An effectiveness and quality-of-life analysis of conservative care versus surgery for moderate and severe cervical myelopathy

• Published in: Canadian Journal of Surgery 2022-12, Vol.65, p.S153-S154
• Main Authors: Sarraj, Mohamed, Marion, Travis, Guha, Daipayan, Pahuta, Mark
• Format: Article
• Language: English
• Subjects: Decision making; Patients; Surgery
• ISSN: 0008-428X; 1488-2310

Background: There is a paucity of comparative evidence supporting surgical treatment of degenerative cervical myelopathy (DCM). Only 1 randomized controlled trial has been conducted, which found no benefit to surgery. Systematic reviews of observational comparative studies have also not found surgery to be superior to nonoperative care. In this paper we present a decision analysis on the role of surgery. Methods: A probabilistic patient-level simulation with 100 000 replications was developed using parametric survival models for neurologic progression in cervical spondylotic myelopathy (CSM) and the survivorship of cervical procedures fitted using rigorous metaregression studies on cohorts of 674 and 98 075 patients, respectively. Utilities (quality-adjusted life-year [QALY] weights) for the Modified Japanese Orthopaedic Association (mJOA) score were obtained from a general population utility valuation study. Overall survival was obtained from life tables published by Statistics Canada. In analysis 1, we calculated the time to neurologic progression (TTNP) for patients with DCM treated conservatively, and time to second surgery (TTSS) for patients undergoing cervical surgery. In analysis 2, we compared the QALYs lived by patients with CSM treated conservatively and surgically. Results: When comparing conservative care versus anterior cervical discectomy and fusion (ACDF), artificial disc replacement and laminoplasty (ADR), surgery benefitted only 50 % of patients aged 60 years or older (i.e., TTNP < TTSS). With an infinite expected survival, only 50.4% of patients benefitted from surgery. When comparing conservative care versus laminectomy and fusion, at no time horizon did 50% of patients benefit from surgery. For baseline moderate and severe CSM patients, neither ACDF, ADR, and laminoplasty nor laminectomy and fusion imparted a significant QALY benefit over conservative care. Conclusion: For patients older than 60 years of age, the risk of second surgery is greater than neurologic progression from DCM. For patients younger than 60 years of age treated with ACDF, ADR and laminoplasty, the risk of second surgery is less than the risk of neurologic progression. Neither moderate nor severe CSM patients derive a QALY benefit from surgery. The decision to undergo cervical surgery to prevent neurologic decline must involve shared decision-making with the patient.