 36.8% (35)
12-weeks 52.0% (39)
6-months 62.7% (42)
1-year 69.0% (40)
2-years 61.2% (30)
Drop-Off 16.3% (13)

Preoperative PHQ-9 (RR 1.1, p=0.011) significantly predicted MCID drop-off for VAS neck, while anterior plating (RR 0.6, p=0.029) was a significant protector of preventing drop-off for VAS neck (Table 4). Smoking status (RR 2.2, p=0.038) and preoperative VAS arm (RR 1.2, p=0.001) were significant risk factors for MCID drop-off for VAS arm (Table 5). No significant risk factors for MCID drop-off were observed in NDI (Table 6). Male sex was a significant protector of preventing MCID drop-off for SF-12 PCS (RR 0.4, p=0.025) (Table 7). BMI was a significant risk factor of MCID drop-off for PROMIS-PF (RR 1.1, p=0.006) (Table 8).

Table 4.Risk Factors for VAS Neck MCID Drop-Off
Characteristic RR SE 95% C.I. p-value†
Age 1.0 0.0 (0.9-1.0) 0.160
Gender
Female reference
Male 0.9 0.2 (0.5-1.5) 0.638
Body mass index (BMI) 1.0 0.0 (0.9-1.1) 0.340
Smoking Status
Non-smoker reference
Smoker 1.4 0.5 (0.7-2.8) 0.370
Diabetes
Non-Diabetic reference
Diabetic 1.4 0.5 (0.7-3.0) 0.364
Ageless CCI 1.1 0.2 (0.9-1.4) 0.696
ASA 1.3 0.3 (0.8-2.2) 0.340
Workers’ Compensation Status
Non-WC reference
WC 1.1 0.3 (0.6-1.9) 0.747
Preoperative PROM Scores
VAS Neck 0.4 0.1 (0.3-0.8) 0.668
VAS Arm 1.0 0.1 (0.9-1.1) 0.822
NDI 1.0 0.0 (0.9-1.0) 0.313
SF-12 PCS 1.0 0.0 (0.9-1.0) 0.192
PROMIS PF 1.0 0.0 (0.9-1.1) 0.944
PHQ-9 1.1 0.0 (1.0-1.1) 0.011
Operative Duration 1.0 0.0 (0.9-1.0) 0.881
Estimated Blood Loss 1.0 0.0 (0.9-1.0) 0.520
Length of Stay 1.0 0.0 (0.9-1.0) 0.177
Number of Operative Levels
Single reference
Multilevel 0.7 0.2 (0.4-1.2) 0.162
Anterior Cervical Plating
Stand-Alone Cage reference
Anterior Plate 0.6 0.2 (0.2-0.9) 0.029
Spinal Pathologies
HNP 0.9 0.3 (0.5-1.8) 0.759
Central Stenosis 0.7 0.2 (0.4-1.2) 0.183
Myeloradiculopathy 1.2 0.5 (0.5-2.6) 0.693

ASA = American Society of Anesthesiologists; CCI = Charlson Comorbidity Index; NDI= Neck Disability Index; PHQ-9= Patient Health Questionnaire-9; PROMIS PF = Patient-Reported Outcomes Measurement Information System physical function; RR = Relative Risk; SF-12 PCS = 12 Item Short Form Physical Component Summary; VAS = Visual Analog Scale; HNP = herniated nucleus pulposus
Boldface indicates statistical significance
†p-value calculated using poisson regression with robust error variance

Table 5.Risk Factors for VAS Arm MCID Drop-Off
Characteristic RR SE 95% C.I. p-value†
Age (years) 1.0 0.0 (0.9-1.0) 0.208
Gender
Female reference
Male 0.7 0.2 (0.4-1.4) 0.283
Body mass index (BMI) 1.0 0.0 (0.9-1.1) 0.111
Smoking Status
Non-smoker reference
Smoker 2.2 0.8 (1.0-4.6) 0.038
Diabetes
Non-Diabetic reference
Diabetic 1.1 0.6 (0.4-3.4) 0.838
Ageless CCI 1.1 0.2 (0.8-1.6) 0.488
ASA 0.7 0.2 (0.4-1.2) 0.227
Workers’ Compensation Status
Non-WC reference
WC 1.1 0.4 (0.6-2.3) 0.730
Preoperative PROM Scores
VAS Neck 1.1 0.1 (0.9-1.2) 0.240
VAS Arm 1.2 0.1 (1.1-1.3) 0.001
NDI 1.0 0.0 (0.9-1.0) 0.138
SF-12 PCS 1.0 0.0 (0.9-1.0) 0.938
PROMIS PF 1.0 0.0 (0.9-1.0) 0.407
PHQ-9 1.0 0.0 (0.9-1.1) 0.986
Operative Duration (min) 1.0 0.0 (0.9-1.0) 0.732
Estimated Blood Loss (mL) 1.0 0.0 (0.9-1.0) 0.683
Length of Stay (hours) 1.0 0.0 (0.9-1.0) 0.560
Number of Operative Levels
Single reference
Multilevel 0.6 0.2 (0.3-1.3) 0.227
Anterior Cervical Plating
Stand-Alone Cage reference
Anterior Plate 1.0 0.4 (0.5-2.0) 0.955
Spinal Pathologies
HNP 1.6 0.8 (0.6-4.2) 0.383
Central Stenosis 0.6 0.2 (0.3-1.2) 0.129
Myeloradiculopathy 1.0 0.4 (0.4-2.4) 0.943

ASA = American Society of Anesthesiologists; CCI = Charlson Comorbidity Index; NDI= Neck Disability Index; PHQ-9= Patient Health Questionnaire-9; PROMIS PF = Patient-Reported Outcomes Measurement Information System physical function; RR = Relative Risk; SF-12 PCS = 12 Item Short Form Physical Component Summary; VAS = Visual Analog Scale; HNP = herniated nucleus pulposus
Boldface indicates statistical significance
†p-value calculated using poisson regression with robust error variance

