Novel (nua) Kinase 1 (NUAK1) encodes a serine-threonine protein kinase, mutations in which are associated with autism spectrum disorder. Direct phosphorylation targets of NUAK1 have been elusive hindering mechanistic understanding of its role in brain development. Here, we characterize autism-associated NUAK1 variants and show their differential impact on catalytic activity and subcellular distribution. We engineered ATP-analog sensitive NUAK1 and utilized its specificity towards bulky analogs to identify over 30 hitherto unknown direct phosphorylation targets of NUAK1. We demonstrate that Pleckstrin Homology and Sec7-domain containing protein 3 (PSD3) is a bona fide phosphorylation target of NUAK1. A guanine exchange factor (GEF) for ARF6 GTPase, PSD3 is phosphorylated by NUAK1 at S476. Expression of phosphodeficient PSD3 leads to aberrant activation of ARF6 and generation of PI(4,5)P 2 that accumulates in intracellular vesicles. In neurons, phosphomutant PSD3 leads to enhanced spine maturation in an ARF6 dependent fashion. This study reveals direct neuronal substrates of an autism risk gene NUAK1, and delineates a mechanism by which PSD3 phosphorylation regulates ARF6 activation and spine maturation.
Acute cervical spinal cord injury (CSCI) combined with traumatic brain injury (TBI) represents a severe form of polytrauma associated with high mortality and disability. The complex clinical presentation of acute CSCI with TBI poses numerous challenges throughout the diagnostic and therapeutic process. To standardize clinical diagnostic and therapeutic workflows, the Spine Committee, Sports Medicine Branch of the Chinese Medical Doctor Association, in collaboration with a multidisciplinary team of experts, has developed this consensus based on evidence-based medicine and the modified Delphi method. By standardizing diagnostic and treatment procedures, clarifying surgical timing and sequence, optimizing anesthesia and hemodynamic management, and strengthening prevention and treatment of complications, this consensus aims to improve patient survival, promote functional recovery, and reduce complications. The ultimate goals are to enhance overall quality of care and patients' quality of life, while providing theoretical and practical foundations for future research and innovation in this field. 成人急性颈脊髓损伤（CSCI）合并颅脑创伤是一种严重多系统创伤，致死、致残率高。急性CSCI合并颅脑创伤病情复杂，治疗过程面临诸多挑战。为规范临床诊疗流程，中国医师协会运动医学医师分会脊柱学组联合多学科专家团队，基于循证医学证据与改良德尔菲法制定本共识。通过规范诊疗流程、明确手术时机与顺序、加强麻醉与循环管理及并发症防治等关键环节，提高患者生存率、促进功能恢复，减少并发症发生，提升整体救治质量与患者生活质量，并为未来相关研究的开展和创新提供理论基础和实践参考。.
Prolonged hospital length of stay (LOS) is an increasingly important quality metric among regulators and payers that has been associated with worse patient outcomes and decreased patient satisfaction. The aim of this study was to identify predictors of prolonged hospital LOS after surgery for Meyerding grade 2 spondylolisthesis using a multicenter prospectively collected registry. The prospectively collected Spine CORe™ Quality Outcomes Database (QOD) study group cohort, which consisted of 328 patients from 14 sites, was used to identify all patients who underwent single-stage lumbar fusion for Meyerding grade 2 lumbar spondylolisthesis. Prolonged LOS was defined as ≥ 4 days (75th percentile). An array of demographic, comorbidity, and perioperative factors known to impact LOS were collected for each patient. Bivariate tests, including the chi-square goodness of fit and independent t-test, were used to identify variables associated with prolonged LOS. Multivariable logistic regression analysis was conducted to determine independent predictors of prolonged LOS. The QOD cohort comprised 328 patients with a follow-up rate of > 80%. After excluding patients with an anterior or lateral surgical approach and missing LOS data, the final cohort included 268 patients, of whom 52 (19.4%) experienced a prolonged LOS. In the univariate analysis, older age, dependent ambulation, insurance status, depression, greater estimated blood loss, longer operative duration, multilevel fusion (2 or more levels), perioperative complications (e.g., incidental durotomy and urinary tract infection), and nonhome discharge were associated with prolonged LOS. In the adjusted model, multilevel arthrodesis independently increased the odds of prolonged LOS (OR 2.11, 95% CI 1.07-4.18; p = 0.03), whereas private insurance (vs Medicare/Medicaid/government) was associated with lower odds (OR 0.42, 95% CI 0.20-0.87; p = 0.02). Patient-reported outcomes at 60 months did not differ between the groups with and without prolonged LOS. In this multicenter Spine CORe™ QOD study, multilevel lumbar fusion and noncommercial insurance were the principal independent predictors of prolonged LOS after surgery for grade 2 spondylolisthesis. These findings are valuable for patient informed consent, as well as to identify higher-risk patients who could benefit from earlier inpatient resource allocation (social work and counseling) to facilitate timely discharge.
