|Year : 2021 | Volume
| Issue : 2 | Page : 170-175
Return to work after surgical treatment for cervical spondylotic myelopathy
Arun John Paul, Rohit Amritanand, Kenny S David, Venkatesh Krishnan
Department of Spine Surgery, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||08-Feb-2021|
|Date of Decision||29-Apr-2021|
|Date of Acceptance||03-May-2021|
|Date of Web Publication||16-Jul-2021|
Department of Spine Surgery, Christian Medical College, Vellore, Tamil Nadu.
Source of Support: None, Conflict of Interest: None
Purpose: The purpose of the study was to determine the rate and predictors of return to work (RTW) after surgery for cervical spondylotic myelopathy (CSM). Overview of Literature: RTW is arguably the most important outcome following spine surgery from a patient’s perspective. But, to the best of our knowledge, there have been no reports in the English literature describing RTW among patients undergoing surgery for moderate-to-severe CSM. Materials and Methods: We included adult patients with CSM with Nurick grade ≥ 3 who underwent surgery. They were divided into two groups: those who returned to work within 6 months (group 1) and those who did not (group 2) and their outcomes were analyzed. Results: A total of 34 patients were included in the study. Baseline characteristics were comparable between the groups. Only 18 (52.9%) patients returned to work by 6 months. The nature of work had a statistically significant association with RTW by 6 months (P = 0.005) with failure to RTW specifically seen in manual laborers. Age, body mass index, symptom duration, pre-operative absenteeism, smoking, diabetes mellitus, number of levels operated, surgical approach, and post-operative complications did not have significant association with RTW. Better functional outcomes were seen in patients who returned to work as calculated using Nurick grade (P = 0.000) and modified Japanese Orthopedic Association score (P = 0.001). All the patients who returned to work and 75% of the patients who did not RTW were satisfied with the outcome of surgery (P = 0.039). Conclusion: In spite of functional improvement, CSM was associated with poor RTW with manual laborers being the most vulnerable group. This study will help surgeons modulate patient expectations as well as provide a platform for counseling them.
Keywords: Cervical spondylotic myelopathy, manual laborer, mJOA, urick, return to work
|How to cite this article:|
Paul AJ, Amritanand R, David KS, Krishnan V. Return to work after surgical treatment for cervical spondylotic myelopathy. Indian Spine J 2021;4:170-5
|How to cite this URL:|
Paul AJ, Amritanand R, David KS, Krishnan V. Return to work after surgical treatment for cervical spondylotic myelopathy. Indian Spine J [serial online] 2021 [cited 2021 Aug 4];4:170-5. Available from: https://www.isjonline.com/text.asp?2021/4/2/170/321561
| Introduction|| |
Cervical spondylotic myelopathy (CSM) is the most common cause of myelopathy at >55 years of age causing progressing disability and impairment of quality of life. It is a progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs. It causes narrowing of central spinal canal leading to cervical spinal cord compression, resulting in various signs and symptoms. Surgical treatment results in improved neurological outcomes in patients with severe neurological deficits. It can be performed by both anterior and posterior approaches each having its own indications, advantages, and disadvantages.
Return to work (RTW) has been well described in lumbar spine surgeries,,,,, and other orthopedic procedures such as anterior cruciate ligament reconstruction, shoulder reconstruction, and replacement surgeries. In the case of cervical spine surgery, a paper by Bhandari et al. showed that significant negative predictors to RTW were duration of pre-operative sick leave and post-operative neck pain along with age and disability claims. But their study was restricted to patients with cervical radiculopathy who underwent cervical discectomy. A study by Goh et al. showed that among CSM patients who underwent anterior surgery, severe myelopathy was associated with lower rates of RTW and early surgical intervention for patients with mild myelopathy was associated with higher rates of RTW. Another study by the same authors showed that poor baseline mental health did not influence improvement in RTW two years after anterior surgery for CSM. In larger segments of worldwide population, there is limited access to quality healthcare facilities like those in developed economies and absence of social support, especially for the elderly. For them, RTW is arguably the most important factor that determines the quality of their life. It is often forgotten or overlooked as the usual outcomes that the spine surgeon focusses upon are improvement in pain, neurological recovery, radiological fusion, and implant status. Unlike any other study in the English literature, our study focusses on patients who had no ulterior motive not to go back to work after surgery. It provides a comprehensive overview to the readers regarding the outcome of surgery for CSM in terms of RTW.
The primary goal of our study was to determine the rate and predictors of RTW after surgery for CSM. In addition, we intended to analyze the association between functional outcomes and RTW and the impact complications have upon this important outcome measure.
| Materials and Methods|| |
This was a prospective follow-up of retrospectively collected data. Our study was reviewed and accepted by the Institutional Review Board and Ethics Committee of the hospital (IRB Min No. 10940 dated November 7, 2017). We included all the patients with clinico-radiological diagnosis of CSM between 2012 and 2017 who underwent surgical treatment. We excluded patients with cervical myelopathy secondary to trauma, tumor, or infection. Patients who had retired or were unemployed prior to the onset of the disease, had incomplete data, and patients with tandem stenosis who were undergoing a staged procedure were also excluded. The follow-up of the patients in this study was both by personal interviews (23.5%) and telephonic video conversations (76.5%).
The patients were divided into two categories: patients who returned to work within 6 months of surgery (group 1; n = 18) and those who did not RTW within 6 months of surgery (group 2; n = 16), and their data were collected. We chose the 6-month mark to allow adequate time for the resolution of surgical pain and to accommodate soft tissue healing. It also gave adequate time for the patients to undergo physiotherapy and rehabilitation, so that they would be able to return to their near pre-disease state.
The pre-operative and post-operative functional status was measured using the Nurick grade and modified Japanese Orthopedic Association (mJOA) scores. The mJOA score was divided into mild [15–17], moderate [12–14], and severe [0–11], based on the severity of the disease.
The occupational profile was categorized as service, self-employed, manual laborer, and home makers. The service category included patients in professional and semi-professional jobs, the self-employed category included patients involved in small- or large-scale business, and manual laborers included farmers, head loaders, and daily wage workers.
Data were summarized using the mean (standard deviation) for continuous variables based on the normality. The categorical data were expressed as number and frequency. The outcome was presented with 95% confidence interval. χ2 test was used to associate categorical variables. All the analyses were performed using STATA I/c 15 software.
| Results|| |
A total of 77 patients with CSM were operated from January 2012 to December 2017. Of these, 12 patients were Nurick grade ≤2, 9 patients were unemployed prior to the onset of disease, 7 patients had tandem lumbar canal stenosis and 8 patients’ data were incomplete. Of the 41 eligible patients,7 (14.2%) patients were lost to follow-up. So, 34 patients (n = 34) were included in the study. Eighteen (52.9%) patients returned to work at 6 months (group 1) and 16 (47.1%) patients did not RTW at 6 months after surgery (group 2).
The baseline characteristics of both the groups are shown in [Table 1]. The mean age was 55.4 ± 9.2 years in group 1 and 57.9 ± 6.3 years in group 2 (P= 0.373). The mean duration of symptoms of patients in group 1 was 13 ± 9.4 months and in group 2 was 21.4 ± 26.5 months (P = 0.219). The two most common presenting complaints in both the groups were hand symptoms and inability to ambulate. Diabetes mellitus was seen in 3 out of 18 patients (16.6%) in group 1, and 3 out of 16 patients (18.7%) in group 2 (P ≥ 0.99). Eight out of 18 patients (44.4%) in group 1 and 8 out of 16 patients (50%) in group 2 consumed tobacco (P ≥ 0.99).
[Table 2] shows the operative details and occupational profile of the patients. None of the patients in group 1 underwent ≥4 level surgery, whereas 3 out of 16 patients (18.5%) in group 2 underwent ≥4 level surgery. Of the 25 patients who underwent anterior surgery, 15 (60%) belonged to group 1 and 10 (40%) belonged to group 2. Of the nine patients who underwent posterior surgery, three (33.3%) belonged to group 1 and six (66.7%) belonged to group 2. In terms of occupational profile, 9 out of 12 patients (75%) in the service category, 3 out of 7 patients (42.8%) in the self-employed category, and 5 out of 6 patients (83.3%) among the home makers returned to work by 6 months post-operatively. Out of the nine patients in the manual laborer category, only one patient (11.1%) returned to work by 6 months after surgery (P = 0.005).
The pre-operative and post-operative functional scores are shown in [Table 3]. The pre-operative Nurick grade was 3.78 ± 0.73 in group 1 and 3.81 ± 0.75 in group 2. The post-operative Nurick grade was 1.28 ± 0.57 in group 1 and 3.19 ± 0.98 in group 2. The pre-operative and post-operative mJOA scores were 11.83 ± 3.09 and 15.83 ± 1.29, respectively, in group 1 when compared with 10.69 ± 1.96 and 13.25 ± 2.84, respectively, in group 2.
The complications profile is shown in [Table 4]. A total of five patients underwent re-operation: two in group 1 for early graft/implant dislodgment and three in group 2 for wound infection. One patient in each group had transient neurological deficit post-operatively.
| Discussion|| |
RTW is arguably one of the most important outcome patients are concerned about when they consult with the spine surgeon. In fact, it may be the main yardstick the patient uses to judge the success of the intervention. In our study, CSM was associated with poor rate of RTW after surgery. At 6 months after surgical treatment for CSM, it was found to be only 52.9% (18 out of 34 patients) (95% CI: 35.1–70.2%). The percentage of RTW at full follow-up (mean: 32 months; range: 7–72 months) was 61.8% (21 out of 34 patients). In the study by Bhandari et al. which included patients with cervical radiculopathy who underwent cervical discectomy, 62.2% of the patients returned to work by 1 year. Faour et al. compared RTW between patients who underwent cervical fusion for degenerative disc disease and radiculopathy as an indication for surgery in a workers’ compensation setting. Their study found that the RTW rates in the degenerative disc disease group were 50.9% compared with the radiculopathy group which was 62.9%.
In our study, we identified the occupational profile of the patients as the only significant factor that appears to influence RTW. Service category patients and home-makers had high percentage of RTW post-operatively (75% and 83.3%, respectively). Self-employed patients and manual laborers had poor percentage of RTW post-operatively (42.8% and 11.1%, respectively) with the manual laborers category being affected the most. On the contrary, Bhandari et al. showed that manual laborers had higher rates (57.1%) of RTW post-operatively. This was perhaps because they included patients with predominantly radicular pain, whereas our patients were functionally limited due to spinal cord dysfunction. Asher et al. identified 4694 patients with degenerative lumbar spine disease who underwent lumbar spine surgery and looked at the predictive factors that were associated with RTW in them. In their results, they found out that manual labor as an occupation was among many other predictors that were associated with a lower likelihood of RTW at 3 months post-operatively.
Spinal pathologies, especially cervical myelopathy, are often very disabling to such an extent forcing patients to discontinue work. The main functional grading scales used in CSM are the Nurick grade and mJOA score. Moderate-to-severe myelopathy categorized by low mJOA scores causes significant disability, affecting the ambulation and occupation of the patient. This in turn grades them into the Nurick score of ≥ 3. Even though Nurick grade primarily focusses on employment and ambulation, ironically there has been limited research till date in the English literature that specifically delved into RTW among patients who underwent surgery for CSM. In our study, patients in group 1 (RTW <6 months) had better functional outcomes in terms of Nurick grade and mJOA scores. The pre-operative mJOA scores of both the groups were in the severe category. Post-operatively, the mean mJOA score was in the mild category in group 1 and moderate category in group 2, and the difference was statistically significant. Post-operatively, none of the patients in group 1 and three (18.7%) patients in group 2 were in the severe category (P = 0.001).
The post-operative complications observed among the patients were wound infection, neurological deficits, and early implant/graft dislodgment requiring re-operations. Though not statistically significant, it was found that the development of wound infection was associated with a failure to RTW within 6 months. It was also noted that the early post-operative implant/graft dislodgment did not affect the timing of RTW. This was due to the fact that these patients underwent immediate re-operation and hence there was no delay in the recovery period and RTW.
Patients were asked to subjectively rate their satisfaction of the outcomes of the surgery [Table 5]. All 18 (100%) patients in group 1 were satisfied with the outcome, whereas 12 (75%) patients in group 2 were satisfied with the outcome. The interesting difference here is the fact that 75% of the patients who did not go to work were also satisfied with the outcome in our study, compared with the fact that none of the patients who did not RTW in Bhandari et al.’s study was satisfied with the outcome. This was probably because our study included population with disabling disease who were wheelchair ambulant or bed-ridden pre-operatively. These patients were satisfied with the outcome even if they were able to walk with aids post-operatively. This was seen as a major improvement even if they were not able to go back to their pre-morbid occupation.
|Table 5: Comparison of subjective response to surgery among the two groups|
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There were a number of limitations that we confronted during the study. Out of the 49 patients who were eligible for the study, 7 (14.2%) patients were lost to follow-up. Also the follow-up period was short and highly varied (7–72 months). Even though we have an excellent follow-up system, there was significant percentage of lost to follow-up and varied follow-up periods because of the fact that most of our patients are from far off locations (>1700 km = 27 patients). The study patients belonged to the moderate-to-severe mJOA category, and 21 out of the 34 patients (61.7%) belonged to Nurick grade of ≥4 pre-operatively. It is difficult for the relatives to bring a patient with significant mobility problems to the hospital multiple times. Another limitation was the small sample size. This was due to the fact that we had a very select group of patients to study the RTW following surgery for CSM. Though the recruitment of the patients was retrospective in nature, all the patients were followed up prospectively and analyzed over personal interviews and telephonic video conversations.
To the best of our knowledge, this is the first study analyzing the rates and the potential predictors of RTW in patients with moderate-to-severe CSM. This study focussed on a single main objective, i.e., RTW, which is shown to be an important functional outcome measure following any surgery. The baseline characteristics and the pre-operative functional scores of both the groups were comparable. Hence, we had a homogeneous group of patients to begin with.
| Conclusion|| |
In spite of functional improvement, CSM was associated with poor RTW by 6 months after surgery, with manual laborers being the most vulnerable group. Age, body mass index, duration of symptoms, pre-operative absenteeism from work, smoking, diabetes mellitus, number of levels operated, surgical approach, and post-operative complications did not appear to have any association with post-operative RTW. This study will help surgeons modulate patient expectations as well as provide a platform for counseling them. Further research is warranted in this area of interest. Prospective studies with bigger sample size and regular follow-up including the predictors found for RTW will give more precise and reliable estimates. In spite of its limitations, our study has significant value as a starting point for predicting the outcome of surgery for CSM to guide pre-operative counseling, shared-decision making, and advising patients of their likelihood of returning to work.
Financial support and sponsorship
Conflicts of interest
None of the authors declare any conflicts of interest.
Dr Arun John Paul: work concept and design, data acquisition, analysis, interpretation, manuscript preparation, final approval, accountable to all aspects of work;
Dr Rohit Amritanand: work concept and design, data analysis and interpretation, critical revision, final approval, accountable to all aspects of work;
Dr Kenny Samuel David: work concept and design, critical revision, final approval, accountable to all aspects of work;
Dr Venkatesh Krishnan: work concept and design, critical revision, final approval, accountable to all aspects of work.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]