Ιmpact of Neck and Arm Pain on Overall Health Status
Scott D. Daffner, MD, Alan S. Hilibrand, MD, Brett S. Hanscom, M.S., Brian T. Brislin, MD, Alexander R. Vaccaro, MD, Todd J. Albert, MD
Spine 28(17):2030-2035, 2003. © 2003 Lippincott Williams & Wilkins
Abstract and Introduction
Study Design: A prospective, multicenter, cross-sectional analysis of data from the National Spine Network database.
Objectives: To compare the relative impact of radicular and axial symptoms associated with disease of the cervical spine on general health as measured by the SF-36 Health Survey, and to compare the impact of these symptoms among patients of varying age and symptom duration.
Background: Degenerative disorders of the cervical spine can cause debilitating symptoms of neck and arm pain. Physicians generally treat radiculopathy more aggressively than axial neck pain alone, although it has never been shown that the presence of radiculopathy leads to a greater impairment of physical and mental function.
Materials and Methods: SF-36 Health Survey data were collected from all consenting patients seen within the National Spine Network. Patients with symptoms referable to the cervical spine (as per their physician) were included (n = 1,809). SF-36 scores for all eight scales (bodily pain (BP), vitality (VT), general health (GH), mental health (MH), physical function (PF), role physical (RP), role emotional (RE), and social function (SF), and two summary scales (Physical Component Summary [PCS] and Mental Component Summary [MCS]) were calculated. Age/gender normative scores were subtracted from the scale scores to produce a negative "impact" score, which reflected how far below normal health status these patients were. Patients were grouped according to location of symptoms (axial only, radicular only, or axial and radicular), age (younger than 40, 40 to 60, and older than 60 years), and symptom duration (acute: <6 wk; subacute: 6 wk-6 mo; and chronic: >6 mo). SF-36 scores were compared between all groups using analysis of variance and multiple comparisons with Bonferroni adjustment.
Results: Patients who presented with both axial and radicular symptoms had the lowest SF-36 scores relative to age and gender norms. These scores were significantly lower than those for patients with only axial or only radicular symptoms across all eight subscales (P < 0.05- P < 0.0001). Scores for patients with only axial pain were significantly lower than for patients with only radicular pain for VT (P < 0.04) and GH (P < 0.004). Patients younger than 40 and those between ages 40 to 60 years were significantly more impacted by their symptoms than patients older than 60 years for all eight scales (P < 0.01). PCS scores were similar for acute, subacute, and chronic groups, whereas MCS scores were significantly worse for patients with chronic pain.
Conclusions: Combined neck and arm pain were much more disabling than either symptom alone. Younger patients (younger than 40 or 40-60) were more affected by these symptoms than patients older than 60 years. In addition, as symptom duration increased, a negative impact on mental health was observed, although chronic symptoms did not affect physical health. This study suggests that patients with a significant component of axial pain in conjunction with cervical radiculopathy should be considered the most affected of all patients with cervical spondylosis. Given the evidence that the treatment methods at the disposal of physicians are effective, this study suggests that prompt treatment of these patients may help avoid the harmful effects of chronic symptoms on mental functioning, especially among younger patients who were found to be more impacted by the symptoms.
Degenerative conditions of the cervical spine can cause debilitating symptoms of neck and/or arm pain. The lifetime prevalence of neck pain has been estimated to be nearly 67%, with a point prevalence of 22%. Although the financial and social impacts of low back pain have received emphasis, the disability caused by neck and arm pain may also impose a substantial financial burden and a major impact on the lives of those affected. Few studies, however, have examined the impact of neck and/or arm pain on the overall functional and health status of patients. Disability associated with neck and arm pain may extend beyond the patient's obvious symptoms to affect overall health status. The degree to which overall health is impacted may be an important factor in determining which patients may benefit from more intensive nonoperative and operative treatment.
The Medical Outcomes Study Short Form 36 (SF-36) is a multipurpose health status survey with 36 questions used to assess eight subscales including: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH). Each subscale is scored from 0 to 100, with higher scores representing better function. In addition, the data may be grouped into two higher-order clusters of physical and mental health to demonstrate an overall impact on physical (physical component scale [PCS]) and mental (mental component scale [MCS]) functioning. It has been used in multiple studies assessing patients with numerous health problems, including spinal disorders, and has been demonstrated to be a reliable assessment of patients' overall health status.
Recently, health status outcomes data have been used to evaluate conditions of the cervical spine. Klein and colleagues successfully used preoperative and postoperative SF-36 scores to demonstrate the efficacy of anterior cervical discectomy and fusion in the treatment of cervical radiculopathy. Fanuele and colleagues used SF-36 scores to demonstrate that the PCS scores of patients with spinal disorders were significantly lower than those of the general United States population.
These previous studies have demonstrated the negative impact on health experienced by patients with spinal diagnoses. They do not, however, directly assess the impact of the symptoms (e.g., back pain or neck pain) with which the patients present. This is important, because most patients present to physicians with symptoms rather than a diagnosis, and it is on the basis of the severity of these symptoms that the intensity of an initial treatment regimen is based. For this reason, this study was designed to compare the differential impact of the symptoms associated with disorders of the cervical spine. We compared the differences in the impact of axial (neck) pain alone, radicular (arm) pain alone, and combined axial and radicular pain on overall health status and stratified the data on the basis of patient age and symptom chronicity to determine the differential impact of these symptoms on physical and mental health status in different population groups.
Materials and Methods
Prospective data were collected from all consenting patients evaluated at participating centers of the National Spinal Network (NSN) between 1998 and 2001. The NSN is a nonprofit organization of 28 academic institutions, hospitals, private physician practices, and individual physicians specializing in the treatment of spinal disorders and was founded on the premise of improving spinal care based on longitudinal assessment of patient outcomes. Patients agreeing to participate in the NSN data collection project were asked to complete a health assessment questionnaire before evaluation and treatment for their condition. Clinicians also completed an evaluation of the patient after their examination. The patient questionnaire included demographic information, symptomatic history, medication usage, the Oswestry Disability Index (ODI), and the SF-36 functional health status questionnaire.
The study group consisted of all patients with axial and/or radicular symptoms identified by their physician as referable to the cervical spine. The baseline (initial visit) SF-36 scores for all eight subscales (PF, RP, BP, GH, VT, SF, RE) and the two summary scales (PCS and MCS) were calculated. Age- and gender-matched normative scores for each patient were subtracted from the measured scores to derive an "impact" score, which demonstrated how far patients' health status was below that of people of similar age and gender (hence, a negative number) in the general population. The age-gender normative score was calculated for each individual patient based on values available in the SF-36 users manual, and the normative values were subtracted from the patient's scores. Because normative data were not available for the ODI, "impact" scores were not derived for these data.
The primary independent variable was the location of symptoms (axial only, radicular only, or axial and radicular). In addition, two secondary variables were also studied: age (younger than 40, 40-60, older than 60 years) and duration of symptoms (acute: less than 6 wk; subacute: 6 wk-6 mo; chronic: more than 6 mo). The SF-36 scores were compared between all groups using analysis of variance and multiple comparisons with Bonferroni adjustment.
A total of 1,809 patients completed questionnaires. The demographics of the patient population are summarized in Table 1. The average age of patients was 48.9 years (range 18-91), and 52.3% were female. Ninety-three patients (5.1%) presented with arm pain alone, 533 patients (29.5%) presented with neck pain only, and 1,183 patients (65.4%) reported both axial and radicular symptoms. Patients in this last group were asked to delineate the relative contribution of neck and arm pain; 380 (32%) reported 25% radicular and 75% axial pain, 429 (36%) reported 50% radicular and 50% axial pain, and 374 (32%) reported 75% radicular and 25% axial pain.
Symptom duration was reported as less than 6 weeks by 15.5% of patients, between 6 weeks and 6 months by 27.6%, and more than 6 months by 56.9% of patients. Most patients (57.5%) were between ages 40 and 60 years; 24.2% were younger than 40 and 18.3% were older than 60.
Patients who presented with combined axial and radicular symptoms had the lowest SF-36 scores, relative to age and gender norms (Table 2, Figure 1). These scores were significantly lower than those for the other symptom groups across seven of the eight scales (2-13 points lower; P = 0.049-P < 0.001; GH not significant). Scores for patients with only axial pain were significantly lower than for those patients with only radicular pain for GH (P < 0.013). Differences between the axial only and the radicular only groups were not significant for the other seven subscales.
Figure 1. SF-36 "impact" scores (score minus age-gender norm score) for patients listed by symptomatic report.
Overall, patients younger than 40 and between ages 40 and 60 were significantly more impacted (6-31 points) than patients older than 60 for all eight scales (P = 0.05-P < 0.001; Figure 2). Only scores for BP and RP were significantly different between patients younger than 40 and those between ages 40 and 60 among patients with radicular only or axial and radicular symptoms.
Figure 2. SF-36 "impact" scores for patients by age group.
The impact of axial pain alone did not significantly change with the duration of symptoms; however, for the patients with some degree of radicular pain, those with acute or subacute symptom duration were significantly more impacted than those with chronic symptoms for four of the subscales (VT, GH, MH, PF; P = 0.048-P < 0.001).