Surgical intervention for grade 2 lumbar spondylolisthesis is routinely performed, but outcomes in older patients, in whom the disease is most prevalent, remain poorly understood. The aim of this study was to compare patient-reported surgical outcomes between age groups (< 65 years of age vs ≥ 65 years of age) with 5 years of follow-up. The authors hypothesized that patients would have sustained improvement in outcomes in response to surgical treatment for grade 2 spondylolisthesis regardless of age. The multicenter prospectively collected Quality Outcomes Database by the Spine CORe™ study group was retrospectively analyzed for patients who underwent arthrodesis for grade 2 lumbar spondylolisthesis. Across 14 high-enrolling sites, 328 patients with 81% follow-up were identified. Baseline and postoperative 3-month, 1-year, 2-year, and 5-year outcomes including numeric rating scale (NRS) back pain (score 0-10), NRS leg pain (score 0-10), Oswestry Disability Index (ODI), EQ-5D scores, and patient satisfaction using the North American Spine Society (NASS) index, were evaluated. These outcomes were compared between younger (< 65 years of age, n = 188) and older (≥ 65 years of age, n = 140) age groups using Wilcoxon rank-sum tests. EQ-5D and ODI scores were significantly improved postoperatively in the younger and older age groups (p < 0.001). ODI scores were not significantly different between the age groups at baseline (p = 0.37) or postoperatively at any time point (p > 0.05). EQ-5D scores were not significantly different between the younger and older patient groups at baseline (p = 0.47) or postoperatively at any time point (p > 0.05). NRS leg pain (p = 0.68) and back pain (p = 0.45) scores were not significantly different at baseline across age groups. NRS leg pain was not significantly different postoperatively (p > 0.05). Older patients had lower back pain scores (p = 0.03) at 3 months postoperatively, but not at any other time points (p > 0.05). Leg and back pain scores improved postoperatively up to 5 years of follow-up in all patients (p < 0.0001). A majority of the younger (83.5%) and older (89.5%) patients reported satisfaction with their surgical outcome up to 5 years after surgery, and postoperative NASS satisfaction scores were not significantly different between the younger and older age groups at any time point (p > 0.05). In response to surgical treatment, patients over 65 years of age have significant improvements similar to those of younger patients. Surgical treatment is a viable option for improvement regardless of age.
Unemployment following surgery incurs significant societal costs. The authors aimed to identify predictors of return to work (RTW) following surgery for patients with grade 1 lumbar spondylolisthesis. This Spine CORe™ study is a post hoc analysis of prospectively collected data from the Quality Outcomes Database (QOD) grade 1 lumbar spondylolisthesis module. Patients were divided into 2 groups: employed preoperatively and unemployed preoperatively. Univariate and multivariate instruments were used to identify predictors of RTW/employment within 5 years postoperatively. Across the 12 highest enrolling QOD sites (Spine CORe™ group), 608 patients were enrolled with 81% having Oswestry Disability Index (ODI) follow-up data. Of these 608 patients, 604 patients had baseline employment status recorded. Of 275 patients who were employed preoperatively, 249 had RTW follow-up data. Of the 329 patients unemployed preoperatively, 218 had RTW follow-up data. The study cohort follow-up for RTW was 77%. By 5 years postoperatively, 87.1% (n = 217) of those employed preoperatively and 22.0% (n = 48) of those unemployed preoperatively returned to work. In each cohort, there were no differences in age, sex, BMI, and American Society of Anesthesiologists class between those who did and those who did not RTW. These results remained consistent in the subgroup analysis of patients younger than 65 years at baseline. However, the only difference observed in this age group was within the preoperatively unemployed cohort, where the RTW group had a lower BMI (28.4 ± 5.5 vs 32.8 ± 9.0, p = 0.001). On multivariate analysis for the preoperatively employed cohort, college degree (OR 3.6, 95% CI 1.3-12.2) and active employment (OR 6.0, 95% CI 1.9-19.8) remained independent predictors of returning to work. For those preoperatively unemployed, a college degree (OR 2.2, 95% CI 1.1-4.4) independently predicted RTW. Approximately 87% of patients employed preoperatively RTW, and 22% of patients unemployed preoperatively returned to the workforce within 60 months after surgery for grade 1 spondylolisthesis. College-level education independently predicted RTW for both preoperatively employed and preoperatively unemployed patients.
