C3-6 laminoplasty takes over C3-7 laminoplasty with significantly lower incidence of axial neck pain

The Effect of a Cervical Brace on Postoperative Axial Symptoms Following Single-level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

This study aims to investigate the effect of cervical brace utilization on postoperative axial symptoms in patients undergoing single-segment anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Anterior cervical discectomy and fusion (ACDF) is the most commonly used surgical method in the treatment of cervical spondylosis. For patients with single-segment ACDF. The absence of a neck brace after surgery is safe and does not affect the outcome of surgery. However, the effect on the incidence of AS is unclear.

METHODS

Patients who underwent anterior cervical single-segment ACDF between May 2020 and August 2021 were retrospectively analyzed. Participants were divided into brace group and nonbraced groups. The incidence of axial symptoms, cervical mobility, and postoperative quality of life were then compared between the 2 groups.

RESULTS

A total of 121 patients were included in this study: 62 in the brace group and 59 in the nonbraced group. There were no statistically significant variations observed in the overall demographic characteristics, including age, sex, body mass index, smoking status, and disease duration. The study findings showed that there was a significant decrease in the occurrence of axial symptoms among patients in nonbraced group, in addition to a considerable increase in cervical mobility 1 month following the surgery.

CONCLUSIONS

The omission of a cervical brace following surgery in patients undergoing single-segment ACDF reduced the incidence of early postoperative axial symptoms, improved their overall quality of life, and facilitated the recovery of postoperative cervical mobility.

A stacking ensemble machine learning model for predicting postoperative axial pain intensity in patients with degenerative cervical myelopathy

Machine learning (ML) has been extensively utilized to predict complications associated with various diseases. This study aimed to develop ML-based classifiers employing a stacking ensemble strategy to forecast the intensity of postoperative axial pain (PAP) in patients diagnosed with degenerative cervical myelopathy (DCM). A total of 711 consecutive postoperative DCM patients were included between 2016 and 2024, and after excluding patients who did not meet the inclusion criteria and those who met the exclusion criteria, a total of 484 patients were ultimately included in this study. The intensity of PAP was assessed using a standardized Numerical Rating Scale (NRS) score one year following surgery. Participants were randomly allocated into training and testing sub-datasets in a ratio of 8:2. 91 initial ML classifiers were developed, from which the top three highest-performing classifiers were subsequently integrated into an ensemble model utilizing 13 different machine learning models. The area under the curve (AUC) served as the primary metric for evaluating the predictive performance of all classifiers. The classifiers EmbeddingLR-RF (AUC = 0.81), EmbeddingRF-MLP (AUC = 0.81), and RFE-SVM (AUC = 0.80) were recognized as the leading three models. By implementing an ensemble learning approach such as stacking, an enhancement in performance for the ML classifier was observed after amalgamating these three models, with SVM ensemble classifier performed the best (AUC = 0.91). Decision curve analysis underscored the advantages conferred by these ensemble classifiers; notably, prediction curves for PAP intensity among DCM patients exhibited significant variability across the top three initial classifiers. The ensemble classifiers effectively predicted PAP intensity in DCM patients, showcasing substantial potential to aid clinicians in managing DCM cases while optimizing medical resource utilization.

Risk factors for residual neuropathic pain using specific screening tools in postoperative patients with ossification of the posterior longitudinal ligament of the cervical spine

PURPOSE

Ageing, long illness duration, and poor preoperative Japanese Orthopaedic Association (JOA) score were reported to be risk factors for residual pain after cervical ossification of the posterior longitudinal ligament (cOPLL). In this study, we focused on residual neuropathic pain (NeP) and aimed to elucidate risk factors for residual NeP after cOPLL.

METHODS

Total of 234 patients who underwent cOPLL surgery were included. NeP was evaluated using painDETECT (PDQ) and Spine painDETECT (SPDQ) questionnaires. Score of ≥ 13 / ≥ 0 was defined as NeP for PDQ/SPDQ. Patient backgrounds factors, preoperative radiographic factors and surgical factors were reviewed, and comparisons between the NeP(+) and NeP(-) groups were made. Independent risk factors for residual NeP were evaluated using multiple logistic regression analysis.

RESULTS

Prevalence of residual NeP after cOPLL was 22.6% on PDQ and 55.1% on SPDQ. Preoperative JOA score was significantly lower in the NeP(+) group for PDQ compared with that in the NeP(-) group. Additionally, cervical lordosis angle was significantly lower in the NeP(+) group for SPDQ compared with that in the NeP(-) group. Following multiple logistic regression analysis, poor preoperative JOA score was identified as a risk factor for NeP on the PDQ. Poor preoperative JOA score and low cervical lordosis angle were identified as risk factors using the SPDQ.

CONCLUSIONS

We found high prevalence of residual NeP after cOPLL. Patients with a poor preoperative JOA score and low cervical lordosis angle might be at risk for residual NeP after surgery evaluated by PDQ or SPDQ and should be monitored with greater care after surgery.

Safety and Efficacy of Combined Imbrication Axle Reconstruction and Z-Type Titanium Plate Fixation for Hinge Fracture Displacement During Open-Door Laminoplasty

BACKGROUND

 Open-door laminoplasty is a classical decompression method used to treat cervical spondylotic myelopathy. However, hinge fracture displacement (HFD) is a common occurrence during this procedure. The current study aimed to investigate the safety and efficacy of a combined imbrication axle reconstruction and Z-type titanium plate fixation method for HFD during open-door laminoplasty.

METHODS

 In total, 617 patients with cervical spondylotic myelopathy who underwent C3-C7 open-door laminoplasty from March 2015 to October 2018 were included in this retrospective study. Overall, 73 patients developed HFD during surgery. Of these, 43 underwent combined imbrication axle reconstruction and Z-type titanium plate fixation (IRZF group) and 30 underwent traditional titanium plate fixation (TF group). Data such as the operative time, intraoperative blood loss volume, and distribution of fractured hinges were recorded. Both groups were compared in terms of improvement in neurologic function, cervical curvature index, hinge fusion rate, incidence of C5 palsy, severity of axial symptoms, and development of complications.

RESULTS

 The operative time and intraoperative blood loss were slightly higher in the IRZF group than in the TF group; however, the differences were not significant (p > 0.05). Furthermore, there was no significant difference between the groups in terms of the number of fractured segments and the distribution of fractured hinges (p > 0.05). The cervical curvature index did not decline in the two groups (p > 0.05). The IRZF group had a higher hinge fusion rate than the TF group at 3 (79.6 vs. 57.1%) and 12 (93.9 vs. 74.3%) months postoperatively (p < 0.05). There was no significant difference in the incidence of C5 palsy between the two groups (9.3 vs. 6.7%; p > 0.05). However, the TF group had more severe axial symptoms than the IRZF group (p < 0.05). The neurologic function of the two groups increased postoperatively as per the Japanese Orthopaedic Association scoring system (p < 0.05). Nevertheless, there was no significant difference in terms of neurologic function at any observational time point (p > 0.05). One patient in the TF group with hinge nonunion underwent laminectomy due to lamina displacement into the spinal canal and nerve root compression.

CONCLUSION

 In patients with HFD, IRZF facilitates a more intimate contact between the lamina and the lateral mass and, therefore, achieves fractured hinge fusion without additional surgical trauma. This technical improvement can significantly promote neurologic recovery, decrease the severity of axial symptoms, and prevent the development of spinal cord or nerve root recompression.

Alternate levels versus all levels mini-plate fixation in C3-6 cervical laminoplasty: a retrospective comparative study

OBJECTIVE

The purpose of this study is to compare radiological and clinical outcomes between alternate levels (C4 and C6) and all levels mini-plate fixation in C3-6 unilateral open-door laminoplasty.

METHODS

Ninety-six patients who underwent C3-6 unilateral open-door laminoplasty with alternate levels mini-plate fixation (54 patients in group A) or all levels mini-plate fixation (42 patients in group B) between September 2014 and September 2019 were reviewed in this study. Radiologic and clinical outcomes were assessed. Clinical results included Visual Analogue Scale (VAS) of axial neck pain and Japanese Orthopedic Association (JOA) score. Radiographic results included cervical range of motion (ROM), cervical curvature index (CCI), and the spinal canal expansive parameters including open angle, anteroposterior diameter (APD), and Pavlov`s ratio.

RESULTS

There was no significant difference in VAS, JOA score, ROM, and CCI between two groups. There was no significant difference in canal expansion postoperatively between two groups. However, open angle, APD, and Pavlov`s ratio in group A decreased significantly during the follow-up. In group B, APD, Pavlov`s ratio, and open angle were maintained until the final follow-up. There was no hardware failure or lamina reclosure occurred in both groups during the follow-up. The mean cost of group B was higher than that of group A.

CONCLUSIONS

Despite the differences in the maintenance of canal expansion, alternate levels mini-plate fixation can achieve similar clinical outcomes as all levels mini-plate fixation in C3-6 unilateral open-door laminoplasty. As evidenced in this study, we believe C3-6 laminoplasty with alternate levels (C4 and C6) mini-plate fixation is an economical, effective, and safe treatment method.

Effectiveness of additional C2 decompression of the cervical spinal canal after cervical laminoplasty: a retrospective cohort study

PURPOSE

This study aimed to assess the effects of additional C2 decompression of the cervical spinal canal on the postoperative outcomes after cervical laminoplasty in patients with cervical stenosis caused by ossification of the posterior longitudinal ligament (OPLL).

MATERIALS AND METHODS

This retrospective cohort study included patients with cervical stenosis due to OPLL and treated between April 2014 and December 2015. The patients who underwent C2-7 (additional C2 decompression) and C3-7 posterior decompression were compared using the Japanese Orthopedic Association (JOA) scores, visual analog scale (VAS) scores, axial symptom scores, and intervals between the posterior margin of the vertebral body and the K-line.

RESULTS

There were 36 and 24 patients in the additional C2 decompression and control groups, respectively. The JOA scores were higher in the additional C2 decompression group than the controls at 1 and 3 years (p < 0.05). Upper extremity motor function after the operation and at 1 and 3 years and lower extremity motor function after operation were improved in the additional C2 decompression group (all p < 0.05 vs. controls). VAS scores were lower in the additional C2 decompression group than controls at 1 year (p < 0.05). Axial symptom scores in the additional C2 decompression group were decreased postoperatively but increased at 1 and 3 years (p < 0.05 vs. controls). Finally, the posterior shift of the K-line in the additional C2 decompression group was significant (from 0.98 to 1.68 cm, p < 0.05).

CONCLUSIONS

Additional C2 decompression might improve the effectiveness of cervical laminoplasty in patients with cervical stenosis caused by OPLL.

Comparative effectiveness and functional outcome of C3 & C7 dome-hybrid open-door laminoplasty with traditional unilateral open-door laminoplasty for cervical spondylotic myelopathy

OBJECTIVE

The C3 & C7 dome-hybrid open-door laminoplasty was proven to be an effective treatment for multi-levels cervical spondylotic myelopathy (CSM). However, its superiority over traditional unilateral open-door laminoplasty (UOLP) remains questionable, and no studies have compared the efficacy of this technique with traditional UOLP. This study aimed to compare the effectiveness of C3 & C7 dome-hybrid open-door laminoplasty with traditional UOLP in treating multi-levels CSM.

