Hostname: page-component-586b7cd67f-g8jcs Total loading time: 0 Render date: 2024-11-28T17:09:00.706Z Has data issue: false hasContentIssue false
  • English
  • Français

Clinical Equipoise and Treatment Decisions in Cervical Spondylotic Myelopathy

Published online by Cambridge University Press:  02 December 2014

Michael Benatar
Michael Benatar*
Affiliation:
Department of Neurology, Emory University, The Emory Clinic, Atlanta, GA, USA
Rights & Permissions [Opens in a new window]

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

The primary objective of this study is to evaluate clinician attitudes towards the treatment of cervical spondylotic myelopathy (CSM) in order to determine whether clinical equipoise exists for a segment of this patient population. The secondary objective is to examine the factors that influence treatment decisions.

Methods:

Cross-sectional internet-based survey of neurologists, neurosurgeons and orthopedic surgeons.

Results:

Between 40-60% of respondents recommended surgery for (1) patients with minimal or no symptoms, but incidentally discovered increased T2 signal within the cervical cord on MRI, (2) patients with mild symptoms and indentation of the cervical cord but without increased T2 signal and (3) those with at least moderately severe clinical findings accompanied by MRI showing effacement of the thecal sac but without indentation of the cord or increased T2 signal. The severity of the radiological abnormalities most strongly influence treatment decisions.

Conclusion:

We conclude that clinical equipoise does exist for certain groups of patients with CSM, suggesting that a randomized controlled trial could be performed in this population.

Résumé:

RÉSUMÉ: Objectif:

Le principal objectif de cette étude était d'évaluer l'attitude des cliniciens concernant le traitement de la myélopathie cervico-arthrosique (MCA) afin d'établir s'il existe un équilibre clinique pour une partie de cette population de patients. L'objectif secondaire était d'examiner les facteurs qui influencent la décision de traitement.

Méthodes:

Il s'agit d'une enquête transversale par Internet auprès des neurologues, des neurochirurgiens et des orthopédistes.

Résultats:

De 40 à 60% des répondants recommandaient la chirurgie: 1) aux patients qui avaient peu ou pas de symptômes, chez qui une augmentation du signal T2 au niveau de la moelle cervicale était une découverte fortuite; 2) aux patients présentant des symptômes légers et une indentation de la moelle cervicale sans augmentation du signal T2; 3) à ceux qui avaient des manifestations cliniques modérément sévères et une IRM démontrant un effacement du sac thécal sans indentation de la moelle ou sans augmentation du signal T2. La sévérité des anomalies radiologiques influence fortement la décision de traitement.

Conclusions:

Nous concluons que l'équilibre clinique existe pour certains groupes de patients atteints de MCA et qu'un essai contrôlé, randomisé, pourrait être fait dans cette population de patients.

Type
Original Articles
Information
Canadian Journal of Neurological Sciences , Volume 34 , Issue 1 , February 2007 , pp. 47 - 52
Copyright
Copyright © The Canadian Journal of Neurological 2007

References

1. http://www.ahrq.gov/data/hcup/Google Scholar
2. Arnasson, O, Carlsson, C, Pellettieri, L. Surgical and conservative treatment of cervical spondylotic radiculopathy and myelopathy. Acta Neurochir. 1987;84:48–53.Google Scholar
3. Bishari, S. The posterior operation - treatment of cervical spondylosis with myelopathy: long term follow up study. J Neurol Neurosurg Psychiatr. 1971;34:393–5.CrossRefGoogle Scholar
4. Campbell, A, Phillips, D. Cervical disk lesions with neurological disorder. BMJ. 1960:481–5.CrossRefGoogle Scholar
5. Clarke, E, Robinson, PK. Cervical myelopathy: a complication of cervical spondylosis. Brain. 1956;79:483–510.CrossRefGoogle ScholarPubMed
6. Ebersold, MJ, Pare, MC, Quast, LM. Surgical treatment for cervical spondylitic myelopathy. J Neurosurg. 1995;82:745–51.CrossRefGoogle ScholarPubMed
7. Fager, C. Posterior surgical tactics for the neurological syndromes of cervical disc and spondylotic lesions. Clin Neurosurg. 1978; 25:218–44.Google Scholar
8. Gonazlez-Feria, L. The effect of surgical immobilization after laminectomy in the treatment of advanced cases of cervical spondylotic myelopathy. Acta Neurochir. 1975;31:185–93.Google Scholar
9. Guidetti, B, Fortunia, A. Long-term results of surgical treatment of myelopathy due to cervical spondylosis. J Neurosurg. 1969; 30:714–21.CrossRefGoogle ScholarPubMed
10. Haft, H, Shenkin, HA. Surgical end results of cervical ridge and disk problems. JAMA. 1963; 186:312–15.CrossRefGoogle ScholarPubMed
11. Hamanishi, C, Tanaka, S. Bilateral multilevel laminectomy with or without posterolateral fusion for cervical spondylotic myelopathy: relationship to type of onset and time until operation. J Neurosurg. 1996;85:447–51.Google Scholar
12. Inoue, H, Ohmori, J, Ishida, Y, Suzuki, K, Takatsu, T. Long-term follow-up review of suspension laminotomy for cervical compression myelopathy. J Neurosurg. 1996; 85:817–23.Google Scholar
13. Laterre, C, Stroobandt, G. Changes in clinical signs after decompressive laminectomy in cervical spondylosis with myelopathy. Acta Neurol Belg. 1976;76:286–90.Google Scholar
14. Lees, F, Turner, JA. Natural history and prognosis of cervical spondylosis. BMJ. 1963;2:16-17-1610.Google Scholar
15. Nurick, S. The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain. 1972;95:101–8.Google Scholar
16. Peserico, L, Uihlein, A, Baker, GS. Surgical treatment of cervical myelopathy associated with cervical spondylosis. Acta Neurchir. 1962;10:365–75.Google Scholar
17. Pipegras, D. Posterior decompression for myelopathy due to cervical spondylosis: laminectomy alone versus laminectomy with dentate ligament section. Clin Neurosurg 1976;24:508–15.CrossRefGoogle Scholar
18. Roberts, A. Myelopathy due to cervical spondylosis treated by collar immobilization. Neurology. 1966;16:951–4.CrossRefGoogle Scholar
19. Scoville, W, Dohrmann, G, Corkill, G. Late results of cervical disc surgery. J Neurosurg. 1976;45:203–10.Google Scholar
20. Stoops, WL, King, RB. Chronic myelopathy associated with cervical spondylosis. JAMA. 1965;192:281–4.Google Scholar
21. Yuhl, ET, Hanna, D, Rasmussen, T, Richter, RB. Diagnosis and surgical therapy of chronic midline cervical disk protrusions. Neurology. 1955;5:494–509.Google Scholar
22. King, JT, Moossy, J, Tsevat, J, Roberts, MS. Multimodal assessment after surgery for cervical spondylotic myelopathy. J Neurosurg Spine. 2005;2:525–34.CrossRefGoogle ScholarPubMed
23. Sampath, P, Bendebba, M, Davis, JD, Ducker, T. Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review. Spine. 2000;25:670–6.CrossRefGoogle ScholarPubMed
24. Kadanka, Z, Bednarik, J, Vohanka, S, Vlach, O, Stejskal, L, Chaloupka, R, et al. Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study. Eur Spine J. 2000;9:538–44.Google Scholar
25. Fouyas, IP, Statham, PF, Sandercock, PA. Cochrane review on the role of surgery in cervical spondylotic radiculomyelopathy. Spine. 2002;27:736–47.Google Scholar
26. Rowland, LP. Surgical treatment of cervical spondylotic myelopathy. Time for a controlled trial. Neurology. 1992; 42:5–13.Google Scholar
27. Freedman, B. Equipoise and the ethics of clinical research. N Engl J Med. 1987;317:141–5.Google Scholar
28. Lin, I, Schaeffer, N. Using survey participants to estimate the impact of nonparticipation. Public Opin Q. 1995; 59:236–58.Google Scholar
29. Irvine, D, Foster, J, Newell, D, Klukvin, B. Prevalence of cervical spondylosis in a general practice. Lancet. 1965;14:1089–92.Google Scholar
30. Teresi, LM, Lufkin, RB, Reicher, MA, Moffit, BJ, Vinuela, FV, Wilson, GM, et al. Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology. 1987;164:83–8.Google Scholar
31. Kadanka, Z, Mares, M, Bednarik, J, Smrcka, V, Krbec, M, Stejskal, L, et al. Approaches to spondylotic cervical myelopathy. Conservative versus surgical results in a 3-year follow-up study.Google Scholar