715561 - Cervical Spine Steroid Injections for Delay of Surgery for Cervical Spondylotic Myelopathy

Thursday, February 27, 2020

2:05 PM – 2:10 PM

Location: 208

Participants should be aware of the following financial/non-financial relationships:

Ryan Lee, MBA: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Mustfa K. Manzur, MPH, MS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Andre Samuel, MD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Steven McAnany, MD: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Sravisht Iyer, MD: Globus Medical (Individual(s) Involved: Self, Products/Services: None): Consulting/Speaking; Healthgrades (Individual(s) Involved: Self, Products/Services: None): Advisory Board; Innovasis (Individual(s) Involved: Self, Products/Services: Innovasis Ax ALIF cage): Research Funding (to institution)

Todd Albert, MD: American Orthopaedic Association (Individual(s) Involved: Self, Products/Services: Board: Treasurer): Board Member; ASIP (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Augmedics (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Biomerix (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; BIOMET (Now ZIMMER BIOMET) (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Bonovo Orthopedics, Inc. (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Crosstrees Medical (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; CytoDyn Inc. (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; DePuy Synthes Spine (Individual(s) Involved: Spouse/Partner, Products/Services: Royalty): Royalties from Intellectual Property; Elsevier, Inc. (Individual(s) Involved: Self, Products/Services: Authorship): Authorship; Gentis (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Innovative Surgical Designs, Inc. (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; InVivo Therapeutics (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Invuity (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; JP Medical Publishers (Individual(s) Involved: Self, Products/Services: Authorship): Authorship; Morphogenesis (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; NuVasive, Inc. (Individual(s) Involved: Self, Products/Services: Consulting): Consultant; Paradigm Spine, LLC (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Physician Recommended Nutriceuticals (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; PMIG (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Pulse Equity (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Scoliosis Research Society (SRS) (Individual(s) Involved: Self, Products/Services: Board member- Past President): Editorial board; Spinicity (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Springer (Individual(s) Involved: Self, Products/Services: Authorship): Authorship; Strathspey Crown (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Surg.IO LLC (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest; Thieme Medical Publishers (Individual(s) Involved: Self, Products/Services: Authorship): Authorship; United Health Group (Individual(s) Involved: Self, Products/Services: Advisory Board Membership): Advisory Board Membership; Vital 5 (Individual(s) Involved: Self, Products/Services: Stock): Ownership Interest

Avani S. Vaishnav, MBBS: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Catherine Himo Gang, MPH: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Sheeraz Qureshi, MD, MBA: AMOpportunities (Individual(s) Involved: Self, Products/Services: Honoraria): Honoraria; Avaz Surgical (Individual(s) Involved: Self, Products/Services: Ownership Interest): Ownership Interest; Globus Medical, Inc. (Individual(s) Involved: Self, Products/Services: Consulting & Speaker): Consulting & Speaker; Healthgrades (Individual(s) Involved: Self, Products/Services: Advisory Board): Advisory Board; LIfelink.com (Individual(s) Involved: Self, Products/Services: Advisory Board Member): Advisory Board Member; Minimally Invasive Spine Study Group (Individual(s) Involved: Self, Products/Services: Treasurer): Treasurer; Paradigm Spine, LLC (Individual(s) Involved: Self, Products/Services: Consultant): Consultant; RTI (Individual(s) Involved: Self, Products/Services: Consulting): Consulting; Spinal Simplicity, LLC (Individual(s) Involved: Self, Products/Services: Advisory Board Member): Advisory Board Member; Stryker/K2M (Individual(s) Involved: Self, Products/Services: Consulting, Royalties, Designer): Consulting, Royalties, Designer; Vital 5 (Individual(s) Involved: Self, Products/Services: Ownership Interest): Ownership Interest; Zimmer Biomet (Individual(s) Involved: Self, Products/Services: Consulting, Designer): Consulting, Designer

Introduction:
Cervical spine steroid injections are increasingly being used for diagnosis and treatment of degenerative pathology. For
cervical spondylotic myelopathy, traditionally treated with surgery, there has been little investigation of the possible
therapeutic or preventative effects of targeted injections. As injections may be targeted to the epidural space, the
transforaminal region, or the zygapophyseal joints, differing injection modalities may also have variable therapeutic
effects.

Methods:
All patients with a new diagnosis of cervical spondylotic myelopathy, without previous cervical spine surgery, were
identified in a large national private health insurance patient registry. Administration of cervical epidural, transforaminal, or
zygapophyseal steroid injections was determined based on Current Procedural Terminology (CPT) codes. Timing of
surgical treatment (cervical decompression, fusion, or arthroplasty, from anterior or posterior approaches) was also
determined based on CPT codes. Multivariate logistic regression was used to determine the association of steroid
injection administration with surgical treatment at various time points after initial diagnosis (1-, 3-, 6-months, 1-, 2-, 5-
years).

