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Presentation #58: The Fall and Fracture Risk of Medicare Patients with Cervical Myelopathy

Blizzard, Daniel J. MD, MS; Gallizzi, Michael A. MD, MS; Sheets, Charles PT; Penrose, Colin T. BA, BS; Isaacs, Robert E. MD; Brown, Christopher R. MD

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Spine Journal Meeting Abstracts: 2015 - Volume 2015 - Issue - p 220–221
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Introduction: A significant breadth of literature has documented the potential fall risk of patients with neurological diseases including stroke, dementia and Parkinson's disease. Slowed velocity, unsteady/neuropathic gait, increased double support time and shorter strides have all been linked to an increase risk in falls. However, no studies to date have assessed the frequency and impact of falls in patients with cervical myelopathy. Knowledge of the fall risk and resultant injuries of patients with gait abnormalities can play a pivotal role in determining treatment of the gait disturbance as the morbidity of repeated falls may outweigh the morbidity associated with an operative intervention. The purpose of the study herein is to determine the fall and injury risk of patients with cervical myelopathy and evaluate the potential protective effect of operative intervention.

Methods: The PearlDiver database was used to search the Medicare sample from 2005‐2012 using International Classification of Disease, 9th Edition (ICD‐9) codes. This search yielded 35,997,166 control patients without cervical myelopathy, vestibular disease or Parkinson's disease. ICD‐9 codes for cervical myelopathy identified a total 601,390 patients. ICD‐9 procedure codes identified 77,346 patients that first had a diagnosis of cervical myelopathy and subsequently underwent cervical decompression with or without fusion. Incidence (IN), risk ratios (RRs) and respective 95% confidence intervals (CIs) were recorded over the sample period.

Results: Patients with cervical myelopathy had a statistically significant increase incidence of all complications compared to the control group (Figure 1): 11.3% incidence of falling (RR 8.08), 3.7% of hip fracture (RR 2.62), 5.9% incidence of leg and ankle fractures (RR 2.57), 0.8% incidence of femur fracture (RR 3.61) and 6.2% incidence of head injury (RR 7.34). The subset of patients with cervical myelopathy that underwent cervical decompression surgery had a significant reduction in falls (RR: 0.83), head injuries (0.87) and skull fractures (RR: 0.78), and leg and ankle fractures (RR: 0.88), but no improvement in the incidence of hip, femur or pelvis fractures (Figure 2).

Figure 1
Figure 1:
Figure 1. Forest Plot depicting the relative risk (RR) of complications for patients with cervical myelopathy compared to healthy, age‐matched controls. The vertical line corresponds to a RR of 1, or equivalent risk, to controls.
Figure 2
Figure 2:
Figure 2. Forest Plot depicting the relative risk (RR) of complications for patients with cervical myelopathy that underwent cervical decompression surgery compared to patients with cervical myelopathy that did no undergo operative treatment. Values to the left of the vertical RR = 1 line define complications with reduce incidence in the cervical decompression group.

Conclusions: Cervical myelopathy has a very significant, negative effect on patient morbidity. The relative risk of sustaining falls, lower extremity fractures, and head injuries if 2.6‐8.1 times more likely in patients with cervical myelopathy compared to controls. Cervical decompression reduced the incidence of falls, but did not reduce the incidence of all musculoskeletal complications measured. The reduction in falls and injuries is likely more significant than the data reflects given the inherent treatment bias of patients with more severe disease and, presumably, higher rates of falls and injuries undergoing operative treatment. The high rate of falls and resultant injuries in this population should be considered when determining myelopathy treatment and when managing musculoskeletal injuries sustained in this population to choose treatments that emphasize protection and stability.

© 2015 Lippincott Williams & Wilkins, Inc.