This presentation is part of: Oral Concurrent Session A - Clinical Strategies and Guidelines
SHOULD PROPHYLACTIC SURGICAL FUSION BE OFFERED TO PATIENTS WITH RHEUMATOID ARTHRITIS AND CERVICAL INSTABILITY BEFORE DEVELOPMENT OF NEUROLOGICAL DEFICITS? A DECISION ANALYSIS
Yan Liu, MD, Beate Sander, RN MA MEcDev, and Andreas Maetzel, MD, MSc, PhD. University Health Network, Division of Clinical Decision Making, Toronto, ON, Canada
Background: Surgical fusion is routinely proposed to patients with rheumatoid involvement of the cervial spine in the presence of neurological symptoms. Successful outcomes of surgery have prompted surgeons to advocate intervention in patients with pain alone in the absence of neurological signs. Objective: To evaluate the benefits of surgery as a prophylactic measure for patients with painful cervical instability in the absence of neurological signs (Ranawat I) [PROPH], versus only for those whose disease progresses to neurological involvement (Ranawat >=II) [NEURO]. Methods: We developed a decision analysis model with a comprehensive representation of the transitions of patients with cervical instability between Ranawat stages, surgical complications and death. A systematic search of Medline was performed to obtain estimates of events in the model. We excluded studies that contained less than 10 patients, and were published before 1985, after which CT and MRI imaging modalities were routinely used. Primary outcomes considered were the progression from Ranawat I to Ranawat >=II and mortality. We adopted a time horizon of 7 years, the average time of observation in the supporting literature. Sensitivity analysis was performed on key variables. Results: Seven studies met eligibility criteria, providing input to the following baseline variables: 1) progression from Ranawat I to >=II: 57% (NEURO) vs. 8% (PROPH); 2) chance of non-permanent surgical complications: 14% (both PROPH and NEURO); 3) chance of permanent surgical complications: 2% (PROPH) vs. 5% (NEURO); 4) improvement to Ranawat I with NEURO: 30%. Neither was associated with increased mortality directly related to surgery. Adopting PROPH would lead to a higher proportion of patients remaining in Ranawat I or 0 (free of pain) (92%) as compared to NEURO (57%). Sensitivity analysis shows that preference of PROPH over NEURO is robust. PROPH would be outperformed by NEURO only if natural progression to RII/RIII is less than 10% or if more than 40% of prophylactic surgeries result in RII/RIII or death. Conclusion: Results of this decision analysis indicate that PROPH is a realistic option, to be discussed with patients who present with cervical instability. With NEURO, RI is realized only by a minority of patients once they progress to RII or RIII. High-quality, prospective, observational studies are needed to corroborate these findings. Cost-effectiveness and quality of life assessment would provide added value.
