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Research ArticleCervical Spine

How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

Srikanth N. Divi, Dhruv K.C. Goyal, Barrett I. Woods, Kristen J. Nicholson, Harold I. Salmons, Matthew S. Galetta, Mahir A. Qureshi, Meghan E. Lam, Andrew L. DiMatteo, D. Greg Anderson, Mark F. Kurd, Jeffrey A. Rihn, Ian D. Kaye, Christopher K. Kepler, Alan S. Hilibrand, Alexander R. Vaccaro, Kristen E. Radcliff and Gregory D. Schroeder
International Journal of Spine Surgery April 2022, 16 (2) 240-246; DOI: https://doi.org/10.14444/8212
Srikanth N. Divi
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Dhruv K.C. Goyal
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Barrett I. Woods
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Kristen J. Nicholson
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
PhD
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Harold I. Salmons
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Matthew S. Galetta
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
BA
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Mahir A. Qureshi
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
BS
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Meghan E. Lam
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
BA
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Andrew L. DiMatteo
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MS
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D. Greg Anderson
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Mark F. Kurd
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Jeffrey A. Rihn
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Ian D. Kaye
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Christopher K. Kepler
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MDMBA
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Alan S. Hilibrand
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Alexander R. Vaccaro
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MDPhDMBA
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Kristen E. Radcliff
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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Gregory D. Schroeder
1 Department of Orthopaedic Surgery, Rothman Institute Thomas Jefferson University, Philadelphia, PA, USA
MD
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    Table 1

    Demographic data and surgical characteristics between visual analog scale pain groups.

    DemographicNeck (n = 46)Neutral (n = 57)Arm (n = 19)Univariate Analysis, P Valuea
    Age52.0 (49.0, 54.0)48.0 (46.0, 51.0)49.0 (45.0, 53.0)0.307
    Sex
     Men24 (52.2%)28 (49.1%)7 (36.8%)0.525
     Women22 (47.8%)29 (50.9%)12 (63.2%)
    Body mass index28.5 (27.0, 30.1)29.4 (27.8, 31.0)30.1 (27.3, 32.8)0.497
    Smoking status
     Never25 (45.3%)29 (50.9%)11 (57.9%)0.824
     Current8 (17.4%)13 (22.8%)2 (10.5%)
     Former13 (37.3%)15 (26.3%)6 (31.6%)
    Follow-Up, mo20.2 (18.2, 22.3)19.2 (18.0, 20.4)20.7 (17.2, 24.2)0.989
    Worker's compensation received prior to surgery?
     No37 (80.4%)49 (86.0%)17 (89.5%)0.598
     Yes9 (19.6%)8 (14.0%)2 (10.5%)
    Levels fused
     119 (41.3%)18 (31.6%)5 (26.3%)0.357
     217 (37.0%)32 (56.1%)9 (47.4%)
     310 (21.7%)7 (12.3%)5 (26.3%)
    Revision surgery?
     No42 (91.3%)51 (89.5%)17 (89.5%) —
     Yes4 (8.7%)6 (10.5%)2 (10.5%)
    • Data presented as n (%) and median (IQR). Kruskal-Wallis H test, Pearson Χ 2 analysis, or Fisher exact test were used to compare baseline demographics and surgical characteristics between groups.

    • aP < 0.05.

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    Table 2

    Patient-reported outcome measurements between VAS pain groups.

    PROMIntervalN (n = 46)NE (n = 57)A (n = 19)Univariate Analysis, P ValueMultivariate Regression, β Coefficient (95% CI), P Value
    Paired Samples t TestKruskal-Wallis H Test or χ2 Analysis
    PCS-12Preoperative32.7 (31.0, 34.5)32.9 (30.9, 34.8)35.3 (30.7, 39.9)N: <0.001aNE: <0.001aA: 0.0640.762N: -NE: 2.300 (−1.707, 6.306), 0.258A: −0.532 (−6.015, 4.951), 0.848
    Postoperative39.4 (35.9, 42.8)41.4 (38.5, 44.4)40.0 (34.1, 46.0)0.617
    Delta6.6 (3.3, 10.0)8.3 (6.0, 10.6)4.7 (−0.3, 9.8)0.323
    RR9.6%12.1%6.8%—0.419
    % MCID39.1%50.9%36.8%0.382
    MCS-12Preoperative47.6 (43.8, 51.4)46.4 (43.0, 49.7)46.2 (40.8, 51.6)N: 0.401NE: 0.076A: 0.3180.836N: -NE: 3.772 (−0.551, 8.096), 0.087A: 4.791 (−1.066, 10.648), 0.108
    Postoperative45.8 (42.4, 49.2)49.6 (46.7, 52.5)49.8 (43.0, 56.6)0.072
    Delta−1.8 (−6.0, 2.4)2.8 (−0.7, 6.4)3.6 (−3.8, 11.1)0.161
    RR−7.7%1.9%4.3%—0.130
    % MCID26.1%40.4%42.1%0.255
    NDIPreoperative45.0 (41.0, 50.0)47.0 (41.0, 52.0)37.0 (28.0, 46.0)N: <0.001aNE: <0.001aA: <0.001a 0.177N: -NE: −7.554 (−15.211, 0.103), 0.053A: −10.571 (−21.102, −0.041), 0.049a
    Postoperative33.6 (26.6, 40.5)27.5 (20.9, 34.1)19.7 (10.6, 28.8)0.063
    Delta−11.6 (−17.4, −5.9]−19.3 (−25.0, −13.5)−17.4 (−25.8, −9.0)0.330
    RR25.6%40.0%51.7%—0.106
    % MCID45.7%50.9%52.6%0.825
    VAS neckPreoperative6.5 (6.0, 7.0)6.8 (6.2, 7.4)4.3 (3.0, 5.5)N: <0.001aNE: <0.001aA: 0.025a 0.001a N: -NE: −1.020 (−2.128, 0.087), 0.071A: −1.170 (−2.782, 0.442), 0.153
    Postoperative4.2 (3.3, 5.1)3.2 (2.4, 3.9)2.5 (1.2, 3.7)0.065
    Delta−2.3 (−3.2, −1.4)−3.6 (−4.4, −2.7)−1.8 (−3.4, −0.2)0.082
    RR34.2%51.1%29.1%—0.197
    % MCID47.8%59.6%42.1%0.302
    VAS armPreoperative3.0 (2.2, 3.9)6.8 (6.2, 7.4)6.3 (5.1, 7.5)N: 0.362NE: <0.001aA: 0.001a <0.001a N: -NE: −1.521 (−2.921, –0.121), 0.034aA: −1.505 (−3.219, 0.210), 0.085
    Postoperative3.5 (2.6, 4.5)2.8 (2.0, 3.6)3.1 (1.6, 4.6)0.541
    Delta0.5 (−0.6, 1.7)−4.0 (−4.8, −3.2)−3.1 (−4.8, –1.5)<0.001a
    RR36.2%58.7%51.1%—0.263
    % MCID19.6%63.2%42.1%<0.001a
    • Note: NPreoperative, postoperative, and delta data are presented as mean (95% CI). Neck, neutral, and arm pain dominant groups outcomes compared with univariate analysis—paired samples t test, Kruskal-Wallis H testing with Dunn multiple pairwise comparisons conducted for post hoc analysis, or Pearson Χ 2 analysis—and multivariate regression. RR were defined as: (delta outcome score/[optimal outcome score – observed outcome score]), where the following optimal outcome scores were used: 100 (PCS-12 and MCS-12) or 0 (NDI). The percentage of patients reaching the MCID was based on the following threshold values: PCS-12, 8.1 points; MCS-12, 4.7 points; and NDI, 15 points. Multivariate regression analysis conducted using the neck pain dominant group as a baseline for comparison—controlling for age, sex, body mass index, smoking status, (never, current, and former), follow-up (mo), and No. of levels fused.

    • aIndicates statistical significance (P < 0.05).

    • A, arm; MCID, minimum clinically important difference; MCS-12, Mental Component Score of the Short Form-12 Survey; N, neck; NDI, Neck Disability Index; NE, neutral; PCS-12, Physical Component Score of the Short Form-12 Survey; RR, recovery ratios; VAS, visual analog scale.

    • View popup
    Table 3

    Patient-reported outcome measurements between VAS ANR groups.

