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INTRODUCTION: Degenerative cervical myelopathy (DCM) is a condition of growing concern due to its increasing incidence among the ageing population. It involves age-associated pathological changes of the cervical spine that can result in spinal cord compression. This can lead to deficits in motor and sensory function of the upper and lower limbs, issues with balance and dexterity, as well as bladder and bowel disturbance. Patients can be categorised as having mild, moderate, or severe degenerative cervical myelopathy depending on their modified Japanese Orthopaedic Association (mJOA) score. This condition is generally managed surgically; however, patients with mild degenerative cervical myelopathy may be offered or opt for non-surgical treatment initially. AIMS: The main aim of this study is to evaluate the surgical management of patients with DCM and to ascertain the degree of mJOA improvement from pre-surgery and one-year post-surgery follow-up. The second aim of the study is to explore the demographics within Northern Ireland who are diagnosed with DCM and who undergo surgery. This information could allow for better planning of services in the future for this patient cohort. METHODS: This is a retrospective review of the surgical management of degenerative cervical myelopathy within the Regional Spinal Orthopaedic Unit in Northern Ireland over three years with one-year follow-up. The data was retrospectively collected from the Fracture Outcome Research Database. A total of 102 patients (10:7, male:female) with DCM were retrospectively evaluated. Exclusion criteria included all patients diagnosed with spinal tumour, fracture, central cord syndrome, and dislocation. Two patients were removed due to incorrect coding of DCM diagnosis and were not included. Key variables assessed were gender, age, symptoms, type of surgery, complications, and MRC score and mJOA score pre-surgery, 48 hours, six months, and one year post surgery. The choice of surgery was guided by the maximal angle of compression, the number of vertebral levels involved, patient comorbidities, and anesthetic risk. RESULTS: The sample consisted of 60 men (58.82%) and 42 women (41.17%) with an average age of 57.17 ± 12.13 years ranging from 27 to 83 years old. Statistical analysis was conducted to explore the effect of time before and after surgery up to one year on the mJOA score. There was a significant difference in mJOA score pre-surgery and at six months and one year post surgery (R = 0.579053, p <0.001). Of the patients, 61.8% with a length of stay greater than three days and 71.4% of patients with a length of stay greater than seven days had a posterior approach surgery. A multiple linear regression analysis revealed that the mJOA score pre-surgery and the presence of complications significantly predicted the length of stay post-surgery (ß -1.044, p = .011 and ß -5.791, p = .028). CONCLUSION: The first key finding of this study is that the mJOA score tends to improve after surgery for the majority of patients, particularly at six months, which is consistent with the literature. The second key finding is that anterior approach surgery is associated with a lower rate of complications and shorter post-surgery length of stay in hospital compared to posterior approach surgery. The third key finding is that the pre-surgery mJOA score and the presence of complications post surgery significantly predict the post-surgery length of stay.
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Degenerative cervical myelopathy (DCM) is a spinal condition of growing importance due to its increasing prevalence within the ageing population. DCM involves the degeneration of the cervical spine due to various processes such as disc ageing, osteophyte formation, ligament hypertrophy or ossification, as well as coexisting congenital anomalies. This article provides an overview of the literature on DCM and considers areas of focus for future research. A patient with DCM can present with a variety of symptoms ranging from mild hand paraesthesia and loss of dexterity to a more severe presentation of gait disturbance and loss of bowel/bladder control. Hoffman's sign and the inverted brachioradialis reflex are also important signs of this disease. The gold standard imaging modality is MRI which can identify signs of degeneration of the cervical spine. Other modalities include dynamic MRI, myelography, and diffusion tensor imaging. One important scoring system to aid with the diagnosis and categorisation of the severity of DCM is the modified Japanese Orthopaedic Association score. This considers motor, sensory, and bowel/bladder dysfunction, and categorises patients into mild, moderate, or severe DCM. DCM is primarily treated with surgery as this can halt disease progression and may even allow for neurological recovery. The surgical approach will depend on the location of degeneration, the number of cervical levels involved and the pathophysiological process. Surgical approach options include anterior cervical discectomy and fusion, corpectomy, or posterior approach (laminectomy ± fusion). Conservative management is also considered for some patients with mild or non-progressive DCM or for patients where surgery is not an option. Conservative treatment may include physical therapy, traction, or neck immobilisation. Future recommendations include research into the prevalence rate of DCM and if there is a difference between populations. Further research on the benefit of conservative management for patients with mild or non-progressive DCM would be recommended.
