title: Prediction of Postoperative Clinical Recovery of Drop Foot Attributable to Lumbar Degenerative Diseases, via a Bayesian Network.
abstract: BACKGROUND
  Drop foot resulting from degenerative lumbar diseases can impair activities of daily living. Therefore, predictors of recovery of this symptom have been investigated using univariate or/and multivariate analyses. However, the conclusions have been somewhat controversial. Bayesian network models, which are graphic and intuitive to the clinician, may facilitate understanding of the prognosis of drop foot resulting from degenerative lumbar diseases.
  
  
  OBJECTIVE
  (1) To show a layered correlation among predictors of recovery from drop foot resulting from degenerative lumbar diseases; and (2) to develop support tools for clinical decisions to treat drop foot resulting from lumbar degenerative diseases.
  
  
  METHODS
  Between 1993 and 2013, we treated 141 patients with decompressive lumbar spine surgery who presented with drop foot attributable to degenerative diseases. Of those, 102 (72%) were included in this retrospective study because they had drop foot of recent development and had no diseases develop that affect evaluation of drop foot after surgery. Specifically, 28 (20%) patients could not be analyzed because their records were not available at a minimum of 2 years followup after surgery and 11 (8%) were lost owing to postoperative conditions that affect the muscle strength evaluation. Eight candidate variables were sex, age, herniated soft disc, duration of the neurologic injury (duration), preoperative tibialis anterior muscle strength (pretibialis anterior), leg pain, cauda equina syndrome, and number of involved levels. Manual muscle testing was used to assess the tibialis anterior muscle strength. Drop foot was defined as a tibialis anterior muscle strength score of less than 3 of 5 (5 = movement against gravity and full resistance, 4 = movement against gravity and moderate resistance, 3 = movement against gravity through full ROM, 3- = movement against gravity through partial ROM, 2 = movement with gravity eliminated through full ROM, 1 = slight contraction but no movement, and 0 = no contraction). The two outcomes of interest were postoperative tibialis anterior muscle strength (posttibialis anterior) of 3 or greater and posttibialis anterior strength of 4 or greater at 2 years after surgery. We developed two separate Bayesian network models with outcomes of interest for posttibialis anterior strength of 3 or greater and posttibialis anterior strength of 4 or greater. The two outcomes correspond to "good" and "excellent" results based on previous reports, respectively. Direct predictors are defined as variables that have the tail of the arrow connecting the outcome of interest, whereas indirect predictors are defined as variables that have the tail of the arrow connecting either direct predictors or other indirect predictors that have the tail of the arrow connecting direct predictors. Sevenfold cross validation and receiver-operating characteristic (ROC) curve analyses were performed to evaluate the accuracy and robustness of the Bayesian network models.
  
  
  RESULTS
  Both of our Bayesian network models showed that weaker muscle power before surgery (pretibialis anterior ≤ 1) and longer duration of neurologic injury before treatment (> 30 days) were associated with a decreased likelihood of return of function by 2 years. The models for posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater were the same in terms of the graphs, showing that the two direct predictors were pretibialis anterior muscle strength (score ≤ 1 or ≥ 2) and duration (≤ 30 days or > 30 days). Age, herniated soft disc, and leg pain were identified as indirect predictors. We developed a decision-support tool in which the clinician can enter pretibialis anterior muscle strength and duration, and from this obtain the probability estimates of posttibialis anterior muscle strength. The probability estimates of posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater were 94% and 85%, respectively, in the most-favorable conditions (pretibialis anterior ≥ 2; duration ≤ 30 days) and 18% and 14%, respectively, in the least-favorable conditions (pretibialis anterior ≤ 1; duration > 30 days). On the sevenfold cross validation, the area under the ROC curve yielded means of 0.78 (95% CI, 0.68-0.87) and 0.74 (95% CI, 0.64-0.84) for posttibialis anterior muscle strength of 3 or greater and posttibialis anterior muscle strength of 4 or greater, respectively.
  
  
  CONCLUSIONS
  The results of this study suggest that the clinician can understand intuitively the layered correlation among predictors by Bayesian network models. Based on the models, the decision-support tool successfully provided the probability estimates of posttibialis anterior muscle strength to treat drop foot attributable to lumbar degenerative diseases. These models were shown to be robust on the internal validation but should be externally validated in other populations.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan. show@yb3.so-net.ne.jp.|Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan. show@yb3.so-net.ne.jp.
authors.forename: Shota
authors.initials: S
authors.lastname: Takenaka
authors.affiliation: Orthopaedic Surgery, National Hospital Organization, Osaka Medical Center, 2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan.
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Aono
mesh_terms: D000203:Activities of Daily Living; D000328:Adult; D001499:Bayes Theorem; D001696:Biomechanical Phenomena; D003661:Decision Support Techniques; D019299:Decompression, Surgical; D005260:Female; D033023:Foot Joints / Q000503:physiopathology*; D020233:Gait Disorders, Neurologic / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D006801:Humans; D016015:Logistic Models; D008159:Lumbar Vertebrae / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009119:Muscle Contraction; D018482:Muscle, Skeletal / Q000503:physiopathology*; D019637:Orthopedic Procedures / Q000379:methods*; D018579:Patient Selection; D011237:Predictive Value of Tests; D016059:Range of Motion, Articular; D020127:Recovery of Function; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013122:Spinal Diseases / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome