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Assessing the Impact of Preoperative Conservative Treatment Options Prior to Cervical Surgical

Procedures: A Michigan Spine Surgery Improvement Collaborative (MSSIC) Study

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Matthew R. Cederman, BS1, Christopher L. Nikolopoulos, BS1, Arthur Saroyan, BS1, Jeffrey Fischgrund, MD1,2,

Richard Easton, MD1,2, Jad Khalil, MD1,2, Khalid Odeh, MD1,2

1. Oakland University William Beaumont School of Medicine, Rochester, MI, USA, 48309

2. Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA, 48073

Introduction

  • Cervical radiculopathy and myelopathy are prevalent conditions that significantly impair function and quality of life, most commonly resulting from degenerative cervical spine pathology causing spinal cord compression.1-5
  • While postoperative rehabilitation has been extensively studied, the role of preoperative conservative interventions remains controversial, with mixed evidence regarding their impact on surgical outcomes.6-7
  • Initial management is typically nonoperative and includes physical therapy, oral medications, activity modification, and epidural steroid injections aimed at pain relief and functional improvement.
  • When conservative treatment fails or neurological deficits progress, surgical intervention is indicated. Anterior cervical discectomy and fusion (ACDF) and cervical total disc replacement (cTDR) are well-established surgical options with high patient satisfaction.8-12
  • With increasing emphasis on value-based care and outcome optimization, the effect of preoperative conservative management on postoperative complications, recovery, and patient satisfaction in cervical spine surgery remains incompletely understood.

Aims and Objectives

  • To evaluate the association between preoperative conservative treatment and postoperative outcomes, including complications, recovery, and patient-reported function, in patients undergoing ACDF or cTDR.
  • To identify clinical and demographic predictors of achieving meaningful postoperative improvement in neck pain following cervical spinal surgery.

Methods

  • Retrospective cohort study of patients undergoing ACDF or cTDR (2017–2023) utilizing the MSSIC database
  • Inclusion: Age ≥18, primary ACDF or cTDR, ≤3 operative cervical levels
  • Exclusion: Trauma, revision surgery, >3 levels
  • Cohort: 13,404 patients; ACDF: 12,363; cTDR: 1,041
  • Preoperative treatment groups:
    • None (control)
    • PT/C (physical therapy ± chiropractic)
    • INJ (injections)
    • MTC (multiple/other treatments)
  • Variables: 
    • Demographics
    • BMI
    • Symptom duration
    • ASA class
  • Outcomes:
    • Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function (baseline, 90 days)
    • MCID defined as ≥ +4.5
    • Depression screening via Patient Health Questionnaire (PHQ-2) (score ≥3)
  • Statistics:
    • Welch t-test, chi-square analysis
    • Multivariable GEE models for MCID neck pain
    • *Significance set at P < 0.05

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  • Length of stay
  • Comorbidities
  • Postoperative complications

Study Cohort

  • 13,404 patients, 52.1% female; mean age 55.5 ± 11.7 years
  • Stratified by ACDF vs cTDR and preoperative conservative treatment

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ACDF

  • Preoperative treatment patients were younger, female, and had longer symptom duration (P < .001)
  • Shorter hospital stay with preoperative treatment

(<1.7 vs 2.15 days, P < .017)

  • INJ and MTC cohorts had higher baseline anxiety/depression (P < .011)

Postoperative Outcomes

  • Lower complication rates in treatment cohorts (P < .041)
  • Reduced postoperative pain and weakness:

PT/C: less axial neck pain (7.2%, P = .039)

PT/C and INJ: less weakness (8.8%, 6.6%) vs control (10.5%)

  • Lower 90-day readmissions:

PT/C 4.9%, MTC 4.3% vs control 7.9% (P < .001)

Functional & Disposition Outcomes

  • More frequent home discharge and return to work in treatment cohorts (P < .014)
  • Higher 90-day PROMIS PF in PT/C and MTC

(P < .001); no MCID difference

  • Lower postoperative depression in PT/C (P = .027)

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cTDR

  • No baseline demographic differences; longer symptom duration in treatment cohorts (P < .015)
  • Shorter hospital stay in PT/C and MTC cohorts (<0.9 vs 1.5 days, P < .004)
  • Fewer unplanned returns to OR in MTC cohort (0.2% vs 1.7%, P = .039)
  • Discharge, satisfaction, PROMIS PF, and depression outcomes largely equivalent across cohorts

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Multivariate Analysis (MCID – Neck Pain, 90 Days)

ACDF: Older age, white race, no painkillers at baseline, and osteoporosis ↑ MCID odds. Symptom duration ≥1 year and anxiety ↓ MCID odds. BMI effect statistically significant but clinically minimal

cTDR: Older age and white race ↑ MCID odds; hypertension ↓ MCID odds

Results

Figure 1. Baseline and 90-day postoperative PROMIS Physical Function questionnaire, a 0-100 scale with average of 50 and SD of 10, in ACDF (A) and cTDR (B).

Table 1. Patient demographics, stratified by treatment cohort and operative procedure (ACDF or cTDR).

Table 2. Postoperative complications, stratified by treatment cohort and operative procedure (ACDF or cTDR).

Figure 2. Baseline and 90-day postoperative PHQ-2 questionnaire in ACDF (A) and cTDR (B).

Figure 3. Multivariable analysis for ACDF and cTDR for achieving MCID in neck pain at 90-days postoperative. Further subcategorized based upon patient characteristics, health history, and preoperative treatment cohorts.

Conclusions

  • Preoperative conservative treatment in ACDF patients is associated with younger age, fewer comorbidities, longer symptom duration, fewer postoperative complications, higher rates of home discharge and return-to-work, improved physical function, and lower depression.
  • In cTDR patients, preoperative conservative care was linked to shorter hospital stays and longer symptom duration, with no other significant differences.
  • Multivariate analysis identified age, BMI, osteoporosis, symptom duration, and anxiety as significant predictors of achieving MCID in neck pain at 90 days.
  • Preoperative management had no significant impact upon reaching MCID in neck pain for ACDF or cTDR.
  • Future studies with standardized preoperative protocols are needed to clarify benefits, optimize outcomes, and reduce patient costs.

Acknowledgements

We would like to acknowledge Jacob Keeley, MS and the MSSIC team for their contributions.

References

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