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Preoperative mental distress is more important for long-term outcome than the difference between surgical modalities, arthroplasty or fusion in patients with cervical radiculopathy
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.ORCID iD: 0000-0002-9231-7608
Institutionen för lärande, informatik, management och etik. Department for learning, informatics, management and ethics.ORCID iD: 0000-0001-9901-6886
Uppsala Clinical Research.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.ORCID iD: 0000-0002-2724-6372
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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 [en]
Artificial disc replacement, Hospital anxiety and depression scale, Treatment outcome, Neck disability index, Cervical radiculopathy
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:uu:diva-345940OAI: oai:DiVA.org:uu-345940DiVA, id: diva2:1189923
Projects
Cervical radiculopathy, studies on pain analysis and treatmentAvailable from: 2018-03-13 Created: 2018-03-13 Last updated: 2018-03-13
In thesis
1. Cervical Radiculopathy: Studies on Pain Analysis and Treatment
Open this publication in new window or tab >>Cervical Radiculopathy: Studies on Pain Analysis and Treatment
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
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
Cervical radiculopahy, Artificial disc replacement
National Category
Orthopaedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:uu:diva-345977 (URN)978-91-513-0272-0 (ISBN)
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

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