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Cervical Radiculopathy: Studies on Pain Analysis and Treatment
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.ORCID iD: 0000-0002-9231-7608
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Description
Abstract [en]

Background: Knowledge about how to interpret pain-analyzing tools such as the pain drawing test and the visual analog scale (VAS) in cervical spine patients are sparse; hence, they have never been validated for this subgroup of patients. The method of artificial disc replacement (ADR) has been developed as an alternative treatment to fusion surgery after decompression for cervical degenerative disc disease (DDD) with radiculopathy. Preserved motion of ADR devices aims to prevent immobilization side effects such as stiffness, dysphagia and adjacent segment pathology. Long-term follow-ups of these devices compared with the gold standard treatment are needed to create future guidelines.

Objectives: This thesis aims at (1) validating the pain drawing as an investigational tool for the cervical spine, (2) validating the VAS for the cervical spine regarding the measurement noise and the minimum clinically important difference (MCID), (3) comparing ADR with fusion surgery at 5-years of follow-up regarding outcome and complications in a randomized controlled trial (RCT) as well as in the Swedish spine (Swespine) registry, and (4) investigating possible predictors to outcome after surgical treatment of cervical radiculopathy.

Methods: An RCT with 153 patients undergoing surgery for cervical radiculopathy was performed. Baseline data, the Neck disability index (NDI), two sets of VAS-neck and VAS-arm scores, the EQ-5D, Hospital anxiety and depression scale (HADS), Dysphagia short questionnaire and a pain drawing test were gathered preoperatively and after 5 years. Radiographs in flexion/extension and MRIs were done preoperatively and at follow-up. All patients registered in Swespine since January 1st, 2006 with cervical DDD and radiculopathy treated with ADR or fusion surgery, were included. Baseline data, the NDI, EQ-5D, and VAS-neck and VAS-arm scores were analyzed at 1, 2, 5 and 10-years of follow-up as well as the information regarding secondary surgeries.

Results: Pain drawings interpreted with the simple body region method showed good inter-rater reliability in cervical spine patients. Markings in the upper arm region on the pain drawing predicted surgical treatment outcome and markings in the head region predicted depression. The measurement noise was ~10 mm and the MCID was ~20 mm on a 100 mm pain VAS. In both the RCT and Swespine register the outcome after ADR surgery were comparable with fusion at 5 years of follow-up, except for an elevated risk regarding secondary surgery on the index level in the ADR group. Fifty percent of the patients in the RCT, allocated to ADR surgery had preserved motion of less than 5°, at the 5-year follow-up, and 25%, mostly men were spontaneously fused. Preserved motion did not prevent adjacent segment pathology. High values of preoperative HADS scores were negative predictors of outcome.

Conclusions: In patients with cervical DDD and radiculopathy both the pain drawing test and the VAS are validated tools to interpret the patients’ pain. Preoperative mental distress affects long-term outcome much more than the allocated treatment, ADR or fusion surgery in patients with cervical radiculopathy.

Clinical Trial Registration: ISRCTN, registration number: 44347115.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. , p. 111
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1442
Keywords [en]
Cervical radiculopahy, Artificial disc replacement
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:uu:diva-345977ISBN: 978-91-513-0272-0 (print)OAI: oai:DiVA.org:uu-345977DiVA, id: diva2:1190074
Public defence
2018-05-05, Gustavianum, Akademigatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-04-10 Created: 2018-03-13 Last updated: 2018-04-10
List of papers
1. Pain drawings predict outcome of surgical treatment for degenerative disc disease in the cervical spine
Open this publication in new window or tab >>Pain drawings predict outcome of surgical treatment for degenerative disc disease in the cervical spine
2017 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 122, no 3, p. 194-200Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Pain drawings have been frequently used in the preoperative evaluation of spine patients. For lumbar conditions comprehensive research has established both the reliability and predictive value, but for the cervical spine most of this knowledge is lacking. The aims of this study were to validate pain drawings for the cervical spine, and to investigate the predictive value for treatment outcome of four different evaluation methods.

METHODS: We carried out a post hoc analysis of a randomized controlled trial, comparing cervical disc replacement to fusion for radiculopathy related to degenerative disc disease. A pain drawing together with Neck Disability Index (NDI) was completed preoperatively, after 2 and 5 years. The inter- and intraobserver reliability of four evaluation methods was tested using κ statistics, and its predictive value investigated by correlation to change in NDI.