Table 6.Risk Factors for NDI MCID Drop-Off
Characteristic RR SE 95% C.I. p-value†
Age (years) 1.0 0.0 (0.9-1.0) 0.153
Gender
Female reference
Male 1.5 0.6 (0.7-3.1) 0.329
Body mass index (BMI) 1.0 0.0 (0.9-1.1) 0.096
Smoking Status
Non-smoker reference
Smoker 1.2 0.6 (0.5-3.2) 0.695
Diabetes
Non-Diabetic reference
Diabetic 1.7 0.8 (0.7-4.4) 0.276
Ageless CCI 1.1 0.3 (0.6-1.9) 0.687
ASA 1.2 0.4 (0.6-2.4) 0.679
Workers’ Compensation Status
Non-WC reference
WC 0.8 0.3 (0.4-1.9) 0.655
Preoperative PROM Scores
VAS Neck 1.0 0.1 (0.9-1.1) 0.920
VAS Arm 1.0 0.1 (0.9-1.1) 0.745
NDI 1.0 0.0 (.9-1.0) 0.209
SF-12 PCS 1.0 0.0 (0.9-1.0) 0.199
PROMIS PF 1.0 0.0 (0.9-1.0) 0.472
PHQ-9 0.9 0.1 (0.8-1.1) 0.298
Operative Duration (min) 1.0 0.0 (0.9-1.0) 0.560
Estimated Blood Loss (mL) 1.0 0.0 (0.9-1.0) 0.661
Length of Stay (hours) 1.0 0.0 (0.9-1.0) 0.190
Number of Operative Levels
Single reference
Multilevel 0.9 0.3 (0.4-1.8) 0.718
Anterior Cervical Plating
Stand-Alone Cage reference
Anterior Plate 0.5 0.2 (0.3-1.1) 0.084
Spinal Pathologies
HNP 0.7 0.3 (0.3-1.6) 0.399
Central Stenosis 0.9 0.3 (0.4-1.9) 0.795
Myeloradiculopathy 0.7 0.3 (0.3-1.6) 0.359

ASA = American Society of Anesthesiologists; CCI = Charlson Comorbidity Index; NDI= Neck Disability Index; PHQ-9= Patient Health Questionnaire-9; PROMIS PF = Patient-Reported Outcomes Measurement Information System physical function; RR = Relative Risk; SF-12 PCS = 12 Item Short Form Physical Component Summary; VAS = Visual Analog Scale; HNP = herniated nucleus pulposus
†p-value calculated using poisson regression with robust error variance

Table 7.Risk Factors for SF-12 PCS MCID Drop-Off
Characteristic RR SE 95% C.I. p-value†
Age (years) 1.0 0.0 (0.9-1.0) 0.780
Gender
Female reference
Male 0.4 0.2 (0.2-0.9) 0.025
Body mass index (BMI) 1.0 0.0 (0.9-1.1) 0.599
Smoking Status
Non-smoker reference
Smoker 2.1 0.9 (0.9-4.7) 0.083
Diabetes
Non-Diabetic reference
Diabetic 2.1 1.0 (0.8-5.2) 0.112
Ageless CCI 1.1 0.2 (0.8-1.6) 0.444
ASA 1.1 0.3 (0.6-1.9) 0.839
Workers’ Compensation Status
Non-WC reference
WC 1.2 0.5 (0.5-2.7) 0.733
Preoperative PROM Scores
VAS Neck 0.9 0.1 (0.8-1.1) 0.497
VAS Arm 1.0 0.1 (0.9-1.1) 0.983
NDI 1.1 0.0 (0.9-1.0) 0.517
SF-12 PCS 1.0 0.0 (0.9-1.0) 0.089
PROMIS PF 1.0 0.0 (0.9-1.1) 0.707
PHQ-9 1.0 0.1 (0.9-1.1) 0.683
Operative Duration (min) 1.0 0.0 (0.9-1.0) 0.756
Estimated Blood Loss (mL) 1.0 0.0 (0.9-1.0) 0.499
Length of Stay (hours) 1.0 0.0 (0.9-1.0) 0.800
Number of Operative Levels
Single reference
Multilevel 1.1 0.4 (0.5-2.4) 0.779
Anterior Cervical Plating
Stand-Alone Cage reference
Anterior Plate 1.6 0.8 (0.6-4.2) 0.309
Spinal Pathologies
HNP 0.5 0.2 (0.2-1.1) 0.082
Central Stenosis 1.4 0.6 (0.7-3.1) 0.356
Myeloradiculopathy 0.8 0.3 (0.3-1.7) 0.495

ASA = American Society of Anesthesiologists; CCI = Charlson Comorbidity Index; NDI= Neck Disability Index; PHQ-9= Patient Health Questionnaire-9; PROMIS PF = Patient-Reported Outcomes Measurement Information System physical function; RR = Relative Risk; SF-12 PCS = 12 Item Short Form Physical Component Summary; VAS = Visual Analog Scale; HNP = herniated nucleus pulposus
Boldface indicates statistical significance
†p-value calculated using poisson regression with robust error variance

