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Clinical and patient-reported outcomes after anterior cervical decompression and fusion surgery: A focus on functioning and daily life
Linköping University, Department of Medical and Health Sciences, Division of Physiotherapy. Linköping University, Faculty of Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Activity and Health.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Anterior cervical decompression and fusion (ACDF), with or without an intervertebral cage to add support to the fused segment, is an established surgical treatment of cervical radiculopathy due to cervical disc disease. High recovery rates and pain reductions after surgery have been reported, with similar results with or without a cage. A few small studies have evaluated neck-related physical function and patient-reported disability with less promising results. No previous studies have evaluated clinical and patientreported measures of functioning or compared the Cloward Procedure with the Cervical Intervertebral Fusion Cage (CIFC) more than 10 year after surgery. No studies have explored the patients’ perspective on surgical outcome Knowledge on long-term functioning may provide a base for improved postoperative care and rehabilitation. Combining the perspectives of clinicians and patients may provide a better understanding of outcome after ACDF surgery than has previously been reported.

The overall aim of the thesis was to evaluate long-term functioning after anterior cervical decompression and fusion surgery due to cervical disc disease, and to provide new insights into patients’ experiences of daily life after surgery.

The more than 10-year patient-reported outcomes of pain, disability and psychosocial factors (n=77), as well as clinical outcomes of neck-related physical function (n=51) were evaluated and compared between the Cloward Procedure and the CIFC. Preoperative and surgery-related factors of importance for a good outcome in neck-related pain and disability at 10-year follow-up were also identified. Fourteen women were interviewed at 1.5 to 3 years after ACDF to explore their experiences of daily life.

There were no differences between the surgical techniques in long-term neck-related pain or patient-reported disability. Secondary outcomes were, with a few exceptions, similar between groups. Neck-related pain decreased after surgery and remained improved from the 2-year to the 10-year follow-up. However, disability ratings remained improved only in the CIFC group. Predictors of a successful outcome in neck-related pain intensity were high preoperative neck-related pain intensity (Odds Ratio 1.06) and nonsmoking (Odds Ratio 3.03). Male gender was the only predictive factor of a successful outcome in neck-related disability (Odds Ratio 4.33). Moderate to severe pain and patient-reported disability were seen in half of the participants at the 10-year follow-up, and neck-related physical impairments were seen in between 18% (cervical flexion) and 82% (neck-muscle endurance) of participants. Daily life was experienced as recovered or improved by women after ACDF surgery. However they were at the same time affected and limited by remaining symptoms. Behaviors and activities were altered to adjust to the symptoms. Social support provided by family, social and occupational networks, and by healthcare professionals were experienced as important in a good daily life.

In conclusion: long-term pain, physical function and patient-reported disability were similar between the two ACDF techniques. High preoperative pain intensity, non-smoking and male gender predicted a good long-term outcome. Individuals after ACDF surgery experienced improvements in pain intensity and a good effect of surgery although they simultaneously reported residual or recurrent disability.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 77 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1443
National Category
Physiotherapy Nursing
Identifiers
URN: urn:nbn:se:liu:diva-117347DOI: 10.3384/diss.diva-117347ISBN: 978-91-7519-134-8 (print)OAI: oai:DiVA.org:liu-117347DiVA: diva2:807497
Public defence
2015-05-22, Berzeliussalen, Campus US, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2015-04-23 Created: 2015-04-23 Last updated: 2015-05-06Bibliographically approved
List of papers
1. A Comparison Between the Carbon Fiber Cage and the Cloward Procedure in Cervical Spine Surgery A Ten- to Thirteen-Year Follow-Up of a Prospective Randomized Study
Open this publication in new window or tab >>A Comparison Between the Carbon Fiber Cage and the Cloward Procedure in Cervical Spine Surgery A Ten- to Thirteen-Year Follow-Up of a Prospective Randomized Study
2011 (English)In: SPINE, ISSN 0362-2436, Vol. 36, no 12, 919-925 p.Article in journal (Refereed) Published
Abstract [en]