RESULTS: Included were 151 patients, mean age of 47 years, female/male: 78/73. The interobserver reliability was fair for the modified Ransford and Udén methods, good for the Gatchel method, and very good for the modified Ohnmeiss method. Markings in the shoulder and upper arm region on the pain drawing were positive predictors of outcome after 2 years of follow-up, and markings in the upper arm region remained a positive predictor of outcome even after 5 years of follow-up.

CONCLUSIONS: Pain drawings were a reliable tool to interpret patients' pain prior to cervical spine surgery and were also to some extent predictive for treatment outcome.

Keywords
Cervical spine, Neck Disability Index, outcome, pain drawing, repeatability, surgical treatment
National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-326701 (URN)10.1080/03009734.2017.1340372 (DOI)000414107800007 ()28718697 (PubMedID)
Available from: 2017-07-25 Created: 2017-07-25 Last updated: 2019-02-08Bibliographically approved
2. Anxiety and depression affect pain drawings in cervical degenerative disc disease
Open this publication in new window or tab >>Anxiety and depression affect pain drawings in cervical degenerative disc disease
2017 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 122, no 2, p. 99-107Article in journal (Refereed) Published
Abstract [en]

Introduction: Pain drawings have been frequently used in the preoperative evaluation of spine patients. Until now most investigations have focused on low back pain patients, even though pain drawings are used in neck pain patients as well. The aims of this study were to investigate the pain drawing and its association to preoperative demographics, psychological impairment, and pain intensity. Methods: We carried out a post hoc analysis of a randomized controlled trial, comparing cervical disc replacement to fusion for radiculopathy related to degenerative disc disease. Preoperatively the patients completed a pain drawing, the Hospital Anxiety and Depression Scale (HADS), and a visual analogue scale (VAS). The pain drawing was evaluated according to four established methods, now modified for cervical conditions. Comparisons were made between the pain drawing and age, sex, smoking, and employment status as well as HADS and VAS. Results: Included were 151 patients, mean age of 47 years, female/male: 78/73. Pain drawing results were not affected by age, sex, smoking, and employment status. Patients with non-neurogenic pain drawings according to the modified method by Ransford had higher points on HADS-anxiety, HADS-depression, and HADS-total. Patients with markings in the head region had higher score on HADS-depression. Markings in the neck and lower arm region were associated with high values of VAS-neck and VAS-arm. Conclusions: Pain drawings were affected by both pain intensity and anxiety/depression in cervical spine patients. Therefore, the pain drawing can be a useful tool when interpreting the patients' pain in correlation to psychological impairment and pain location.

Place, publisher, year, edition, pages
TAYLOR & FRANCIS LTD, 2017
Keywords
Cervical spine, degenerative disc disease, Hospital Anxiety and Depression Scale, pain drawings, pain modality, surgical treatment
National Category
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-323497 (URN)10.1080/03009734.2017.1319441 (DOI)000401756500005 ()28503982 (PubMedID)
Available from: 2017-06-22 Created: 2017-06-22 Last updated: 2019-02-08Bibliographically approved
3. Validation of the Visual Analogue Scale in the Cervical Spine
Open this publication in new window or tab >>Validation of the Visual Analogue Scale in the Cervical Spine
2018 (English)In: Journal of Eurosurgery : Spine, ISSN 1547-5654, E-ISSN 1547-5646, Vol. 28, no 3, p. 227-235Article in journal (Refereed) Published
Abstract [en]

Objective: The Visual analogue scale (VAS) is frequently used to measure treatment outcome in patients with cervical spine disorders. The minimum clinically important difference (MCID) is the smallest change in a score that has clinical importance to the patient. Although it has been established for other medical fields, knowledge of the VAS MCID for the cervical spine is sparse, and it has rarely been considered in relation to measurement noise. The goals in this study were as follows: 1) to validate the VAS-neck and VAS-arm instruments for the cervical spine (e.g. repeatability); 2) to investigate the possible influence of predictive factors and the Hospital Anxiety and Depression Scale (HADS) score on repeatability; and 3) to compute the MCID with five different methods.

Methods: A post hoc analysis of a prospective randomized controlled trial with 151 patients undergoing surgery for cervical radiculopathy due to degenerative disc disease (DDD) was performed. Information on age, sex, smoking habits, exercise and employment status, HADS score, and VAS-neck and VAS-arm scores was gathered before surgery and after 1 year. The VAS was applied twice on every occasion with 15 minutes in-between. Repeatability and the association with predictors and HADS score were analyzed using the one-sample t-test, linear regression models and Spearman correlation. The MCID was calculated with the following methods: average change, change difference, receiver operating characteristic curve, effect size, and minimum detectable change (MDC).

Results: The repeatability in VAS-neck was 8.1 mm and in VAS-arm 10.4 mm. Less consistent values on the VAS correlated to female sex and higher values on HADS. For VAS-neck the MCID ranged from 4.6 to 21.4 and for VAS-arm it ranged from 1.1 to 29.1. The highest MCID came from the MDC method, which was the only method that gave values above the measurement noise in both VAS-neck and VAS-arm.

Conclusions: Measurement noise in VAS-neck and VAS-arm for the cervical spine was influenced by female sex and HADS score. The only method to compute MCID that consistently gave results above the measurement noise in VAS-neck and VAS-arm was the MDC. 

Place, publisher, year, edition, pages
Charlottesville, Virginia: , 2018
Keywords
Visual analogue scale, Minimum clinically important difference, Cervical degenerative disc disease, Surgical treatment, Hospital anxiety and depression scale.
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-327266 (URN)10.3171/2017.5.SPINE1732 (DOI)000426297500001 ()
Projects
Cervical radiculopathy: Studies on pain analysis and treatment
Available from: 2017-08-07 Created: 2017-08-07 Last updated: 2019-02-08Bibliographically approved
4. Artificial disc replacement versus fusion in patients with cervical degenerative disc disease and radiculopathy: a randomized controlled trial with 5-year outcomes
Open this publication in new window or tab >>Artificial disc replacement versus fusion in patients with cervical degenerative disc disease and radiculopathy: a randomized controlled trial with 5-year outcomes
Show others...
2019 (English)In: Journal of Neurosurgery: Spine, ISSN 1547-5654, E-ISSN 1547-5646, Vol. 30, no 3, p. 323-331Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE

The method of artificial disc replacement (ADR) has been developed as an alternative treatment to fusion surgery after decompression for cervical degenerative disc disease (DDD) with radiculopathy. Preserving the motion of ADR devices aims to prevent immobilization side effects such as adjacent-segment pathology (ASP). However, long-term follow-up evaluations using MRI are needed to investigate if this intent is achieved.

METHODS

The authors performed a randomized controlled trial with 153 patients (mean age 47 years) undergoing surgery for cervical radiculopathy. Eighty-three patients received an ADR and 70 patients underwent fusion surgery. Outcomes after 5 years were assessed using patient-reported outcome measures using the Neck Disability Index (NDI) score as the primary outcome; motion preservation and heterotopic ossification by radiography; ASP by MRI; and secondary surgical procedures.

RESULTS

Scores on the NDI were approximately halved in both groups: the mean score after 5 years was 36 (95% confidence interval [CI] 31–41) in the ADR group and 32 (95% CI 27–38) in the fusion group (p = 0.48). There were no other significant differences between the groups in six other patient-related outcome measures. Fifty-four percent of the patients in the ADR group preserved motion at the operated cervical level and 25% of the ADRs were spontaneously fused. Seventeen ADR patients (21%) and 7 fusion patients (10%) underwent secondary surgery (p = 0.11), with 5 patients in each group due to clinical ASP.

CONCLUSIONS

In patients with cervical DDD and radiculopathy decompression as well as ADR, surgery did not result in better clinical or radiological outcomes after 5 years compared with decompression and fusion surgery.

Keywords
artificial disc replacement, treatment outcome, Neck Disability Index, cervical radiculopathy, adjacent-segment pathology
National Category
Orthopaedics Neurology
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-345965 (URN)10.3171/2018.9.SPINE18659 (DOI)000462447900004 ()30641852 (PubMedID)
Projects
Cervical radiculopathy, studies on pain analysis and treatment
Note

Title in thesis list of papers: Artificial Disc Replacement versus Fusion in Patients with Cervical Degenerative Disc Disease with radiculopathy ‒ 5-year Outcomes

Available from: 2018-03-13 Created: 2018-03-13 Last updated: 2019-04-16Bibliographically approved
5. Artificial Disc Replacement versus Fusion in Patients with Cervical Degenerative Disc Disease with radiculopathy: 5-year Outcomes from the National Swedish Spine Register
Open this publication in new window or tab >>Artificial Disc Replacement versus Fusion in Patients with Cervical Degenerative Disc Disease with radiculopathy: 5-year Outcomes from the National Swedish Spine Register
Show others...
2019 (English)In: Journal of Neurosurgery: Spine, ISSN 1547-5654, E-ISSN 1547-5646, Vol. 30, no 2, p. 159-167Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The long-term efficacy of artificial disc replacement (ADR) surgery compared with fusion after decompression for the treatment of cervical degenerative disc disease and radiculopathy has not previously been investigated in a population-based setting.

METHODS: All patients with cervical degenerative disc disease and radiculopathy who were in the national Swedish Spine Registry (Swespine) beginning in January 1, 2006, were eligible for the study. Follow-up information was obtained up to November 15, 2017. The authors compared, using propensity score matching, patients treated with anterior decompression and insertion of an ADR with patients who underwent anterior decompression combined with fusion surgery. The primary outcome was the Neck Disability Index (NDI), a patient-reported function score ranging from 0% to 100%, with higher scores indicating greater disability and a minimum clinically important difference of > 15%.

RESULTS: A total of 3998 patients (2018: 1980 women/men) met the inclusion criteria, of whom 204 had undergone arthroplasty and 3794 had undergone fusion. After propensity score matching, 185 patients with a mean age of 49.7 years remained in each group. Scores on the NDI were approximately halved in both groups after 5 years, but without a significant mean difference in NDI (3.0%; 95% CI -8.4 to 2.4; p = 0.28) between the groups. There were no differences between the groups in EuroQol-5 Dimensions or in pain scores for the neck and arm.

CONCLUSIONS: In patients with cervical degenerative disc disease and radiculopathy, decompression plus ADR surgery did not result in a clinically important difference in outcomes after 5 years, compared with decompression and fusion surgery.

Keywords
Cervical radiculopathy, Artificial disc replacement, Surgical treatment outcome, Anterior decompression and fusion
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-345976 (URN)10.3171/2018.7.SPINE18657 (DOI)000461013000002 ()30485205 (PubMedID)
Projects
Cervical radiculopathy, studies on pain analysis and treatment
Available from: 2018-03-13 Created: 2018-03-13 Last updated: 2019-04-16Bibliographically approved
6. Preoperative mental distress is more important for long-term outcome than the difference between surgical modalities, arthroplasty or fusion in patients with cervical radiculopathy
Open this publication in new window or tab >>Preoperative mental distress is more important for long-term outcome than the difference between surgical modalities, arthroplasty or fusion in patients with cervical radiculopathy
Show others...
2018 (English)In: Journal of Neurosurgery: Spine, ISSN 1547-5654Article in journal (Refereed) Accepted
Abstract [en]

OBJECTIVE: Several efforts have been made to investigate the long-term efficacy of artificial disc replacement surgery compared with fusion after decompression for the treatment of cervical degenerative disc disease and radiculopathy. However, research about the impact of mental distress on surgical treatment outcome is sparse. Our aim was to investigate the potential predictive value of preoperative risk factors to long-term outcome.

METHODS: We randomly assigned 153 patients (mean age 47 years) with single- or double-level cervical degenerative disc disease and radiculopathy to receive either anterior cervical discectomy and fusion (n=70) or artificial disc replacement (ADR, n=83). The primary outcome was the Neck Disability Index (NDI), a patient-reported function score that ranges from 0 to 100%, with higher scores indicating greater disability. Preoperative variables such as sex, age, smoking, employment status, strenuous job, neck pain duration, arm pain duration, exercise, Hospital Anxiety and Depression Scale (HADS) scores, NDI and if one- or two-levels of surgery were performed as well as the allocated treatment were analyzed in multiple linear regression models with 5-year NDI as outcome.

RESULTS: There were 47 patients (32%) with either HADS anxiety or HADS depression scores of 10 points or more. High values on preoperative HADS were negative predictors of outcome (P = 0.009). Treatment allocation had no effect on 5-year NDI (P = 0.32).

CONCLUSION: Preoperative mental distress measured with HADS score affects long-term outcome in surgically treated patients with cervical radiculopathy.

Trial registration: The study was registered at ISRCTN (registration number: 44347115).

Place, publisher, year, edition, pages
Charlottesville, Virginia: , 2018
Keywords
Artificial disc replacement, Hospital anxiety and depression scale, Treatment outcome, Neck disability index, Cervical radiculopathy
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-345940 (URN)
Projects
Cervical radiculopathy, studies on pain analysis and treatment
Available from: 2018-03-13 Created: 2018-03-13 Last updated: 2018-03-13

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