Tecnología para el proceso:

3.1 Summary

There is considerable uncertainty concerning patient selection and operation timing for cervical spondylotic myelopathy (CSM). Attempts have therefore been made to quantify CSM severity to provide an adjunct to clinical decision-making. The aim of the study described in this chapter was to determine, by means of a 7-item questionnaire, the attitudes of clinicians regarding the importance of quantitative assessment in normal management of CSM, their actual use of such assessment and how current scales fall short of ideal.

Quantitative assessment was regarded by 117 respondents as being almost as important as history, imaging and clinical examination; overall function and rate of progression were also highlighted as major factors. However, only 4 believed there was a “gold-standard” scale and the actual use of scales was low and fragmented. There were clear differences between specialities in both attitudes and practice.

The discrepancy between the importance attached to quantitative measurement and its actual use suggests that current scales are under-utilised or unsuitable for clinical practice. A new easy-to use scale may be required that better reflects clinicians’ attitudes.

3.2 Introduction

A major difficulty with the management of cervical spondylotic myelopathy (CSM) is that its often slow and insidious course coupled with the potential hazards of surgery can result in uncertainty concerning the optimal operative procedure to perform and the optimal stage in the disease at which to perform the procedure. Current assessment of CSM generally involves subjective and non-standardised assessment of patients (Lunsford, Bissonette et al., 1980a;Harsh, Sypert et al., 1987). Partly as a result, clinicians vary greatly in their selection practices for surgery (Hadley and Sonntag, 1996;Sypert, 1992;Allen, 1952;Bakay, Cares et al., 1970;Gonzales-Feria, 1975;Sypert and Arpin-Sypert, 1996; Alexander, 1996).

The aim of this study was therefore to survey, by means of a questionnaire, clinicians’ current attitudes to assessment of CSM severity. It was considered important to look at practices of all doctors potentially involved, including general practitioners and geriatricians, rather than just operators, because such clinicians determine initial referrals. In addition, the actual current use of quantitative assessment was surveyed. Finally, if there was a lack of use of quantitative measures, an attempt was made to ascertain in what way the existing measures do not meet clinicians’ requirements.

Conducting such a survey before embarking on an original project looking into quantitative assessment of CSM would hopefully provide some initial insights into actual use of scales and into the properties of a scale that would make it most useful to clinicians.

3.3 Experimental Protocol

Two hundred postal questionnaires (see Appendix 11) were sent out in July 1998 to randomly selected UK clinicians involved in management of CSM. Replies included Neurologists 15%, Neurosurgeons 31%, Orthopaedic-spinal surgeons 26%, Rheumatologists 7%, Care of the Elderly Physicians 6% and General Practitioners 15%. This distribution is shown in fig 3.1.

The main points of interest were: (i) the relative importance of different methods of CSM severity assessment, (ii) the important qualities of a scale, iii) whether or not they considered a ‘gold standard’ scale to exist already, (iv) their actual use of scales in academic or clinical practice and (v) other criteria they actually used for assessment.

other 6% O rth o p a ed ic 26% R h eu m a to lo g ist 7% G P 15% N e u r o lo g ist 15% N e u r o su r g e o n 31%

Figure 3.1 Pie chart show ing the clinicians that responded to the questionnaire.

3.4 Results

R esponses to the questionnaire w ere received from 65% o f clin ician s (n = l 17).

3.4.1 C lo sed questioning m ost im portant criteria f o r assessm ent. ( Q uestion 2).

H istory and im aging w ere jo in tly the m ost frequently ind icated single m ost im portant criterion for determ ining C S M functional severity (fig. 3.2).

In addition to considering the m ost single im portant c riterio n , the overall index o f im portance o f the five param eters (history, ex am in atio n , im aging, quantitative m easurem ent or “ unknow n/ d o n ’t know ”), w as d eterm ined by req u estin g the clinicians to rank the param eters in order o f im portance, 4 being the m ost im p o rtan t and 0 the least. T he scores o f all the clinicians w ere then sum m ed fo r each p a ra m ete r and divided by the n u m ber o f clinicians to give a norm alised m easure w here, fo r ex am p le, a final result o f 4

w ould indicate it had been ranked top by each clinician. D ata analysed in this way revealed that q u antitative functional assessm ent and clinical ex am in atio n w ere ranked alm ost as im portant as history and im aging (fig. 3.3). In o th er w ords, w hile not as often ranked top, these m easures w ere often ranked 2"^ or 3"^^ rather than last. T hus, overall, no p aram eter stood out as being very im portant or very unim portant.

Single Best Means of functional Assessment

D on't k n ow H istory Q u a n tita tiv e fu n ctio n a l A s s e s s m e n t C lin ical E x a m in a tio n Im a g in g

F igure 3.2 C linical H istory and Im aging w ere both con sid ered the single m ost im portant criteria for assessing functional severity.

F urth er analysis revealed that in ter-speciality differen ces ex isted in attitudes regarding the relative im portance o f the different factors (question 1). In particular, G Ps w ere unsure about C SM assessm ent (fig. 3.4).

H i s t o r y C l i n i c a l