Delayed Diagnosis of Cervical Spondylotic Myelopathy
Delayed Diagnosis of Cervical Spondylotic Myelopathy
One hundred forty-six patients had undergone an operation for degenerative CSM at our spine unit between January 2009 and December 2010. Complete (hospital and community) medical information and diagnostic workup were available for 42 of these patients, who composed the study population. The following results and conclusions pertain to this group of patients, which included 27 men and 15 women with a mean age of 52.5 ± 12.6 years (range 20–77 years).
The mean time to diagnosis of CSM from the first physician visit was 2.2 ± 2.3 years (range 1.7 months–8.9 years), during which patients had a mean of 5.2 ± 3.6 physician visits due to CSM-related complaints (Table 2).
The initial physician visit after symptom onset was to a family practitioner in 69% of cases and to an orthopedic surgeon in an additional 21.4%. Only 9.6% of first physician visits were to other disciplines such as the emergency department or to an internal medicine specialist. Of note, none of the patients were examined by a neurologist or a neurosurgeon at first.
On the second physician visit, patients were most commonly examined by an orthopedic surgeon (48.8%) or by a family practitioner (26.8%). This time, only 9.8% of patients were evaluated by a neurologist and 2.4% by neurosurgeons, whereas 12.2% of the patients were examined by practitioners from other specialties (for example emergency medicine physicians, ENT experts, urologists, and others).
On the third physician visit, patients were examined by orthopedic surgeons (38.5%), neurologists (25.6%), neurosurgeons (18%), or family practitioner (12.8%), as well as physicians from other disciplines (5.1%). Figure 1 summarizes the distribution of patient visits by physician specialty
(Enlarge Image)
Figure 1.
Bar graph showing distribution of patients by clinic visits and physician specialty.
The most common diagnoses given were carpal tunnel syndrome (43.1%) and cervical disc radiculopathy without neurological deficit (35.7%). Additionally, other nonspecific, generalized diagnoses (for example, cervicalgia, upper-limb pain, general medical examination, backache, and so on) were documented. The workup suggested for further evaluation of the patients generally included upper-limb EMG (83.7%), cervical spine CT (63.1%), and bone scan (35.8%). Of all cases examined, only a single orthopedic surgeon on a single patient's first visit referred the patient for a cervical spine MRI examination. Only 2 physicians (1 trainee in emergency medicine and 1 anesthesiologist working in a pain clinic) referred 2 additional patients for cervical spine MRI on their second visit.
When reviewing the total number of physician visits, 37.3% were to orthopedic surgeons, 30.9% were to family physicians, 16.4% were to neurologists, and only 8.2% were to neurosurgeons, with 7.2% to other disciplines. Conversely, the diagnosis of CSM was most frequently made by neurosurgeons (38.1%), followed by neurologists (28.6%), and far less commonly by orthopedic surgeons (19%), family physicians (4.8%), and other disciplines (9.5%). Figure 2 shows percentages for clinic visits and diagnosis reached in patients with CSM, categorized by physician specialty.
(Enlarge Image)
Figure 2.
Bar graph showing percentages for clinic visits of patients with CSM and for the diagnosis reached, categorized by physician specialty.
Uniformly, neurological examination performed by a family practitioner or a community-based orthopedic surgeon included only motor strength and light touch sensation, if performed at all. History taking directed at cervical myelopathic signs and symptoms, such as walking difficulties and hand clumsiness, was not documented in any of the visits other than the last, when the diagnosis was ultimately made. Similarly, only on that final visit was a neurological examination, oriented at CSM-like walking pattern, muscle tone, reflexes, and pathological reflexes, conducted.
On admission to surgery, myelomalacia was evident on the MRI studies of 40% of patients, and cervical myelopathy with a mean Nurick grade of 2.9 ± 0.53 was documented. The lag period from diagnosis to surgery averaged 2.1 ± 1.1 months.
At the time of diagnosis the most common symptoms were as follows: upper-limb paresthesia (85.7%), unbalanced gait (66.6%), upper-limb weakness (61.9%), neck pain (59.5%), lower-limb paresthesia (50%), lower-limb weakness (42.8%), impaired motor coordination (35.7%), and urinary incontinence (16.6%). Figure 3 shows patients' symptoms on admission for surgery.
(Enlarge Image)
Figure 3.
Bar graph showing patients' symptoms on admission for surgery.
Results
One hundred forty-six patients had undergone an operation for degenerative CSM at our spine unit between January 2009 and December 2010. Complete (hospital and community) medical information and diagnostic workup were available for 42 of these patients, who composed the study population. The following results and conclusions pertain to this group of patients, which included 27 men and 15 women with a mean age of 52.5 ± 12.6 years (range 20–77 years).
The mean time to diagnosis of CSM from the first physician visit was 2.2 ± 2.3 years (range 1.7 months–8.9 years), during which patients had a mean of 5.2 ± 3.6 physician visits due to CSM-related complaints (Table 2).
The initial physician visit after symptom onset was to a family practitioner in 69% of cases and to an orthopedic surgeon in an additional 21.4%. Only 9.6% of first physician visits were to other disciplines such as the emergency department or to an internal medicine specialist. Of note, none of the patients were examined by a neurologist or a neurosurgeon at first.
On the second physician visit, patients were most commonly examined by an orthopedic surgeon (48.8%) or by a family practitioner (26.8%). This time, only 9.8% of patients were evaluated by a neurologist and 2.4% by neurosurgeons, whereas 12.2% of the patients were examined by practitioners from other specialties (for example emergency medicine physicians, ENT experts, urologists, and others).
On the third physician visit, patients were examined by orthopedic surgeons (38.5%), neurologists (25.6%), neurosurgeons (18%), or family practitioner (12.8%), as well as physicians from other disciplines (5.1%). Figure 1 summarizes the distribution of patient visits by physician specialty
(Enlarge Image)
Figure 1.
Bar graph showing distribution of patients by clinic visits and physician specialty.
The most common diagnoses given were carpal tunnel syndrome (43.1%) and cervical disc radiculopathy without neurological deficit (35.7%). Additionally, other nonspecific, generalized diagnoses (for example, cervicalgia, upper-limb pain, general medical examination, backache, and so on) were documented. The workup suggested for further evaluation of the patients generally included upper-limb EMG (83.7%), cervical spine CT (63.1%), and bone scan (35.8%). Of all cases examined, only a single orthopedic surgeon on a single patient's first visit referred the patient for a cervical spine MRI examination. Only 2 physicians (1 trainee in emergency medicine and 1 anesthesiologist working in a pain clinic) referred 2 additional patients for cervical spine MRI on their second visit.
When reviewing the total number of physician visits, 37.3% were to orthopedic surgeons, 30.9% were to family physicians, 16.4% were to neurologists, and only 8.2% were to neurosurgeons, with 7.2% to other disciplines. Conversely, the diagnosis of CSM was most frequently made by neurosurgeons (38.1%), followed by neurologists (28.6%), and far less commonly by orthopedic surgeons (19%), family physicians (4.8%), and other disciplines (9.5%). Figure 2 shows percentages for clinic visits and diagnosis reached in patients with CSM, categorized by physician specialty.
(Enlarge Image)
Figure 2.
Bar graph showing percentages for clinic visits of patients with CSM and for the diagnosis reached, categorized by physician specialty.
Uniformly, neurological examination performed by a family practitioner or a community-based orthopedic surgeon included only motor strength and light touch sensation, if performed at all. History taking directed at cervical myelopathic signs and symptoms, such as walking difficulties and hand clumsiness, was not documented in any of the visits other than the last, when the diagnosis was ultimately made. Similarly, only on that final visit was a neurological examination, oriented at CSM-like walking pattern, muscle tone, reflexes, and pathological reflexes, conducted.
On admission to surgery, myelomalacia was evident on the MRI studies of 40% of patients, and cervical myelopathy with a mean Nurick grade of 2.9 ± 0.53 was documented. The lag period from diagnosis to surgery averaged 2.1 ± 1.1 months.
At the time of diagnosis the most common symptoms were as follows: upper-limb paresthesia (85.7%), unbalanced gait (66.6%), upper-limb weakness (61.9%), neck pain (59.5%), lower-limb paresthesia (50%), lower-limb weakness (42.8%), impaired motor coordination (35.7%), and urinary incontinence (16.6%). Figure 3 shows patients' symptoms on admission for surgery.
(Enlarge Image)
Figure 3.
Bar graph showing patients' symptoms on admission for surgery.
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