Surgical management of cervical spondylotic myelopathy (CSM) aims to improve neurological deterioration. However, long-term predictors of outcome are unknown. The present study examined highest and lowest patient-reported satisfaction at the 5-year follow-up. The authors hypothesized that the most satisfied patients experience durable long-term improvement and have distinct characteristics compared to the least satisfied patients. Prospectively collected data from the Spine CORe™ study group of the Quality Outcomes Database cervical spine module were retrospectively reviewed. Patients were stratified by North American Spine Society (NASS) satisfaction scores of 1 (most satisfied) and 4 (least satisfied). Demographics, surgical characteristics, and patient-reported outcome measures (PROMs) were compared between cohorts at baseline and 24 and 60 months of follow-up. A mixed-effects logistic regression assessed independent predictors of those who were most and least satisfied at 60 months. Univariate and multivariable analyses were repeated in the subsample of most satisfied patients at 2 years. Univariate analysis was completed for the subsample of least satisfied patients at 2 years. Of 1085 patients with CSM, 895 (82%) completed the 60-month follow-up. Of these 895 patients, 106 died within 5 years of surgery of unrelated causes, and 785 provided satisfaction scores at 60 months of follow-up. Of the 785 patients, 621 patients met inclusion criteria of reporting an NASS score of 1 or 4 at 60 months: 560 (90.2%) were most satisfied and 61 (9.8%) were least satisfied. The most satisfied cohort included more patients with bachelor's degrees (25% vs 13%, p = 0.043), more anterior cervical discectomies and fusions (61% vs 48%, p = 0.038), shorter hospitalizations (1.7 ± 1.8 vs 2.8 ± 2.6 days, p = 0.002), fewer laminectomies (23% vs 39%, p = 0.004), and fewer smokers (p = 0.036). Most satisfied patients reported higher baseline EuroQol visual analog scale (EQ-VAS) scores (60.8 ± 21.3 vs 51.5 ± 24.8, p = 0.008), but other baseline PROMs were similar. In multivariable analysis, college education (OR 2.54, p = 0.004), preoperative depression (OR 2.75, p = 0.043), higher baseline EQ-VAS score (OR 1.02, p = 0.009), and shorter hospitalization (OR 0.81, p = 0.003) independently predicted the most satisfaction at 60 months. Among 60-month least satisfied patients, 28% were most satisfied at 24 months. Among 60-month most satisfied patients, 2.9% were least satisfied at 24 months. Among 24-month most satisfied patients, maintenance of most satisfaction at 60 months was independently predicted by older age (OR 1.09, p = 0.045), preoperative pain (OR 9.28, p = 0.013), and higher 24-month neck pain numeric rating scale (NP-NRS) score (OR 1.58, p = 0.047). Neck Disability Index- and modified Japanese Orthopaedic Association (mJOA)-based independence measures correlated with a bidirectional satisfaction shift between 2 and 5 years. Highest NASS satisfaction scores at 5 years after surgery for CSM are predicted by college education of the patients, preoperative depression, higher baseline EQ-VAS scores, and shorter hospital length of stay. Younger age, lack of preoperative pain, and lower 2-year NP-NRS scores predict movement from most satisfied to least satisfied. After surgery for CSM, the majority of patients report the highest satisfaction NASS rating at 5 years, but delayed satisfaction reversals exist and warrant monitoring.
The minimal clinically important difference (MCID) is widely used to interpret patient-reported outcome measures (PROMs) in cervical spondylotic myelopathy (CSM). However, consensus on its definition is lacking, and its long-term consistency remains unknown. The objective of this study was to determine if MCID thresholds for PROMs at 5 years after surgery for CSM remained consistent when compared to previously established 2-year values. The Spine CORe™ study group performed a post hoc analysis of the prospective Quality Outcomes Database. Eight established anchor- and distribution-based methods were applied to define MCID thresholds for the following PROMs: Neck Disability Index (NDI), neck pain numeric rating scale (NP-NRS), arm pain numeric rating scale (AP-NRS), 5-dimension EuroQol health utility questionnaire (EQ-5D) for quality-adjusted life years, and modified Japanese Orthopaedic Association (mJOA) scores. Predictive validity was evaluated using area under the curve (AUC) analysis with North American Spine Society satisfaction as the anchor, and results were compared with calculated 2-year values from the same cohort using DeLong's test. A total of 1085 patients were originally enrolled, with ≥ 80% follow-up for all PROMs except the mJOA score (79%). At 5 years, optimal percentage change and ≥ 30% improvement methods were consistently highest performing for the NDI (AUC 0.71 and 0.68, respectively), NP-NRS (AUC 0.65 for both), and AP-NRS (AUC 0.73 and 0.72, respectively) scores. For the EQ-5D score, both the optimal numeric cutoff and one-half standard deviation methods performed best, yielding a consistent MCID threshold of 0.11 (AUC 0.64 for both). For the mJOA score, the severity-adjusted method provided the strongest discrimination, with an AUC of 0.74 at 5 years. MCID thresholds were consistent between 2 and 5 years, except for the severity-adjusted MCID for the mJOA score (0.74 at 5 years vs 0.65 at 2 years, p = 0.026). The 30% improvement threshold corresponded to absolute changes of 11.3 points for the NDI score, 1.5 points for the NP-NRS score, and 1.4 points for the AP-NRS score based on mean baseline scores. To the authors' knowledge, this represents the largest cohort of patients with CSM in the United States with validated, long-term 5-year MCID thresholds. This study establishes practical MCID definitions for NDI (≥ 30% improvement threshold of 11.3 points), NP-NRS and AP-NRS (≥ 30% improvement thresholds of 1.5 and 1.4 points, respectively), EQ-5D (optimal numeric cutoff of 0.11), and mJOA (severity-adjusted: ≥ 3 points for severe, ≥ 2 for moderate, ≥ 1 for mild) scores that can serve as benchmarks for evaluating improvement after CSM surgery in both research and routine clinical practice.