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Introduction Hip fracture is commonly seen in elderly patients because of low-energy trauma. It carries significant morbidity and mortality. Scoring systems such as the Nottingham hip fracture score (NHFS) have shown a good correlation with increased mortality as the value of these scores increases. In our study, we aim to ascertain the hip fracture mortality in our population, compare the mortality in hip fractures compared to previously reported figures in literature and nationally reported figures during the first year of the COVID-19 pandemic, and also ascertain the usefulness of NHFS in predicting mortality in hip fractures. Methods We gathered mortality data on hip fracture patients admitted to our unit from January 1, 2020 to December 31, 2020. NHFS was calculated for all patients and the 30-day mortality rate was compared to previously reported hip fracture mortality rates using the standard mortality ratio (SMR). One-year mortality was stratified by placing patients in high and low NHFS groups. The log-rank test was used to compare hip fracture survival at one month and at one year in the high NHFS (NHFS >4) group and low NHFS group (NHFS value 4 or below). Additionally, a log-rank test was used to compare one-month and one-year survival in hip fractures managed with hemiarthroplasty, dynamic hip screw and intramedullary nail. Results In 2020, 388 patients were admitted with hip fractures to our unit. The crude mortality rate was 3.9% at 30 days and 20.88% at one year. Compared to the National Hip Fracture Database report for 2020, the incidence risk ratio for mortality was 0.46 (p-value<0.05). The SMR at 30 days was 0.34 (CI=0.17-0.51) and the SMR at one year was 0.63 (CI=0.49-0.77). The survival rate was higher at 30 days and one year in the low NHFS group compared to the high NHFS group (p-value<0.01). The survival rate at one month and one year were similar in groups managed with hemiarthroplasty, dynamic hip screws, and intramedullary nails (p-value>0.05). Conclusions Hip fracture mortality has been decreasing steadily and we noted a lower rate of hip fracture mortality compared to figures reported previously as per NHFS studies even though the study was conducted during the COVID-19 pandemic period. We also noted lower 30-day mortality in our hospital as compared to the national 30-day mortality rate for hip fracture patients in 2020.
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Background Hip fracture is a debilitating injury, especially in older individuals, which is associated with significant morbidity and mortality. In recent decades, there has been a great focus on early rehabilitation and discharge after hip fractures. The aim of such efforts is to minimize the financial and clinical burden of this condition. We conducted our study during the COVID-19 pandemic and compared the length of hospital stay (LOS) in 2020 to the LOS in 2019. Additionally, we studied the factors which may impact the LOS, such as premorbid status according to established scoring systems, the type of fracture, an operation performed, and time to surgery. Methods We collected the data regarding the length of stay (in days) for all hip fracture patients admitted to our unit from 1st January 2019 until 31st December 2020. We then compared the mean LOS for both years using the t-test. We calculated the Nottingham Hip Fracture Score (NHFS) and American Society of Anaesthesiologists (ASA) scores for patients admitted in 2020 and calculated the correlation between increasing values of these scores and the LOS. We also compared the mean LOS for patients admitted in 2020 based on the type of fracture and type of management. We studied the correlation between the time to surgery and the LOS for patients admitted in 2020. Results Three hundred and eighty-eight patients were admitted with hip fractures in 2020, and 452 were admitted in 2019. LOS in 2020 was significantly lower (23.39 days) compared to 2019 (31.36 days) with p<0.01. While evaluating data from 2019, it was noted that there was a small positive correlation between LOS and NHFS (r=0.231, p<0.001) and LOS and ASA (r=0.18, p<0.001). The mean LOS for intracapsular fractures was noted to be lower than that of extracapsular fractures, but this was not statistically significant (p=0.17). An ANOVA test showed that the mean LOS for patients undergoing hemiarthroplasty, dynamic hip screws (DHS), and intramedullary nails (IMN) was significantly longer than for patients managed with total hip replacement or patients managed non-operatively (F=3.551, p<0.01). Conclusion Hip fracture patients admitted to our department were discharged quicker during the first year of the COVID-19 pandemic. The LOS for hip fractures increases with an increase in their NHFS or ASA scores. Extracapsular and intracapsular fractures lead to roughly the same periods of inpatient stay. Patients undergoing hemiarthroplasty, DHS, or IMN stay longer in the hospital compared to other treatment modalities.