    PROMIntervalNAPD (ANR ≤1.0) (n = 91)APD (ANR >1.0) (n = 31)Univariate Analysis, P ValueMultivariate Regression, β Coefficient (95% CI), P Value
    Paired Samples t TestIndependent Samples t Test or χ2 Analysis
    PCS-12Preoperative33.1 (31.6, 34.5)33.6 (30.6, 36.5)NAPD: <0.001aAPD: <0.001a 0.691NAPD: -APD: 0.675 (−3.647, 4.998), 0.757
    Postoperative40.0 (37.6, 42.4)41.8 (37.5, 46.0)0.412
    Delta6.9 (4.8, 9.0)7.7 (3.9, 11.6)0.522
    RR10.2%10.7% — 0.661
    % MCID41.8%51.6%0.340
    MCS-12Preoperative47.0 (44.4, 49.7)46.0 (41.9, 50.2)NAPD: 0.903APD: 0.031a 0.615NAPD: -APD: 4.179 (−0.466, 8.823), 0.077
    Postoperative46.9 (44.5, 49.3)52.1 (47.9, 56.3)0.008a
    Delta−0.2 (−3.0, 2.7)5.5 (−0.1, 11.0]0.043a
    RR0.0%0.1% — 0.114
    % MCID30.8%48.4%0.076
    NDIPreoperative46.0 (42.0, 50.0)42.0 (35.0, 48.0)NAPD: <0.001aAPD: <0.001a 0.243NAPD: -APD: −9.808 (−18.053, –1.563), 0.020a
    Postoperative31.9 (26.8, 37.0)18.8 (12.2, 25.4)0.011a
    Delta−13.9 (−18.0, –9.7)−22.8 (−30.2, –15.4)0.038a
    RR31.1%51.7% — 0.059
    % MCID45.1%61.3%0.118
    VAS neckPreoperative6.5 (6.0, 7.0)5.6 (4.8, 6.5)NAPD: <0.001aAPD: 0.001a 0.041a NAPD: -APD: −0.704 (−1.929, 0.552), 0.258
    Postoperative3.8 (3.1, 4.4)2.5 (1.6, 3.3)0.076
    Delta−2.8 (−3.4, –2.1)−3.0 (−4.1, –1.8)0.504
    RR41.2%42.1% — 0.331
    % MCID51.6%54.8%0.748
    VAS armPreoperative4.7 (4.1, 5.4)7.0 (6.3, 7.7)NAPD: <0.001aAPD: <0.001a 0.001a NAPD: -APD: −0.942 (−2.268, 0.384), 0.162
    Postoperative3.3 (2.7, 4.0)2.5 (1.5, 3.5)0.264
    Delta−1.4 (−2.2, –0.6)−4.4 (−5.6, –3.2)0.001a
    RR48.3%57.4% — 0.499
    % MCID37.4%61.3%0.020a
    • Note: Preoperative, postoperative, and delta data are presented as mean (95% CI). VAS ANR group outcomes compared with univariate analysis—paired samples t test, Kruskal-Wallis H testing with Dunn multiple pairwise comparisons conducted for post hoc analysis, or Pearson Χ 2 analysis—and multivariate regression. RR were defined as: (delta outcome score/[optimal outcome score – observed outcome score]), where the following optimal outcome scores were used: 100 (PCS-12 and MCS-12) or 0 (NDI).2 The percentage of patients reaching the % MCID was based on the following threshold values: PCS-12, 8.1 points; MCS-12, 4.7 points; and NDI, 15 points.3,4 Multivariate regression analysis conducted using the neck pain dominant group as a baseline for comparison—controlling for age, sex, Body Mass Index, smoking status, (never, current, former), follow-up (months), and No. of levels fused.

    • aIndicates statistical significance (P < 0.05).

    • ANR, arm neck ratio; APD, arm pain dominant; MCID, minimum clinically important difference; MCS-12 , Mental Component Score of the Short Form-12 Survey; NAPD, non-arm pain dominant; NDI , Neck Disability Index ; PCS-12 , Physical Component Score of the Short Form-12 Survey; RR, recovery ratios; VAS, visual analog scale.

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International Journal of Spine Surgery
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How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?
Srikanth N. Divi, Dhruv K.C. Goyal, Barrett I. Woods, Kristen J. Nicholson, Harold I. Salmons, Matthew S. Galetta, Mahir A. Qureshi, Meghan E. Lam, Andrew L. DiMatteo, D. Greg Anderson, Mark F. Kurd, Jeffrey A. Rihn, Ian D. Kaye, Christopher K. Kepler, Alan S. Hilibrand, Alexander R. Vaccaro, Kristen E. Radcliff, Gregory D. Schroeder
International Journal of Spine Surgery Apr 2022, 16 (2) 240-246; DOI: 10.14444/8212

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How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?
Srikanth N. Divi, Dhruv K.C. Goyal, Barrett I. Woods, Kristen J. Nicholson, Harold I. Salmons, Matthew S. Galetta, Mahir A. Qureshi, Meghan E. Lam, Andrew L. DiMatteo, D. Greg Anderson, Mark F. Kurd, Jeffrey A. Rihn, Ian D. Kaye, Christopher K. Kepler, Alan S. Hilibrand, Alexander R. Vaccaro, Kristen E. Radcliff, Gregory D. Schroeder
International Journal of Spine Surgery Apr 2022, 16 (2) 240-246; DOI: 10.14444/8212
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