Cervical spondylotic myelopathy (CSM) is a

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1 WScJ 4: 1-5, 2013 Functional Evaluation Using the Modified Japanese Orthopedic Association Score (mjoa) for Cervical Spondylotic Myelopathy by Age, Gender, and Type of Disease Parisa Azimi 1*, Sohrab Shahzadi 1, Edward C Benzel 2, Ali Montazari 3 1 Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2 Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA 3 Mental Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran Abstract AIM: This study aimed to evaluate functionality in patients diagnosed with Cervical spondylotic myelopathy (CSM) disorders using the modified Japanese Orthopedic Association score (mjoa). Material and Methods: A sample of patients with CSM who were a candidate for decompressive surgery entered into this cross-sectional study. The mjoa scores were obtained for the functional assessment of patients. In addition to descriptive statistics, the data were compared among study subgroups as categorized by age, gender and type of disease. Results: Sixty-three patients were entered into the study. The mean age of the patients was 54 ± 8.3 years; ranging from 21 to 79. All patients were diagnosed as having a cervical herniated disc (n = 36) or cervical spinal stenosis (n = 27). Overall, the mean mjoa score for all patients was 9.82 (SD = 1.0). The mjoa score for men was significantly higher than for women (P < ). The mjoa score in younger patients was significantly higher than in older patients (P < ). No significant difference was observed for type of disease (P = 0.47). Conclusions: The findings suggest that the functionality score as measured by the mjoa might be a useful parameter for helping clinicians manage patients with CSM prior to surgery. Key words: Cervical spondylotic myelopathy, JOA score, Outcome Background Cervical spondylotic myelopathy (CSM) is a progressive degenerative disease of the cervical spine as it is usually a chronic and progressive disease. As people grow older, the prevalence of CSM increases (4). Since the disease impairs patients functionality and induces suffering and pain, studying functionality and pain in these patients is considered a very important issue both for the patients and the clinicians concerns. Patients are worried for their daily living conditions and clinicians are concerned with the fact that they want to offer patients a better management plan and provide optimal care. It has been suggested that indicating the extent to which a patient is functional is essential to reduce patients burdens and have a better profile of patients. In addition, indicating the subgroup of patients for whom a different management might be needed is of prime importance. There are several instruments for measuring the performance status or functionality in patients with chronic diseases including patients who are suffering 1

2 Functional Evaluation of CSM Patients from cancer or musculoskeletal diseases. For instance, oncologists usually use the Karnofsky performance status (KPS) in cancer patients, while clinicians prefer to use functionality scales in patients who are suffering from pain due to cervical disorders in order to have a better understanding of patient management. As such, the modified Japanese Orthopedic Association score (mjoa) is among one of the well-known instruments for measuring functionality in patients with spinal diseases. However, the main question is whether we need to consider age, gender and type of the disease when using the mjoa or whether the mjoa score could be judged to make appropriate informed clinical decisions regardless of these independent variables. Thus, the aim of this study was to evaluate functionality in patients diagnosed with CSM diseases and to compare patients subgroups by age, gender, and type of disease. Methods Patients and data collection This study included 63 consecutive patients (35 females and 28 males) who were referred to a teaching hospital for surgical treatment of CSM between April 2007 and April The diagnosis of CSM was made based on clinical symptoms, neurological examinations, and imaging including plain radiography, computed tomography (CT) and magnetic resonance imaging (MRI) of the cervical and spine. All patients had the typical symptoms of CSM. The stenotic level(s) were localized on the MRI or CT images. There were no restrictions on patient selection with regard to types of CSM, age or other characteristics. Patients with diagnosis of cervical tumor, cervical syrinx, cervical fracture and spinal anomalies were excluded. The study measure The modified Japanese Orthopedic Association score (mjoa) was used to measure functionality. It is a selfadministered, disease-specific tool created on the basis of the Japanese Orthopedic Association score. It consists of 4 sections including 20 items: Motor dysfunction score of the upper extremities (6 items), Motor dysfunction score of the lower extremities (8 items), Sensation (4 items), and Sphincter dysfunction (4 items). The score for each section ranges from 0 to 5, 0 to 7, 0 to 3, and 0 to 3 respectively, giving a total score ranging from 0 to 18. The higher score denotes absence of any motor, sensory or sphincter dysfunction (1,2). Additional measures The Nurick classification was used to evaluate neurological functioning. It is a five-point scale ranging from Grade 0 (root symptoms only) to Grade 5 (wheelchairdependency) (9). The characteristics of patients including age, gender and body weight, and symptoms duration (in months) were also recorded. Statistical analysis All statistical analyses were performed using the PASW Statistics 18 Version 18 (SPSS, Inc., 2009, Chicago, IL, USA). The t-test was used for comparison. P < 0.05 was considered statistically significant. Ethics The Ethics Committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran, approved the study. All patients gave their informed consent after receiving both written and oral information about the project. Results The characteristics of patients The characteristics of the CSM patients are shown in Table 1. Sixty-three patients were eligible to enter into the study during the four-year course of study. The mean age of the patients was 54 ± 8.3 (21 to 79 years). All patients were diagnosed as having cervical herniated disc (n = 36) or cervical spinal stenosis (n = 27). All patients had received conservative treatment at different medical centers prior to surgery. Assessment of patients neurological functions using the Nurick classification immediately prior to surgery revealed that 12 of the 63 patients were Grade 0, 36 were Grade 1, and 15 were Grade 2. The mjoa score As shown in Table 1 the mean mjoa score of patients was 9.8 (SD = 1.0). The mean score for the four sections of mjoa (the upper extremities, motor dysfunction score of the lower extremities, sensation, sphincter dysfunction) ranged from 1.23 (SD = 0.90) to 3.34 (SD = 1.1). The mean mjoa score for men was significantly higher than for women (P< ). There was also a significant difference between older and younger patients (P< ). No significant difference was observed for type of disease. The results are shown in Table 2 to 4. 2