Study Design. Ten- to 13-year follow-up of a prospective randomized study. Objective. To compare the 10- to 13-year outcomes of anterior cervical decompression and fusion (ACDF) with a cervical intervertebral fusion cage (CIFC), and the Cloward procedure (CP) using a broad clinical and patient-centered assessment. Summary of Background Data. There are few prospective studies and none with a follow-up of 10 years or more. Methods. Patient questionnaires completed 10 years or more after ACDF. Seventy-three patients (77%) responded. Radiographs were obtained at 2 years. Results. Apart from greater fulfillment of preoperative expectation (P = 0.01) and less headache (P = 0.005) in the CIFC group compared with the CP group, there were no significant differences in the outcomes of the two surgical methods. Pain intensity improved in comparison with preoperative levels in both the CIFC and CP groups (P andlt; 0.0001), but the Neck Disability Index (NDI) only improved in the CIFC group (P = 0.04). Only those with a healed fusion benefited from an improved NDI (P = 0.02). There was no deterioration in pain intensity or NDI after the 2-year follow-up. Conclusion. The outcomes of the two surgical methods, with a few exceptions, were equal at 10- to 13-year follow-up, and there was no deterioration in outcome after the 2-year follow-up. Pain intensity improved more than disability, which may indicate that further improvement of physical function requires early more extensive postoperative rehabilitation. Despite persisting disability, repeat surgery was relatively uncommon.

Place, publisher, year, edition, pages
J B Lippincott Co, 2011
Keyword
cervical spine, disc, cage, Cloward, outcome
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-68683 (URN)10.1097/BRS.0b013e3181e8e4a3 (DOI)000290473500011 ()
Note

Original Publication: Anna Hermansen, Rune Hedlund, Ludek Vavruch and Anneli Peolsson, A Comparison Between the Carbon Fiber Cage and the Cloward Procedure in Cervical Spine Surgery A Ten- to Thirteen-Year Follow-Up of a Prospective Randomized Study, 2011, SPINE, (36), 12, 919-925. http://dx.doi.org/10.1097/BRS.0b013e3181e8e4a3 Copyright: J B Lippincott Co http://www.lww.com/

Available from: 2011-05-27 Created: 2011-05-27 Last updated: 2015-04-23
2. Positive predictive factors and subgroup analysis of clinically relevant improvement after anterior cervical decompression and fusion for cervical disc disease: a 10-to 13-year follow-up of a prospective randomized study Clinical article
Open this publication in new window or tab >>Positive predictive factors and subgroup analysis of clinically relevant improvement after anterior cervical decompression and fusion for cervical disc disease: a 10-to 13-year follow-up of a prospective randomized study Clinical article
2013 (English)In: Journal of Eurosurgery : Spine, ISSN 1547-5654, E-ISSN 1547-5646, Vol. 19, no 4, 403-411 p.Article in journal (Refereed) Published
Abstract [en]

Object. The main purpose of this 10- to 13-year follow-up of a prospective randomized study was to identify preoperative factors that predicted good long-term outcome after anterior cervical decompression and fusion (ACDF) with the Cloward procedure or the cervical intervertebral fusion cage. A second purpose was to investigate subgroup differences at the 10-year follow-up between patients with and without clinically relevant improvement (CRI) and between men and women. less thanbrgreater than less thanbrgreater thanMethods. To evaluate clinically meaningful outcomes, good outcome was defined as CRI in neck-related pain intensity (andgt;= 30-mm improvement on a visual analog scale), and CRI in neck-specific disability (andgt;= 20% improvement in the neck disability index [NUT]) from preoperative measurements to the 10-year follow-up. A total of 73 patients (77% of the original study sample) completed questionnaires at least 10 years after ACDF. less thanbrgreater than less thanbrgreater thanResults. High preoperative neck-related pain intensity and preoperative nonsmoking status were predictors of CRI in neck-related pain intensity, and male sex was a predictor of CRI in neck-specific disability; however, no additional predictive factors were identified for good outcome after ACDF. The surgical procedure, number of operated levels, and radiological factors such as healing status did not influence the prediction models. Individuals without CRI in neck-specific disability (75%) and pain intensity (43%) reported a worse outcome for several psychosocial outcome variables compared with those with CRI. At the 10-year follow-up, women reported significantly greater neck- and arm-related pain intensity than men, and women also reported more disability and worse psychosocial status. Women reported CRI on the NDI less frequently than men (p = 0.01). less thanbrgreater than less thanbrgreater thanConclusions. Preoperative predictive factors of good outcome 10-13 years after ACDF included initial high neck-related pain intensity, nonsmoking status at the time of surgery, and male sex. There were greater improvements in pain intensity than in neck-specific disability, and the latter showed a greater association with psychosocial factors. These results suggest the need for multimodal postoperative rehabilitation for patients who do not have a satisfactory outcome after ACDF.

Place, publisher, year, edition, pages
American Association of Neurological Surgeons, 2013
Keyword
cervical disc disease, radiculopathy, anterior cervical fusion, clinical relevant outcome, prognostic factors
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-100024 (URN)10.3171/2013.7.SPINE12843 (DOI)000324964700002 ()
Note

Funding Agencies|Swedish Research Council||Medical Research Council of Southeast Sweden (FORSS)||County Council of Ostergotland||

Available from: 2013-10-25 Created: 2013-10-25 Last updated: 2017-12-06
3. Evaluation of Physical Function in Individuals 11 to 14 Years after AnteriorCervical Decompression and Fusion Surgery: A Comparison betweenPatients and Healthy Reference Samples and Between 2 Surgical Techniques
Open this publication in new window or tab >>Evaluation of Physical Function in Individuals 11 to 14 Years after AnteriorCervical Decompression and Fusion Surgery: A Comparison betweenPatients and Healthy Reference Samples and Between 2 Surgical Techniques
2014 (English)In: Journal of Manipulative and Physiological Therapeutics, ISSN 0161-4754, E-ISSN 1532-6586, Vol. 37, no 2, 87-96 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The purpose of this study was to evaluate neck-related physical function in individuals 11 to 14 years after anterior cervical decompression and fusion (ACDF) surgery for degenerative cervical disk disease and to compare the long-term outcome of 2 surgical techniques, including the Cloward procedure and cervical intervertebral fusion cage. Methods: In this cross-sectional study, 51 individuals, 11 years or more after ACDF, underwent testing of cervical active range of motion, hand-grip strength, static and dynamic balance, neck muscle endurance, and completed pain ratings. The participants values were compared with values of age-and sex-matched healthy individuals to evaluate impairments. Correlations between different test scores and pain were performed. Group differences were analyzed between the 2 surgical techniques. Results: Sixty-five percent and 82% exhibited impairment in ventral and dorsal neck muscle endurance, respectively. Impairment rates of 18% to 39% for cervical active range of motion, 27% to 43% for hand-grip strength, 37% for standing balance, and 35% for dynamic balance were recorded. Twenty-nine percent of the participants had impairment (greater than30 mm visual analog scale) in pain. There were no significant differences in physical function between the 2 surgical treatment groups (Cloward procedure or cervical intervertebral fusion cage) (P = .10-.92). Conclusions: In those studied, a large percentage of patients who had anterior cervical decompression and fusion surgery have impairments in neck-related physical function when compared 11 to 14 years after surgery with age-and sex-matched healthy reference individuals. Neck-specific function, but not balance, was statistically correlated to pain. Neck muscle endurance was most affected, and balance impairments were also present in one-third of the individuals. There were no differences in long-term physical function between the 2 surgical techniques.

Place, publisher, year, edition, pages
Elsevier, 2014
Keyword
Cervical Vertebrae; Neck Muscles; Physical Endurance; Range of Motion; Postural Balance; Surgical Procedure
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-104837 (URN)10.1016/j.jmpt.2013.11.002 (DOI)000330584200004 ()
Available from: 2014-02-28 Created: 2014-02-28 Last updated: 2017-12-05Bibliographically approved
4. Women’s experiences of daily life after anterior cervical decompression and fusion surgery: A qualitative interview study
Open this publication in new window or tab >>Women’s experiences of daily life after anterior cervical decompression and fusion surgery: A qualitative interview study
2016 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, E-ISSN 1651-2081, Vol. 48, no 4, 352-358 p.Article in journal (Refereed) Published
Abstract [en]

Subjects: Fourteen women aged 39-62 years (median 52 years), were included 1.5 to 3 years after ACDF for cervical degenerative disc disease.

Methods: Individual semi-structured interviews were analyzed by qualitative content analysis with an inductive approach.

Results: The women described their experiences of daily life in five different ways; Experiences of recovery; Experiences of symptoms in daily life influence feelings and thoughts; Making daily life work; Importance of social  and occupational networks; Experiences of the influence of healthcare professionals and interventions on daily life.

Conclusion: This interview study provides insight into women’s daily life after ACDF. While improved after surgery, informants also experienced remaining symptoms and limitations in daily life. A variety of mostly active coping strategies were used to manage daily life. Social support from family, friends, occupational networks and healthcare professionals positively influenced daily life. These findings provide knowledge on aspects of daily life that should be considered in individualized postoperative care and rehabilitation in an attempt to provide better outcomes in women after ACDF.

Place, publisher, year, edition, pages
Uppsala, Sweden: Stiftelsen Rehabiliteringsinformation /Foundation for Rehabilitation Information, 2016
Keyword
Daily life, cervical spine, research interview, content analysis
National Category
Medical and Health Sciences Physiotherapy
Identifiers
urn:nbn:se:liu:diva-117344 (URN)10.2340/16501977-2076 (DOI)000372456100005 ()26999327 (PubMedID)
Note

Funding agencies: NSC FoU-fond; County Council of Ostergotland

Available from: 2015-04-23 Created: 2015-04-23 Last updated: 2017-12-04Bibliographically approved

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