Abstract
Surgical management of cervical spondylotic myelopathy (CSM) aims to improve neurological deterioration. However, long-term predictors of outcome are unknown. The present study examined highest and lowest patient-reported satisfaction at the 5-year follow-up. The authors hypothesized that the most satisfied patients experience durable long-term improvement and have distinct characteristics compared to the least satisfied patients.
Prospectively collected data from the Spine CORe™ study group of the Quality Outcomes Database cervical spine module were retrospectively reviewed. Patients were stratified by North American Spine Society (NASS) satisfaction scores of 1 (most satisfied) and 4 (least satisfied). Demographics, surgical characteristics, and patient-reported outcome measures (PROMs) were compared between cohorts at baseline and 24 and 60 months of follow-up. A mixed-effects logistic regression assessed independent predictors of those who were most and least satisfied at 60 months. Univariate and multivariable analyses were repeated in the subsample of most satisfied patients at 2 years. Univariate analysis was completed for the subsample of least satisfied patients at 2 years.
Of 1085 patients with CSM, 895 (82%) completed the 60-month follow-up. Of these 895 patients, 106 died within 5 years of surgery of unrelated causes, and 785 provided satisfaction scores at 60 months of follow-up. Of the 785 patients, 621 patients met inclusion criteria of reporting an NASS score of 1 or 4 at 60 months: 560 (90.2%) were most satisfied and 61 (9.8%) were least satisfied. The most satisfied cohort included more patients with bachelor's degrees (25% vs 13%, p = 0.043), more anterior cervical discectomies and fusions (61% vs 48%, p = 0.038), shorter hospitalizations (1.7 ± 1.8 vs 2.8 ± 2.6 days, p = 0.002), fewer laminectomies (23% vs 39%, p = 0.004), and fewer smokers (p = 0.036). Most satisfied patients reported higher baseline EuroQol visual analog scale (EQ-VAS) scores (60.8 ± 21.3 vs 51.5 ± 24.8, p = 0.008), but other baseline PROMs were similar. In multivariable analysis, college education (OR 2.54, p = 0.004), preoperative depression (OR 2.75, p = 0.043), higher baseline EQ-VAS score (OR 1.02, p = 0.009), and shorter hospitalization (OR 0.81, p = 0.003) independently predicted the most satisfaction at 60 months. Among 60-month least satisfied patients, 28% were most satisfied at 24 months. Among 60-month most satisfied patients, 2.9% were least satisfied at 24 months. Among 24-month most satisfied patients, maintenance of most satisfaction at 60 months was independently predicted by older age (OR 1.09, p = 0.045), preoperative pain (OR 9.28, p = 0.013), and higher 24-month neck pain numeric rating scale (NP-NRS) score (OR 1.58, p = 0.047). Neck Disability Index- and modified Japanese Orthopaedic Association (mJOA)-based independence measures correlated with a bidirectional satisfaction shift between 2 and 5 years.
Highest NASS satisfaction scores at 5 years after surgery for CSM are predicted by college education of the patients, preoperative depression, higher baseline EQ-VAS scores, and shorter hospital length of stay. Younger age, lack of preoperative pain, and lower 2-year NP-NRS scores predict movement from most satisfied to least satisfied. After surgery for CSM, the majority of patients report the highest satisfaction NASS rating at 5 years, but delayed satisfaction reversals exist and warrant monitoring.