1. Giuseppe Barbagallo, MD University of Catania, Catania, Italy
International Variations in the Clinical Presentation
and Management of Cervical Spondylotic Myelopathy.
One Year Outcomes of the AOSpine Multi-Center Prospective Study.
Giuseppe Barbagallo, MD
University of Catania, Catania, Italy
On Behalf of the CSM-I Site Investigators : Michael Fehlings, MD, University of Toronto, Toronto, ON, Canada; Branko Kopjar, MD, University of Washington, Seattle, WA; Ronald Bartels, MD, University Nijmegen Medical Centre, Nijmegen, Netherlands; Vincenzo Albanese, PhD, Medical University of Catania, Catania, Italy; Helton Defino, MD, University of Sao Paulo - Ribeirao Preto, Sao Paulo, Brazil; Paul Arnold, MD, University of Kansas, Kansas City; Qiang Zhou, MD, Southwestern Hospital, ChongQing, China; Mehmet Zileli, MD, Ege University, Izmir, Turkey; Gamaliel Tan, MD, Tan Tock Seng Hospital, Singapore, Singapore; Osmar Moraes, MD, Hospital Santa Marcelina, Sao Paulo, Brazil; Shashank Kale, MD, All India Institute of Medical Sciences, New Dehli India; Ciaran Bolger, MD, Beaumont Hospital, Dublin, Ireland; Manuel Alvarado, MD, Hospital San Juan de Dios, Caracas, Venezuela; Massimo Scerrati, MD, Medical University of Ancona, Ancona, Italy

2. Background
Cervical spondylotic myelopathy (CSM) is the commonest cause of spinal cord impairment.
There is a lack of evidence regarding the long term outcomes of surgical treatment for CSM.
We report on the one year outcomes of a large prospective multicenter study to evaluate the impact of surgery on outcomes of CSM.

3. Patients
379 patients with clinically confirmed CSM and imaging evidence of cord compression (MRI or CT-myelogram) were enrolled in the prospective cohort study. Patients underwent anterior surgery (discectomy/corpectomy and instrumented fusion) or posterior surgery (laminectomy and fusion or laminoplasty) based on the judgment of the operating surgeon.

4. Subjects accounting
379 subjects were enrolled at 13 sites around the world.
One year follow-up data are currently available for 193 subjects.
Outcomes evaluations
modified Japanese Orthopaedic Assessment scale (mJOA), Nurick Score, Neck Disability Index (NDI), Short Form-36v2, and an assessment of treatment complications.

5. Primary Investigators and Regions
City
Primary
Investigator
North America
Toronto
Dr. M. Fehlings
Kansas City
Dr. P. Arnold
Asia / Pacific
ChongQing
Dr. Q. Zhou
New Dehli
Dr. S. Kale
Singapore
Dr. G. Tan
Latin America
Ribeirao Preto
Dr. H. Defino
Sao Paulo
Dr. O. Moraes
Caracas
Dr. M. Alvarado
Europe
Nijmegen
Dr. R. Bartels
Izmir
Dr. M. Zileli
Dublin
Dr. C. Bolger
Catania
Dr. G. Barbagallo
Ancona
Dr. M. Scerrati
125
121 81 52

6. Demographics Variable Anterior (N=224) Posterior (N=144)
Circumferential (N=9)
P-value
Age
54.0±12.1
59.8±12.2
55.5±9.2
<.01
Male Gender
55.3%
73.5%
44.44%
mJOA
12.9±2.1
11.9±2.9
12±2.8
Nurick
4.1±1.1
4.6±1.4
4.8±1.3
NDI
38.5±20.3
38.4±21.9
34.9±24.8
.84
SF36 V2 PCS
35.6±8.6
34.4±8.8
34.1±8.6
.30
SF36 V2 MCS
38.7±9.7
39.1±10.3
37.7±7.4
.91
Levels
2.95±.9
4.7±.9
3.9±0.9

7. 12 months outcomes (N=193) Variable Baseline 12 Months P value mJOA
12.5±2.9
15.1±2.7
<.01
Nurick
4.3±1.2
2.9±1.5
NDI
38.2±20.9
26.7±19.1
SF36 PCS
35.1±8.6
43.2±10.1
SF36 MCS
38.8±9.9
45.2±10.6

8. 12 months outcomes (N=193) - mJOA

9. Regional Differences in Demographics
Variable
North America
(N =113)
Latin America
(N =43)
Europe
(N =123)
Asia pacific
(N =57)
P value
Age
59.7±11.6
54.6±10.2
57.4±12.1
50.5±13.2
<.001
Male Gender
57.0%
71.1%
59.3%
70.3%
Surgery
Anterior
56.7%
23.1%
72%
67.5%
Posterior
39.2%
76.9%
24.8%
32.5%
Circumferential
4.1% 0%
3.2%
Number of levels
4.2±1.3
4.1±1.1
3.2±1.0
3.3±1.2
Regional Differences in Baseline Variables
Variable
North America
Latin America
Europe
Asia Pacific
P Value
MJOA
12.2±2.3
12.4±3.5
13.1±2.9
12.3±3.2
n.s.
NDI
37.6±21.7
39.1±20.6
37±20.7
41.9±20.3
Nurick
4.2±1.0
4.4±1.6
4.2±1.2
4.6±1.4
PCS
35.3±9.8
35.4±8.8
34.8±7.8
35.0±8.2
MCS
39.2±10.4
41.8±11.2
37.9±8.8
37.8±9.4

10. Regional Differences in Outcomes
Variable
North America
Latin America
Europe
Asia Pacific
P value
mJOA
2.76(0.29)
2.07(0.38)
1.30(0.28)
2.92(0.39)
0.0006
NDI
7.21(2.42)
10.24(3.20)
8.23(2.28)
12.42(4.31)
0.7345
Nurick
1.56(0.17)
0.62(0.23)
1.18(0.16)
1.45(0.23)
0.0087
PCS
6.06(1.22)
10.53(1.52)
4.58(1.12)
12.35(1.55)
0.0002
MCS
5.04(1.30)
8.91(1.63)
3.17(1.19)
9.77(1.66)
0.0036
*Values in table show changes in outcome between baseline and 12 months adjusted for baseline predictors. Numbers in parenthesis are standard error.

11. Discussion
Surgical treatment for CSM results in sustained improvement in generic and disease HRQOL
The amount of improvement varied across the regions.
Subjects from Asia & Pacific and Latin America had larger improvements in outcome than those from North America and Europe.
The impact of differences in age (much younger in Asia/Pacific) and socio-cultural perceptions of disability and impairment likely play a role in these observations

12. Acknowledgements
Study is funded by AOSpine International, a non-for-profit organization for excellence in spine.