High fructose intake has been linked to metabolic and cognitive disturbances, yet its effects on hippocampal synaptic architecture remain unclear. We examined whether four weeks of fructose feeding alter metabolic parameters or CA1 synaptic ultrastructure in adult rats maintained on isocaloric AIN-93G diets containing fructose, glucose, or starch as the primary carbohydrate source. Serum biochemical and hormonal profiles showed only modest, diet-specific differences without major metabolic disruption. Quantitative electron microscopy revealed similar dendritic spine density, postsynaptic density length, perforated synapse frequency, and multisynaptic bouton density across groups, whereas fructose-fed rats displayed a small but significant reduction in spine area and an alteration in circularity. These localized geometric changes occurred without broader synaptic remodeling. Overall, our findings indicate that short-term fructose exposure under metabolically controlled, solid-diet conditions produces minimal metabolic and ultrastructural effects, in contrast to the pronounced disturbances reported in metabolically stressful paradigms, suggesting that structural consequences of fructose depend strongly on dietary context and metabolic load.
Patient satisfaction is an important outcome to measure quality of care. The hypothesis of this study was that more severe baseline neck disability (Neck Disability Index [NDI] scores 70-100) is associated with less frequent postoperative satisfaction in cervical spondylotic myelopathy. This study used the 14-site Spine CORe™ study group's cervical dataset module from the Quality Outcomes Database, which included 1085 patients. Baseline demographics, clinical variables, and surgical parameters were collected. Patient-reported outcomes (PROs) collected include EQ-5D, NDI, and numeric rating scale for neck pain and arm pain scores. Heat maps were created to demonstrate the association of NDI scores with postoperative satisfaction. There were 1085 patients in this study with a 5-year follow-up rate of 83% for the NDI. PROs significantly improved 1 and 5 years postoperatively. Multivariate regression models found baseline NDI scores to be associated with 1- and 5-year satisfaction (OR 0.98 [95% CI 0.97-0.99], p = 0.004). Heat maps were created to determine the significance of baseline, 1-year, and 5-year NDI scores on satisfaction rates. The level of satisfaction decreased with increasing 1- and 5-year NDI scores. Additionally, patients with higher baseline NDI scores required a more significant change in NDI to achieve satisfaction with surgery. Patients with more severe disability measured by the NDI require a greater change in postoperative NDI scores to meet satisfaction. Despite the importance of postoperative satisfaction, failure to achieve satisfaction should not be assumed to be due to lack of clinical benefit. Discussing a patient's goals and expectations preoperatively is essential to maximize the probability of achieving satisfaction.
Discharge to an inpatient rehabilitation facility or other acute care facility is a significant driver of healthcare costs. The authors sought to identify predictors of nonroutine discharge after surgery for grade 2 lumbar spondylolisthesis. The Quality Outcomes Database from the 14 highest enrolling sites (Spine CORe™ study group) was queried for adult patients who underwent surgery for grade 2 lumbar spondylolisthesis. Nonroutine discharge was defined as discharge to a postacute or nonacute care setting or transfer to another acute care facility. Univariate analysis and multivariate logistic regression were utilized to identify predictors of nonroutine discharge. The follow-up rate at 5 years was 81%. Of the 328 patients identified, 47 (14.3%) had nonroutine discharge. On univariate analysis, patients with nonroutine discharge were more likely to be older (67.4 ± 11.3 years vs 59.4 ± 12.2 years, p < 0.0001), be female (85.1% vs 65.5%, p = 0.007), have diabetes (36.2% vs 12.1%, p < 0.0001), have osteoporosis (21.3% vs 8.2%, p = 0.02), have a higher mean baseline numeric rating scale (NRS) leg pain score (7.5 ± 2.2 vs 6.6 ± 2.8, p = 0.04), and have a higher mean baseline Oswestry Disability Index (ODI) score (55.4 ± 15.7 vs 46.5 ± 16.5, p = 0.0006) compared to patients with a routine discharge. Patients who had completed a 4-year college degree, were employed and working, and were independently ambulatory were more likely to have a routine discharge (p < 0.0001). Multivariate analysis showed that older age (OR 1.06, 95% CI 1.01-1.11, p = 0.01), female sex (OR 2.64, 95% CI 1.01-6.87, p = 0.04), need for an assistive device to ambulate preoperatively (OR 3.01, 95% CI 1.02-7.36, p = 0.02), and diabetes (OR 2.80, 95% CI 1.20-6.56, p = 0.02) were independently associated with nonroutine discharge. Patients with a nonroutine discharge had significantly greater length of stay compared to patients with a routine discharge (4.7 ± 2.2 vs 3.2 ± 2.1 days, p < 0.0001). In this large, prospective, multicenter study, patients with nonroutine discharge after surgery for grade 2 lumbar spondylolisthesis were more likely to be older, female, have diabetes, and require an assistive device to ambulate preoperatively.
Surgery for cervical spondylotic myelopathy (CSM) aims to halt disease progression. However, some patients will also ultimately note relief from their myelopathic symptoms. This study aimed to identify factors that predict improvement from moderate or severe myelopathy to mild or no myelopathy through an analysis of preoperative clinical and demographic data. Predictive models were developed to identify patients likely to achieve durable relief from myelopathy 24 months after surgery for CSM. Data were obtained from the Quality Outcomes Database (QOD) CSM dataset, a prospective registry cohort of 1085 patients from the 14 Spine CORe™ sites. Patients were excluded if they were younger than 18 years, were missing baseline or 24-month modified Japanese Orthopaedic Association scale (mJOA) scores, or had baseline mJOA score > 14. The remaining patients were partitioned into a training (n = 467) or test (n = 117) set. Logistic regression and random forest models, with and without principal component analysis, were trained to predict whether patients achieved mild/no myelopathy at 24 months, which was defined as an mJOA score of 15 or greater. Overall, 584 patients (47.1% female) with moderate to severe myelopathy met the prespecified inclusion criteria, with a mean ± SD age of 61.7 ± 11.2 years, body mass index (BMI) 30.3 ± 6.3 kg/m2, and preoperative mJOA score 11.2 ± 2.4. At 24 months, 45% of patients (n = 263) had mJOA score > 14. There were no significant differences in performance between models with area under the receiver operating characteristic curve (AUROC) near 0.63 and area under the precision-recall curve (AUPRC) near 0.56. Significant positive predictors of postoperative relief from myelopathy in both the models and sensitivity analysis were symptom duration ≤ 12 months (OR 1.88, 95% CI 1.20-2.94, p < 0.01) and participation in activities outside the home (OR 2.19, 95% CI 1.12-4.27, p = 0.02). In a large prospective registry cohort of patients operated on for CSM, consistent factors associated with myelopathic symptom relief at 24 months were symptom duration ≤ 12 months and participation in activities outside the home. The finding that longer symptom duration was associated with a decreased propensity for relief from myelopathic symptoms suggests that earlier surgery may be beneficial for patients with moderate to severe myelopathy.
The authors aimed to evaluate the prevalence of sleep disturbance in patients with grade 2 lumbar spondylolisthesis and assess postoperative trajectories and predictors of improvement at 5 years. They hypothesized that surgical treatment of grade 2 spondylolisthesis would result in high rates of long-term improvement in sleep disturbance. Patients with grade 2 lumbar spondylolisthesis were identified from the 14-site Spine CORe™ study group within the Quality Outcomes Database (QOD). Sleep disturbance was measured using the sleep item of the Oswestry Disability Index (ODI) at baseline and 3, 12, 24, and 60 months postoperatively. The prevalence of baseline sleep disturbance was determined. Clinically meaningful improvement was defined using minimal clinically important difference thresholds. Predictors of improvement were analyzed using multivariate Firth's logistic regression, and associations with pain, disability, quality of life, and satisfaction were assessed. A total of 328 patients underwent surgery for grade 2 spondylolisthesis. At baseline, 300 of 328 patients (91.5%) reported sleep disturbance. The 60-month follow-up rate in this subgroup was 81% (21 died within 5 years of surgery of unrelated causes and 223 of the 300 patients followed up at 5 years). Improvement in sleep disturbance was observed in 165 patients (74.0%), while 58 patients (26.0%) continued to report sleep disturbance at 60 months. Those with improved sleep were more likely to achieve clinically meaningful gains in back pain (80.5% vs 50.0%, p < 0.001), leg pain (83.6% vs 53.4%, p < 0.001), EQ-5D (31.1% vs 7.3%, p < 0.001), and ODI (62.8% vs 5.3%, p < 0.001) scores, with a trend toward higher satisfaction in patients with improved sleep (88.5% vs 77.8%; risk difference 10.7%, 95% CI -0.01 to 0.23). On multivariate analysis, only private insurance (OR 2.20, 95% CI 1.03-4.78; p = 0.041) was associated with greater odds of 60-month sleep improvement. Sleep disturbance was highly prevalent in 91.5% of patients with grade 2 spondylolisthesis, and 74.0% experienced meaningful improvement by 3 months and this was sustained for 5 years following surgery. Sleep recovery was closely tied to gains in pain, disability, and quality of life. These results demonstrate that surgery for grade 2 spondylolisthesis not only improves mechanical symptoms but also substantially alleviates sleep disturbance.
Severe traumatic brain injury (TBI) during pregnancy is a rare but challenging condition. There is scarce evidence in this population, and severe TBI management during gestation remains empirical and extrapolated from data on non-pregnant women. The World Society of Emergency Surgery (WSES) and the European Association of Neurosurgical Societies (EANS) collaborated to establish a multidisciplinary consensus panel of 115 physicians with vast expertise in the management of severe TBI, including cases of pregnant women. A modified Delphi approach was adopted. Two online questionnaires were conducted between February and June 2025. The list of statements (36) was distributed to the panelists to allow voting and to propose any comments and/or changes. The analysis of results was performed by an experienced non-voting methodologist. Statements were classified as strong suggestion, weak suggestion or no suggestion when >85%, 75-85% and <75% of votes were in favor, respectively. A consensus was reached, generating 36 strong suggestions regarding several important aspects in the care of isolated severe TBI during pregnancy. This consensus provides practical suggestions to support a clinician's decision-making in the management of severe isolated TBI during pregnancy in high-income countries. However, these statements are based mainly on expert opinion, and further evidence is required in this field.