METHODS

A retrospective study of multi-levels CSM with laminoplasty was performed, including 35 cases of traditional UOLP and 27 cases of C3 & C7 dome-hybrid open-door laminoplasty. Radiographic evaluation parameters and clinical outcomes were recorded to evaluate the surgical effectiveness.

RESULTS

There was no significant difference in demographic baseline parameters. At the final follow-up, the C2-C7 Cobb angle of the modified group was significantly greater than that of the traditional group (p = 0.026). Meanwhile, the C2-C7 SVA of the modified group was significantly smaller than that of the traditional group (p = 0.009). Clinical outcomes such as VAS, NDI, and SF-12 scores, improved significantly in the modified group compared to the traditional group, while the JOA scores had no significant difference in both groups. There was no significant difference in the overall rate of complications between the two groups.

CONCLUSION

Both techniques have satisfactory outcomes in treating multi-levels CSM. Comparing with traditional UOLP, C3 & C7 dome-hybrid open-door laminoplasty has a greater superiority in reducing postoperative neck pain and maintaining the cervical sagittal alignment. It is proven to be a feasible management for patients with multi-levels CSM.

Analysis of risk factors for axial symptoms after posterior cervical open-door laminoplasty

BACKGROUND

Laminoplasty (LP), a procedure commonly used to treat cervical spondylotic myelopathy (CSM), often results in the development of axial symptoms (AS) postoperatively. This study aims to analyze the risk factors associated with the occurrence of AS after LP.

METHODS

We collected and evaluated clinical data from 264 patients with CSM who underwent LP treatment at our institution from January 2018 to January 2022 through a single-center retrospective study. Of the patients, 153 were male and 111 were female, with an average age of 58.1 ± 6.7 years. All patients underwent C3-7 posterior laminoplasty. Based on the occurrence of postoperative axial symptoms, the patients were divided into an AS group and a non-AS group. General information, including age, gender, disease duration, Japanese Orthopaedic Association (JOA) score, postoperation early function training, and collar-wearing time, was recorded and compared between the two groups. Surgical-related data, such as operative segments, surgical time, intraoperative blood loss, intraoperative facet joint destruction, and destruction of the C7 spinous process muscle insertion, were also compared. Imaging data, including preoperative cervical curvature, cervical range of motion, preoperative encroachment rate of the anterior spinal canal, and angle of laminar opening, were collected. Univariate and multivariate logistic regression analyses were used to identify risk factors for the development of AS after LP, and receiver operator characteristic (ROC) curves were utilized to explore the optimal preoperative parameters.

RESULTS

All 264 patients successfully underwent surgery and were followed up for an average of 19.5 ± 6.8 months. At the 6-month follow-up, 117 patients were diagnosed with AS, resulting in an incidence rate of 40.2%. The multivariate logistic regression analysis identified that preoperative encroachment rate of anterior spinal canal (Pre-op ERASC), intraoperative facet joints destruction (Intra-op FJD), intraoperative open-door angle (Intra-op OA), destroy the C7 spinous process muscle insertion (Destroy C7 SPMI), postoperative loss of cervical curvature (Post-op LCC), and postoperative loss of cervical range of motion (Post-op LCROM) were independent risk factors for AS. Conversely, preoperative cervical curvature (Pre-op CC) and postoperation early function training (Post-op EFT) were protective factors against AS. According to the ROC curve, the cutoff values for preoperative anterior spinal canal occupation rate and preoperative cervical curvature were 28.5% and 16.5°, respectively. When the preoperative anterior spinal canal occupation rate was greater than 28.5% or the preoperative cervical curvature was less than 16.5°, AS was more likely to occur after surgery.

CONCLUSION

High preoperative anterior spinal canal occupation rate, facet joint damage during surgery, C7 spinous process muscle stop point damage, larger angle of laminar opening, and greater postoperative cervical curvature loss and cervical range of motion loss are associated with an increased risk of developing AS after cervical laminoplasty. Conversely, a larger preoperative cervical curvature and early postoperative functional exercises can help reduce the occurrence of AS.

Axial Symptoms After Conventional and Modified Laminoplasty: A Meta-analysis

PURPOSE

The study aims to evaluate the impact of procedural variations in single-door laminoplasty on axial symptoms (AS) and neurologic outcomes.

METHODS

A comprehensive literature search was conducted across PubMed, EMBASE, and the Cochrane Library, adhering to specific inclusion criteria. We extracted data on the prevalence of AS in both the modified and conventional laminoplasty groups from the selected studies. Neurologic outcomes were assessed using the Japanese Orthopedic Association (JOA) recovery rate, which was subsequently converted to Hedge's g for analysis. Forest plots were generated to visualize the effect sizes, and publication bias was assessed using both funnel plots and Egger's test.

RESULTS

Fourteen studies comprising 1201 patients were included in this meta-analysis focused on AS. The aggregated SMD was -0.891 with a 95% CI of -1.146 to -0.631 (P < 0.01), denoting a statistically significant reduction in AS in the modified laminoplasty group compared with the conventional approach. Of the 14 studies, 10, encompassing 898 patients, contributed data for JOA recovery rate analysis. The overall effect size was 0.089, with a 95% CI ranging from -0.090 to 0.267, and a P value of 0.2901, indicating no significant difference in neurologic outcomes between the 2 techniques. No evidence of publication bias was detected.

CONCLUSIONS

This meta-analysis demonstrates that modified laminoplasty is associated with a significant reduction in the incidence and severity of axial symptoms, without compromising neurologic functionality.

Axial Neck Pain after Cervical Laminoplasty with Preserving C7 Spinous Process Using C7 Arcocristectomy: A Prospective Study

STUDY DESIGN

Single-blinded, randomized, single-center, prospective study.

PURPOSE

This study aims to compare the radiographical and clinical outcomes between C7 laminoplasty and C7 arcocristectomy, which preserves the C7 spinous process.

OVERVIEW OF LITERATURE

Laminoplasty is a widely used surgical method that decompresses the cervical spinal cord. However, axial neck pain is one of the major factors of dissatisfaction, and still, it is not clearly solved the reduction method of postoperative axial neck pain.

METHODS

Thirty-one patients with multilevel cervical spondylotic myelopathy who required C6-C7 level decompression surgery were operated and followed up for 24 months. One group (15 patients) received C7 arcocristectomy without laminoplasty, and the other group (16 patients) received C7 laminoplasty. Flexion, neutral, and extension angles were measured using the Cobb method at C2-C7 to evaluate preoperative and postoperative radiographic parameters. Range of motion (ROM), ROM preservation rate of the cervical spine, C2-C7 sagittal vertical axis (SVA), and T1 slope were measured using C-spine lateral X-ray. The Visual Analog Scale (VAS) and modified Japanese Orthopedic Association (JOA) score were used to compare preoperative and postoperative clinical symptoms.

RESULTS

Flexion, neutral, extension angles of the cervical spine, C2-C7 SVA, T1 slope, ROM, ROM preservation rate, and modified JOA score were not significantly different between the two groups (p>0.05). In the C7 arcocristectomy group, the average postoperative VAS for axial neck pain was increased in 13.3% (2/15) of the patients, whereas in the C7 laminoplasty group, the average postoperative VAS was increased in 43.8% (7/16) of the patients (p=0.018).

CONCLUSIONS

C7 arcocristectomy, which preserves the C7 spinous process and posterior structures, is a useful technique for relieving axial neck pain.

Trends in cervical laminoplasty and 30-day postoperative complications: 10-year results from a retrospective, multi-institutional study of 1095 patients

PURPOSE

This study aimed to investigate the recent 10-year trends in cervical laminoplasty and 30-day postoperative complications.

METHODS

This retrospective multi-institutional cohort study enrolled patients who underwent laminoplasty for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament. The primary outcome was the occurrence of all-cause 30-day complications. Trends were investigated and compared in the early (2008-2012) and late (2013-2017) periods.

RESULTS

Among 1095 patients (mean age, 66 years; 762 [70%] male), 542 and 553 patients were treated in the early and late periods, respectively. In the late period, patients were older at surgery (65 years vs. 68 years), there were more males (66% vs. 73%), and open-door laminoplasty (50% vs. 69%) was the preferred procedure, while %CSM (77% vs. 78%) and the perioperative JOA scores were similar to the early period. During the study period, the rate of preservation of the posterior muscle-ligament complex attached to the C2/C7-spinous process (C2, 89% vs. 93%; C7, 62% vs. 85%) increased and the number of laminoplasty levels (3.7 vs. 3.1) decreased. While the 30-day complication rate remained stable (3.9% vs. 3.4%), C5 palsy tended to decrease (2.4% vs. 0.9%, P = 0.059); superficial SSI increased significantly (0% vs. 1.3%, P = 0.015), while the decreased incidence of deep SSI did not reach statistical significance (0.6% vs. 0.2%).

CONCLUSIONS

From 2008 to 2017, there were trends toward increasing age at surgery and surgeons' preference for refined open-door laminoplasty. The 30-day complication rate remained stable, but the C5 palsy rate halved.

Radiographical Results of Adolescent Idiopathic Scoliosis with Major Curve at Proximal Thoracic Spine

Introduction

Adolescent idiopathic scoliosis (AIS) with a major curve at the main thoracic (MT) area is classified as Lenke type 1, 2, or 3 depending on the flexibility of the proximal thoracic (PT) curve and lumbar curve. No definite classification has been established for a major curve at the PT spine. The purpose of this study is to investigate the radiographic characteristics before and after correction surgery for AIS with a major curve at the PT area.

Methods

This is a retrospective cohort study at a single academic institution. Twelve patients with a major curve at the PT spine participated in our study and followed for at least two years after surgery. We evaluated the pre- and postoperative Cobb angles of the curve, curve range, location of the apex, sagittal parameters, and shoulder balance-related parameters. All patients were treated by posterior correction and fusion surgery using pedicle screw constructs.

Results

The patients were classified as having a double-curve (DC) type, in which the MT curve was structural, or a single-curve (SC) type, in which the MT curve was corrected to less than 25° on supine side-bending films. The mean correction rates for the PT curve were favorable in both groups (DC, 65.7%±9.6%; SC, 39.2%±4.9%). The mean Cobb angle of the lumbar curve improved in the DC group (preoperative, 17.1°±4.0°; postoperative, 5.0°±4.2°) but deteriorated in the SC group (preoperative, 7.1°±1.2°; postoperative, 12.4°±4.4°) after surgery.

Conclusions

We illustrated the postoperative radiographical changes of 12 consecutive patients with the major curve at the PT curve. Although posterior correction and fusion surgery corrected the PT curve satisfactorily in both DC and SC patients, the Cobb angle of the lumbar curve deteriorated after surgery in all SC patients. Surgeons need to pay attention to the fusion area, especially LIV, when operating the SC curve type.

Indication of C2-C7 Cervical Laminoplasty with Muscle and Ligament Preservation in Patients with Kyphosis

OBJECTIVE

Cervical laminoplasty is generally not indicated in patients with kyphosis because of poor outcomes. Therefore, data on the effectiveness of posterior structure-preserving techniques in patients with kyphosis are limited. This study investigated how laminoplasty with muscle and ligament preservation can benefit patients with kyphosis via risk factor analyses of postoperative complications.

METHODS

Clinicoradiological outcomes of 106 consecutive patients, including patients with kyphosis, who had undergone C2-C7 laminoplasty in a muscle- and ligament-preserving fashion, were retrospectively analyzed. Surgical outcomes, including neurological recovery, were assessed, and sagittal parameters were measured on radiographs.

RESULTS

Surgical outcomes of patients with kyphosis were comparable to outcomes of other patients except for axial pain (AP), which was significantly more frequent in patients with kyphosis. Moreover, AP was significantly associated with alignment loss (AL) >0°. Substantial local kyphosis (local kyphosis angle >10°) and greater value of range of motion (ROM) during flexion minus ROM during extension were identified as risk factors for AP and AL >0°, respectively. Receiver operating characteristic curve analysis indicated ROM during flexion minus ROM during extension cutoff value of 0.7° for predicting AL >0° in patients with kyphosis (sensitivity: 77%; specificity: 84%). Substantial local kyphosis combined with ROM during flexion minus ROM during extension >0.7° had 56% sensitivity and 84% specificity for predicting AP in patients with kyphosis.

CONCLUSIONS

Although patients with kyphosis had a significantly higher incidence of AP, C2-C7 cervical laminoplasty with muscle and ligament preservation may not be contraindicated in selected patients with kyphosis by risk stratification for AP and AL using newly identified risk factors.

Quantitatively biomechanical response analysis of posterior musculature reconstruction in cervical single-door laminoplasty

BACKGROUND AND OBJECTIVE

The current trend of laminoplasty is developing toward the goal of muscle preservation and minimum tissue damage. Given this, muscle-preserving techniques in cervical single-door laminoplasty have been modified with protecting the spinous processes at the sites of C2 and/or C7 muscle attachment and reconstruct the posterior musculature in recent years. To date, no study has reported the effect of preserving the posterior musculature during the reconstruction. The purpose of this study is to quantitatively evaluate the biomechanical effect of multiple modified single-door laminoplasty procedures for restoring stability and reducing response level on the cervical spine.

METHODS

Different cervical laminoplasty models were established for evaluating kinematics and response simulations based on a detailed finite element (FE) head-neck active model (HNAM), including ① C3 - C7 laminoplasty (LP_C37), ② C3 - C6 laminoplasty with C7 spinous process preservation (LP_C36), ③ C3 laminectomy hybrid decompression with C4 - C6 laminoplasty (LT_C3 + LP_C46) and ④ C3 - C7 laminoplasty with unilateral musculature preservation (LP_C37 + UMP). The laminoplasty model was validated by the global range of motion (ROM) and percentage changes relative to the intact state. The C2 - T1 ROM, axial muscle tensile force, and stress/strain levels of functional spinal units were compared among the different laminoplasty groups. The obtained effects were further analysed by comparison with a review of clinical data on cervical laminoplasty scenarios.

RESULTS

Analysis of the locations of concentration of muscle load showed that the C2 muscle attachment sustained more tensile loading than the C7 muscle attachment, primarily in flexion-extension (FE) and in lateral bending (LB) and axial rotation (AR), respectively. Simulated results further quantified that LP_C36 primarily produced 10% decreases in LB and AR modes relative to LP_C37. Compared with LP_C36, LT_C3 + LP_C46 resulted in approximately 30% decreases in FE motion; LP C37 + UMP also showed a similar trend. Additionally, when compared to LP_C37, LT_C3 + LP_C46 and LP C37 + UMP reduced the peak stress level at the intervertebral disc by at most 2-fold as well as the peak strain level of the facet joint capsule by 2-3-fold. All these findings were well correlated with the result of clinical studies comparing modified laminoplasty and classic laminoplasty.

CONCLUSIONS

Modified muscle-preserving laminoplasty is superior to classic laminoplasty due to the biomechanical effect of the posterior musculature reconstruction, with a retained postoperative ROM and loading response levels of the functional spinal units. More motion-sparing is beneficial for increasing cervical stability, which probably accelerates the recovery of postoperative neck movement and reduces the risk of the complication for eventual kyphosis and axial pain. Surgeons are encouraged to make every effort to preserve the attachment of the C2 whenever feasible in laminoplasty.

Is Severe Neck Pain a Contraindication to Performing Laminoplasty in Patients With Cervical Spondylotic Myelopathy?

STUDY DESIGN

Retrospective review.

OBJECTIVE

The purpose of this study was to investigate the surgical outcomes in a cohort of patients with severe preoperative axial neck pain undergoing laminoplasty for cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

No study has investigated whether patients with severe axial symptoms may achieve satisfactory neck pain and disability outcomes after laminoplasty.

METHODS

We performed a retrospective review of 91 patients undergoing C4-6 laminoplasty for CSM at a single academic institution between 2010 and 2021. Patient-reported outcome measures (PROMs), including Neck Disability Index (NDI), visual analog scale (VAS) Neck, and VAS Arm, were recorded preoperatively and at 6 months and 1 year postoperatively. Patients were stratified as having mild pain if VAS neck was 0-3, moderate pain if 4-6, and severe pain if 7-10. PROMs were then compared between subgroups at all the perioperative time points.

RESULTS

Both the moderate and severe neck pain subgroups demonstrated a substantial improvement in VAS neck from preoperative to 6 months postoperatively (-3.1±2.2 vs. -5.6±2.8, respectively; P <0.001), and these improvements were maintained at 1 year postoperatively. There was no difference in VAS neck between subgroups at either the 6-month or 1-year postoperative time points. Despite the substantially higher mean NDI in the moderate and severe neck pain subgroups preoperatively, there was no difference in NDI at 6 months or 1 year postoperatively ( P =0.99). There were no differences between subgroups in the degree of cord compression, severity of multifidus sarcopenia, sagittal alignment, or complications.

CONCLUSIONS

Patients with moderate and severe preoperative neck pain undergoing laminoplasty achieved equivalent PROMs at 6 months and 1 year as patients with mild preoperative neck pain. The results of this study highlight the multifactorial nature of neck pain in these patients and indicate that severe axial symptoms are not an absolute contraindication to performing laminoplasty in well-aligned patients with CSM.

＜Editors' Choice＞ Neck pain after cervical laminoplasty is associated with postoperative atrophy of the trapezius muscle

Cervical laminoplasty is a safe and effective treatment for cervical myelopathy. However, it has a higher frequency of postoperative axial pain than other methods. A variety of causes of postoperative axial pain have been reported, but these have not been fully elucidated. This study aimed to investigate the association between postoperative axial pain and changes in the posterior neck muscles before and after surgery. The study included 93 patients with cervical myelopathy who underwent surgery at our institute between June 2010 and March 2013. The patients with greater preoperative and 1-year postoperative neck pain visual analog scale scores comprised the neck pain group. The cross-sectional area of the cervical posterior extensor muscles and the trapezius muscle were measured by magnetic resonance imaging before and 1 year after surgery at the C3/4, C4/5, and C5/6 levels to compare with neck pain. The total cross-sectional area atrophy rate (C3/C4, C4/C5, and C5/C6) of the trapezius muscle was significantly larger in patients with neck pain (12.8 ± 13.2) than in those without (6.2 ± 14.4; p<0.05). The cross-sectional area atrophy rate of the trapezius muscle at only the C5/6 level was significantly higher in patients with neck pain (16.7 ± 11.7) compared to those without (3.3 ± 14.4; p<0.001). No significant differences were found in the cross-sectional areas of the cervical posterior extensor muscles. Trapezius atrophy, especially at the lower cervical vertebrae, was associated with neck pain after cervical laminoplasty.

Cervical Paraspinal Muscle Fatty Infiltration is Directly Related to Extension Reserve in Patients With Cervical Spine Pathology

STUDY DESIGN/SETTING

Retrospective review of a prospectively collected database.

OBJECTIVE

The objective of this study was to determine the relationship between paracervical muscle area, density, and fat infiltration and cervical alignment among patients presenting with cervical spine pathology.

BACKGROUND CONTEXT

The impact of cervical spine alignment on clinical outcomes has been extensively studied, but little is known about the association between spinal alignment and cervical paraspinal musculature.

METHODS

We examined computed tomography scans and radiographs for patients presenting with cervical spine pathology. The posterior paracervical muscle area, density, and fat infiltration was calculated on axial slices at C2, C4, C6, and T1. We measured radiographic parameters including cervical sagittal vertical axis, cervical lordosis, T1 slope (T1S), range of motion of the cervical spine. We performed Pearson correlation tests to determine if there were significant relationships between muscle measurements and alignment parameters.

RESULTS

The study included 51 patients. The paracervical muscle area was higher for males at C2 ( P =0.005), C4 ( P =0.001), and T1 ( P =0.002). There was a positive correlation between age and fat infiltration at C2, C4, C6, and T1 (all P <0.05). The cervical sagittal vertical axis positively correlated with muscle cross-sectional area at C2 ( P =0.013) and C4 ( P =0.013). Overall cervical range of motion directly correlated with muscle density at C2 ( r =0.48, P =0.003), C4 ( r =0.41, P =0.01), and C6 ( r =0.53. P <0.001) and indirectly correlated with fat infiltration at C2 ( r =-0.40, P =0.02), C4 ( r =-0.32, P =0.04), and C6 ( r =-0.35, P =0.02). Muscle density correlated directly with reserve of extension at C2 ( r =0.57, P =0.009), C4 ( r =0.48, P =0.037), and C6 ( r =0.47, P =0.033). Reserve of extension indirectly correlated with fat infiltration at C2 ( r =0.65, P =0.006), C4 ( r =0.47, P =0.037), and C6 ( r =0.48, P =0.029).

CONCLUSIONS

We have identified specific changes in paracervical muscle that are associated with a patient's ability to extend their cervical spine.

A novel surgical technique for cervical laminoplasty in patients with multilevel cervical spondylotic myelopathy: A case report and literature review

Cervical laminoplasty is a posterior-based surgical decompression technique for the treatment of multilevel cervical spondylotic myelopathy (CSM) that may improve the preservation of cervical mobility, spinal canal structure, and natural lordosis. Although this procedure is considered to be comparatively safe, with fewer complications than those seen with laminectomy, several postoperative problems have been noted, including axial neck pain, C5 nerve palsy, and failed resolution of radiculopathy. Hence, various modifications have been made to improve the safety and effectiveness of this technique. Here, we report the case of a 74-year-old man with multilevel CSM who underwent posterior cervical laminoplasty in the C3-C7 segments using a novel surgical technique, termed alternating-side cervical laminoplasty. Preoperative and postoperative assessments, including visual analog scale, modified Japanese Orthopaedic Association, neck disability index scores, and imaging data, were collected and analyzed. The results of a 5-year follow-up indicated that the patient recovered well, with no development of axial neck pain. This is the first report of this modified open-door laminoplasty, which we propose may be a better surgical option for preventing postoperative axial neck pain in patients with multilevel CSM. Additionally, opening the laminae on the alternating sides during laminoplasty could provide a flexible approach to complete decompression on different radiculopathy sides.

Novel Three-Holed Titanium Plate Fixation during Open Door Laminoplasty for Cervical Spondylotic Myelopathy: Comparison with Conventional Titanium Plate

OBJECTIVE

For reconstructing the posterior cervical muscular-ligament complex, attachment points and various modified techniques were designed and applied in clinical practice. This study investigated the clinical and radiographic outcomes of open door laminoplasty with modified centerpiece mini-plate fixation and extensor attachment point reconstruction in the treatment of cervical spondylotic myelopathy (CSM).

METHODS

Sixty-nine patients with CSM who underwent C3-C7 open door laminoplasty at our hospital from January 2016 to May 2018 were divided into two groups: 37 and 32 patients underwent laminoplasty with modified and conventional centerpiece titanium plate fixation (MPF and CPF groups), respectively. Changes in cervical spinal angle (CSA), cervical range of motion (ROM), posterior cervical muscle atrophy, neurological function (Japanese Orthopaedic Association [JOA] score), Neck Disability Index (NDI), and axial symptom severity were compared between the two groups.

RESULTS

There were no significant differences in operative duration (136.7 ± 23.9 vs 128.3 ± 21.5 min, t = 1.525, p > 0.05), volume of intraoperative blood loss (275.9 ± 33.1 vs 268.2 ± 31.6 ml, t = 0.984, p > 0.05), lamina open angle (41.2° ± 4.5° vs 39.4° ± 4.1°, t = 1.726, p > 0.05), and spinal cord drift distance (2.4 ± 0.3 vs 2.3 ± 0.4 mm, t = 1.184, p > 0.05) between the two groups. After surgery, JOA score significantly increased (p < 0.05), and neurological recovery rates were similar (62.7% vs 63.4%, t = 0.208, p > 0.05). The NDI score was significantly decreased in both the groups (p < 0.05); however, the MPF group recovered to a greater degree than the CPF group (8.3 ± 1.2 vs 9.8 ± 1.4) (t = 4.793, p < 0.05). There was no significant change in cervical ROM postoperatively compared with preoperatively in either group (p > 0.05). CSA decreased from 21.7° ± 2.8° to 18.3° ± 2.1°, and posterior cervical muscle cross-sectional area decreased from 35.2 ± 4.9 cm² to 31.0 ± 4.1 cm² in the CPF group (p < 0.05), but no significant change was observed in the MPF group (20.6° ± 2.5° to 20.4° ± 2.6°and 35.9 ± 5.1 to 34.1 ± 4.6 cm² , respectively) (p > 0.05). Postoperative axial symptom severity was significantly worse in the CPF group than in the MPF group (Z = -2.357, p < 0.05).

CONCLUSIONS

As an improvement to the conventional titanium plate, the modified centerpiece titanium plate effectively provides an attachment point for the posterior muscle-ligament complex, reducing posterior cervical muscle atrophy and improving neck function, without inflicting additional surgical trauma.

Analysis of risk factors of axial neck pain in posterior cervical single-door laminoplasty from the perspective of cervical sagittal plane

Objective

We carried out this study to explore the possible relationship between the cervical sagittal parameters in radiological images and axial neck pain (ANP) for patients who had underwent posterior cervical single-door laminoplasty.

Method

141 patients were enrolled in the study from January 2018 to January 2021, among which 38 were enrolled into the ANP group and 103 were enrolled into the non-ANP group. C2–7 Cobb angle, C2–7 sagittal vertex axis (SVA), thoracic inlet angle, neck tilt, and T1 slope were measured using computed tomography. Spearman correlation tests were used to analyze the possible correlation between radiological parameters and ANP. Logistic regression was carried out to analyze the potential risk factor for the occurrence of ANP. Receiver operating characteristic (ROC) curve and area under the ROC curve were used to evaluate the significant result and the optimal diagnostic value.

Results

As for radiographic parameters in the sagittal plane, the results suggested that only T1 slope and C2–7 SVA were statistically different between the ANP and non-ANP group (p = 0.001 and p = 0.047). Patients whose surgery involved the C2 spinous process demonstrated severe ANP symptoms than patients in the non-ANP group (p = 0.003). The Spearman correlation test showed that no statistical differences were found between visual analog scale (VAS) and radiological morphology parameters and only C2 involvement was found to correlate with postoperative VAS with respect to surgery. Logistic multivariate regression analysis demonstrated that only C2 involvement and T1 slope were significantly different when C2–7 SVA, T1 slope, C2 involvement together were included into consideration, with p values of 0.01 and 0.001.

Conclusion

According to our research, C2 involvement and greater T1 slope were independent risk factors of ANP for the patients who underwent laminoplasty of cervical spine.

Biomechanical behaviour of tension-band-reconstruction titanium plate in open-door laminoplasty: a study based on finite element analysis

OBJECTIVE

To investigate and evaluate the biomechanical behaviour of tension-band-reconstruction (TBR) and ordinary titanium plates in open-door laminoplasty by finite element (FE) analysis.

METHODS

TBR titanium plate and ordinary titanium plate were implanted into a validated finite element model of healthy adult cervical vertebrae. Among them, 5 ordinary titanium plate were used in model A, 2 TBR titanium plates and 3 ordinary titanium plates were used in model B, and 5 TBR titanium plates were used in model C. The same loading conditions was applied identically to all models. Range of motion (ROM) of the vertebral body, stress distribution of the titanium plate and intradiscal pressure (IDP) were compared in flexion, extension, lateral bending and rotation.

RESULTS

The ROM of model B and C was similar in flexion and extension, and both were smaller than that of model A. The highest von Mises stress in the titanium plate appears is in model C. The IDP in C2/3 was significantly higher than that in other segments in flexion. There was no significant difference in IDP among three models in left lateral bending and left axial rotation.

CONCLUSION

Application of TBR titanium plate in open-door laminoplasty can reduced ROM in flexion, extension and axial rotation of the cervical vertebrae. But the increase of stress in TBR titanium plate could lead to higher risk of adverse events such as titanium plate deformation. Moreover, compared with complete TBR titanium plate, the combination of TBR titanium plate for C3 and C7 with ordinary titanium plate for the other vertebrae largely reduce the stress of the titanium plates by ensuring stability. The proposed FE model (C2-T1) exhibits a great potential in evaluating biomechanical behaviour of TBR titanium plate for open-door laminoplasty.

Cervical Laminoplasty Versus Posterior Laminectomy and Fusion: Trends in Utilization and Evaluation of Complication and Revision Surgery Rates

INTRODUCTION

Cervical laminoplasty (LP) and laminectomy with fusion (LF) are common operations used to treat cervical spondylotic myelopathy. Conflicting data exist regarding which operation provides superior patient outcomes while minimizing the risk of complications. This study evaluates the trends of LP compared with LF over the past decade in patients with cervical myelopathy and examines long-term revision rates and complications between the two procedures.

METHODS

Patients aged 18 years or older who underwent LP or LF for cervical myelopathy from 2010 to 2019 were identified in the PearlDiver Mariner Database. Patients were grouped independently (LP versus fusion) and assessed for association with common medical and surgical complications. The primary outcome was the incidence of LP versus LF for cervical myelopathy over time. Secondary outcomes were revision rates up to 5 years postoperatively and the development of complications attributable to either surgery.

RESULTS

In total, 1,420 patients underwent LP and 10,440 patients underwent LF. Rates of LP (10.5% to 13.7%) and LF (86.3% to 89.5%) remained stable, although the number of procedures nearly doubled from 865 in 2010 to 1,525 in 2019. On matched analysis, LP exhibited lower rates of wound complications, surgical site infections, spinal cord injury, dysphagia, cervical kyphosis, limb paralysis, incision and drainage/exploration, implant removal, respiratory failure, renal failure, and sepsis. Revision rates for both procedures at were not different at any time point.

CONCLUSION

From 2010 to 2019, rates of LP have not increased and represent less than 15% of posterior-based myelopathy operations. Up to 5 years of follow-up, there were no differences in revision rates for LP compared with LF; however, LP was associated with fewer postoperative complications than LF.

LEVEL OF EVIDENCE

Level III retrospective cohort study.

Axial Neck-Shoulder Pain After Posterior Correction and Fusion for Adolescent Idiopathic Scoliosis With Structural Thoracic Curve: Does Cranial Fusion Level Affect Neck Symptoms?

STUDY DESIGN

A retrospective cohort study using prospectively collected data.

OBJECTIVES

To investigate the incidence and impact of fusion to the upper thoracic spine on neck-shoulder symptoms after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Axial neck-shoulder pain is established as a sequela of posterior cervical spine surgery and is mainly caused by the dissection of extensor muscles in the cervical and upper thoracic spine.

MATERIALS AND METHODS

Sixty-three female patients with AIS who underwent PSF using segmental pedicle screw constructs for structural main thoracic curve with a minimum 2-year follow-up were included. Axial neck-shoulder pain was assessed using the visual analog scale and cervical spine function domain score of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire. The patients were divided into 2 groups, a higher group (underwent fusion up to T3 or above, n=27) and a lower group (underwent fusion up to T4 or below, n=36), and radiologic and clinical outcomes were compared.

RESULTS

The incidence of axial neck-shoulder pain (visual analog scale ≥30) preoperatively and at the 2-year follow-up was 29 and 40%, respectively. The pain and mental health domains of the Scoliosis Research Society-22 and cervical spine function domain of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire were correlated with the severity of axial neck pain. In the comparison of clinical outcomes between the 2 groups, the pain domain score of the Scoliosis Research Society-22 in the lower group was significantly better than that in the higher group at the 2-year follow-up (P<0.05). Other parameters showed no significant differences preoperatively or at the 2-year follow-up.

CONCLUSION

Female patients with AIS had a relatively high incidence of axial neck-shoulder pain after PSF, which affected their health-related quality of life. Both groups showed similar clinical outcomes, and the cranial fusion level did not affect axial neck-shoulder pain and cervical spine function.

LEVEL OF EVIDENCE

Level 3.

Laminoplasty and simultaneous C2 semi-laminectomy with internal fixation in treating ossification of the posterior longitudinal ligament in cervical discs at C2 segment

OBJECTIVE

To explore the effect of open-door laminoplasty and simultaneous C2 semi-laminectomy with lateral mass screw fixation (LSLF) in treating ossification of the posterior longitudinal ligament (OPLL) in cervical discs at C2 segment.

METHODS

In this retrospective study, 76 patients diagnosed with OPLL in cervical discs at C2 segment from November 2016 to May 2019 were included. These patients were assigned into a LSLF group (n=41, LSLF surgery) and LF group (n=35, laminectomy and lateral mass screw fixation) according to the treatment they received. The surgery time and intraoperative blood loss were recorded. Improvements in neurological function (JOA score), cervical curvature index (CCI), spinal cord drift distance, cross-sectional area (CSA) of the posterior muscles from cervical spine, occurrence of C5 palsy, and severity of axial symptoms were evaluated between LSLF group and LF group.

RESULTS

Compared with LF group, the operative time was longer and blood loss volume was higher in LSLF group (P<0.05). No statistical difference was found in decompression width between LSLF group and LF group, while the drift distance of spinal cord in LSLF group was larger than that in LF group (P<0.05). No obvious differences were observed in anteroposterior dural sac diameter after the surgery between LSLF group and LF group. CSA in LF group decreased more than that in LSLF group (P<0.05). No remarkable difference was obtained in CCI at the final follow-up between LSLF group and LF group. The NDI score after surgery in the LSLF group was significantly decreased compared to LF group (P<0.05), while no differences were observed in JOA scores or the neurological recovery rate between LSLF group and LF group. The occurrence of C5 palsy in the LSLF group was 4.9%, which was less than that of LF group (20.0%). In contrast to LF group, postoperative axial symptoms in LSLF group were decreased (P<0.05).

CONCLUSION

Compared to LF, LSLF could better improve neck functions, and reduce the severity of axial symptoms and the occurrence of C5 palsy for patients with OPLL at C2 segment.

The Kappa Line as a Regional Modification of the K-line: A Predictor of Neurological Outcome and Indicator of the Adequate Level of Decompression in Selective Laminoplasty

STUDY DESIGN

This is a retrospective cohort study.

OBJECTIVE

The aim was to introduce Kappa line (modification of K-line) for the prediction of postoperative neurological recovery after selective cervical laminoplasty (LMP) and use in determining the decompression level.

SUMMARY OF BACKGROUND DATA

The K-line is a radiographic marker that can predict prognosis and aid in surgical planning for patients undergoing LMP through C3 to C7. However, its efficacy in LMP involving limited segments is unclear. Furthermore, no specific radiographic marker to predict the prognosis of selective LMP has been reported.

MATERIALS AND METHODS

Fifty-one consecutive patients with a minimum 2-year follow-up after selective LMP for cervical myelopathy caused by ossification of posterior longitudinal ligament were retrospectively reviewed. The Kappa line was defined as a straight line connecting the midpoints of the spinal canal made by remaining bony structure after decompression procedures on a plain lateral radiograph in the neutral position. Patients were classified as K-line (+) or (-) and Kappa line (+) or (-) based on whether the ossified mass crossed the indicator line.

RESULTS

The Kappa line (+) group demonstrated significantly higher Japanese Orthopaedic Association (JOA) recovery rate (P=0.01), final JOA score (P<0.01), and dural sac diameter (P<0.01) postoperatively than the Kappa line (-) group. Cord compression grade was significantly lesser in the Kappa line (+) group. However, the K-line-based classification did not demonstrate significant difference in JOA recovery rate, final JOA score, and cord compression grade between the (+) and (-) groups; the dural sac diameter was significantly higher in the K-line (+) group (P<0.01).

CONCLUSIONS

The Kappa line showed better correlation with ossification of posterior longitudinal ligament size and cervical alignment, providing better prediction of neurological recovery and remaining cord compression following selective LMP. Therefore, the Kappa line can aid in determining the level of decompression in selective LMP.

Long-term Clinical Outcomes of Microendoscopic Laminotomy for Cervical Spondylotic Myelopathy: A 5-Year Follow-up Study Compared With Conventional Laminoplasty

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to characterize the long-term clinical and radiographic results of articular segmental decompression surgery using endoscopy [cervical microendoscopic laminotomy (CMEL)] for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP).

SUMMARY OF BACKGROUND DATA

The spinal cord compression in CSM consists of a pincer mechanism due to bulging disk and a hypertrophied ligamentum flavum. The long-term clinical benefits of segmental decompression surgery, which removes the dorsal compressive elements of articular segment in CSM patients, have not yet been elucidated.

MATERIALS AND METHODS

Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n=81) underwent CMEL or ELAP. All patients were followed postoperatively for >5 years. The preoperative and 5-year follow-up evaluation included neurological assessment [Japanese Orthopaedic Association (JOA) score], JOA recovery rates, axial neck pain (visual analog scale), and cervical sagittal alignment (C2-C7 subaxial cervical angle).

RESULTS

Sixty-four patients (CMEL group: 33, ELAP group: 31) were included for analysis. The preoperative JOA score was 10.1 points in the CMEL group and 11.1 points in the ELAP group (P=0.15). The JOA recovery rates were similar, 58.6% in the CMEL group and 55.2% in the ELAP group (P=0.55). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (P<0.01). At 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.9 degrees gain in lordosis [vs. 2.3 degrees loss of lordosis in the ELAP group (P<0.05)] and lower incidence of postoperative kyphosis.

CONCLUSIONS

CMEL is a novel, less invasive, technique that allows for multilevel posterior cervical decompression for treatment of CSM. Our 5-year follow-up data demonstrates that patients after CMEL have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional laminoplasty counterparts.

Factors Significantly Associated with Postoperative Neck Pain Deterioration after Surgery for Cervical Ossification of the Posterior Longitudinal Ligament: Study of a Cohort Using a Prospective Registry

Postoperative neck pain has been reported as an unsolved postoperative complication of surgery for cervical ossification of the posterior longitudinal ligament (OPLL). The aim of the present study was to elucidate factors having a significant association with postoperative deterioration of neck pain in cervical OPLL patients. We studied a cohort of patients in a prospective registry of 478 patients who had undergone cervical spine surgery for cervical OPLL. We excluded those without evaluation of preoperative neck pain. Therefore, 438 patients were included in the present study. Neck pain was evaluated with the visual analogue scale (VAS, 0-100 mm). Postoperative neck pain deterioration was defined as a ≥20 mm increase of VAS neck pain. Patient factors, neurological status, imaging factors and surgical factors were assessed. Univariate analyses followed by multivariate analysis using stepwise logistic regression was performed. Six months after surgery, 50 (11.6%) patients showed postoperative neck pain deterioration and 76 (17.4%) patients showed postoperative neck pain deterioration 2 years after surgery. Six months after surgery, the rate of neck pain deterioration was significantly higher in patients who had undergone posterior surgery. Two years after surgery, the number of levels fused was significantly correlated with neck pain deterioration.

Relationship of Change in Cervical Curvature after Laminectomy with Lateral Mass Screw Fixation to Spinal Cord Shift and Clinical Efficacy

BACKGROUND AND STUDY AIMS

 Although laminectomy with lateral mass screw fixation (LCSF) is an effective surgical treatment for cervical spondylotic myelopathy (CSM), loss of cervical curvature may result. This study aimed to investigate the effect of cervical curvature on spinal cord drift distance and clinical efficacy.

PATIENTS AND METHODS

 We retrospectively analyzed 78 consecutive CSM patients with normal cervical curvature who underwent LCSF. Cervical curvature was measured according to Borden's method 6 months after surgery. Study patients were divided into two groups: group A, reduced cervical curvature (cervical lordosis depth 0-7mm; n = 42); and group B, normal cervical curvature (cervical lordosis depth 7-17mm; n = 36). Spinal cord drift distance, laminectomy width, neurologic functional recovery, axial symptom (AS) severity, and incidence of C5 palsy were measured and compared.

RESULTS

 Cervical lordosis depth was 5.1 ± 1.2 mm in group A and 12.3 ± 2.4 mm in group B (p < 0.05). Laminectomy width was 21.5 ± 2.6 mm in group A and 21.9 ± 2.8 mm in group B (p > 0.05). Spinal cord drift distance was significantly shorter in group A (1.9 ± 0.4 vs. 2.6 ± 0.7 mm; p < 0.05). The Japanese Orthopaedic Association (JOA) score significantly increased after surgery in both groups (p < 0.05). Neurologic recovery rate did not differ between the two groups (61.5 vs. 62.7%; p > 0.05). AS severity was significantly higher in group A (p < 0.05). C5 palsy occurred in three group A patients (7.1%) and four group B patients (11.1%), but the difference was not significant (p > 0.05).

CONCLUSION

 After LCSF, 53.8% of the patients developed loss of cervical curvature. A smaller cervical curvature resulted in a shorter spinal cord drift distance. Loss of cervical curvature was related to AS severity but not improvement of neurologic function or incidence of C5 palsy.

C7 Fracture as a Complication of C7 Dome-Like Laminectomy : Impact on Clinical and Radiological Outcomes and Evaluation of the Risk Factors

Objective

Cervical expansive laminoplasty is an effective surgical method to address multilevel cervical spinal stenosis. During surgery, the spinous processes of C2 and C7 are usually preserved to keep the insertion points of the cervical musculature and nuchal ligament intact. In this regard, dome-like laminectomy (undercutting of C7 lamina) instead of laminoplasty is performed on C7 in selected cases. However, resection of the lamina can weaken the C7 lamina, and stress fractures may occur, but this complication has not been characterized in the literature. The objective of the present study was to investigate the incidence and risk factors for C7 laminar fracture after C7 dome-like laminectomy and its impact on clinical and radiological outcomes.

Methods

Patients who underwent cervical open-door laminoplasty combined with C7 dome-like laminectomy (n=123) were classified according to the presence of C7 laminar fracture. Clinical parameters (neck/arm pain score and neck disability index) and radiologic parameters (C2–7 angle, C2–7 sagittal vertical axis, and C7–T1 angle) were compared between the groups preoperatively and at postoperatively at 3, 6, 12, and 24 months. Risk factors for complications were evaluated, and a formula estimating C7 fracture risk was suggested.

Results

C7 lamina fracture occurred in 32/123 (26%) patients and occurred at the bilateral isthmus in 29 patients and at the spinolaminar junction in three patients. All fractures appeared on X-ray within 3 months postoperatively, but patients did not present any neurological deterioration. The fracture spontaneously healed in 27/32 (84%) patients at 1 year and in 29/32 (91%) at 2 years. During follow-up, clinical outcomes were not significantly different between the groups. However, patients with C7 fractures showed a more lordotic C2–7 angle and kyphotic C7–T1 angle than patients without C7 fractures. C7 fracture was significantly associated with the extent of bone removal. By incorporating significant factors, the probability of C7 laminar fracture could be assessed with the formula 'Risk score = 1.08 × depth (%) + 1.03 × length (%, of the posterior height of C7 vertebral body)', and a cut-off value of 167.9% demonstrated a sensitivity of 90.3% and a specificity of 65.1% (area under the curve, 0.81).

Conclusion

C7 laminar fracture can occur after C7 dome-like laminectomy when a substantial amount of lamina is resected. Although C7 fractures may not cause deleterious clinical outcomes, they can lead to an unharmonized cervical curvature. The chance of C7 fracture should be discussed in the shared decision-making process.

Neurological improvement is associated with neck pain attenuation after surgery for cervical ossification of the posterior longitudinal ligament

Although favourable surgical outcomes for myelopathy caused by cervical ossification of the posterior longitudinal ligament (OPLL) have been reported, factors significantly associated with post-operative neck pain attenuation still remain unclear. The primary aim of the present study was to determine factors significantly associated with post-operative neck pain attenuation in patients with cervical OPLL using a prospective multi-centre registry of surgically treated cervical OPLL. Significant postoperative neck pain reduction (50% reduction of neck pain) was achieved in 31.3% of patients. There was no significant difference in neck pain attenuation between surgical procedures. Statistical analyses with univariate analyses followed by stepwise logistic regression revealed neurological recovery as a factor having a significant positive association with post-operative neck pain attenuation (p = 0.04, odds ratio 5.68 (95% confidence interval: 1.27-22.2)). In conclusion, neurological recovery was an independent factor having a significant positive association with post-operative neck pain attenuation in patients with cervical myelopathy caused by OPLL who underwent cervical spine surgery.

Modified K-line for Making Decisions Regarding the Surgical Approach in Patients with K-line (-) OPLL

Objective

To investigate whether the modified K‐line can be used to predict the clinical outcome and to determine the surgical approach for K‐line (−) patients with cervical ossification of the posterior longitudinal ligament (OPLL).

Methods

A new modified K‐line was defined as the line connecting the midpoints of the spinal cord at C₄ and C₆ on the lateral cervical radiographs. A total of four consecutive patients (three men and one woman) with cervical myelopathy due to OPLL were included in this research. The patients were diagnosed with OPLL with K‐line (−) while they were also classified as modified K‐line (+). Preoperative modified K‐line was used to predict the surgical outcome in K‐line (−) patients with OPLL according to the original K‐line. And a modified laminoplasty with C₃ laminectomy and C_4‐6 bilateral open‐door laminoplasty was adopted to perform on all the patients. The Japanese Orthopaedic Association scores before surgery and at 1‐year follow‐up after surgery were evaluated and the recovery rate was calculated. The visual analogue scale (VAS) scores were also evaluated before surgery and after surgery. Furthermore, cervical plain radiographs in neutral position before surgery and after surgery were obtained to measure C₂–C₇ angles for assessing the cervical sagittal alignment.

Results

The results showed that good neurological improvement could be achieved in all K‐line (−) patients who underwent C₃ laminectomy with C₄–C₆ bilateral open‐door laminoplasty. The Postoperative JOA scores improved from 13.5 to 16.5, from 11 to 16.5, from 13 to 16, and from 12.5 to 13, respectively. The mean recovery rate was 65.4% in the K‐line (−) patients. And the VAS scores dropped from 3 to 1, 5 to 2, 5 to 3, and 4 to 2, respectively. The JOA and VAS scores showed satisfaction in all patients at the 1‐year follow‐up. Relatively satisfactory and stable cervical sagittal alignment was observed on postoperative lateral radiography in all patients at the 3‐month follow‐up period. There were no postoperative complications associated with this technique found in all the patients.

Conclusions

Modified K‐line may predict the clinical outcome of this modified laminoplasty and offer guidance regarding the choice of surgical method for K‐line (−) patients with OPLL. Additionally, C₃ laminectomy with C₄–C₆ bilateral open‐door laminoplasty should be recommended for the use in patients with K‐line (−) OPLL, who were also classified as modified K‐line (+). However, further studies with more cases will be required to reveal its generalizability and availability.

A New Posterior Extensor Attachment-Point Reconstruction Technique for Cervical Spondylotic Myelopathy Involving C2 Segment: Clinical Outcome and Safety

BACKGROUND AND STUDY AIM

 Cervical spondylotic myelopathy (CSM) is a common degenerative disease that mainly occurs in elder patients, leading to different degrees of neurological dysfunction. Spinal cord involvement is mainly distributed at the C3-C7 segments, but it may also involve up to the C2 level. This study aimed to assess the clinical efficacy and safety of open-door laminoplasty using a new extensor attachment-point reconstruction technique for treating CSM involving the C2 segment.

PATIENTS AND METHODS

 Fifty-nine patients with CSM involving the C2 segment and undergoing open-door laminoplasty were included in this retrospective study. Based on the titanium plate used in the operation, patients were divided into two groups, a reconstructed titanium plate fixation (RPF) group (n = 28) and a conventional titanium plate fixation (CPF) group (n = 31). Improvements in neurological function, cervical range of motion (ROM), cervical curvature index (CCI), preservation of posterior cervical muscle mass, and axial symptoms were compared between the two groups.

RESULTS

 There were no significant differences in operative time and intraoperative blood loss between the groups (p > 0.05). The Japanese Orthopaedic Association (JOA) score significantly increased in both groups postsurgery (p < 0.05); the neurological recovery rate was similar between the two groups (64.1 ± 13.3% vs. 65.9 ± 14.7%, p > 0.05). There was no significant loss of cervical ROM in either group (p > 0.05). The anteroposterior dural sac diameter at the C2 level was significantly enlarged in both groups (p < 0.05). Alternatively, CCI was significantly reduced in the CRP group (p < 0.05) but unchanged in the RPF group (p > 0.05). The cross-sectional area of the posterior cervical muscles was also significantly reduced in the CPF group (p < 0.05) but maintained in the RPF group (p > 0.05). Finally, axial symptoms were more severe in the CPF group than in the RPF group (p < 0.05).

CONCLUSION

 Laminoplasty is an effective surgical procedure for CSM involving the C2 segment. The reconstructed titanium plate achieved superior maintenance of cervical curvature and reduced both muscle atrophy and severity of axial symptoms compared with titanium conventional plates.

A Feasibility Study of a New Muscle Sparing "C3 Dome-Hybrid Open-Door Laminoplasty": A Surgical Technique, Clinical Outcome, and Learning Curve Description

STUDY DESIGN

Retrospective case series to investigate the result of a new C3 dome-hybrid open-door laminoplasty technique.

OBJECTIVE

This study reports the design and feasibility of a new hybrid laminoplasty technique aimed to reduce the complications of the conventional laminoplasty, with the incorporation of C3 dome-osteotomy, an open-door C4-6 instrumented laminoplasty and C7 cephalad dome-osteotomy.

SUMMARY OF BACKGROUND DATA

Recent findings showed that the preservation of the dorsal muscles attached at either C2 or C7 cervical spine reduced the complications of C3-C7 open-door laminoplasty.

METHODS

A retrospective review of consecutive patients who underwent the C3 dome-hybrid laminoplasty technique by a single surgeon with at least 2 years follow-up was performed. The surgical technique was described in detail. Clinical and radiological outcome data were analyzed.

RESULTS

Twenty six patients with cervical cord compression who underwent C3 dome-hybrid laminoplasty were recruited. The mean postoperative follow-up was 45.6 ± 24.7 (24-101) months. Significant improvements were observed in the preoperative to postoperative mean Japanese Orthopaedic Association (JOA) score (13→15, P < 0.001), Nurick grade (2.3→1.2, P < 0.001), neck disability index (NDI) (23→11, P = 0.011), 36-item short form survey (SF-36) physical component score (40→46, P = 0.027), and neck visual analogue scale (VAS) (3.1→0.3, P < 0.001). There was no significant loss in cervical lordosis from 12° preoperatively to 8° at final follow-up. Postoperative cervical range of motion (ROM) was preserved at 85% and 78% of the preoperative ROM at 2 years and at final follow-up, respectively. When comparing the first 10 patients with the next 16 patients, there was a reduction in mean operation time from 252 ± 75 to 208 ± 7 minutes, mean blood loss from 359 ± 326 to 211 ± 177 mL, and median hospital stay from 7 days (interquartile range [IQR]: 34) to 5 days (IQR: 6).At final follow-up, no patients had revision surgery, spinal infection, C5 palsy, symptomatic cervical kyphosis, or axial neck pain.

CONCLUSION

The new C3 dome-hybrid laminoplasty technique is safe, feasible, and reproducible with good clinical outcomes. This technique may be considered as an alternative to traditional laminoplasty for patients with C3-C7 multi-level myelopathic disease.

LEVEL OF EVIDENCE

3.

Factors associated with postoperative axial symptom after expansive open-door laminoplasty: retrospective study using multivariable analysis

PURPOSE

The aim of the present study was to investigate the factors associated with axial symptom using multivariable analysis.

METHODS

The authors retrospectively assessed 249 patients treated by open-door laminoplasty. The patients were classified into two groups: axial symptom and no axial symptom group. The possible factors included demographic variables (age, sex, BMI, smoking, heart disease, diabetes, preoperative neck pain, preoperative JOA scores, preoperative NDI, course of disease and pathogenesis) and surgical and radiological variables [operation time, intraoperative blood loss, collar wear time, preoperative cervical curvature, postoperative cervical curvature, T1 slope, preoperative and postoperative C2 sagittal vertical axis (C2 SVA)].

RESULTS

The prevalence of axial symptom was 34.9% (89/249). The collar wear time, preoperative and postoperative C2 SVA were risk factors for axial symptom. A cutoff value of 22.6 mm for preoperative C2 SVA and 3.5 weeks for collar wear time predicted the development of axial symptom.

CONCLUSIONS

The longer collar wear time, larger preoperative and postoperative C2 SVA were positively correlated with the higher incidence of axial symptom.

Comparing clinical outcomes of using 3 versus 5 titanium miniplates in laminoplasty for multilevel cervical myelopathy: A prospective cohort study

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this study was to compare clinical outcomes, radiographic changes, and complications of cervical expansive open-door laminoplasty（EOLP）for cervical multilevel myelopathy, using either 3 or 5 titanium miniplates.

SUMMARY OF BACKGROUND DATA

Cervical EOLP is a common and effective operation for cervical myelopathy. Standard procedures utilise either 3 or 5 titanium miniplates; however, no definite conclusion has been given yet on the relationship between clinical outcomes and the quantity of titanium miniplates.

METHOD

We performed a prospective study of 92 patients who underwent EOLP with either 3 (n ​= ​34) or 5 (n ​= ​58) titanium miniplates at our institution from March 2012 to June 2016. Clinical and radiologic outcomes and complications were compared.

RESULT

Compared with the 5 titanium miniplates group, the 3 titanium miniplates group had shorter operation times and less blood loss (P ​< ​0.05) and needed fewer costs (P ​< ​0.01) during index hospitalisation. The preoperative cervical curvature angle decreased in both groups and revealed no significant differences. There was no significant difference between the two groups in the Japanese Orthopedic Association (JOA) score, JOA recovery rate, loss of range of motion (ROM), anteroposterior diameter (APD), or spinal canal complications (P ​> ​0.05).

CONCLUSION

Cervical EOLP using 3 titanium miniplates is associated with shorter operation times, less blood loss, and lower operation costs compared with using 5 titanium miniplates.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Expansive open-door laminoplasty (EOLP) is an effective procedure for treating multilevel cervical spondylotic myelopathy. The present study indicated that 3 titanium miniplates could achieve similar clinical outcomes but with shorter operation times, less blood loss and operation costs compared with 5 titanium miniplates. These findings may provide some references for clinical applications.

Clinical and Radiographic Outcomes of Modified Unilateral Open-door Laminoplasty with Posterior Muscle-Ligament Complex Preservation for Cervical Spondylotic Myelopathy

MINI: The surgical results of modified and traditional open-door laminoplasties were retrospectively compared. There were no differences in neurological outcomes and postoperative complications. However, compared with traditional laminoplasty, modified laminoplasty was associated with better maintenance of cervical curvature and ROM, as well as a lower incidence of postoperative axial symptoms.

STUDY DESIGN

A retrospective comparative study.

OBJECTIVE

The aim of this study was to evaluate the efficacy of modified unilateral open-door laminoplasty with posterior muscle-ligament complex preservation in treating cervical spondylotic myelopathy (CSM).

SUMMARY OF BACKGROUND DATA

The prevalence of axial symptoms after open-door laminoplasty ranges from 5% to 86%. Current modified laminoplasty techniques cannot satisfactorily reduce postoperative axial symptoms.

METHODS

From June 2014 to July 2016, 36 patients with CSM underwent modified laminoplasty with posterior muscle-ligament complex preservation (modified group) and 27 patients underwent traditional laminoplasty (control group). The demographics, operation duration, blood loss volume, cervical curvature, cervical curvature index (CCI), range of motion (ROM), cervical posterior muscle volume on magnetic resonance imaging (MRI), axial symptoms, visual analog scale (VAS) score, Japanese Orthopedic Association (JOA) score, neck disability index (NDI), and complications were recorded and analyzed before operation, after operation, and at the final follow-up.

RESULTS

Cervical flexion curvature, cervical curvature, ROM, and CCI were better in the modified group than in controls at the final follow-up (P < 0.01). Postoperative VAS and NDI scores were significantly reduced in the modified group compared with controls (1.15 ± 0.76 vs. 2.63 ± 1.06, 5.67 ± 2.57 vs. 8.89 ± 5.37, respectively) (P < 0.01). Posterior muscle volume at the hinge side in the modified group was not different at final follow-up relative to that before the operation, whereas it was reduced in controls (P < 0.01). Finally, the incidence of axial symptoms was significantly lower in the modified group than in controls (6% vs. 22%) (P = 0.03).

CONCLUSION

Modified unilateral open-door laminoplasty with posterior muscle-ligament complex preservation is effective for treating CSM with good recovery of neurological functions and satisfactory maintenance of cervical curvature and ROM. Furthermore, it reduces the incidence of postoperative axial symptoms compared with conventional open-door laminoplasty.

LEVEL OF EVIDENCE

3.

Comparison of microendoscopic selective laminectomy versus conventional laminoplasty in patients with degenerative cervcical myelopathy: a minimum 2-year follow-up study

Background

Although microendoscopic partial laminectomy for patients with degenerative cervical myelopathy (DCM) has been reported and demonstrated good results, a detailed comparison of its mid-term surgical results with those of laminoplasty (LP) has not been reported. The aim of this study was to compare the surgical outcomes, complications, and imaging parameters of cervical microendoscopic interlaminar decompression (CMID) via a midline approach versus conventional laminoplasty, with a minimum follow-up period of 2 years.

Methods

Two hundred and fifty-four patients who underwent either LP or CMID for DCM between May 2008 and April 2015 were enrolled. All patients routinely underwent LP (C3–6 or C3–7) before December 2011, whereas CMID was performed at the one or two affected level(s) only in patients with single- or two-level spinal cord compression after 2012.

Surgical procedure (CMID): For single-level patients (e.g., C5–6), partial laminectomy of C5 and C6 was performed under a microendoscope. For two-level patients (e.g., C5–6-7), decompression was completed by performing a C6 laminectomy.

We compared surgical outcomes and radiographic parameters between the CMID and LP groups.

Results

Of the 232 patients followed up for > 2 years, 87 patients with single- or two-level spinal cord compression, 46 that underwent CMID, and 41 that underwent LP were identified. There were no differences in the baseline demographic data of the patients between the groups. CMID showed better outcomes in terms of postoperative axial pain and quality of life, although both procedures showed good neurological improvement. Two and one patient complained of C5 palsy and hematoma, respectively, only in the LP group. The postoperative range of motion was worse and the degree of postoperative posterior spinal cord shift was larger in the LP group.

Conclusion

Selective decompression by CMID demonstrated surgical outcomes equivalent to those of conventional LP, which raises a question regarding the requirement of extensive posterior spinal cord shift in such patients. Although the indications of CMID are limited and comparison with anterior surgery is mandatory, it can be a minimally invasive procedure for DCM. 

Ossified Posterior Longitudinal Ligament Existing at an Intervertebral Level Limits Compensatory Mechanism of Cervical Lordosis after Muscle-Preserving Selective Laminectomy

Introduction

As C7 slope increases, lordotic change of C2-C7 angle compensates for adjustments in cervical sagittal balance. However, ossification of the posterior longitudinal ligament (OPLL) may affect the compensatory mechanism of the cervical spine. This study aims to evaluate the impact of OPLL on cervical lordotic compensation after muscle-preserving selective laminectomy (SL).

Methods

This study involved 235 patients with cervical spondylotic myelopathy (CSM) and OPLL who underwent ≥ 3 consecutive levels of SL. OPLL was classified into continuous, segmental, mixed, or localized type on the basis of the criteria previously reported. In this study, based on the motion preservation at the intervertebral level, patients were divided into CSM (n = 114), OPLL segmental type (OPLL-S; n = 44), and other types of OPLL (OPLL-O; i.e., continuous, mixed, and localized; n = 77). The cervical sagittal alignment, degree of spinal cord decompression, and surgical outcomes were compared among the three groups.

Results

The OPLL-O group had a larger postoperative C7 slope (p = 0.020), larger pre- (p = 0.021) and postoperative (p = 0.001) C2-C7 sagittal vertical axis, and greater pre- (p = 0.034) and postoperative (p = 0.002) C7 slope minus C2-C7 angle. Narrower postoperative spinal cord clearance (PSCC) from OPLL (p < 0.001) and more residual spinal cord compression (p < 0.001) were observed in the OPLL-O group. Correlation between postoperative C7 slope minus C2-C7 angle and PSCC was detected (r = −0.238, p < 0.001). The recovery rate of the Japanese Orthopedic Association score was slightly lower in the OPLL-O group (p < 0.001), and it was correlated with postoperative residual spinal cord compression (r = −0.305, p < 0.001).

Conclusions

OPLL-O limits cervical lordotic compensation, resulting in cervical sagittal balance mismatch. It affects the degree of spinal cord decompression, which might be related to surgical outcome.

Incidence and Outcomes of C5 Palsy and Axial Pain After Open-Door Laminoplasty or Laminectomy and Fusion: A Meta-Analysis

OBJECTIVE

C5 palsy and axial pain are significant factors affecting the quality of life after posterior cervical surgery; however, there has been no clear and supportive conclusion on which method is more suitable in a certain case. As a result, we compare the clinical outcomes, complication rates, and anatomical changes between open-door laminoplasty (ODL) and laminectomy and fusion (LF) for cervical spondylotic myelopathy. This is a systematic literature review and meta-analysis.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, and the Cochrane library. The following outcomes were extracted and analyzed: the cases of C5 palsy and axial pain patients, Japanese Orthopaedic Association, range of motion (ROM), and cervical curvature. Data analysis was conducted with RevMan 5.3. The I² statistics were used to evaluate heterogeneity.

RESULTS

A total of 9 studies were included in the final analysis, all of which were prospective or retrospective cohort studies. The pooled data showed that the incidences of C5 palsy and axial pain in LF were higher than those in ODL. The study indicated that there was no significant difference in pre- and postoperative Japanese Orthopaedic Association scores, preoperative cervical ROM, pre- and postoperative cervical curvature between the 2 groups, but there was significant difference in ROM after operation. These results indicate that ODL was superior to LF in maintaining cervical ROM.

CONCLUSIONS

Our results demonstrate that the lower incidence of C5 palsy and axial pain can be achieved by using ODL compared with LF. However, current data only provide weak support, if any, favoring ODL over for clinical improvement in reduce these 2 complications.

Mental State Can Influence the Degree of Postoperative Axial Neck Pain Following Cervical Laminoplasty

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To investigate factors influencing the incidence of moderate to severe postoperative axial neck pain following cervical laminoplasty.

METHODS

We reviewed 125 patients with cervical myelopathy who underwent double-door laminoplasty. The primary outcomes were the Numerical Rating Scale score (NRS score, 0-10) for neck pain, the Short Form 36 (SF-36) Health Survey score (Physical and Mental Component Summary scores [PCS and MCS, respectively]), and satisfaction. Imaging parameters on plain radiographs and magnetic resonance imaging were also evaluated. Patients with moderate to severe postoperative neck pain (NRS ≥ 5) were compared with those with no or mild neck pain (NRS ≤ 4).

RESULTS

One hundred and three patients (82%) with complete data were eligible for inclusion. There were 67 men and 36 women, with a mean age of 65 years (32-89 years). Twenty-five patients (23%) had moderate to severe postoperative axial pain (NRS ≥ 5) and were compared with the other 78 patients (NRS ≤ 4), which revealed several predictive factors, including female sex, the presence of preoperative neck pain, low postoperative PCS, low preoperative and postoperative MCS, and satisfaction with the treatment. Multivariable logistic regression analysis revealed that the postoperative MCS (P = .002) was a risk factor for postoperative neck pain, although the preoperative MCS did not reach statistical significance (P = .06).

CONCLUSIONS

Patients with a low mental state, possibly before surgery, are at a high risk for postoperative axial neck pain. None of the imaging parameters were statistically different.

Severe C8 or T1 Symptoms after Cervical Laminoplasty and Related Factors: Are Tere Any Differences between C3-C6 Laminoplasty and C3-C7 Laminoplasty?

Study Design

Retrospective study.

Purpose

We experienced the situation wherein some patients had new-onset pain or dysesthesia around the ring and little fingers (C8 symptom) or ulnar aspect of the forearm (T1 symptom) after cervical laminoplasty (LP). We investigated the incidence and the cause of new C8 or T1 symptoms and the clinical outcomes after C3–C6 LP or C3–C7 LP.

Overview of Literature

There were some reports regarding complications after cervical LP. However, there was no report regarding C8 or T1 symptoms after cervical LP.

Methods

Among the 33 patients enrolled in this study, 11 and 22 patients were treated with C3–C6 LP and C3–C7 LP, respectively. We prospectively evaluated C8 or T1 symptoms daily postoperatively for 1 week. The distance of the posterior spinal cord shifting and posterior subarachnoid space from C2 to T1 was measured by T2-weighted midsagittal magnetic resonance imaging (MRI). We evaluated pre- and postoperative axial neck pain, Japanese Orthopaedic Association (JOA) score, and JOA score improvement rate.

Results

C8 or T1 symptoms occurred in five and three patients with C3–C6 LP (45.5%) and C3–C7 LP (13.6%), respectively. The distance of the posterior subarachnoid space in C3–C6 LP at C7 was significantly shorter than that in C3–C7 LP at T1 on MRI 24 hours postoperatively (p=0.0448). Postoperative axial neck pain, pre- and postoperative JOA scores, and JOA score improvement rate were not significantly different.

Conclusions

The incidence of C8 or T1 symptoms in C3–C6 LP was higher than that in C3–C7 LP. C8 or T1 symptoms would be caused by the posterior fila radicularia and spinal cord impingement on the intact lower end of the lamina.

Clinical and radiological outcomes following open door laminoplasty: a single center evolution of the technique

BACKGROUND

A comparison of clinical and radiological outcomes after two different variants of open door laminoplasty for cervical spondylotic myelopathy (CSM) is described.

METHODS

Fifty-five patients underwent cervical laminoplasty for CSM. Between 2005 to 2009, 32 patients underwent open-door laminoplasty (Group A) performed with a monolateral exposure with contralateral "green stick" laminar fracture. A technical variant consisting in bilateral exposure, spinous process removal and symmetrical muscular closure was applied in the other 23 (Group B), from 2009 to 2016. A retrospective analysis of surgical results between the two groups was performed.

RESULTS

In group B, the mean operative time was longer and the mean volume of intraoperative blood loss was much higher than in group A. Both differences were not significant (p=0.1601 and p=0.0884, respectively). The average hospitalization was nonsignificantly longer in group B (7.3±1.8 vs. 6.5±1.6 d; p= 0.0947). Postoperatively, axial neck pain was more severe in group A at last follow-up than preoperatively (P>0.05). mJOA scores and Nurick grades improved significantly in both groups at last follow-up; in group A, the mean recovery rates were 41.5 % by mJOA scores and 29.4 % by Nurick grades, whereas in group B they were 52.7 % and 36.8 %, respectively.

CONCLUSIONS

Applying some few variations to a standard monolateral approach, although slightly more time and blood consuming, could reduce the incidence of long term axial symptoms and, in our experience, are not burdened by worsening of outcomes. A prospective, multicentric study with a longer follow-up should be conducted in order to confirm our findings.

Postoperative neck symptoms of posterior approach for cervical compressive myelopathy: Expansive open-door laminoplasty vs. segmental partial laminectomy

BACKGROUND

Laminoplasty is widely accepted as a standard treatment of cervical compressive myelopathy. However, due to the risk of postoperative complications such as neck symptoms, segmental partial laminectomy (SPL) is performed instead, which results in fewer postoperative symptoms. The aim of this study was to describe the difference in the incidence and severity of postoperative neck symptoms between traditional C3-C7 expansive open-door laminoplasty (ELAP) and SPL.

METHODS

A retrospective and comparative study was performed regarding neck complications following the two surgical procedures. Twenty patients underwent SPL, and an additional 20 age- and gender-matched patients underwent traditional C3-C7 ELAP. Preoperative and postoperative JOA scores were measured, and postoperative neck symptoms in both groups were evaluated using a self-administered questionnaire, according to the Neck Pain and Disability Scale.

RESULTS

The total incidence of postoperative neck symptoms in the SPL group was similar to that in the ELAP group; however, the severity of symptoms was remarkably lower in the SPL group than in the ELAP group.

CONCLUSIONS

SPL seems to be a better procedure for reducing postoperative neck symptoms, when compared with C3-C7 ELAP.

An anatomical study of the spinous process of the seventh cervical vertebrae based on the three-dimensional computed tomography reconstruction

Palpation of the seventh cervical vertebra (C7) is important for the diagnosis and treatment of neck and chest conditions. However, the spinous process of C7 (C7-SP) displays an anatomical deviation among individuals. The present study aimed to clarify anatomic characteristics of C7-SP by using a three-dimensional (3D) computed tomographic (CT) reconstruction technique. A total of 245 subjects meeting the selection criteria were examined. After CT scanning, the images were reconstructed in 3D. All subjects were grouped according to their deviation of C7-SP: Deviating to the right (DR group), deviating to the left (DL group) and no deviation (ND group). Three distances and three angles were recorded on C7-SP. The vertical distances between the borders of the left and right transverse processes and the tip of the SP, were termed DLTS and DRTS, respectively. The length of the SP was also determined. The angle of the SP deviation was referred to as ∠α, the angle between the SP axis and the line crossing the tips of the transverse processes was referred to as ∠β and the angle between the vertebral body axis and the SP axis was referred to as ∠γ. Among the three groups, differences in ∠α and ∠β were statistically significant (P<0.05). Furthermore, the DLTS was significantly different between the DL and ND groups (P<0.05). In addition, a significant difference in the DRTS was identified between the DR and ND groups (P<0.05). 3D CT reconstruction was reliable for studying anatomic characteristics of C7-SP. Based on this, patients may be preliminarily grouped according to the deviation of their C7-SP and the measurement of the C7-SP may guide clinical diagnoses and treatments.

Limiting fusion levels by combining anterior cervical decompression and fusion with posterior laminectomy: Technical note

BACKGROUND

Authors aim to report on the outcomes of combining selective anterior cervical decompression and fusion (ACDF) with laminectomy in patients with cervical spondylotic radiculomyelopathy (CSR).

METHODS

10 patients with ACDF and posterior laminectomy reviewed.

RESULTS

60% female population, mean age 61 ± 3 years, mean BMI 24.7 ± 3.4 kg/m2. VAS and NDI showed significant improvement, p < 0.001, p = 0.02 respectively. Mean PCS 31.9 ± 2.7, MCS 38.9 ± 3.4 improved to mean PCS 42.2 ± 5.1, MCS 51.0 ± 4.7, p = 0.09 and 0.06 respectively. At final follow up fusion rate was 90% and all patients had Nurick Grade 0.

CONCLUSION

In this pilot study, procedure shown to be safe with improved symptoms.

Impact of Cervical Sagittal Alignment on Axial Neck Pain and Health-related Quality of Life After Cervical Laminoplasty in Patients With Cervical Spondylotic Myelopathy or Ossification of the Posterior Longitudinal Ligament: A Prospective Comparative Study

STUDY DESIGN

This is prospective observational study.

OBJECTIVE

To prospectively investigate the correlation among axial neck pain; a newly developed patient-based quality of life outcome measure, the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ); and cervical sagittal alignment after open-door laminoplasty for cervical myelopathy.

SUMMARY OF BACKGROUND DATA

Many studies have focused on postoperative axial neck pain after laminoplasty. However, the correlation among cervical sagittal alignment, neck pain, and JOACMEQ has not been investigated.

MATERIALS AND METHODS

In total, 57 consecutive patients treated by open-door laminoplasty for cervical myelopathy were included (mean age, 63.7 y; 15 women and 42 men) and divided into 2 groups according to diagnosis [cervical spondylotic myelopathy (CSM) group: 35 patients, and ossification of the posterior longitudinal ligament (OPLL) group: 22 patients]. JOA score, a subdomain of cervical spine function (CSF) in the JOACMEQ, and the visual analog scale for axial neck pain were assessed preoperatively and 12 months postoperatively. Radiographic cervical sagittal parameters were measured by C2 sagittal vertical axis (C2 SVA), C2-C7 lordosis, C7 sagittal slope (C7 slope), and range of motion.

RESULTS

C2 SVA values in both groups shifted slightly anteriorly between preoperative and 12-month postoperative measurements (CSM: +19.7±10.9 mm; OPLL: +22.1±13.4 mm vs. CSM: +23.2±16.1 mm; OPLL: +28.7±15.4 mm, respectively). Postoperative axial neck pain in the OPLL group showed strong negative correlations with C2 SVA and C7 slope. Strong negative correlations were found between axial neck pain and CSF in both the preoperative CSM and OPLL groups (CSM: r=-0.45, P=0.01; OPLL: r=-0.61, P<0.01) and between axial neck pain and CSF in the postoperative OPLL group (r=-0.51, P=0.05).

CONCLUSIONS

This study demonstrated a significant negative correlation between neck pain and CSF in both the CSM and OPLL groups preoperatively and in the OPLL group postoperatively. Radiographic cervical sagittal alignment did not significantly correlate with preoperative or postoperative axial neck pain.

Why Does C5 Palsy Occur After Prophylactic Bilateral C4-5 Foraminotomy in Open-Door Cervical Laminoplasty? A Risk Factor Analysis

STUDY DESIGN

Retrospective study.

OBJECTIVES

To evaluate the efficacy of bilateral C4-5 foraminotomy in preventing occurrence of postoperative C5 palsy and to identify possible risk factors for its development.

METHODS

A total of 70 consecutive patients who underwent open-door laminoplasty with bilateral C4-5 foraminotomy were included. Clinical, radiographic, and operative data was reviewed. Development of postoperative C5 palsy was analyzed.

RESULTS

A total of 54 males and 16 females were reviewed. Mean age was 56 years (range, 30-86 years). The primary pathology was spondylosis in 76% of cases and ossified posterior longitudinal ligament in 21%. Radiographic evidence of C4-5 foraminal stenosis was seen in 81% of the patients. The mean duration of preoperative symptoms was 7 ± 19 months. Four (5.7%) out of 70 patients developed C5 palsy after open-door laminoplasty with bilateral C4-5 foraminotomy. Multivariate analysis showed that a long duration of preoperative symptoms (>12 months) and the presence of preoperative C4-5 T2-MRI cord signal change were statistically significant risk factors for the development of C5 palsy even after bilateral C4-5 foraminotomy in open-door laminoplasty (P < .0001 and P = .036, respectively).

CONCLUSIONS

Prophylactic bilateral C4-5 foraminotomies do not completely eliminate the occurrence of C5 palsy. Prolonged duration of symptoms and presence of preoperative T2-MRI cord signal change increase the risk for developing postoperative C5 palsy despite foraminotomy.

Microendoscopic laminotomy versus conventional laminoplasty for cervical spondylotic myelopathy: 5-year follow-up study

OBJECTIVE The goal of this study was to characterize the long-term clinical and radiological results of articular segmental decompression surgery using endoscopy (cervical microendoscopic laminotomy [CMEL]) for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP). METHODS Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n = 78) underwent CMEL or ELAP. All patients were followed postoperatively for more than 5 years. The preoperative and 5-year follow-up evaluations included neurological assessment (Japanese Orthopaedic Association [JOA] score), JOA recovery rates, axial neck pain (using a visual analog scale), the SF-36, and cervical sagittal alignment (C2-7 subaxial cervical angle). RESULTS Sixty-one patients were included for analysis, 31 in the CMEL group and 30 in the ELAP group. The mean preoperative JOA score was 10.1 points in the CMEL group and 10.9 points in the ELAP group (p > 0.05). The JOA recovery rates were similar, 57.6% in the CMEL group and 55.4% in the ELAP group (p > 0.05). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (p < 0.01). At the 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.6° gain in lordosis (versus 1.2° loss of lordosis in the ELAP group [p < 0.05]) and lower incidence of postoperative kyphosis. CONCLUSIONS CMEL is a novel, less invasive technique that allows for multilevel posterior cervical decompression for the treatment of CSM. This 5-year follow-up data demonstrates that after undergoing CMEL, patients have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional ELAP counterparts.