Results:
A total of 39,590 patients with a new diagnosis of cervical spondylotic myelopathy were identified. A total of 6,405
patients (16.2%) underwent cervical epidural steroid injections, 1,426 (3.6%) underwent transforaminal steroid injections,
and 647 (1.6%) underwent zygapophyseal injections. Mean time from initial diagnosis to surgery was 180.2 days
(standard deviation = 345.9 days). In multivariate analysis (Table 1) epidural injections were associated with a decreased
odds of surgery within 1 month of diagnosis (odds ratio [OR] = 0.69, P < 0.001), while transforaminal and zygapophyseal
injection were not associated with decreased odds of surgery. At long term follow up, epidural injections were associated
with slightly increased odds of surgery within 5 years of diagnosis (OR = 1.17, P = 0.019). Interestingly, transforaminal
and zygapophyseal injections were associated with increased odds of surgery at 6 months (zygapophyseal injections
only), 1-, 2-, and 5-years after diagnosis (P < 0.05).
DISCUSSION AND

Conclusion:
Epidural steroid injections do not prevent surgical treatment of cervical spondylotic myelopathy in the long run. There may
be some short-term symptomatic benefits that lead to delayed surgical treatment, although the clinical benefits have yet to
be demonstrated. No significant benefit is seen with transforaminal or zygapophyseal injections for treatment of cervical
myelopathy.

Presenting Author(s)

Mustfa K. Manzur, MPH, MS

Medical Student
Sidney Kimmel Medical College at Thomas Jefferson University

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Co-Author(s)

Ryan Lee, MBA

Research Fellow
Hospital for Special Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Andre Samuel, MD

Resident
Hospital for Special Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Steven McAnany, MD

Assistant Professor
Hospital for Special Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Sravisht Iyer, MD

Assistant Attending, Spine Surgery
Hospital for Special Surgery

Disclosure: Globus Medical : Consulting/Speaking (Status: Ongoing); Healthgrades : Advisory Board (Status: Ongoing); Innovasis : Research Funding (to institution) (Status: Ongoing)

Todd Albert, MD

Surgeon in Chief Emeritus
Hospital for Special Surgery

Disclosure: American Orthopaedic Association : Board Member (Status: Ongoing); ASIP : Ownership Interest (Status: Ongoing); Augmedics : Ownership Interest (Status: Ongoing); Biomerix : Ownership Interest (Status: Ongoing); BIOMET (Now ZIMMER BIOMET) : Ownership Interest (Status: Ongoing); Bonovo Orthopedics, Inc. : Ownership Interest (Status: Ongoing); Crosstrees Medical : Ownership Interest (Status: Ongoing); CytoDyn Inc. : Ownership Interest (Status: Ongoing); DePuy Synthes Spine (Spouse/Partner) : Royalties from Intellectual Property (Status: Ongoing); Elsevier, Inc. : Authorship (Status: Ongoing); Gentis : Ownership Interest (Status: Ongoing); Innovative Surgical Designs, Inc. : Ownership Interest (Status: Ongoing); InVivo Therapeutics : Ownership Interest (Status: Ongoing); Invuity : Ownership Interest (Status: Ongoing); JP Medical Publishers : Authorship (Status: Ongoing); Morphogenesis : Ownership Interest (Status: Ongoing); NuVasive, Inc. : Consultant (Status: Ongoing); Paradigm Spine, LLC : Ownership Interest (Status: Ongoing); Physician Recommended Nutriceuticals : Ownership Interest (Status: Ongoing); PMIG : Ownership Interest (Status: Ongoing); Pulse Equity : Ownership Interest (Status: Ongoing); Scoliosis Research Society (SRS) : Editorial board (Status: Ongoing); Spinicity : Ownership Interest (Status: Ongoing); Springer : Authorship (Status: Ongoing); Strathspey Crown : Ownership Interest (Status: Ongoing); Surg.IO LLC : Ownership Interest (Status: Ongoing); Thieme Medical Publishers : Authorship (Status: Ongoing); United Health Group : Advisory Board Membership (Status: Ongoing); Vital 5 : Ownership Interest (Status: Ongoing)

Avani S. Vaishnav, MBBS

Research Fellow
Hospital for Special Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Catherine Himo Gang, MPH

Senior Research Coordinator
Hospital for Special Surgery

Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.

Sheeraz Qureshi, MD, MBA

Associate Professor
Hospital for Special Surgery

Disclosure: AMOpportunities : Honoraria (Status: Ongoing); Avaz Surgical : Ownership Interest (Status: Ongoing); Globus Medical, Inc. : Consulting & Speaker (Status: Ongoing); Healthgrades : Advisory Board (Status: Ongoing); LIfelink.com : Advisory Board Member (Status: Ongoing); Minimally Invasive Spine Study Group : Treasurer (Status: Ongoing); Paradigm Spine, LLC : Consultant (Status: Ongoing); RTI : Consulting (Status: Ongoing); Spinal Simplicity, LLC : Advisory Board Member (Status: Ongoing); Stryker/K2M : Consulting, Royalties, Designer (Status: Ongoing); Vital 5 : Ownership Interest (Status: Ongoing); Zimmer Biomet : Consulting, Designer (Status: Ongoing)