Insurance status is known to influence access to spine surgery, but its role in cervical spondylotic myelopathy (CSM) remains underexplored. The authors hypothesized that government insurance payor status would be associated with delayed care access, evidenced by prolonged symptom duration and greater baseline symptom severity relative to those with private insurance. This was a prospective observational cohort study of 1085 patients enrolled in the Quality Outcomes Database CSM module of the 14-site Spine CORe™ study group. Patients were included if they had complete data for insurance, symptom duration, and baseline patient-reported outcomes (PROs). Insurance status was categorized as private, Medicare, Medicaid, or Veterans Affairs (VA)/federal. Primary outcomes included surrogates of access to care, assessed by symptom duration (> 12 months) and baseline PROs, i.e., the Neck Disability Index (NDI) and EQ-5D. Associations were evaluated using multivariable logistic regression analysis. A total of 1085 patients with CSM who underwent surgery were enrolled, with more than 80% completing 5-year follow-up. Patients were excluded if they were uninsured or did not report baseline symptom duration, EQ-5D score, or NDI score, leaving a cohort of 977 patients for analysis. The proportion of patients reporting symptom duration > 12 months differed by insurance status (p < 0.001): highest in VA/federal (18/24, 75%), followed by Medicaid (45/70, 64%), Medicare (206/375, 55%), and private insurance (228/508, 45%). Compared to those who had private insurance, patients covered by VA/federal insurance (OR 3.85, 95% CI 1.56-10.89), Medicaid (OR 2.05, 95% CI 1.18-3.61), and Medicare (OR 1.98, 95% CI 1.39-2.82) had symptom duration > 12 months. Of patients with government insurance payors, Medicaid insurance status was independently associated with worse baseline disability (NDI: β = 7.35, 95% CI 2.35-12.35; p = 0.004) and lower quality of life (EQ-5D: β = -0.12, 95% CI -0.18 to -0.07; p < 0.001). Compared to patients with private insurance, patients covered by government insurance payors (VA/federal insurance, Medicare, and Medicaid) had significantly longer symptom duration before undergoing surgery. Patients with VA/federal insurance coverage had the longest symptom duration of the government payors. Of the government insurance payor types, Medicaid was the only one independently associated with significantly worse baseline disability (NDI) and quality of life (EQ-5D). After controlling for other factors, patients with government insurance coverage, and more specifically Medicaid, have difficulty accessing surgical care in a timely fashion to treat CSM compared to patients with private insurance.
Ultra-severe traumatic brain injury (us-TBI), defined as Glasgow Coma Scale score (GCS) of five-three, is associated with high mortality and severe morbidity amongst survivors. However, in selected patients a favourable recovery may still be achieved. We aimed to characterise what clinical parameters can be used as prognosticators in us-TBI patients. A retrospective, single-centre study of 70 us-TBI patients admitted between the years of 2014-2024. Early clinical, and radiological factors were assessed, and patient outcome (Glasgow outcome scale extended- GOSE) was obtained at 3-12 months. The median age was 52.5 years, 21 had GCS five on admission, 23 GCS four and 26 had GCS three. Four patients had on admission bilaterally dilated pupils, 35 patients had unilateral mydriasis, 11 had miotic pupils and 20 had normal pupils. Thirty-one patients (44%) succumbed to their injuries. Median GOSE was three, and nine patients (13%) achieved an excellent outcome (GOSE 7-8) - these patients were younger (median age 26 years) and showed normalised pupil reactivity post-operatively. A favourable outcome (GOSE≥5) was achieved in 19 patients (28%). A combination of GCS 3 and bilaterally dilated pupils was uniformly fatal. Despite presenting with a low level of consciousness (GCS 3-5) and pupillary abnormalities in 71%, survival was observed in 56% of us-TBI patients, and nine (13%) made an excellent recovery (GOSE 7-8). Improved pupillary reactivity post-intervention may be a positive prognosticator. Our data argue against therapeutic nihilism in us-TBI patient presenting with GCS scores of 5-3.
The purpose of this study was to evaluate patients undergoing surgery for cervical spondylotic myelopathy who presented with severe arm pain to determine which factors are associated with persistent and improved postoperative arm pain. Of the patients with CSM included from 14 Spine CORe™ study group sites participating in the Quality Outcomes Database, those who presented with severe arm pain preoperatively (numeric rating scale [NRS] scores 7-10) were selected for analysis. Within this subset, patients who reported persistent severe arm pain (NRS scores 7-10) postoperatively were compared with patients who had moderate and improved/mild arm pain (NRS scores 4-6 and 0-3, respectively) postoperatively. NRS scores for arm pain were recorded at baseline and postoperatively at 3 months, 1 year, 2 years, and 5 years. Demographics, comorbidities, and patient-reported outcome measures (Neck Disability Index [NDI], quality-adjusted life years [QALY], modified Japanese Orthopaedic Association [mJOA] scale, and EuroQol visual analog scale [EQ-VAS]) were evaluated. These factors were compared between patients with persistent and those with improved arm pain at the 5-year follow-up using the Wilcoxon rank-sum test. Of 1085 patients with CSM, 458 reported severe arm pain (NRS scores 7-10) preoperatively. Of these, 60.7% of patients reported mild arm pain (NRS scores 0-3), 20.4% reported moderate arm pain (NRS scores 4-6), and 18.9% reported persistent severe arm pain (NRS scores 7-10) at the 5-year follow-up. Patients with persistent severe pain had significantly higher NDI scores (p = 0.001) and lower mJOA (p = 0.04), QALY (p = 0.02), and EQ-VAS (p < 0.00001) scores at baseline. Patients with mild/improved arm pain were significantly more likely to have postgraduate education (p = 0.04). Patients with early postoperative improvement in arm pain (at 3 months, p < 0.0001) had sustained improvement through the 5-year postoperative time point. However, patients with persistent severe pain at 5 years had consistently higher pain at all postoperative time points (3 months, 1 year, and 2 years), which significantly worsened between the 2- and 5-year time points (mean NRS scores from 4.8 to 8, p < 0.001). Among patients who underwent surgery for CSM who presented with severe radicular arm pain (NRS scores 7-10), 81.1% reported improvement (NRS scores 0-6), and 18.9% reported persistent severe arm pain 5 years after surgery. Persistent arm pain was associated with increased preoperative disability (mJOA, NDI, QALY, and EQ-VAS), while postgraduate education was associated with improved arm pain. Patients with early postoperative improvement in arm pain demonstrated a durable result through 5 years of follow-up, which could improve further. Conversely, those with severe postoperative arm pain had persistent pain at 2 years, which further deteriorated between 2 and 5 years, thus warranting careful long-term surveillance.
The objective of this study was to determine the time frame of clinical improvement in patient-reported outcomes (PROs) following surgical decompression for cervical spondylotic myelopathy (CSM). Based on previously published 12-month data from this group, the authors hypothesized that the average time to minimal clinically important difference (MCID) improvement would primarily occur by 3 months postoperatively regardless of preoperative myelopathy severity. They also hypothesized that there would be minimal additional improvement between 3 months and 5 years after surgery. This was a post hoc analysis of prospectively collected data from the 14-site Spine CORe™ study group of the Quality Outcomes Database (QOD). Patients were stratified according to myelopathy severity using the modified Japanese Orthopaedic Association (mJOA) myelopathy scale into mild (mJOA score 15-17), moderate (mJOA score 12-14) or severe (mJOA score < 12). PRO measures included the Neck Disability Index (NDI), numeric rating scale (NRS) for neck and arm pain, and EQ-5D for quality-adjusted life years. PROs were recorded at baseline, 3-month, 12-month, 2-year, and 5-year intervals. MCID thresholds were calculated using previously validated methods in this cohort. Time to meet the MCID cutoff and the proportion of patients achieving MCID at each time point were determined. A total of 1085 patients (with ≥ 80% follow-up at 60 months for all PRO measures [PROMs]) were enrolled. Patients with more severe myelopathy had worse baseline comorbidities (e.g., BMI, American Society of Anesthesiology class, ambulation dependence) and lower PRO scores. Average PROs met the MCID threshold in each category at 3 months postoperatively, regardless of baseline myelopathy severity. Of the patients with complete 5-year follow-up data, the majority achieved the MCID cutoff threshold for PROMs at 3 months (50%-73%, depending on the PROM). A minority of patients went on to meet the MCID for PROMs at 12 months (12%-21%), 2 years (4%-8%), and 5 years (1%-6%). Between 4% and 25% of patients never achieved MCID cutoffs at any time point. On average, patients achieved clinically meaningful improvement in PROs at 3 months postoperatively, regardless of preoperative severity. While the majority (50%-73%, depending on the PROM) reached MCID within 3 months, an additional 12%-21% improved by 12 months, 4%-8% by 2 years, and only 1%-6% by 5 years; 4%-25% never reach the MCID. This 5-year follow-up study clarifies the timeline of clinical improvement after surgery for CSM and provides a useful tool for both surgeon planning and patient counseling.
Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord dysfunction, leading to worsening disability and poor quality of life. The long-term benefits of surgery for patient quality of life remain incompletely defined. Given the current emphasis on value-based care, this study aimed to identify 1) how surgery improves quality of life and 2) what factors are associated with quality of life improvement in patients operated on for CSM. The Spine CORe™ study group performed a post hoc analysis of the prospectively collected, 14-site Quality Outcomes Database CSM cohort. The primary outcome was the 5-dimension EuroQol-5 (EQ-5D) score, assessed at baseline and at 3, 12, 24, and 60 months postoperatively. The minimal clinically important difference (MCID) for the EQ-5D score was defined as 0.11. A multivariable logistic model was used to identify preoperative factors associated with the MCID for the 60-month EQ-5D score, controlling for variables reaching a p value < 0.20 on univariate analysis. Quality-adjusted life years (QALYs) gained were also calculated using the area under the curve method, with baseline projected QALYs subtracted from observed values. At 60 months, follow-up status was available for 895 of 1085 patients (82.4%). A total of 788 patients had EQ-5D scores recorded at 60 months for inclusion in the initial phase of this analysis. The mean EQ-5D score improved significantly from 0.58 ± 0.22 at baseline to 0.76 ± 0.22 at 60 months (p < 0.001), with gains evident by 3 months and sustained through all subsequent follow-up intervals. At 60 months, 58.7% of patients achieved the EQ-5D MCID. Multivariable analysis identified greater baseline numeric rating scale neck pain score and use of anterior cervical corpectomy and fusion (ACCF) as independent predictors of decreased odds of MCID achievement (p < 0.05). Conversely, lower baseline EQ-5D scores, corresponding to worse quality of life, were associated with increased odds of improvement (p < 0.05). The authors further found in the full cohort of patients that there was a mean QALY gain of 0.72 ± 1.11 following surgery. Patients undergoing surgery for CSM experience significant and durable postoperative improvements in their quality of life, with notable gains of 0.72 QALYs achieved 5 years after surgery. Additionally, more than 50% of patients achieve a clinically meaningful benefit in EQ-5D score at 5 years. Greater baseline neck pain severity and ACCF were associated with reduced odds of achieving the MCID, whereas worse baseline quality of life was associated with greater odds of achieving long-term improvement. Overall, these findings confirm that surgery for CSM yields sustained quality of life benefits for the majority of patients.
Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction worldwide and can be treated through anterior or posterior approaches. Both strategies achieve acceptable results, but the growing prevalence of obesity poses unique challenges. Data directly comparing outcomes across body mass index (BMI) strata are limited. Here, the authors examined rates of achieving minimal clinically important differences (MCIDs) in patient-reported outcomes (PROs) between anterior and posterior approaches relative to BMI. This was a post hoc analysis of prospectively collected data from the 14-site Spine CORe™ study group of the Quality Outcomes Database (QOD). Baseline data and PROs-including numeric rating scale (NRS) neck and arm pain, Neck Disability Index (NDI), EQ-5D, and modified Japanese Orthopaedic Association (mJOA) scores-were collected through 60 months. Patients were stratified by an a priori BMI threshold of 30 kg/m2 and by surgical approach (anterior vs posterior). Multivariable regression was used to compare achievement of MCID across approaches within each BMI group. In parallel, unsupervised clustering of baseline-adjusted PROs was combined with a doubly robust estimation framework to assess approach-specific probabilities of achieving optimal outcomes across the continuous BMI spectrum. Among 1085 patients, 759 (70.0%) underwent anterior and 326 (30.0%) underwent posterior surgery. Anterior approaches were associated with shorter length of stay and fewer nonhome discharges (p < 0.001). For patients with BMI < 30 kg/m2, anterior surgery conferred higher odds of achieving MCID in NRS arm pain (OR 0.45, p = 0.032). For those with BMI ≥ 30 kg/m2, anterior surgery was associated with greater odds of achieving MCID in mJOA (OR 0.32, p = 0.007) and NDI (OR 0.42, p = 0.031) scores. The results were consistent in sensitivity analyses. The doubly robust model identified a BMI range of 29.1-36.7 kg/m2, where anterior approaches significantly increased the probability of optimal outcomes (risk difference > 8.1%; lower confidence interval > 0). Anterior approaches also demonstrated greater probability of achieving optimal outcomes at higher BMIs, though without statistical significance. For BMI < 30 kg/m2, both approaches improved disability and quality of life, with anterior surgery offering added relief of arm pain. For BMI ≥ 30 kg/m2, anterior surgery provided superior functional and disability outcomes. Most importantly, anterior surgery became significantly more advantageous beginning at BMI 29.1 kg/m2. However, approach selection remains multifactorial, as anterior and posterior cohorts differed in mean age (anterior 58.7 vs posterior 64.5 years) and mean operated levels (anterior 1.9 vs posterior 4.2 levels). While anterior approaches may be most commonly employed for younger patients or for one- and two-level pathology, posterior approaches remain an important option for multilevel cervical stenosis or in the elderly to avoid dysphagia. Thus, this study highlights BMI as just one of many key factors in approach selection for CSM, but should not replace individualized clinical decision-making.
Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction, and anterior cervical discectomy and fusion (ACDF) is the gold standard treatment. Cervical disc arthroplasty (CDA) is a relatively novel, motion preserving alternative to ACDF. The aim of this study was to assess CDA versus ACDF in the surgical treatment of CSM at a 5-year follow-up. This study used the 14-site Spine CORe™ study group cervical module of the Quality Outcomes Database (QOD), which included 1085 patients. Baseline demographics, clinical variables, and surgical parameters were collected. Patient-reported outcome measures (PROMs) included the EQ-5D, Neck Disability Index (NDI), and numeric rating scale (NRS) for neck pain and arm pain. Of the 1085 patients, 22 patients who underwent CDA with baseline and 5-year follow-up PROMs data who met the inclusion/exclusion criteria were selected. Nearest-neighbor propensity score matching was performed using a 4:1 matching ratio. Five-year PROMs were compared between the CDA and ACDF groups using the 2-sample t-test for continuous variables. Multivariable linear regression was performed to identify predictors of 5-year myelopathy severity. There were 1085 patients in the 14-site Spine CORe™ study group's QOD cervical module; 110 matched patients were analyzed, including 22 who underwent CDA (mean age 47.73 years) and 88 who underwent ACDF (mean age 48.89 years). The subcohort had 100% of PROMs data (NDI, NRS, EQ-5D, and mJOA) at the 5-year follow-up. There were no significant differences for 1- and 2-level operations between the CDA and ACDF groups (p = 0.34). There were no significant differences in 5-year PROMs between the two groups. Patients improved in each PROM category in both treatment groups when comparing baseline with 5-year PROMs. While the rate of reoperation at 5 years was higher in the ACDF group compared with the CDA group, there was no statistically significant difference (17.0% vs 9.1%, p = 0.52). In appropriately selected patients with CSM, CDA can provide comparable outcomes to ACDF while preserving cervical motion.