3 P Azimi et al. Table 1: The characteristics of the study sample (n = 63) Age groups (Year) Gender Weight (kg) Duration of symptoms (months) mjoa score (mean, SD) Type of Disease Nurick classification Number Percentage Mean (SD) 54 (8.3) Range 21 to 79 Male Female Mean (SD) 84.4 (10.8) Mean (SD) 24.4 (22.6) Motor dysfunction of the upper extremities 3.34 (1.1) Motor dysfunction of the lower extremities 3.15 (1.3) Sensation 1.23 (0.9) Sphincter dysfunction 2.10 (0.6) Total 9.82 (1.0) Cervical herniated disc Cervical spinal stenosis Grade Grade Grade Table 2: The mjoa score by gender Male (n = 28) Female (n = 35) Mean (SD) Mean (SD) P Motor dysfunction score of the upper extremities 3.81 (1.0) 2.87 (1.2) < Motor dysfunction score of the lower extremities 3.62 (1.1) 2.69 (1.4) < Sensation 1.50 (0.6) 0.95 (1.2) < Sphincter dysfunction 2.63 (0.2) 1.56 (1.1) < Total (0.9) 8.07 (1.2) <

4 Functional Evaluation of CSM Patients Table 3: The mjoa score by age <50 (n = 20) (n = 25) >62 (n = 19) Mean (SD) Mean (SD) Mean (SD) P Motor dysfunction score of the upper extremities 4.25 (1.0) 3.32 (1.3) 2.94 (1.3) < Motor dysfunction score of the lower extremities 4.06 (1.1) 2.95 (1.5) 2.16 (1.5) < Sensation 1.80 (0.6) 0.98 (1.2) 0.70 (1.2) < Sphincter dysfunction 2.79 (0.2) 2.0 (1.1) 1.50 (1.1) < Total (1.2) 9.25 (1.6) 7.3 (1.4) < Table 4: The mjoa score by type of disease Cervical herniated disc (n = 36) Cervical spinal stenosis (n = 27) Mean (SD) Mean (SD) P Motor dysfunction score of the upper extremities 3.49 (1.1) 3.24 (1.1) 0.35 Motor dysfunction score of the lower extremities 3.25 (1.3) 2.95 (1.3) 0.43 Sensation 1.23 (0.9) 1.22 (0.9) 0.77 Sphincter dysfunction 2.15 (0.6) 2.11 (0.6) 0.31 Total (1.0) 9.52 (1.0) 0.47 Discussion The findings from this study suggest that a statistically significant difference exists between functionality score in CSM patients by age and gender but not for type of disease. It seems that using such a indicator in clinical practice might be a helpful tool for measuring functionality and decision-making instead of measuring walking time and number of steps taken over 30 meters (11), evaluating gait function (7,12), evaluating increased signal intensity (ISI) seen on T2-weighted MRI (5), or using the foot tapping test (FTT) (8). A multicenter study reported a baseline mjoa preoperative score and classified CSM severity as mild (mjoa score 15), moderate (12 14), or severe (<12) (4). Accordingly, and as the mean mjoa score for our patients was 9.82, we conclude that they had severe dysfunction and they underwent surgery. In fact this indicates that those patients who might be classified as having severe dysfunction should receive surgery. Williams et al. (13) have reported a mean mjoa score of 9.67 (SD=3.05) for functionality, which was similar to the results in the current investigation [9.82 (SD=1.0)]. We did not find any other studies to report on preoperative functional evaluation of the CSM patients. However, these results suggested that the mjoa is quite a simple and easy instrument to be completed for CSM patients at clinical practice at the patients first visits. Evidence suggests that women usually suffer more from pain especially from musculoskeletal pain (10). Similarly we found that there were significant differences between men and women in motor, sensory and sphincter dysfunction and the mjoa discriminated well between male and female patients as expected. The mean preoperative mjoa scores in the younger group were higher than the mjoa scores for the elderly group. These are consistent with the findings from study by Edwards (3). In addition, the mjoa scores did not differ for type of disease. There were some limitations inherent to this study. Functionality was assessed at one point in time. A multipoint assessment is needed for further study. In addition we think there would have been other measures while we did not use such instruments. Future studies might use the Cooper Myelopathy Scale (CMS), the Prolo score, the Japanese Orthopaedic Association Cervical 4

5 P Azimi et al. Myelopathy Evaluation Questionnaire (JOACMEQ), or the European Myelopathy Score (EMS). To the authors best knowledge, no evidence-based guidelines exist for the assessment of these patients. However, we believe that these fundamental data assessed by the mjoa in patients diagnosed with CSM are important for patients improved management and care. Conclusion The findings suggest that a statistically significant difference exists between age subgroups, and male and female CSM patients in terms of preoperative functional status. It seems that functionality score as measured by the mjoa might be a useful parameter for helping clinicians to manage patients with cervical spondylotic myelopathy prior to surgery. Competing interests The authors declare that they have no competing interests. Acknowledgment The authors thank the staff of the Neurosurgery Unit at Imam-Hossain Hospital, Tehran, Iran. REFERENCES 1. Azimi P, Shahzadi S, Benzel EC, Montazari A: Measuring motor, sensory and sphincter dysfunctions in patients with cervical myelopathy using the modified Japanese Orthopedic Association (mjoa) score: a validation study. World Spinal Column Journal [In press]. 2. Benzel EC, Lancon J, Kesterson L, Hadden T: Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. J Spinal Disord 4: , Edwards RR: Age differences in the correlates of physical functioning in patients with chronic pain. J Aging Health 18: 56-69, Fehlings MG, Smith JS, Kopjar B, Arnold PM, Yoon ST, Vaccaro AR, Brodke DS, Janssen ME, Chapman JR, Sasso RC, Woodard EJ, Banco RJ, Massicotte EM, Dekutoski MB, Gokaslan ZL, Bono CM, Shaffrey CI: Perioperative and delayed complications associated with the surgical treatment of cervical spondylotic myelopathy based on 302 patients from the AOSpine North America Cervical Spondylotic Myelopathy Study. J Neurosurg Spine 16: , Kim CR, Yoo JY, Lee SH, Lee DH, Rhim SC: Gait analysis for evaluating the relationship between increased signal intensity on t2-weighted magnetic resonance imaging and gait function in cervical spondylotic myelopathy. Arch Phys Med Rehabil 91: , Klineberg E: Cervical spondylotic myelopathy: a review of the evidence. Orthop Clin North Am. 41: , Kuhtz-Buschbeck JP, Johnk K, Mader S, Stolze H, Mehdorn M: Analysis of gait in cervical myelopathy. Gait Posture 9: 184-9, Numasawa T, Ono A, Wada K, Yamasaki Y, Yokoyama T, Aburakawa S, Takeuchi K, Kumagai G, Kudo H, Umeda T, Nakaji S, Toh S: Simple foot tapping test as a quantitative objective assessment of cervical myelopathy. Spine 37:108-13, Nurick S: The pathogenesis of the spinal cord disorder associates with cervicalspondylosis. Brain 95: , Ruau D, Liu LY, Clark JD, Angst MS, Butte AJ: Sex differences in reported pain across 11,000 patients captured in electronic medical records. J Pain 13: , Singh A, Crockard HA: Quantitative assessment of cervical spondylotic myelopathy by a simple walking test. Lancet 354: 370-3, Suzuki E, Nakamura H, Konishi S, Yamano Y: Analysis of the spastic gait caused by cervical compression myelopathy. J Spinal Disord Tech 15: , Williams KE, Paul R, Dewan Y: Functional outcome of corpectomy in cervical spondylotic myelopathy. Indian J Orthop 43: 205-9, Manuscript submitted December 3, Accepted December 12, Address correspondence to: Parisa Azimi, Department of Neurosurgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran Phone: parisa.azimi@gmail.com 5

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