The Association of Race, Rurality, and Neighborhood Disadvantage With Disease Severity at Initial Presentation in Cervical Spondylotic Myelopathy: A Cohort Study

Abstract

Study design: Retrospective Cohort Study.

Objectives: To examine the impact of neighborhood-level socioeconomic factors on the delay of care and severity of disease among degenerative cervical myelopathy (DCM) patients at initial presentation.

Summary of background data: DCM is the most common etiology for spinal cord dysfunction among adults worldwide. Previous literature has suggested that social determinants of health, including neighborhood-level socioeconomic status such as the Area of Deprivation Index (ADI), may impact spine surgery outcomes in DCM.

Materials and methods: We performed a single-institution retrospective analysis of all patients undergoing spine surgery for the treatment of DCM from 2010 to 2022. Patients were identified using CPT and ICD9/10 codes. Data was collected via a review of the electronic medical record. ADI was extracted from patients' addresses. Multivariate and univariate analysis was used to assess the relationship between socioeconomic variables and myelopathy characteristics.

Results: A total of 490 patients (mean age: 60.3±11.3 yr) were identified. Residence in rural areas was associated with a higher Nurick score [odds ratio (OR)=2.48, P =0.011], and lower modified Japanese Orthopedic Association Scale (mJOA) score (OR=2.51, P =0.014) at presentation, and longer times to presentation [hazard ratio (HR)=0.48, P =0.003]. Having high ADI was independently associated with shorter times to presentation (HR=1.46, P <0.001), but predicted a higher Nurick score (OR=1.6, P =0.021) and lower mJOA score (OR=1.86, P =0.002). Unemployment was associated with longer times to presentation (HR=0.66, P <0.001), higher Nurick score (OR=4.5, P <0.001), and lower mJOA score (OR=4.51, P <0.001), while race was not.

Conclusions: This is the first single institution study investigating the influence of neighborhood-level measures such as ADI on presentation status and disease burden in patients with DCM. High ADI predicts shorter disease duration but more severe DCM symptoms. Rural residence, unemployment, and nonprivate insurance were independently associated with prolonged and more severe DCM symptoms while race was not.

Level of evidence: Level 3.

Keywords: area deprivation; degenerative cervical myelopathy; disease burden; health disparities; neighborhood socioeconomic deprivation; outcomes; readmissions; social determinants of health; socioeconomic status.