Summary scores for PCS and MCS are summarized in Table 3, Table 4. Overall, patients with acute, subacute, and chronic symptoms were similar in terms of overall physical health, as measured by the PCS summary score, but a longer duration of symptoms caused a greater negative impact on patients' mental health (Figure 3). Scores for MCS summary score were significantly worse for patients with chronic symptoms than for patients with acute symptoms (P < 0.001). Similarly, age seemed to have little effect on the overall PCS score, whereas MCS scores were significantly lower for patients younger than 40 and those between ages 40 and 60 compared with those older than 60 (P < 0.001). Patients with both axial and radicular symptoms demonstrated significantly more impact on the PCS score than those with either axial (P < 0.001) or radicular (P = 0.002) symptoms alone. Scores for MCS were significantly lower for those with combined axial and radicular symptoms than for those patients with only radicular symptoms (P = 0.004).
Figure 3. SF-36 "impact" scores for patients by duration of symptoms.
Scores for the ODI demonstrated a similar trend. The average score for patients with combined axial and radicular pain was 63.7, whereas those for patients with only axial symptoms and only radicular symptoms were 71.6 and 74.6, respectively (higher scores indicate less impairment of function). Again, the difference between patients with both axial and radicular symptoms and those with only axial or radicular symptoms alone was significant (P < 0.001 and P < 0.001, respectively), whereas the difference between the latter two groups was not significant (P = 0.562). Figure 4 compares raw scores for PCS, MCS, and ODI for the patients in this study.
Figure 4. Comparison of raw scores for PCS, MCS, and ODI for patients by symptomatic report.
Neck and back pain affect a large portion of the population and account for between $38 and $50 billion of spending annually. Low back pain is a leading cause of physician visits in this country (second only to the common cold), and it has been estimated that low back pain leads to 10% to 15% of missed work days per year. Fanuele et al. found that the presence of a spinal disorder significantly lowered patients' SF-36 scores and that these disorders had a similar impact on PCS score as several chronic conditions, including congestive heart failure, COPD, lupus, cancer, primary hip or knee arthroplasty, and glenohumeral degenerative joint disease. Although neck pain has received less attention in the scientific literature, it is often associated with similar pathophysiology and treatment as low back pain. Neck pain affects up to three-quarters of all people in their lifetime, and nearly one-quarter of the population at any given point in time.[1, 8, 9] Viikari-Junutura et al. reported a positive correlation between intensity of neck pain and difficulty during work, leisure time, and sleep. The authors also demonstrated a statistically significant relationship between these symptoms and the number of missed work days.
Furthermore, Abdu et al. recently reported that patients with cervical diagnoses also had significantly lower SF-36 PCS scores than the population at large and that the spinal diagnosis was the major driver of low PCS score. This study, however, did not examine the impact of the actual symptoms of neck and arm pain that accompany cervical spine disorders. In addition, Abdu et al. did not study the effect of these symptoms on patients of different ages, nor did they study the cumulative effect that these symptoms have over time.
The present study had three important findings. First, patients with combined axial and radicular symptoms had significantly lower SF-36 scores than those patients with either isolated axial or radicular pain. Secondly, patients of working age (i.e., younger than 60) were significantly more impacted by their symptoms than older patients across all eight subscales. Finally, we demonstrated that longer symptom duration was associated with a negative impact on mental health status.
There are a number of reasons why combined axial and radicular symptoms may have had a significantly greater impact on health status. These symptoms usually represent a combination of axial pain with neck motion and neurologic symptoms in the extremities (shooting pains, numbness, weakness, paresthesias). Axial pain alone is more common than radicular pain in the population at a low level of intensity and frequently responds to medications and minor modifications in activity.[12, 13] As a result, many patients are able to adapt to low-intensity symptoms. The addition of radicular symptoms may be associated with a greater degree of axial pain and may be more difficult to assimilate than for patients reporting neck pain alone. Surprisingly, in this study, patients with purely radicular symptoms were the least impaired by their symptoms. It is possible that some patients presenting with radiculopathy alone may have had a nonspinal problem, such as carpal tunnel syndrome, tennis elbow, or a peripheral neuropathy, and may have been less impaired by these symptoms than patients with cervical radiculopathy. In addition, the overall number of patients with arm pain alone was smaller than the other groups, making it more difficult to draw conclusions from the data.
Younger patients are generally healthier and more active; symptoms that impair activities have a much greater impact on a younger, healthier population who are more likely to care for children and/or have a job. In addition, younger patients have greater expectations of their physical capabilities than older individuals. It should be noted that age-gender norms are much lower for older patients, because the elderly have a variety of other medical problems that lower their overall health status. Treating younger patients more expeditiously may therefore be better than waiting for the benign natural history of these spinal disorders to take their course, especially among younger patients with neck and arm pain.