Table 8.Risk Factors for PROMIS PF MCID Drop-Off
Characteristic RR SE 95% C.I. p-value†
Age (years) 1.0 0.0 (0.9-1.1) 0.150
Gender
Female reference
Male 1.2 0.6 (0.4-3.4) 0.750
Body mass index (BMI) 1.1 0.0 (1.0-1.1) 0.006
Smoking Status
Non-smoker reference
Smoker - - -
Diabetes
Non-Diabetic reference
Diabetic 1.7 1.0 (0.5-5.7) 0.366
Ageless CCI 1.1 0.4 (0.5-2.1) 0.835
ASA 2.1 1.0 (0.8-5.2) 0.118
Workers’ Compensation Status
Non-WC reference
WC 0.9 0.5 (0.2-2.9) 0.795
Preoperative PROM Scores
VAS Neck 1.0 0.1 (0.8-1.4) 0.742
VAS Arm 0.8 0.1 (0.7-1.0) 0.062
NDI 1.0 0.0 (0.9-1.0) 0.805
SF-12 PCS 1.0 0.0 (0.9-1.1) 0.459
PROMIS PF 1.0 0.0 (0.9-1.1) 0.901
PHQ-9 0.9 0.1 (0.7-1.2) 0.529
Operative Duration (min) 1.0 0.0 (0.9-1.0) 0.375
Estimated Blood Loss (mL) 1.0 0.0 (0.9-1.1) 0.244
Length of Stay (hours) 1.0 0.0 (0.9-1.0) 0.268
Number of Operative Levels
Single reference
Multilevel 0.8 0.4 (0.3-2.2) 0.607
Anterior Cervical Plating
Stand-Alone Cage reference
Anterior Plate 0.6 0.3 (0.2-1.6) 0.282
Spinal Pathologies
HNP 0.4 0.2 (0.1-1.1) 0.083
Central Stenosis 0.6 0.3 (0.2-1.7) 0.353
Myeloradiculopathy 0.5 0.3 (0.2-1.6) 0.248

ASA = American Society of Anesthesiologists; CCI = Charlson Comorbidity Index; NDI= Neck Disability Index; PHQ-9= Patient Health Questionnaire-9; PROMIS PF = Patient-Reported Outcomes Measurement Information System physical function; RR = Relative Risk; SF-12 PCS = 12 Item Short Form Physical Component Summary; VAS = Visual Analog Scale; HNP = herniated nucleus pulposus
Boldface indicates statistical significance
†p-value calculated using poisson regression with robust error variance

Discussion

Spinal surgery has primarily turned to patient reported outcome measures (PROMs) to assess the effectiveness of surgical procedures, including anterior cervical discectomy and fusion (ACDF) (Staartjes et al. 2019). Translating PROMs into clinical significance has proved more complex, with Jaeschke et al. noting a disconnect between statistically significant PROMs and clinical significance (Parker et al. 2011, 2012; Jaeschke, Singer, and Guyatt 1989; Jenkins et al. 2020). Minimally important clinical difference (MCID) was created to address this discrepancy and evaluate progression of PROMs following spinal surgery in a clinically significant context. Nonetheless, many times MCID is achieved at one time point, yet this achievement may not be maintained at successive time points. Our study aims to assess the predictive capability of preoperative and perioperative characteristics on a patient’s ability to maintain a previously attained MCID at subsequent time points following ACDF.

PROMIS PF drop-off: BMI

An increased body mass index (BMI) has been associated with development of degenerative disc disease due to greater mechanical load and stimulation of chronic inflammatory pathways, leading to increased risk for cervical myelopathy and radiculopathy (Zhang et al. 2020; Fatima et al. 2020). Interestingly, BMI has not significantly impacted postoperative PROMs, attainment of MCID across PROMs, patient satisfaction, narcotics consumption, length of hospital stay, or healthcare costs following ACDF (Narain et al. 2018; Sielatycki et al. 2016). Nevertheless, greater BMI has predicted significantly decreased Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) scores following other surgical procedures, suggesting a potential relationship among the two variables (Katakam et al. 2021; Blanchett et al. 2019). Katakam et al. established that for each one-unit increase in BMI, there was an additional 2% risk of failure to attain MCID following total joint arthroplasty (Katakam et al. 2021). Our findings uniquely demonstrated that higher BMI is significantly associated with failure to maintain previously achieved MCID for PROMIS-PF. For this reason, surgeons should acknowledge the increased possibility of lack of maintainance of clinically meaningful physical funciton improvement among obese ACDF candidates. Early weight management education in the preoperative period may allow for obese patients to have a better chance of maintaining clinically meaningful improvements in their postoperative physical health.

VAS Arm MCID drop-off: Preoperative VAS arm, Smoking Status

Patients with cervical radiculopathy often experience unilateral neck pain, arm pain, or a combination of both due to impingement of a nerve from a herniated disc or bony spurs (Eubanks 2010; Eubanks et al. 2011; Iyer and Kim 2016). Several studies have demonstrated a significant reduction in arm pain, measured by VAS arm, following ACDF (Massel et al. 2017; Laratta et al. 2018). Carreon et al. concluded that patients with a three-point decrease in arm pain achieved MCID, while those with a four-point decrease reached substantial clinical benefit (SCB) following cervical fusion (Carreon et al. 2010). Our findings uniquely demonstrate higher preoperative arm pain as a significant risk factor for loss of previously attained MCID for VAS arm. Therefore, patients with more severe baseline arm pain should be informed that they will be more prone to losing previously achieved clinically significant long-term pain improvements. As alignment of provider and patient expectations has been associated with improved satisfaction (and thus clinical outcomes), relaying this evidence-based trend to this patient population is crucial, especially among those presenting with arm pain as their predominant symptom (Tabibian et al. 2017). To counteract this unfavorable trend, postoperative treatment modalities such as structured physiotherapy may be considered to increase expectation fulfillment, an association demonstrated by Wibault et al. (2018).

It is commonly understood that smoking is a risk factor for incomplete bone healing in spinal fusion procedures (Berman et al. 2017; Echt et al. 2018). Mangan et al. showed smokers had significantly decreased fusion rates compared to non-smokers, while other studies found similar fusion rates among the two cohorts following ACDF (Goldberg et al. 2002; Samartzis et al. 2005; Luszczyk et al. 2013). Nevertheless, clinical findings including fusion rates may not align with patients’ perceived health status as measured by PROMs (Jaeschke, Singer, and Guyatt 1989). Our findings identified preoperative smoking as a significant predictor for loss of previously attained MCID for VAS arm following ACDF. In an effort to improve long-term clinical outcomes following ACDF for smokers, implementation of preoperative education and recommendation of pre/postoperative smoking cessation resources may be beneficial. Preoperative medical education may include consultations with patients to inform them of the long-term postoperative implications of smoking on ACDF. Likewise, resources for smoking cessation can be discussed preoperatively and postoperatively to encourage patients to quit behaviors that may impede maintenance of clinical recovery in arm pain following ACDF.

SF-12 PCS MCID drop-off: Male Sex

The incidence of cervical radiculopathies is higher in males compared to females, putting them at greater risk for requiring ACDF management (Radhakrishnan et al. 1994; Robinson et al. 2014). Prior literature has also demonstrated that male sex is associated with a significantly greater risk for any adverse event and numerous specific adverse events (e.g. pneumonia, sepsis, death) following ACDF (Radhakrishnan et al. 1994; Basques et al. 2018). While aforementioned studies have evaluated the impact of sex on incidence and surgical complications of ACDF, the relationship between sex and PROMs or MCID achievement/drop-off across PROMs has yet to be assessed. Our study found that male sex was a significant protective factor for regression of previously attained MCID for SF-12 PCS. While males are more prone to cervical radiculopathy and post-surgical complications following ACDF, improved physical functioning is likely to remain through a minimum of 2-years following fusion, which may provide comfort and positively influence a patient’s decision to undergo surgery. Further studies on the impact of male vs. female sex on PROMs, MCID attainment, and MCID drop-off in patients undergoing cervical fusions would add invaluable insight on the relationship between sex and postoperative success following ACDF. Future implications of these findings will allow for appropriate preoperative and postoperative measures to be taken so that optimal patient outcomes following ACDF can be achieved for both genders.

VAS Neck MCID drop-off: PHQ-9, Anterior Plate Fixation

In 2016, neck and back pain accounted for the largest amount of healthcare expenditure at $134.5 billion, with neck pain affecting over 20% of the representative population in the US (Dieleman et al. 2020; Genebra et al. 2017). Multiple studies have confirmed the effectiveness of ACDF in significantly improving several PROMs, including neck pain, through extended follow-ups (Massel et al. 2017; Oliver et al. 2018; Song et al. 2009). Recent advancements in ACDF have led to an increase in use of anterior plate fixation in addition to conventional stand-alone interbody cage for enhanced stability (Cheung et al. 2019). While the anterior plating can significantly improve radiographic outcomes following fusion by restoring lordosis and decreasing subsidence, a meta-analysis by Cheung et al. demonstrated no differences among cage-plate vs. cage-only cohorts for PROMs, including Odom’s criteria, VAS neck, VAS arm, Japanese Orthopaedic Association (JOA) score, and NDI (Oliver et al. 2018; Cheung et al. 2019). Notably, the cage-plate cohort demonstrated increased surgical complications, including dysphagia and adjacent segment disease, highlighting potential drawbacks of anterior fixation (Cheung et al. 2019). Prior research has yet to evaluate the impact of anterior plating on MCID achievement and drop-off for PROMs, including VAS neck. Our study established that anterior plating was protective against the loss of previously gained MCID in patients with neck pain. While there are many potential benefits to using anterior plate fixation technique during ACDF, there are numerous risks. Physicians ought to discuss the evidence-based advantages and disadvantages of anterior plating with patients considering ACDF treatment (Viswanathan and Manoharan 2017).

Prior literature has demonstrated chronic neck pain as a significant risk indicator for preoperative depression, which in turn is a well-established predictor of poorer postoperative outcomes following ACDF (Elbinoune et al. 2016; Harris et al. 2020; Phan et al. 2017). Alvin et al. found that increasing preoperative PHQ-9 was significantly associated with inferior Quality-of-Life (QOL) outcomes following ACDF (Alvin et al. 2016). Our results distinctly highlight preoperative PHQ-9 as a significant risk factor for loss of previously achieved MCID for neck pain. Appreciation of this finding emphasizes the interrelatedness of mental health and postoperative surgical outcomes. In an effort to allow for greater longevity of neck pain improvement following ACDF, it may be beneficial for surgeons to preoperatively console patients about the importance of depression management and recommend guidance from mental health providers.

Limitations

There are numerous limitations to this study. External validity was weakened due to all fusions being performed at one academic center by a single surgeon. Our results were based on outcomes collected from patient perception and thus prone to subjectivity and recall bias. Many individuals did not complete PROMs to full follow-up at 2-years, resulting in selection bias that skewed results to represent outcomes of remaining patients more accurately. Finally, the lack of control in the number of levels for ACDFs studied (single- and multi-level included) may introduce a confounder and limit the generalizability of our findings.

Conclusion

Our findings revealed a number of risk factors predictive of regression from initially achieved MCID for various PROMs following ACDF including: higher BMI, greater preoperative arm pain, smoking, and depression. Interestingly, male sex and anterior plating were significant protective factors for long-term retention of clinically significant improvements following ACDF. By identifying and addressing preoperative risk-inducing and protective factors for MCID drop-off, providers can help patients achieve greater longevity of benefits associated with cervical fusion. Furthermore, by communicating these evidence-based trends to patients in the preoperative period, surgeon and patient expectations may become better aligned, allowing for greater likelihood of patient satisfaction.


Correspondence:

Kern Singh, MD
Professor
Department of Orthopaedic Surgery
Rush University Medical Center
1611 W. Harrison St, Suite #300
Chicago, IL 60612
Phone: 312-432-2373
Fax: 708-409-5179
E-mail: kern.singh@rushortho.com

Disclosure

No funds were received in support of this work. No benefits in any form have been or will be received from any commercial party related directly or indirectly to the subject of this manuscript.

IRB Approval

ORA #14051301

Submitted: November 23, 2021 EDT

Accepted: December 27, 2021 EDT

References

Alvin, Matthew D., Jacob A. Miller, Daniel Lubelski, Amy S. Nowacki, Judith Scheman, Manu Mathews, Matthew J. McGirt, Edward C. Benzel, and Thomas E. Mroz. 2016. “The Impact of Preoperative Depression and Health State on Quality-of-Life Outcomes after Anterior Cervical Diskectomy and Fusion.” Global Spine Journal 6 (4): 306–13. https:/​/​doi.org/​10.1055/​s-0035-1562932.
Google ScholarPubMed CentralPubMed
Basques, Bryce A., Fady Y. Hijji, Benjamin Khechen, Brittany E. Haws, Benjamin C. Mayo, Dustin H. Massel, Philip K. Louie, Kaitlyn L. Cardinal, Jordan A. Guntin, and Kern Singh. 2018. “Sex Differences for Anterior Cervical Fusion: Complications and Length of Stay.” Spine 43 (15): 1025–30. https:/​/​doi.org/​10.1097/​brs.0000000000002512.
Google Scholar
Berman, Daniel, Jonathan H. Oren, John Bendo, and Jeffrey Spivak. 2017. “The Effect of Smoking on Spinal Fusion.” International Journal of Spine Surgery 11 (4): 29. https:/​/​doi.org/​10.14444/​4029.
Google ScholarPubMed CentralPubMed
Blanchett, Jacob W, Noah A Kuhlmann, Mohsin S Fidai, Peter A Borowsky, Stephanie J Muh, and Eric C Makhni. 2019. “Using Patient-Reported Outcome Measurement Information System Computer Adaptive Testing Domains to Investigate the Impact of Obesity on Physical Function, Pain Interference, and Mental Health in Sports Medicine Patients.” Journal of Obesity & Metabolic Syndrome 28 (4): 246–53. https:/​/​doi.org/​10.7570/​jomes.2019.28.4.246.
Google ScholarPubMed CentralPubMed
Boody, Barrett S., Surabhi Bhatt, Aditya S. Mazmudar, Wellington K. Hsu, Nan E. Rothrock, and Alpesh A. Patel. 2018. “Validation of Patient-Reported Outcomes Measurement Information System (PROMIS) Computerized Adaptive Tests in Cervical Spine Surgery.” Journal of Neurosurgery: Spine 28 (3): 268–79. https:/​/​doi.org/​10.3171/​2017.7.spine17661.
Google ScholarPubMed CentralPubMed
Carreon, Leah Y., Steven D. Glassman, Mitchell J. Campbell, and Paul A. Anderson. 2010. “Neck Disability Index, Short Form-36 Physical Component Summary, and Pain Scales for Neck and Arm Pain: The Minimum Clinically Important Difference and Substantial Clinical Benefit after Cervical Spine Fusion.” The Spine Journal 10 (6): 469–74. https:/​/​doi.org/​10.1016/​j.spinee.2010.02.007.
Google Scholar
Cheung, Zoe B., Sunder Gidumal, Samuel White, John Shin, Kevin Phan, Nebiyu Osman, Rachel Bronheim, Luilly Vargas, Jun S. Kim, and Samuel K. Cho. 2019. “Comparison of Anterior Cervical Discectomy and Fusion With a Stand-Alone Interbody Cage Versus a Conventional Cage-Plate Technique: A Systematic Review and Meta-Analysis.” Global Spine Journal 9 (4): 446–55. https:/​/​doi.org/​10.1177/​2192568218774576.
Google ScholarPubMed CentralPubMed
Deshpande, Prasanna R., B. Lakshmi Sudeepthi, Surulivel Rajan, and C. P. Abdul Nazir. 2011. “Patient-Reported Outcomes: A New Era in Clinical Research.” Perspectives in Clinical Research 2 (4): 137. https:/​/​doi.org/​10.4103/​2229-3485.86879.
Google ScholarPubMed CentralPubMed
Dieleman, Joseph L., Jackie Cao, Abby Chapin, Carina Chen, Zhiyin Li, Angela Liu, Cody Horst, et al. 2020. “US Health Care Spending by Payer and Health Condition, 1996-2016.” JAMA 323 (9): 863. https:/​/​doi.org/​10.1001/​jama.2020.0734.
Google ScholarPubMed CentralPubMed
Echt, Murray, Rafael De la Garza Ramos, Jonathan Nakhla, Yaroslav Gelfand, Phillip Cezayirli, Ryan Holland, Merritt D. Kinon, and Reza Yassari. 2018. “The Effect of Cigarette Smoking on Wound Complications After Single-Level Posterolateral and Interbody Fusion for Spondylolisthesis.” World Neurosurgery 116 (August):e824–29. https:/​/​doi.org/​10.1016/​j.wneu.2018.05.103.
Google Scholar
Elbinoune, Imane, Bouchra Amine, Siham Shyen, Sanae Gueddari, Redouane Abouqal, and Najia Hajjaj-Hassouni. 2016. “Chronic Neck Pain and Anxiety-Depression: Prevalence and Associated Risk Factors.” Pan African Medical Journal 24 (89). https:/​/​doi.org/​10.11604/​pamj.2016.24.89.8831.
Google ScholarPubMed CentralPubMed
Eubanks, Jason David. 2010. “Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms.” American Family Physician 81 (1): 33–40.
Google Scholar
Eubanks, Jason David, Steven W. Thorpe, Vinay K. Cheruvu, Brett A. Braly, and James D. Kang. 2011. “Does Smoking Influence Fusion Rates in Posterior Cervical Arthrodesis with Lateral Mass Instrumentation?” Clinical Orthopaedics & Related Research 469 (3): 696–701. https:/​/​doi.org/​10.1007/​s11999-010-1575-2.
Google ScholarPubMed CentralPubMed
Fatima, Nida, Elie Massaad, Christopher Alvarez-Breckenridge, John E. Berry Candelario, Muhamed Hadzipasic, Ganesh M. Shankar, and John H. Shin. 2020. “Does Obesity Correlate with Postoperative Complications After Elective Posterior Cervical Spine Fusion?” World Neurosurgery 141:e231–38. https:/​/​doi.org/​10.1016/​j.wneu.2020.05.083.
Google Scholar
Field, Jonathan, Michelle M. Holmes, and Dave Newell. 2019. “PROMs Data: Can It Be Used to Make Decisions for Individual Patients? A Narrative Review.” Patient Related Outcome Measures 10 (July):233–41. https:/​/​doi.org/​10.2147/​prom.s156291.
Google ScholarPubMed CentralPubMed
Finkelstein, Joel A., and Carolyn E. Schwartz. 2019. “Patient-Reported Outcomes in Spine Surgery: Past, Current, and Future Directions: JNSPG 75th Anniversary Invited Review Article.” Journal of Neurosurgery: Spine 31 (2): 155–64. https:/​/​doi.org/​10.3171/​2019.1.spine18770.
Google Scholar
Genebra, Caio Vitor Dos Santos, Nicoly Machado Maciel, Thiago Paulo Frascareli Bento, Sandra Fiorelli Almeida Penteado Simeão, and Alberto De Vitta. 2017. “Prevalence and Factors Associated with Neck Pain: A Population-Based Study.” Brazilian Journal of Physical Therapy 21 (4): 274–80. https:/​/​doi.org/​10.1016/​j.bjpt.2017.05.005.
Google ScholarPubMed CentralPubMed
Goldberg, Edward J, Kern Singh, U Van, Ralph Garretson, and Howard S An. 2002. “Comparing Outcomes of Anterior Cervical Discectomy and Fusion in Workman’s versus Non–Workman’s Compensation Population.” The Spine Journal 2 (6): 408–14. https:/​/​doi.org/​10.1016/​s1529-9430(02)00441-2.
Google Scholar
Harris, Andrew B., Majd Marrache, Varun Puvanesarajah, Micheal Raad, Amit Jain, Khaled M. Kebaish, Lee H. Riley, and Richard L. Skolasky. 2020. “Are Preoperative Depression and Anxiety Associated with Patient-Reported Outcomes, Health Care Payments, and Opioid Use after Anterior Discectomy and Fusion?” The Spine Journal 20 (8): 1167–75. https:/​/​doi.org/​10.1016/​j.spinee.2020.03.004.
Google Scholar
Haws, Brittany E., Benjamin Khechen, Mundeep S. Bawa, Dil V. Patel, Harmeet S. Bawa, Daniel D. Bohl, Adam B. Wiggins, Kaitlyn L. Cardinal, Jordan A. Guntin, and Kern Singh. 2019. “The Patient-Reported Outcomes Measurement Information System in Spine Surgery: A Systematic Review.” Journal of Neurosurgery: Spine 30 (3): 405–13. https:/​/​doi.org/​10.3171/​2018.8.spine18608.
Google Scholar
Iyer, Sravisht, and Han Jo Kim. 2016. “Cervical Radiculopathy.” Current Reviews in Musculoskeletal Medicine 9 (3): 272–80. https:/​/​doi.org/​10.1007/​s12178-016-9349-4.
Google ScholarPubMed CentralPubMed
Jaeschke, Roman, Joel Singer, and Gordon H. Guyatt. 1989. “ Measurement of Health Status. Ascertaining the Minimal Clinically Important Difference.” Controlled Clinical Trials 10 (4): 407–15. https:/​/​doi.org/​10.1016/​0197-2456(89)90005-6.
Google Scholar
Jenkins, Nathaniel W., James M. Parrish, Michael T. Nolte, Nadia M. Hrynewycz, Thomas S. Brundage, and Kern Singh. 2020. “Validating the VR-12 Physical Function Instrument After Anterior Cervical Discectomy and Fusion with SF-12, PROMIS, and NDI.” HSS Journal 16 (Suppl2): 443–51. https:/​/​doi.org/​10.1007/​s11420-020-09817-w.
Google ScholarPubMed CentralPubMed
Kamalapathy, Pramod N., Varun Puvanesarajah, Sean Sequeria, Joshua Bell, and Hamid Hassanzadeh. 2021. “Safety Profile of Outpatient vs Inpatient ACDF: An Analysis of 33,807 Outpatient ACDFs.” Clinical Neurology and Neurosurgery 207 (August):106743. https:/​/​doi.org/​10.1016/​j.clineuro.2021.106743.
Google Scholar
Katakam, Akhil, Austin K. Collins, Nicholas Sauder, David Shin, Charles R. Bragdon, Antonia F. Chen, Christopher M. Melnic, and Hany S. Bedair. 2021. “Obesity Increases Risk of Failure to Achieve the 1-Year PROMIS PF-10a Minimal Clinically Important Difference Following Total Joint Arthroplasty.” The Journal of Arthroplasty 36 (7): S184–91. https:/​/​doi.org/​10.1016/​j.arth.2020.11.004.
Google Scholar
Laratta, Joseph L., Jamal N. Shillingford, Comron Saifi, and K. Daniel Riew. 2018. “Cervical Disc Arthroplasty: A Comprehensive Review of Single-Level, Multilevel, and Hybrid Procedures.” Global Spine Journal 8 (1): 78–83. https:/​/​doi.org/​10.1177/​2192568217701095.
Google ScholarPubMed CentralPubMed
Li, ShaoQing, BaoYang Zhang, Yong Shen, and ZhanYong Wu. 2019. “Multivariate Analysis of Poor Outcome after Anterior Surgery in Multilevel Cervical Spondylotic Myelopathy Patients with Heterotopic Ossification and Preoperative Kyphotic Alignment.” Therapeutics and Clinical Risk Management 15 (August):1053–60. https:/​/​doi.org/​10.2147/​tcrm.s208991.
Google ScholarPubMed CentralPubMed
Luszczyk, Myles, Justin S. Smith, Jeffrey S. Fischgrund, Steven C. Ludwig, Rick C. Sasso, Christopher I. Shaffrey, and Alexander R. Vaccaro. 2013. “Does Smoking Have an Impact on Fusion Rate in Single-Level Anterior Cervical Discectomy and Fusion with Allograft and Rigid Plate Fixation? Clinical Article.” Journal of Neurosurgery: Spine 19 (5): 527–31. https:/​/​doi.org/​10.3171/​2013.7.spine13208.
Google Scholar
Massel, Dustin H., Benjamin C. Mayo, Daniel D. Bohl, Ankur S. Narain, Fady Y. Hijji, Steven J. Fineberg, Philip K. Louie, et al. 2017. “Improvements in Neck and Arm Pain Following an Anterior Cervical Discectomy and Fusion.” Spine 42 (14): E825–32. https:/​/​doi.org/​10.1097/​brs.0000000000001979.
Google Scholar
Mouelhi, Yosra, Elisabeth Jouve, Christel Castelli, and Stéphanie Gentile. 2020. “How Is the Minimal Clinically Important Difference Established in Health-Related Quality of Life Instruments? Review of Anchors and Methods.” Health and Quality of Life Outcomes 18 (1). https:/​/​doi.org/​10.1186/​s12955-020-01344-w.
Google ScholarPubMed CentralPubMed
Narain, Ankur S., Fady Y. Hijji, Brittany E. Haws, Krishna T. Kudaravalli, Kelly H. Yom, Jonathan Markowitz, and Kern Singh. 2018. “Impact of Body Mass Index on Surgical Outcomes, Narcotics Consumption, and Hospital Costs Following Anterior Cervical Discectomy and Fusion.” Journal of Neurosurgery: Spine 28 (2): 160–66. https:/​/​doi.org/​10.3171/​2017.6.spine17288.
Google Scholar
Narain, Ankur S., Fady Y. Hijji, Benjamin Khechen, Brittany E. Haws, Dil V. Patel, Daniel D. Bohl, Kelly H. Yom, Krishna T. Kudaravalli, and Kern Singh. 2019. “Risk Factors Associated With Failure to Reach Minimal Clinically Important Difference in Patient-Reported Outcomes Following Anterior Cervical Discectomy and Fusion.” International Journal of Spine Surgery 13 (3): 262–69. https:/​/​doi.org/​10.14444/​6035.
Google ScholarPubMed CentralPubMed
Oliver, Jeremie D., Sandy Goncalves, Panagiotis Kerezoudis, Mohammed Ali Alvi, Brett A. Freedman, Ahmad Nassr, and Mohamad Bydon. 2018. “Comparison of Outcomes for Anterior Cervical Discectomy and Fusion with and without Anterior Plate Fixation.” Spine 43 (7): E413–22. https:/​/​doi.org/​10.1097/​brs.0000000000002441.
Google Scholar
Omidi-Kashani, Farzad, Ebrahim Ghayem Hasankhani, and Reza Ghandehari. 2014. “Impact of Age and Duration of Symptoms on Surgical Outcome of Single-Level Microscopic Anterior Cervical Discectomy and Fusion in the Patients with Cervical Spondylotic Radiculopathy.” Neuroscience Journal 2014 (808596): 1–6. https:/​/​doi.org/​10.1155/​2014/​808596.
Google ScholarPubMed CentralPubMed
Parker, Scott L., Owoicho Adogwa, Alexandra R. Paul, William N. Anderson, Oran Aaronson, Joseph S. Cheng, and Matthew J. McGirt. 2011. “Utility of Minimum Clinically Important Difference in Assessing Pain, Disability, and Health State after Transforaminal Lumbar Interbody Fusion for Degenerative Lumbar Spondylolisthesis.” Journal of Neurosurgery: Spine 14 (5): 598–604. https:/​/​doi.org/​10.3171/​2010.12.spine10472.
Google Scholar
Parker, Scott L., Saniya S. Godil, David N. Shau, Stephen K. Mendenhall, and Matthew J. McGirt. 2013. “Assessment of the Minimum Clinically Important Difference in Pain, Disability, and Quality of Life after Anterior Cervical Discectomy and Fusion: Clinical Article.” Journal of Neurosurgery: Spine 18 (2): 154–60. https:/​/​doi.org/​10.3171/​2012.10.spine12312.
Google Scholar
Parker, Scott L., Stephen K. Mendenhall, David N. Shau, Owoicho Adogwa, William N. Anderson, Clinton J. Devin, and Matthew J. McGirt. 2012. “Minimum Clinically Important Difference in Pain, Disability, and Quality of Life after Neural Decompression and Fusion for Same-Level Recurrent Lumbar Stenosis: Understanding Clinical versus Statistical Significance.” Journal of Neurosurgery: Spine 16 (5): 471–78. https:/​/​doi.org/​10.3171/​2012.1.spine11842.
Google Scholar
Paul, Alexandra R, Vignessh Kumar, Steven Roth, M Reid Gooch, and Julie G Pilitsis. 2017. “Establishing Minimal Clinically Important Difference of Spinal Cord Stimulation Therapy in Post-Laminectomy Syndrome.” Neurosurgery 81 (6): 1011–15. https:/​/​doi.org/​10.1093/​neuros/​nyx153.
Google Scholar
Phan, Kevin, Dane Moran, Thomas Kostowski, Risheng Xu, Rory Goodwin, Benjamin Elder, Seba Ramhmdani, and Ali Bydon. 2017. “Relationship between Depression and Clinical Outcome Following Anterior Cervical Discectomy and Fusion.” Journal of Spine Surgery 3 (2): 133–40. https:/​/​doi.org/​10.21037/​jss.2017.05.02.
Google ScholarPubMed CentralPubMed
