Friday, September 27, 2013
ACDF vs. PT for Cervical Radiculopathy: Finally a Modern RCT
Conventional wisdom has suggested that ACDF leads to faster and more complete recovery from cervical radiculopathy than non-operative care, though no modern RCT has demonstrated this to be true. In response to this vacuum in the literature, Dr. Engquist and his colleagues from Sweden performed an RCT comparing outcomes between 31 patients treated with ACDF + PT to 32 patients treated with PT alone. During the 2 year follow-up, 5 patients crossed over from the non-operative group to surgery, and none crossed over in the opposite direction. Over the course of follow-up, the ACDF patients improved significantly more on the neck pain VAS than the PT group and also had greater levels of patient satisfaction (at the one year follow-up). The surgery patients also improved more than the non-operative patients on every outcome measure at every time point, though the differences were not significant. Contrary to conventional wisdom, the surgery patients improved substantially more on the neck pain VAS score than the arm pain VAS score. Overall, this study suggests that while surgery patients likely improve faster and to a somewhat greater degree than patients treated with PT alone, most patients treated non-operatively improve as well, and by two years have outcomes that are nearly as good as those treated with ACDF.
The authors should be congratulated for performing a high quality RCT that compares surgery to non-operative treatment. The Spine Patient Outcomes Research Trial (SPORT) demonstrated how difficult this is to do, primarily due to the tendency of patients to crossover between treatment arms. In general, this study confirms commonly held beliefs about cervical radiculopathy, and indicates that the treatment decision for this condition is truly preference sensitive and should be based on individual patients’ values and goals. While the results were not overwhelmingly in favor of surgery, certain study design and analytical features tended to push the results towards the null hypothesis. For one, the study was likely underpowered to detect meaningful differences on some of the outcome measures. While minimal clinically important differences have not been clearly defined for cervical spine outcome measures, this study was only powered to detect a 15 to 20 point difference on the VAS. Additionally, 4 patients crossed over from PT to ACDF between 12 and 24 months and were analyzed in an intention to treat fashion, which likely explains some of the decrease in the advantage of surgery from 12 to 24 months. These factors likely do not change the overall conclusion of the paper, but readers should consider possible Type II error when they note a consistent advantage for surgery that was rarely statistically significant. This paper helps to fill an important void in the literature and also tends to support the idea that cervical radiculopathy will likely improve with surgery or with non-operative care, but that surgery can lead to a greater degree of improvement faster, albeit at the cost of increased risks and a recovery period.
Please read Dr. Engquist’s article on this topic on the September 15 issue and his accompanying commentary. Does this change your approach to treating cervical radiculopathy? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor