Trends in Nonoperative Treatment Modalities Prior to Cervical Surgery and Impact on Patient-Derived Outcomes: Two-Year Analysis of 1522 Patients From the Prospective Spine Treatment Outcome Study

Michael C. Gerling; Kris Radcliff; Robert Isaacs; Kristina Bianco; Cyrus M. Jalai; Nancy J. Worley; Gregory W. Poorman; Samantha R. Horn; Olivia J. Bono; John Moon; Paul M. Arnold; Alexander R. Vaccaro; Peter Passias

doi:10.14444/5031

ABSTRACT

Background Effects of nonoperative treatments on surgical outcomes for patients who failed conservative management for cervical spine pathologies remain unknown. The objective is to describe conservative modality use in patients indicated for surgery for degenerative cervical spine conditions and its impact on perioperative outcomes.

Methods The current study comprises a retrospective review of a prospective multicenter database. A total of 1522 patients with 1- to 2-level degenerative cervical pathology who were undergoing surgical intervention were included. Outcome measures used were health-related quality-of-life scores, length of hospitalization, estimated blood loss, length of surgery, and return-to-work status at 2 weeks, 6 months, 1 year, and 2 years postoperatively. Patients were grouped by diagnosis (radiculopathy vs. myelopathy), then divided based on epidural injection(s), physical therapy (PT), or opioid use prior to enrollment. Univariate t-tests and χ² tests were performed to determine differences between groups and impact on outcomes.

Results Among 1319 radiculopathy patients, 25.7% received preoperative epidural injections, 35.3% received PT, and 35.5% received opioids. Radiculopathy patients who received epidurals and PT had higher 1-year postoperative return-to-work rates (P < .05). Radiculopathy patients without preoperative PT had longer hospitalization times, whereas those who received PT had higher 36-Item Short Form Health Survey (SF-36) physical functioning and physical component scores, lower 2-year visual analog scale (VAS) neck/arm pain scores, and higher 2-year return-to-work incidence (P < .05). Of myelopathy patients (n = 203), 14.8% received epidural injections, 25.1% received opioids, and 41.5% received PT. Myelopathy patients with preoperative PT had worse VAS arm pain scores 2 years postoperatively (P < .05). Patients receiving opioids were younger and had greater baseline–2-year Neck Disability Index improvement (P < .05).

Conclusions Radiculopathy patients receiving epidurals returned to work after 1 year more frequently. PT was associated with shorter hospitalizations, greater SF-36 bodily pain norm and physical component score improvements, and increased return-to-work rates after 1 and 2 years. No statistically significant nonoperative treatment was associated with return-to-work rate in myelopathy patients.

Clinical Relevance These findings suggest certain preoperative conservative treatment modalities are associated with improved outcomes in radiculopathy patients.

Footnotes

Disclosures and COI: M.C.G. reports a past history of personal fees from Paradigm Spine and Stryker Spine, outside the submitted work. K.R. reports personal fees from Globus Medical, 4 Web Medical, Medtronic Advanced Energy, DePuy, Globus, LDR, Orthopedic Sciences Inc., NuVasive, and NEXXT Spine, and grants from Pacira Pharmaceuticals, outside the submitted work; nonfinancial disclosure includes serving on the board of directors at Association for Collaborative Spinal Research and the scientific advisory board of 4 Web Medical, outside the submitted work. R.I. reports grants and personal fees from NuVasive Inc., and personal fees from the Association for Collaborative Spine Research, and serves as a scientific advisor for Providence Medical Technology, outside the submitted work. P.M.A. reports personal fees and nonfinancial support from Evoke Medical and Z-Plasty; personal fees from Medtronic Sofamor Danek, Stryker Spine, and Fzio Med; and travel reimbursement from AOSpine North America, outside the submitted work. A.R.V. reports personal fees from Medtronic, Striker Spine, Biomet Spine, Globus, Aesculap, Thieme, Jaypee, Elsevier, Taylor Francis, DePuy, Medtronic, Gerson Lehrman Group, Guidepoint Global, Medacorp, Innovative Surgical Design, and Orthobullets; expert testimony for Ellipse and Vertex; and stock ownership in Replication Medica, Paradigm Spine, Stout Medical, Progressive Spinal Technologies Advanced Spinal Intellectual Properties, Spine Medica, Computational Biodynamics, Spinology, Small Bone Innovations, Cross Current, In Vivo, Flagship Surgical, Cytonics, Bonovo Orthopaedics, Electrocore, Gamma Spine, Location Based Intelligence, FlowPharma, R.S.I, Rothman Institute and Related Properties, Innovative Surgical Design, and Avaz Surgical, outside the submitted work; and nonfinancial disclosure includes serving on the scientific advisory board for AOSpine, Innovative Surgical Design, and the Association for Collaborative Spine Research, outside the submitted work. P.G.P. reports nonfinancial support from Medicrea and personal fees from Zimmer Biomet, outside the submitted work.