Study Purpose

To examine the presence of radicular pain and its relationship to the degree of lumbar nerve root compression in patients with a degenerative lumbar spine condition about to undergo surgery for either lumbar disc prolapse or lumbar canal stenosis.

Objective: To assess outcome in patients with syrinx and non-syrinx associated Chiari malformations undergoing Foramen Magnum Decompression (FMD).

Methods: 61 patients undergoing FMD for Chiari malformations were prospectively studied with disease specific, generic (SF 36) and subjective (surgeon assessed) outcomes. 34 patients had complete data. Disease specific outcomes were visual analogue pain scores, Neck and Myelopathy disability indices and the Hospital anxiety and depression score. SF 36 scores were compared to normative data. Data were collected pre-operatively, at 3 months and during long-term follow up (12–60 months).

Results: Subjective improvements in headache and neck pain post-operatively were seen in both syrinx and non-syrinx associated patients. Visual Analogue scores showed an improvement in Arm pain, Paraesthesia and Hand tingling by 3 months in the syrinx group only. Non-syrinx patients showed significant improvement post-operatively in the Neck disability index and the SF-36 domains for physical function, role physical and bodily pain by 12 months. Comparison with the SF 36 normative data showed that patients still have significantly impaired quality of life 12 months post operatively despite the improved scores achieved following surgery.

Conclusion: FMD is able to relieve symptoms and improve quality of life in patients with both syrinx and non-syrinx associated Chiari malformations. The SF-36 data presented in this paper allows the health gain associated with FMD to be quantified but its utility as a sole measure of outcome in this complex disorder will be discussed.

Ethics approval: None

Interest Statement: None

Background: Intramedullary spinal cord tumours (ISCT) are rare with an annual incidence of less than 1 per 100,000 population. This makes assessing the efficacy of any treatment regimen difficult. Goals of management currently focus on obtaining a histological diagnosis for prognostic and therapeutic planning, and long-term tumour control. However, current outcome measures are crude and the quality of life outcome after surgery for intramedullary spinal cord tumours remains uncertain.

Aim: The aims of this study are to assess disability and outcome in patients undergoing surgery for ISCT. We aim to provide prospective quality of life data on patients with spinal cord tumours.

Patients and Methods: Data was collected prospectively on patients undergoing surgery for ISCT between 1995–2006 under the care of the senior author. The Short Form 36 (SF36) Health Survey Questionnaire was self-administered prior to surgery and again at 3, 12 and 24 months after surgery. All patients were also classified using the Frankel disability score. SF36 data were analysed using the Friedman test with Dunn’s post-test for multiple comparisons and the Wilcoxon signed rank test for matched pairs.

Results: Sixty-five patients (35 men, 30 women) had surgical interventions for ISCT. The mean age at first operation was 43y and median follow-up time was 60 months. 15% had astrocytomas, 45% ependymomas, 7 haemangioblastomas and 19 miscellaneous tumours.

Seventy-two percent of patients (47/65) were graded Frankel D pre-operatively and 65% (42/65) remained so after surgery. SF36 data were obtained for 17 patients. Pre-operatively, patients with ISCT had significantly lower SF36 physical domain scores when compared with normative data from age-matched population controls (p=0.0096). There was no difference between post-operative scores and those of normal controls. Matched pairs analysis on the patients with complete SF36 data sets (n=12) demonstrated a significant improvement in physical function post-operatively. Eleven of these 12 did not show an improvement in their Frankel grade, remaining Grade D pre- and post-operatively.

Conclusion: From this preliminary study it appears that patients with spinal cord tumours have significantly impaired physical function compared to the normal population. More importantly, we have demonstrated that the SF36 can detect changes in function associated with spinal cord tumour surgery that other, cruder measures, cannot.

BACKGROUND: Physical outcomes following surgery for degenerative spine disease have been well studied. It is only relatively recently however that the importance of psychological factors in determining outcome from spine surgery has been addressed. Previous studies suggest that pre-operative psychological distress is a predictor of poor outcome. In the drive to identify patients who will not benefit from spine surgery these patients may in future be denied surgery.

AIM: The aim of the current study was to examine the relationship between the severity of physical symptoms, levels of pre-operative psychological distress and out-come in patients with degenerative spine disease undergoing elective spinal surgery.

PATIENTS & METHODS: The study was a prospective cohort study. Health status and psychological distress were measured pre-operatively and at 12 months or more post-operatively using the Short Form 36 (SF36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale (HADS). We compared levels of physical disability (SF-36 physical domain scores) and psychological distress (HADS scores) before and after surgery in this group. Comparisons of pre- and post-operative scores were made using the Kruskal-Wallis, Wilcoxon Signed Rank Test and Mann Whitney U tests as appropriate.

RESULTS: A total of 333 patients were included (178 men, 155 women, mean age 54y). Pre-operatively patients with severe levels of anxiety and depression (higher HADS score) had worse (lower) SF-36 physical domain (SF-36 PD) scores compared to those with normal HADS scores (median 181.5 vs 109, p< 0.0001). Both HADS and SF-36 PD scores improved post-operatively (HADS 13 vs 6 p< 0.0001; SF-36 PD 134 vs 250.5 p< 0.0001). Greater reduction in HADS score was observed in patients with severe pre-operative HADS scores compared to those with normal pre-operative HADS scores (p< 0.0001). Patients with severe HADS scores also had greater improvement in SF36 PD scores when compared to patients with normal pre-operative HADS scores (77.24 vs 53.87 p=0.03).

CONCLUSION: Poor physical function pre-operatively correlates with severe psychological distress. Both physical and psychological symptoms improve after surgery. Severe levels of anxiety and depression pre-operatively are associated with the greatest symptomatic improvement and psychological morbidity does not worsen outcome.

Objective: Measuring outcomes from chronic disease in terms of generic, health-related quality of life (HRQoL) instruments is of increasing importance to allow valid comparison of interventions and to accurately assess efficacy of treatment from the patient’s perspective. In this context we sought to establish the role of the generic SF-36 health survey in measuring outcomes from spinal surgery.

Method: A prospective observational study of patients undergoing elective cervical discectomy, lumbar discectomy, and lumbar laminectomy using both disease specific (Myelopathy Disability Index [MDI], Roland Morris Disability Scale [RMDS], Visual Analogue Scales [VAS], Hospital Anxiety and Depression Scales [HADS]) and SF-36 assessment pre-operatively and at 3 months and 12–24 months following surgery. The generic instrument was tested for the components of construct validity in comparison to the established specific measures. Analysis was performed with non-parametric statistics within SPSS.

Results: Six-hundred and twenty patients were followed between 1998 and 2005 (median age 53 years; 203 lumbar discectomy, 177 lumbar laminectomy, 240 cervical discectomy). The principal SF-36 physical domains (Physical Functioning, Bodily Pain) strongly correlated with disease specific scores in all patients (Spearman’s ρ=0.5–0.74, p< 0.001) and similarly SF-36 mental domains correlated with the HADS subscales (ρ=0.30–0.45, p< 0.001) indicating concurrent/convergent validity. Discriminant validity was confirmed by the absence of significant correlation between SF-36 physical domains and the HADS (ρ=0.014–0.14, p> 0.05). In the lumbar laminectomy and cervical discectomy patients disease-specific physical scores prior to surgery strongly predicted early and late outcome (area under the receiver-operating characteristics curve [AUC] = 0.79–0.86, p< 0.001) and the same pattern was mirrored in the SF-36 physical domains (AUC = 0.76–0.78, p< 0.001) demonstrating the predictive validity of the generic measure. Physical Function and Bodily Pain SF-36 domains both had excellent response to change by Cohen’s criteria with effect sizes (standardised mean difference) of 0.86–1.57.

Conclusion: The SF-36 has been shown to possess the necessary features of construct validity in relation lumbar and cervical surgery to be considered as a suitable adjunct or alternative to measuring outcome with disease specific scores. As a widely employed HRQoL instrument the SF-36 should be a convenient means of assessing patients with spinal morbidity in all healthcare settings and the generic measure will permit easier comparison of the clinical and economic efficacy of different interventions.

Objective: To extend the follow up period of previous studies undertaken by the senior author, looking at the clinical outcome and radiological changes observed in patients with either myelopathy or radiculopathy, following anterior cervical discectomy without fusion.

Design: Prospective, observational cohort study of patients undergoing anterior cervical discectomy without fusion and followed up for five years, radiologically, with serial plain radiographs, and clinically, using validated outcome measures including SF36, neck disability index and analogue visual pain scores.

Subjects: 109 Patients undergoing anterior cervical dis-cectomy without fusion under the senior author’s care.

Outcome measures:

Radiological

Occurrence of segmental cervical kyphosis

Results: A total cohort of 109 patients, of mean age 56 years, were followed up after anterior cervical discectomy without fusion, for up to 5 years. Segmental kyphosis was demonstrated on 44%, and loss of overall cervical alignment on 60% of follow up plain radiographs during the third postoperative year. In the cohorts of patients with either loss of cervical alignment or segmental kyphosis at one year the mean clinical outcome scores (Wilcoxon’s matched pairs signed ranks test) continued to improve at the 5 year follow up. The annual rate of loss of cervical alignment in patients unaffected at the first post operative year was around 10% but there was no significant rate of progression of segmental kyphosis. Comparison of the relationship between these radiological changes and clinical outcome (Mann-Whitney U test) did not show any significant correlation.

Conclusions: This study assesses patients over the period during which the anticipated alignment changes associated with undertaking simple anterior cervical discectomy could be having progressive detrimental clinical effects. Where such radiological changes occur they most commonly occur during the first post operative year. However, clinical outcome measures in these patients all improve at one year follow up, and still continue to improve or plateau up to five years post operatively. As anticipated, the most significant clinical improvement, occurs during the first post operative year. During the longer follow up period there is no significant detrimental effect of the radiological changes discussed on clinical outcome.

Study purpose: Cancer patients presenting with symptomatic spinal metastases is an increasing problem. It is widely accepted that surgery plays an important role in the management of these patients and recent studies1 conclude that surgical treatment should be more frequently offered. However, who should be offered surgery remains controversial, largely because of a lack of information about outcome. Our study is a prospective analysis of survival and functional outcome in patients with metastatic spinal disease treated primarily by surgical decompression and stabilisation when indicated.

Methods: Sixty two patients with radiologically suspected metastatic spinal disease, managed by one consultant neurosurgeon, were enrolled into a prospective cohort study. Patients presented with pain and or myelopathy. Survival, continence, walking, analogue pain scores and short form 36 (SF-36) scores were analysed.

Results: Median age was 62 years (22–79 years, 35 female, 27 male) with the commonest primary tumours being breast (26%), lymphoma (13%) and prostate (10%). Lung cancer was poorly represented (1 patient). Survival rates were 56% at 1 year, 49% at 2 years and 28% at 3 years. Of 16 patients not walking pre-op, 8 gained the ability to walk, while 5 out of 7 incontinent patients gained continence following surgery.

Conclusion: Our data indicate that long term survival and favourable functional outcomes can be achieved following surgery in patients with metastatic spinal disease. We strongly advocate that patients presenting with metastatic spinal disease be considered for primary surgical treatment but would highlight the importance of appropriate patient selection.