Radhakrishnan, Kurupath, William J. Litchy, W. Michael O’Fallon, and Leonard T. Kurland. 1994. “A Population-Based Study from Rochester, Minnesota, 1976 through 1990.” Brain 117 (2): 325–35. https:/​/​doi.org/​10.1093/​brain/​117.2.325.
Google Scholar
Rahman, R., A. Ibaseta, J.S. Reidler, et al. 2020. “Changes in Patients’ Depression and Anxiety Associated with Changes in Patient-Reported Outcomes after Spine Surgery.” J Neurosurg Spine 2020 (January):1–20.
Google Scholar
Robinson, J., M. Kothari, J.M. Shefner, and Others. 2014. “Clinical Features and Diagnosis of Cervical Radiculopathy.” Accessed 27 (2014).
Google Scholar
Saifi, Comron, Arielle W. Fein, Alejandro Cazzulino, Ronald A. Lehman, Frank M. Phillips, Howard S. An, and K. Daniel Riew. 2018. “Trends in Resource Utilization and Rate of Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion throughout the United States from 2006 to 2013.” The Spine Journal 18 (6): 1022–29. https:/​/​doi.org/​10.1016/​j.spinee.2017.10.072.
Google Scholar
Samartzis, Dino, Francis H. Shen, Edward J. Goldberg, and Howard S. An. 2005. “Is Autograft the Gold Standard in Achieving Radiographic Fusion in One-Level Anterior Cervical Discectomy and Fusion with Rigid Anterior Plate Fixation?” Spine 30 (15): 1756–61. https:/​/​doi.org/​10.1097/​01.brs.0000172148.86756.ce.
Google Scholar
Sedaghat, Ahmad R. 2019. “Understanding the Minimal Clinically Important Difference (MCID) of Patient-Reported Outcome Measures.” Otolaryngology–Head and Neck Surgery 161 (4): 551–60. https:/​/​doi.org/​10.1177/​0194599819852604.
Google Scholar
Sielatycki, John A., Chotai Silky, Kay Harrison, David Stonko, Matthew McGirt, and Clinton J. Devin. 2016. “Does Obesity Correlate With Worse Patient-Reported Outcomes Following Elective Anterior Cervical Discectomy and Fusion?” Neurosurgery 79 (1): 69–74. https:/​/​doi.org/​10.1227/​neu.0000000000001252.
Google Scholar
Song, Kyung-Jin, Cyrus E. Taghavi, Kwang-Bok Lee, Ji-Hoon Song, and Jong-Pil Eun. 2009. “The Efficacy of Plate Construct Augmentation Versus Cage Alone in Anterior Cervical Fusion.” Spine 34 (26): 2886–92. https:/​/​doi.org/​10.1097/​brs.0b013e3181b64f2c.
Google Scholar
Staartjes, Victor E., Alessandro Siccoli, Marlies P. de Wispelaere, and Marc L. Schröder. 2019. “Patient-Reported Outcomes Unbiased by Length of Follow-up after Lumbar Degenerative Spine Surgery: Do We Need 2 Years of Follow-Up?” The Spine Journal 19 (4): 637–44. https:/​/​doi.org/​10.1016/​j.spinee.2018.10.004.
Google Scholar
Steinhaus, Michael E., Sravisht Iyer, Francis Lovecchio, Benjamin Khechen, Daniel Stein, Thomas Ross, Jingyan Yang, et al. 2019. “Minimal Clinically Important Difference and Substantial Clinical Benefit Using PROMIS CAT in Cervical Spine Surgery.” Clinical Spine Surgery 32 (9): 392–97. https:/​/​doi.org/​10.1097/​bsd.0000000000000895.
Google Scholar
Tabibian, Borna E., Elizabeth N. Kuhn, Matthew C. Davis, and Patrick R. Pritchard. 2017. “Patient Expectations and Preferences in the Spinal Surgery Clinic.” World Neurosurgery 106 (October):595–601. https:/​/​doi.org/​10.1016/​j.wneu.2017.07.018.
Google Scholar
Vaishnav, Avani S., Catherine Himo Gang, Sravisht Iyer, Steven McAnany, Todd Albert, and Sheeraz A. Qureshi. 2020. “Correlation between NDI, PROMIS and SF-12 in Cervical Spine Surgery.” The Spine Journal 20 (3): 409–16. https:/​/​doi.org/​10.1016/​j.spinee.2019.10.017.
Google Scholar
Viswanathan, V.K., and S.R. Manoharan. 2017. “To Plate or Not to Plate after a Single- or Two-Level Anterior Cervical Discectomy: Fusion with Cage-Plate Construct or Stand-Alone Cage.” Asian Spine Journal 11 (1): 1–3. https:/​/​doi.org/​10.4184/​asj.2017.11.1.1.
Google ScholarPubMed CentralPubMed
Wibault, Johanna, Birgitta Öberg, Åsa Dedering, Håkan Löfgren, Peter Zsigmond, and Anneli Peolsson. 2018. “Structured Postoperative Physiotherapy in Patients with Cervical Radiculopathy: 6-Month Outcomes of a Randomized Clinical Trial.” Journal of Neurosurgery: Spine 28 (1): 1–9. https:/​/​doi.org/​10.3171/​2017.5.spine16736.
Google Scholar
Zhang, Gen‐ai, Wen‐ping Zhang, Ying‐chun Chen, Yu Hou, Wei Qu, and Li‐xiang Ding. 2020. “Impact of Elevated Body Mass Index on Surgical Outcomes for Patients Undergoing Cervical Fusion Procedures: A Systematic Review and Meta‐Analysis.” Orthopaedic Surgery 12 (1): 3–15. https:/​/​doi.org/​10.1111/​os.12572.
Google ScholarPubMed CentralPubMed

This website uses cookies

We use cookies to enhance your experience and support COUNTER Metrics for transparent reporting of readership statistics. Cookie data is not sold to third parties or used for marketing purposes.

Powered by Scholastica, the modern academic journal management system