Factors Influencing Surgical Decision-Making in the Posterior Laminectomy With Fixation for Degenerative Cervical Myelopathy (POLYFIX-DCM) Trial: Survey Study

Stefan Yordanov, Xiaoyu Yang, Oliver Mowforth, Andreas K. Demetriades, Marcel Ivanov, Pierluigi Vergara, Adrian Gardner, Erlick Pereira, Antony Bateman, Alexander Alamri, Jibin Francis, Rikin Trivedi, Mark Kotter, Benjamin Davies, Alexandru Budu

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Degenerative cervical myelopathy (DCM) is estimated to affect 2% of the adult population. DCM occurs when degenerative processes cause compression and injure the spinal cord. Surgery to remove the stress caused by the compression of the spinal cord is the mainstay of treatment, with a range of techniques in use. Although various factors are described to inform the selection of these techniques, there needs to be more consensus and limited comparative evidence.

Objective: The main objective of this survey was to explore the variation of practice and decision-making, with a focus on laminectomy versus laminectomy and fusion in posterior surgery of the cervical spine. We present the results of a survey conducted among the principal investigators (PIs) of the National Institute for Health and Care Research (NIHR) randomized controlled trial on posterior laminectomy with fixation for degenerative cervical myelopathy (POLYFIX-DCM).

Methods: A series of 7 cases were shared with 24 PIs using SurveyMonkey. Each case consisted of a midsagittal T2-weighted magnetic resonance imaging and lateral cervical x-rays in flexion and extension. Surgeons were asked if their preferred approach was anterior or posterior. If posterior, they were asked whether they preferred to instrument and whether they had the equipoise to randomize in the NIHR POLYFIX-DCM trial. Variability in decision-making was then explored using factors reported to inform decision-making, such as alignment, location of compression, number of levels operated, presence of mobile spondylolisthesis, and patient age.

Results: The majority of PIs (16/30, 53%) completed the survey. Overall, PIs favored a posterior approach (12/16, 75%) with instrumentation (75/112, average 66%) and would randomize (67/112, average 62%) most cases. Factors reported to inform decision-making poorly explained variability in responses in both univariate testing and with a multivariate model (R2=0.1). Only surgeon experience of more than 5 years and orthopedic specialty training background were significant predictors, both associated with an anterior approach (odds ratio [OR] 1.255; P=.02 and OR 1.344; P=.007, respectively) and fusion for posterior procedures (OR 0.628; P<.001 and OR 1.344; P<.001, respectively). Surgeon experience also significantly affected the openness to randomize, with those with more than 5 years of experience less likely to randomize (OR –0.68; P<.001).

Conclusions: In this representative sample of spine surgeons participating in the POLYFIX-DCM trial as investigators, there is no consensus on surgical strategy, including the role of instrumented fusion following posterior decompression. Overall, this study supports the view that there appears to be a clinical equipoise, and conceptually, a randomized controlled trial appears feasible, which sets the scene for the NIHR POLYFIX-DCM trial.
Original languageEnglish
Article numbere48321
Number of pages8
JournalJMIR Formative Research
DOIs
Publication statusPublished - 12 Sept 2023

Bibliographical note

Copyright © Stefan Yordanov, Xiaoyu Yang, Oliver Mowforth, Andreas K Demetriades, Marcel Ivanov, Pierluigi Vergara, Adrian Gardner, Erlick Pereira, Antony Bateman, Alexander Alamri, Jibin Francis, Rikin Trivedi, Mark Kotter, Benjamin Davies, Alexandru Budu, POLYFIX-DCM research Collaborative Group. Originally published in JMIR Formative Research (https://formative.jmir.org), 12.09.2023. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

Keywords

  • cervical myelopathy; spondylosis; spondylotic stenosis; disc herniation; ossification posterior longitudinal ligament; degeneration; disability; recovery; questionnaire; decision-making; surgeons; myelopathy; stress; spinal cord; surgeons; surgery; decompression; laminectomy

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