Most symptoms related to a spinal disorder improve over time. Lees and Turner found that over a prolonged course, few patients had progressively worse symptoms and that deterioration (pain or neurologic symptoms) was the exception rather than the rule. More recently, Gore et al. reported that of 205 patients followed-up for a minimum of 10 years, 79% of patients had a decrease in neck pain and 43% reported complete resolution of neck pain. Given this trend, we expected the PCS to improve over time with similar improvements in the MCS as patients adapted to their condition. However, we identified a significant decrease in MCS scores (i.e., greater impact on mental health), with chronic symptoms of neck and arm pain. The relationship between chronic spinal disorders and psychological problems (depression in particular) is well documented.[15, 16] Although we have no information regarding the permanency of these negative changes in MCS with chronic symptoms, these data suggest that successful resolution of these symptoms within 6 months (through nonoperative or operative means) may lead to better mental functioning in patients with cervical spine disease.
One goal of this study was to try to quantify the differential impact of neck and arm pain associated with degenerative changes of the cervical spine independent of diagnosis. In general, the most aggressive treatments should be selected for those patients who are most severely impacted by their symptoms. Typically, surgeons tend to be more aggressive with patients presenting with radicular symptoms, based on good results of surgery in the setting of cervical spondylosis.[17, 18] No objective evidence exists in the literature, however, to suggest that these patients are more affected by their symptoms than those with neck pain. Indeed, the results of this study suggest that patients with arm pain and neck pain may be the best candidates for more aggressive treatment, because their symptoms have the greatest negative impact on overall health status. This is not to imply that one should immediately treat these patients surgically, but rather that given the evidence of the efficacy of available treatment methods,[3, 18-21] one should be less inclined to wait for the "generally benign" natural history of the condition before intervening with a full course of nonoperative treatment, followed by surgery for appropriately refractory patients.[3, 22]
This study has several limitations. First, all of the data for this study come from the NSN database, indicating that patients visited designated spinal care centers and may have already initiated extensive treatment elsewhere. In addition, because this study has a large population, clinically insignificant differences may nevertheless be highly statistically significant. For example, the actual change in the MCS score between the acute (<6 wk) and chronic (>6 mo) groups was only 3.4 points, a change that may be clinically imperceptible. Yet, in our study, this change was statistically significant. Second, because this study's independent variable was the symptom (rather than the diagnosis), it is likely that a small number of the patients may not have had an underlying spinal disorder. Additionally, we did not separate patients based on the relative contribution of neck versus arm pain. For example, a patient with 90% neck pain may have spondylosis or disc degeneration without significant nerve root compression, whereas 90% arm pain is more suggestive of a herniated disc or root impingement. Both patients would be considered to have axial and radicular pain for the purposes of this study.
This study demonstrates that cervical disc disease is most disabling when it is associated with axial (neck) and radicular (arm) pain. Among all age groups, younger patients were significantly more affected than older patients, relative to age-matched controls. In addition, this study demonstrated that chronic symptoms lasting more than 6 months had a negative impact on overall mental health, which was significantly greater than for patients with symptom duration of less than 6 months. Based on the results of this study, we believe the best candidates for aggressive nonoperative or operative treatment of symptomatic cervical spondylosis are younger patients with a significant component of neck and arm pain. Although the benign natural history of symptomatic cervical spondylosis (when not associated with myelopathy) would argue against early surgical intervention,[12, 21] the results of this study also suggest that patients with neck and arm pain should be treated relatively expeditiously to avoid the further negative impact on mental health status observed among patients with symptom duration of more than 6 months.
Table 1. Demographics of patients studied (n = 1,809)
Table 2. SF-36 "impact" scores (score minus age-gender normative score) for patients listed by symptomatic complaint for all eight subscales and comparative p values. (ns = not significant)
Table 3. Mean PCS and MCS summary scores for patients, stratified by symptom, age, and duration. (PCS = physical component summary, MCS = mental component summary, A = axial only, R = radicular only, A + R = axial and radicular combined)
Table 4. Comparative P values for PCS and MCS scores (ns = not significant)
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Sidebar: Key Points
Patients with combined axial and radicular symptoms have lower overall health status than those with either axial or radicular symptoms alone.
Younger patients are more impacted by neck and arm pain than are older patients.
As duration of symptoms increases, mental health status is affected, but physical health status remains unchanged.
Data from the National Spinal Network database were analyzed comparing the relative impact of radicular and axial symptoms associated with disease of the cervical spine on general health as measured by the SF-36 Health Survey. Patients with combined axial and radicular symptoms had the lowest SF-36 scores; younger patients and those with more acute duration of symptoms were also more affected.
Scott D. Daffner, MD*; Alan S. Hilibrand, MD*†; Brett S. Hanscom, M.S.‡; Brian T. Brislin, MD*; Alexander R. Vaccaro, MD*†; Todd J. Albert, MD*†
*Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA; †The Rothman Institute, Philadelphia, PA; and ‡Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH